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Washington University Experience | INFECTION | Fungus | Mucormycosis - Zygomycosis | 12A0 Case 12 History
Case 12 History ---- The decedent was a 28yo male who presented to BJH with progressive fatigue. Initial laboratory workup showed pancytopenia and he was subsequently admitted to the bone marrow transplant service on 7/6. CT of the face was performed and notable for fluid and gas collection along eroded right maxilla consistent with phlegmon and developing abscess from dental disease of the right first molar. Given his pancytopenia, bone marrow biopsy was performed and showed acute myeloid leukemia. On 7/11 the patient underwent extraction of teeth #1,2,3,16,19 and on 7/15 7+3 induction chemotherapy was initiated. On 7/23, the patient became hypotensive with acute kidney injury and elevated liver enzymes and was noted to have blood cultures positive for Streptococcus mitis. On 7/29, he developed right sided weakness and right facial droop, code stroke was called, and subsequent CT of the head demonstrated multifocal hypodensities involving the right cerebellar hemisphere, vermis, right parietal lobe, and bilateral thalami without acute intracranial hemorrhage. Given the concern for intracranial abscess, antimicrobial coverage was broadened to include amphotericin fungal coverage. Subsequent imaging showed areas of hemorrhagic conversion in territories of embolic infarcts and eventual radiographic evidence of intraventricular bleed and herniation. Neurology and Neurosurgery Departments were consulted, but no surgical intervention was pursued given profound thrombocytopenia. On 7/30, ultrasound of the liver showed multiple hypoechoic lesions concerning for developing abscesses and biopsy of the lesions demonstrated only necrotic tissue. The patient continued to decline despite maximal medical therapy, and further discussion with the family determined that tracheostomy would not be in line with the patient's wishes and he was given a trial of extubation on 8/25 until 8/30 at which point he was re-intubated. On 9/6, the family elected to extubate and transition to comfort care and the patient died on 9/8.
