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Case Report
Inc, Bedford, USA) and caspofungin (Cancidas ,Merck & Moreover, consistent visual loss in the left eye was satis-
Co. Inc, Whitehouse Station, NJ, USA ). Following no sig- factorily controlled. After the 12th week of hospitalization,
nificant improvement in both radiological findings and hy- repeat chest CT scan done showed clearance of the nodu-
poxaemia, bronchoscopy and bronchoalveolar lavage (BAL) lar opacities and the patient was discharged in good clini-
was performed and S apiospermum was cultivated 10 days cal condition.
later. He was then referred and admitted to our hospital.
On admission, he was febrile with a body temperature of Case 2
38.6°C, and breathing rate of 29/min in room air. Moist
rales were heard on both lower lungs during ausculta- A 28 year old male driver drove a car through a bridge
tion. The leucocyte count was within the normal range and accidentally rushed into the river of dirty water. He
and transaminase was slightly increased. Percutaneous was rescued by a passerby fifteen minutes later and was
puncture biopsy was performed and culture of pulmonary then sent to a local hospital. On presentation he had
tissue yielded Scedosporium aniospermum which was also cough with sand and mud, chest pain and dyspnea. Chest
isolated from sputum and feaces. Since the Scedosporium CT scans revealed scattered infiltrative shadows in both
aniospermum was reported to be sensitive to itraconazole, lungs,which were representative of water aspiration. He
the antimycotic treatment with Am B was stopped and a was intubatedfor mechanical ventilation , and was given
combination of itraconazole (Xi’an Janssen Pharmaceuti- therapy with dehydration, diuretic and hyperbaric oxygen.
cal Ltd, Xi’an, China)and caspofungin was started intra- However, his pulmonary condition worsened, and the pa-
venously. On day 7 his eyesight in the left eye worsened, tient eventually developed respiratory failure. After twelve
accompanied with congestion and swelling pain which hours, he was transferred to our hospital. On arrival, he
lead to the diagnosis of internal endoophthalmitis. Intra- was febrile, with a breathing rate of 24 breaths/min, heart
vitreal injection of antibiotics, antifungus and steroids was rate of 130 beats/min, blood pressure was 120/60 mmHg.
administered by ophthalmologists intermittently. About 2 Physical examination revealed bilateral crepitations. Labo-
weeks after admission, the patient presented with severe ratory tests upon admission in our hospital showed a
headache with nausea and vomitting. Cerebrospinal fluid white blood cell count of 10.1×109/L, neutrophil percent-
(CSF) examination revealed extremely high (>400mmH20) age of 63.6%, ALT of 280U/L and AST of 147U/L. In ICU,
pressure and slightly increased leucocytes (25*106 cells/ he received treatment with antibiotics (Benzylpenicillin
liter) with a normal glucose, chloride and total protein. Sodium,Reyoung Pharmaceutical Ltd,Shangdong,China)
Blood cultures and a search for fungi in CSF stains and and Fosfomycin Sodium (Northeast Pharmaceutical
cultures yielded negative results. CT of the brain showed Ltd,Shenyang,China) and short-term corticosteroid, Meth-
multiple hypodense lesions and round masses on the ylprednisolone (Pfizer Manufacturing Belgium NV). He suc-
parietal lobe. Magnetic Resonance Imaging (MRI) brain cessfully weaned off mechanical ventilation 7 days after
scan revealed multiple lesions that were enhanced after IV admission, but still had fever and cough. Chest CT revealed
gadolinium, which was suggestive of brain abscesses. Due patty bilateral infiltration with cavitary lesion. A pulmonary
to the fact that intracranial mycosis was highly suspected, biopsy was performed in the cavitary site, and pathology
voriconazole was given instead of itraconazole, which has of the puncture specimen was characterized by lympho-
poor penetration in the CNS tissue. Considering the fact cyte inflammatory infiltration and histiocytosis. Special
that his pulmonary condition did not improve, amphoteri- staining visualized mold hyphae, and fungal analysis
cin B liposome was substituted for caspofungin. Under the yielded Aspergillus Niger, which confirmed the diagnosis of
combined therapy of voriconazole and Am B, the clinical pulmonary mycosis. Therefore, the patient received treat-
and radiological picture improved progressively with re- ment with intravenous infusion amphotericin B liposome
mission of the headache and decrease of lung infiltrates. (Amphotec, Ben Venue Laboratories Inc, Bedford, USA).
About one month after the treatment, the patient’s body
temperature returned to normal. The chest CT scanning
Laboratory and Clinical CInavseestRigeaptoiortn 462 FAM 2014 Nov/Dec Vol.21 Issue 6
123
