An eight year old female with a history of β-thalassemia was admitted to Leeds General Infirmary to
undergo a sibling donor HSCT. She began spiking fevers with rigours 2 days following transplantation
and treated empirically with IV piperacillin/tazobactam (TZP). She was switched to meropenem after an
extended spectrum beta-lactamase producing E.coli was isolated from peripheral blood cultures, which was
TZP resistant. The source of the E. coli was thought to be from the gut, as she had abdominal pain and loose
stools, however stool samples were negative for common enteric pathogens, including C. difficile. Five
days after transplant, she developed pneumonia with a small pleural effusion which was too small to drain.
Clarithromycin was added to cover pneumonia and Ambisome with stat Amikacin if required. Samples were
sent for Mycoplasma, Legionella and a viral panel which were all negative and clarithromycin was stopped
on day 7.
The patient continued to spike fevers and on day 11, a CT chest showed right upper-lobe consolidation and
pulmonary thrombus with ground glass consolidation, and anticoagulants were started. Weekly Aspergillus
antigen (galactomannan) screens were all negative. A bronchoscopy was performed and a soft grey mass of
tissue was seen occluding the upper right bronchus. A bronchoalveolar lavage (BAL) was sent for bacterial
and fungal culture, which grew coagulase-negative Staphylococci but no fungi.
Day 21, the neutrophil count began to return, however the patient was still spiking fevers and had increasing
respiratory distress. CT and chest X-ray show a convex shape into a fissure affecting the whole right upper
lobe, which was thought to be fungal and caspofungin was added in for 7 days. A sample was tested for β-D
glucan, and was negative.
Day 29, the patient underwent a right upper lung resection, which was a difficult procedure with friable
necrotic lung tissue showing mycelia on microscopy with calcaflour. Aspergillus antigen (serum) remained
negative and samples from the lung biopsy were sent for culture, which was negative apart from a coagulase-
negative Staphylococcus. She continued to have increasing oxygen requirements and worsening of chest
radiograph, which now showed left sided lower lung consolidation with a small pleural effusion and patchy
perihilar opacity of the right apex (which was removed). Voriconazole was added.
Day 31, CRP continued to increase and the patient was believed to have severe pulmonary aspergillosis
and ambisome was stopped, whilst voriconazole was continued with caspofungin added in. Day 33, she
had ongoing pulmonary haemorrhage and a serum sample was sent to Bristol for B-D glucan, which was
positive. On day 35, the patient passed away from a sudden hypotensive and hypoxive episode.