Why is biopsy of suspected fungal lung lesions necessary? $ Gabriele Kropshofer a , Bernhard Meister a , Cornelia Lass-Flörl b , Roman Crazzolara a,n a Department of Pediatrics, Anichstrasse 35, Innsbruck 6020, Austria b Department of Hygiene, Microbiology and Social Medicine, Fritz-Pregl-Strasse 3, Innsbruck 6020, Austria article info Article history: Received 24 July 2013 Received in revised form 29 July 2013 Accepted 21 August 2013 Keywords: Childhood Invasive pulmonary infections CT-guided biopsy Aspergillus flavus Amphothericin-B abstract The recognition of antifungal resistance is necessary for the choice of the appropriate treatment in patients with invasive fungal disease. In this case report, the need for a computed tomography-guided percutaneous lung biopsy of a suspected fungal lesion in a patient treated for acute leukemia is demonstrated. Detection of Amphothericin-B resistant Aspergillus flavus infection has prompted the switch in antifungal therapy, followed by full resolution of symptoms, completion of chemotherapy and remission since then. & 2013 The Authors. Published by Elsevier B.V on behalf of International Society for Human and Animal Mycology All rights reserved. 1. Introduction Several studies have been reported concerning the incidence of rare invasive fungal infections (IFIs) and the emergence of antifungal resistance in patients treated for cancer [1,2]. At the same time, numerous evidence-based recommendations have been proposed to simplify the diagnosis of these infections [3]. Unfortunately, there is little or no information on culture-based methods, as they remain largely underused and the impact of the tested antifungal agents on the outcome of the infections is still to be determined. In this way, a case report is presented, in which biopsy of a suspected fungal lesion has been performed and antifungal susceptibility testing has prompted the change in antifungal drugs. 2. Case A 16-year old male adolescent was diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia and sub- jected to treatment with the ESPHALL protocol for high-risk patients [4]. He achieved complete morphological remission in the peripheral blood on day 10 of treatment. On the day 27th of induction chemotherapy the patient developed his first febrile episode. Physical examination was unremarkable. The laboratory tests showed leukopenia (0.5 Â 10 9 /L) with an absolute neutro- philic count of 19/mL, but no elevation of inflammatory proteins (C-reactive protein o0.06 mg/dL) Fig. 1. Invasive fungal infection was suspected by chest X-ray in a ALL patient on day 30 of induction chemotherapy and after 72 h of antibiotic resistant fever in neutropenia. CT scan of the chest on day 31 revealed a suspicious fungal mass associated with halo sign. Prophylactic treatment with Fluconazole was switched to empiric therapy with liposomal Amphothericin-B. 24 h later, CT-guided percutaneous lung biopsy was performed and direct examination confirmed the presence of Aspergillus species. Culture revealed growth of Aspergillus flavus highly resistant to Amphothericin-B. Treatment was immediately changed to Voriconazole. Empirical antibiotic regimen was initiated with Meropenem (1 g three times daily) and Gentamycin (200 mg once daily). Because of continuous fever, Vancomycin (1 g twice daily) was added the day after. Both blood and urine cultures remained sterile. 72 h after developing fever, a chest X-ray was obtained and showed a dis- tinctive mass in the middle of the right lung. Because the radiological image was ambiguous the diagnostics were extended by a chest computed tomography (CT) scan, which confirmed the large mass in the right upper lobe, surrounded by a wide zone of ground-glass attenuation, compatible with the halo sign. Fluconazole (200 mg once daily), included in the treatment as a prophylactive measure at this time, was replaced by liposomal Amphothericin-B and administered at a dose of 3 mg/kg once daily. On the next day CT-guided biopsy was performed. No pneu- mothorax or hemorrhage was noted after the procedure. Immediate direct examination yielded dichotomously branching septated Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/mmcr Medical Mycology Case Reports 2211-7539/$ - see front matter & 2013 The Authors. Published by Elsevier B.V on behalf of International Society for Human and Animal Mycology All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2013.08.002 ☆ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which per- mits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. n Corresponding author. Tel.: þ43 512 504 23600; fax: þ43 512 504 24934. E-mail address: roman.crazzolara@i-med.ac.at (R. Crazzolara). Medical Mycology Case Reports 2 (2013) 141–143