LAUSR

Pleural empyema caused by Aspergillus is a rare, potentially fatal invasive fungal infection,1 resulting generally from a complication of aspergilloma, chronic necrotizing pulmonary aspergillosis, or surgical resection of these diseases.2 Its incidence among cancer patients has increased in recent years, probably due to the increasingly complex immunosuppressive treatments and surgical procedures used.3 Due to its low prevalence, there is uncertainty surrounding the diagnosis and management of invasive fungal infection, and the situation is particularly problematic in patients with underlying malignancy. We report a case of Aspergillus fumigatus pleural empyema in a patient with T-cell acute lymphoblastic leukemia, treated in our hospital. This was a 19-year-old man who had been diagnosed 7 months previously with intermediate-risk cortical phenotype T-cell acute lymphoblastic leukemia. He received induction, consolidation and reinduction therapies, according to standard protocols, and achieved complete remission. Complications associated with the various treatments included vitamin K deficiency, hypofibrinogenemia, pancytopenia (with hemolytic anemia requiring transfusions), hyperglycemia, and hypertransaminasemia. Thirty days after reinduction therapy, he was admitted to the hematology department for loss of vision in the right eye, odynophagia, and fever. Vital signs showed temperature 37.5 C, blood pressure 110/60 mmHg and heart rate 100 bpm. Breathing at rest was normal, and notable findings on physical examination included pallor of the skin and mucosa, Cushingoid facies, bronchial breath sounds in the base of the left hemithorax, with crackles reaching the middle field, edema of the lower limbs, and exudative ulceration of the foreskin. Abdominal examination was normal and no peripheral lymphadenopathies were palpated. The most relevant additional examinations included blood tests: hemoglobin 8.2 g/dl, hematocrit 24.9%, leukocytes 1×103/ 1 (62% neutrophils, 35% lymphocytes), platelets 24×103/ l, total proteins 4.5 g/dl, GOT 117 IU/l, GPT 524 IU/l, GGT 268 IU/l, alkaline phosphatase 424 IU/l, LDH 999 IU/l, triglycerides 371 mg/dl and cholesterol 320 mg/dl. Bone marrow aspirate confirmed remission. A chest computed tomography was performed, showing a pulmonary consolidation in the left base with lucent foci suggesting cavitation, bilateral multiple pulmonary micronodules measuring less than 1 cm associated with cavitation, and left pleural effusion. Abdominal ultrasonography revealed 2 hypoechogenic hepatic lesions with echogenic centers consistent with abscesses.