Dr. Arghya Samanta

PG-3

Department of Pediatrics

A 3 year old male

K/C/O B-cell Acute lymphoblastic leukemia

Undergoing induction phase of chemotherapy

On day 23 of induction

Presented with - high grade fever for last 2 days

Fever- documented, high grade, intermittent , n/a/w chill or rigor

No C/O cough/FB/LM/ vomiting/ pain abdomen/ yellowish

discoloration of eyes or urine/ increased frequency or pain during

micturation/ headache/abnormal body movements

General condition : stable

Vitals : PR-124/m

RR-30/min

T- 102.60 F

B.P. 96/ 54 mm Hg

Anthropometry :

Wt: 12kg (Between -2SD and -3SD)

Ht: 84cm ( < -3SD)

Weight for height ( Between -2SD and -3SD)

Child was underweight, severely stunted and wasted

Pallor present

No icterus/cyanosis/clubbing/edema/LAP/petechiae

No thrombophlebitis/skin rash

Perianal area- normal

Oral cavity- no e/o mucositis, thrush, gingivitis

Per abdomen:

Liver: 3cm below costal margin, firm, non-tender,

smooth surface, round margin, span 8cm

Spleen -NP

CVS, CNS, Respiratory system: WNL

I.V. access gained. CBC, LFT, KFT and Blood culture specimen collected before starting antibiotics

FEBRILE NEUTROPENIA(FN) CBC -Absolute neutrophil count (ANC) 270/cmm

.

Inj. Piperacillin-tazobactum + amikacin added as per protocol

Urine sample sent for culture. CXR PA view- NAD

On D3 of FN, child developed right eye

ptosis.

2 days later, child had right sided muco-

purulent nasal discharge

Fever spikes persisted even after 72

hours of broad spectrum antibiotics

Repeat blood culture specimen sent for pyogenic and fungal culture

Intravenous amphotericin B added i/v/o profound and prolonged neutropenia and a strong suspicion of rhino-orbital mucor

Fever spikes persisted even after 3 days of antibiotics - ANC 80/cmm

Antibiotics upgraded to inj. meropenam+ vancomycin. BDCS- STERILE

Ophthalmologic referral done- s/o preseptal cellulitis.

Radioimaging of orbit+PNS+ brain planned

RETRORBITAL

ENHANCING

LESION

DESTRUCTION OF

BONY WALLS OR

ORBIT AND PNS

S/O MUCORMYCOSES

KOH staining showed filamentous fungi with aseptate hyphae

which was telephonically communicated to us on the same day

Debridement done and tissue aspirate collected and sent for microscopy and C/S

Nasal endoscopy done by ENT surgeons

After 5 days of starting caspofungin, child became afebrile

Fever spike, Orbital swelling not improving even after 10 days of i.v. Voriconazole- Intravenous caspofungin added

Intravenous voriconazole started i/v/o persistent fever spikes and orbital swelling despite 7 days of amphotericin B

Tissue culture showed growth of Mucor spp.

which was sensitive to all the azoles

During this period --chemotherapy withheld

Next cycle – decided to start on antifungal prophylaxis

Antifungals were continued till repeat nasal endoscopy showed clear margins of Paranasal sinuses – total duration 45 days

Gradually the orbital swelling of the child decreased, general condition improved

ANC started rising

B-cell ALL with febrile neutropenia (HR) with

Rhino-orbital mucormycosis

Though the child recovered from rhino-

orbital mucormycosis, he later succumbed

to H1N1 pneumonia.

A 16 year old female child

K/C/O severe aplastic anemia

Fever for last 5-6 days

Received Anti-thymocyte Globulin (ATG)

immuno-suppressive therapy 1 month back.

Was on oral cyclosporine therapy

Visited hospital frequently for blood transfusions

Fever- documented, high grade, intermittent

No h/o cough/FB

No H/O LM/ vomiting/ pain abdomen

No yellowish discoloration of eyes or urine/

increased frequency or pain during

micturation

No headache/abnormal body movements

H/O ongoing construction work in

neighbourhood and our hospital premises

General condition : stable

Vitals : PR-134/m

RR-26/min

T- 101.60 F

B.P. 100/ 58 mm Hg

Anthropometry :

Wt: 32kg (Between -2SD and -3SD)

Ht: 145cm ( btwn -1SD and -2SD)

BMI for age ( Between -1SD and -2SD)

Child was underweight

Pallor

petechial spots

No icterus/cyanosis/clubbing/edema/LAP

No thrombophlebitis

Oral cavity – normal

Perianal area – normal

P/A: No organomegaly

Genito-urinary system - NAD

CVS, CNS, Respiratory system: NAD

I.V. access gained. CBC, LFT, KFT and Blood culture specimen collected before starting antibiotics

FEBRILE NEUTROPENIA(FN) CBC -Absolute neutrophil count (ANC) 350/cmm

.

Inj. Piperacillin-tazobactum + amikacin added as per protocol

Urine sample sent for culture. CXR PA view- NAD

CXR PA view –NAD

USG abdomen + KUB –NAD

No focus of infection identified

FEBRILE NEUTROPENIA WITHOUT A FOCUS

Repeat blood culture sent for pyogenic and fungal C/S

Antibiotics upgraded to meropenam+vancomycin. Previous BDCS-STERILE.

Anti-fungal agent amphotericin B added as per protocol

Fever spike persisted despite 72 hours of antibiotics- ANC 170/cmm

CECT Chest + paranasal sinus to look for invasive

fungal infection

Meanwhile patient had one episode of hemoptysis

? Pulmonary aspergillosis

Clinical pointers- SAA

ATG THERAPY, CSA

FN- prolonged nutropenia

Surrounding construction

Hemoptysis

GROUND-

GLASS

OPACITY

CNODUL

AR

LESION

Child developed shock with DIC with MODS and ultimately expired on day 20 of illness

Child’s clinical condition gradually deteriorated . ANC continued to be < 100/cmm

Serum Galactomannan Ag assay done. Result 3.47 ( normal < 0.5)

INVASIVE ASPERGILLOSIS

Intravenous voriconazole started

Severe Aplastic Anemia with Febrile Neutropenia

with Probable Invasive Pulmonary Aspergillosis