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Zorluk: OrtaHematology and Oncology

An oncologist is asked to evaluate a 54-year-old man admitted for profound neutropenia following induction chemotherapy for acute myeloid leukemia. For the past 5 days, he has been treated with intravenous cefepime for a temperature of 39.2°C (102.6°F) and an absolute neutrophil count of 150/mm³. Today, his temperature remains elevated at 38.9°C (102.0°F). He reports a new, dry cough and mild right-sided chest pain that worsens with deep inspiration. Blood pressure is 114/72 mm Hg, pulse is 108/min, and respirations are 20/min. Pulse oximetry shows 94% on room air. Physical examination reveals diminished breath sounds in the right upper lung field. Laboratory studies show a white blood cell count of 0.6 x 10^9/L (ANC 100/mm³). Blood cultures obtained on admission have shown no growth. A high-resolution CT scan of the chest reveals a 2-cm macronodule with a surrounding zone of ground-glass attenuation in the right upper lobe. Which of the following is the most appropriate next step in management?

  1. A
    Broaden antibacterial coverage to meropenem and vancomycin
  2. B
    Administer intravenous furosemide
  3. C
    Obtain an arterial blood gas
  4. Initiate intravenous voriconazole therapyCevap
  5. E
    Perform a lower extremity venous duplex ultrasound

Cevap

Initiate intravenous voriconazole therapy
The correct answer identifies that a profoundly neutropenic patient with persistent fever despite broad-spectrum antibacterial therapy is at high risk for invasive fungal infections. The development of pleuritic chest pain alongside a chest CT demonstrating a nodule with a surrounding ground-glass opacity (the 'halo sign') is classic for invasive pulmonary aspergillosis. The halo is caused by localized hemorrhage surrounding the invading fungus. The next best step in management is the immediate initiation of anti-mold therapy, with voriconazole being the treatment of choice.

Adım Adım Çözüm

1
Evaluate the timeline of the neutropenic fever.
The patient has experienced persistent fever for 5 days despite receiving appropriate broad-spectrum antibacterial coverage (cefepime).
Persistent fever in a severely neutropenic patient after 4 to 7 days of appropriate antibiotic therapy strongly indicates a secondary or breakthrough fungal infection.
2
Analyze the clinical and radiographic findings.
The patient developed new-onset pleuritic chest pain, a dry cough, and a CT scan showing a macronodule with a ground-glass halo (the 'halo sign').
The halo sign represents pulmonary hemorrhage surrounding an invasive fungal nodule. This finding is highly specific for invasive pulmonary aspergillosis in the setting of prolonged neutropenia.
3
Determine the most appropriate targeted intervention.
Start a targeted antifungal agent active against Aspergillus species.
Intravenous voriconazole is the first-line treatment for invasive pulmonary aspergillosis and should be initiated promptly to prevent further dissemination.

Anahtar Kavram

Patients with persistent neutropenic fever (despite 4-7 days of broad-spectrum antibiotics) and classic chest CT findings (halo sign) require prompt initiation of antifungal therapy targeting Aspergillus, typically with voriconazole.
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Hematology and Oncology

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