IMAGES IN INFECTIOUS DISEASE
Severe cytomegalic pneumonitis associated with pulmonary aspergillosis in a child with immunosuppression due to chemotherapy for treating pineoblastoma
Juliana Paulino Oliveira; Luciana de Paula Lima Gazzola; Stanley de Almeida Araújo
Departamento de Anatomia Patológica e Medicina Legal. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG
A seven-year-old girl with pineoblastoma had had it surgically resected followed by chemotherapy (cyclophosphamide and vincristine; 1.5g/m2) along with methylprednisolone pulses. She developed bilateral amaurosis, febrile pancytopenia, recurrent pneumonia, urinary infection and sepsis. During her last hospitalization, she presented respiratory distress with severe dyspnea. She was treated with prednisone, voriconazole, sulfamethoxazole-trimethoprim, vancomycin, metronidazole, ciprofloxacin, meropenem and amphotericin B over the course of 50 days in hospital, with intermittent recoveries. During an episode of worsened dyspnea, she presented shock and was admitted to the intensive care unit. High-resolution computed tomography on the chest showed bronchiectasis and thickening of the intra and interlobular interstices, together with ground-glass opacity and randomly distributed nodules, which suggested acute respiratory distress syndrome associated with fibrosis (Figure A). Fine-needle biopsy on the lung (middle lobe of the right lung) showed extensive areas of alveolar epithelial erosion, with numerous intra-alveolar macrophages and pneumocytes containing cytomegalic inclusions (Figure B: cells marked with asterisks). Venules (arrow) filled with fibrinous material, cell debris and several large hyphae and fungal spores that stained with silver (Grocott staining) could be seen. These histological findings suggested Aspergillus infection (Figure C: detail of the same venule), which was later confirmed by blood culturing. Following this anatomopathological diagnosis, the patient was treated with ganciclovir and conventional amphotericin B. There was an improvement in the patient's general condition and she was discharged from the Intensive Care Unit. Viral infections should be investigated in immunosuppressed patients, especially after ruling out bacterial and fungal infections.
Recebido para publicação em 20/10/2008
Aceito em 13/01/2009
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Publication in this collection
10 Mar 2009
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