An oncologist evaluates a 45-year-old hospitalized male patient for persistent fever and n… — USMLE Step 2 CK

An oncologist evaluates a $45$ -year-old hospitalized male patient for persistent fever and new respiratory symptoms. The patient is currently on day $15$ of induction chemotherapy for acute lymphoblastic leukemia. His hospital course has been complicated by profound neutropenia. Three days prior, after recording a temperature of $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), he was started on empiric intravenous piperacillin-tazobactam. Despite this intervention, his fevers have remained unremitting. This morning, he developed right-sided pleuritic chest pain and experienced an episode of hemoptysis. Current vital signs include a temperature of $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure of $112/72 \text{ mm Hg}$ , pulse of $110/\text{min}$ , and respiratory rate of $20/\text{min}$ . Pulse oximetry shows $94\%$ on room air. Pulmonary auscultation reveals focal crackles and decreased breath sounds in the right upper lung zone. Laboratory analysis demonstrates a leukocyte count of $200/\text{mm}^3$ with an absolute neutrophil count of $40/\text{mm}^3$ . A high-resolution non-contrast computed tomography scan of the chest reveals a $2.5\text{-cm}$ right upper lobe dense macroscopic nodule surrounded by a peripheral zone of ground-glass attenuation. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A
Initiate intravenous vancomycin
B
Initiate intravenous meropenem
C
Initiate intravenous furosemide
Initiate intravenous voriconazoleCevap
E
Initiate intravenous fluconazole

Cevap

The correct answer is to initiate intravenous voriconazole, as the clinical picture and radiographic findings strongly point to invasive pulmonary aspergillosis.

The correct answer is to initiate intravenous voriconazole. This patient has profound, prolonged neutropenia and presents with unremitting fever despite empiric broad-spectrum antibacterial therapy, pleuritic chest pain, and hemoptysis. His chest computed tomography scan reveals a macroscopic nodule surrounded by a zone of ground-glass attenuation, commonly known as the 'halo sign'. This constellation of clinical and radiographic findings is highly characteristic of invasive pulmonary aspergillosis. The halo sign pathologically represents an area of pulmonary hemorrhage surrounding an angioinvasive fungal infarction. Intravenous voriconazole is the first-line treatment of choice for invasive aspergillosis, offering improved survival and reduced toxicity compared to older therapies.

Adım Adım Çözüm

Identify the primary clinical syndrome and immunocompromised state.

The patient has persistent febrile neutropenia despite broad-spectrum antibacterial therapy, now complicated by pleuritic chest pain and hemoptysis.

Establishing the failure of initial antibacterial therapy in a profoundly neutropenic patient shifts the diagnostic focus toward opportunistic fungal infections.

Interpret the radiographic findings on the chest computed tomography scan.

The scan reveals a dense nodule surrounded by a ground-glass opacity, known classically as the 'halo sign'.

The halo sign is highly specific in severely immunocompromised patients for angioinvasive organisms (most commonly Aspergillus species), with the ground-glass area representing local hemorrhage.

Determine the optimal pharmacologic intervention for the suspected pathogen.

Intravenous voriconazole is the most appropriate addition to the patient's regimen.

Voriconazole is the established first-line drug of choice for invasive pulmonary aspergillosis, yielding better outcomes and lower toxicity than older alternatives like amphotericin B.

Anahtar Kavram

Invasive pulmonary aspergillosis typically presents in patients with prolonged, profound neutropenia as persistent fever, pleuritic chest pain, and hemoptysis; chest imaging classically demonstrates a nodule surrounded by a ground-glass 'halo sign', and the first-line treatment is voriconazole.

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