Dr. Arghya Samanta PG-3 Department of Pediatrics

Transcription

1 Dr. Arghya Samanta PG-3 Department of Pediatrics

2 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

3 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

4 General condition : stable Vitals : PR-124/m RR-30/min T 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

5 Pallor present No icterus/cyanosis/clubbing/edema/lap/petechiae No thrombophlebitis/skin rash Perianal area- normal Oral cavity- no e/o mucositis, thrush, gingivitis

6 Per abdomen: Liver: 3cm below costal margin, firm, non-tender, smooth surface, round margin, span 8cm Spleen -NP CVS, CNS, Respiratory system: WNL

7 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

8 On D3 of FN, child developed right eye ptosis. 2 days later, child had right sided mucopurulent nasal discharge Fever spikes persisted even after 72 hours of broad spectrum antibiotics

9 Ophthalmologic referral done- s/o preseptal cellulitis. Radioimaging of orbit+pns+ brain planned Fever spikes persisted even after 3 days of antibiotics - ANC 80/cmm Antibiotics upgraded to inj. meropenam+ vancomycin. BDCS- STERILE Intravenous amphotericin B added i/v/o profound and prolonged neutropenia and a strong suspicion of rhino-orbital mucor Repeat blood culture specimen sent for pyogenic and fungal culture

10 DESTRUCTION OF BONY WALLS OR ORBIT AND PNS RETRORBITAL ENHANCING LESION

11 Nasal endoscopy done by ENT surgeons Debridement done and tissue aspirate collected and sent for microscopy and C/S KOH staining showed filamentous fungi with aseptate hyphae which was telephonically communicated to us on the same day S/O MUCORMYCOSES

12 Intravenous voriconazole started i/v/o persistent fever spikes and orbital swelling despite 7 days of amphotericin B Fever spike, Orbital swelling not improving even after 10 days of i.v. Voriconazole- Intravenous caspofungin added After 5 days of starting caspofungin, child became afebrile

13 Tissue culture showed growth of Mucor spp. which was sensitive to all the azoles

14 Gradually the orbital swelling of the child decreased, general condition improved ANC started rising Antifungals were continued till repeat nasal endoscopy showed clear margins of Paranasal sinuses total duration 45 days During this period --chemotherapy withheld Next cycle decided to start on antifungal prophylaxis

15 B-cell ALL with febrile neutropenia (HR) with Rhino-orbital mucormycosis

16 Though the child recovered from rhino- orbital mucormycosis, he later succumbed to H1N1 pneumonia.

17 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

18 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

19 General condition : stable Vitals : PR-134/m RR-26/min T 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

20 Pallor petechial spots No icterus/cyanosis/clubbing/edema/lap No thrombophlebitis Oral cavity normal Perianal area normal

21 P/A: No organomegaly Genito-urinary CVS, system - NAD CNS, Respiratory system: NAD

22 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

23 CXR PA view NAD USG abdomen + KUB NAD No focus of infection identified FEBRILE NEUTROPENIA WITHOUT A FOCUS

24 Fever spike persisted despite 72 hours of antibiotics- ANC 170/cmm Antibiotics upgraded to meropenam+vancomycin. Previous BDCSSTERILE. Anti-fungal agent amphotericin B added as per protocol Repeat blood culture sent for pyogenic and fungal C/S

25 CECT Chest + paranasal sinus to look for invasive fungal infection Meanwhile patient had one episode of hemoptysis? Pulmonary aspergillosis

26 Clinical pointers- SAA ATG THERAPY, CSA FN- prolonged nutropenia Surrounding construction Hemoptysis

27 GROUNDGLASS OPACITY CNODUL AR LESION

28 INVASIVE ASPERGILLOSIS Intravenous voriconazole started Serum Galactomannan Ag assay done. Result 3.47 ( normal < 0.5) Child s clinical condition gradually deteriorated. ANC continued to be < 100/cmm Child developed shock with DIC with MODS and ultimately expired on day 20 of illness

29 Severe Aplastic Anemia with Febrile Neutropenia with Probable Invasive Pulmonary Aspergillosis