2.3 Case 3
A 45-year-old man was admitted to the hospital with fever of unknown
origin. He had high fever 5 days ago and the maximum body temperature
was 40.5 ℃ accompanied by headache, dizziness, body aches, fatigue and
sore throat. He went to other medical institution and completed some
examinations. The lung CT showed inflammation of the upper lobes of both
lungs. The C-reactive protein (CRP) was 52.02mg·L-1.
He was treated with piperacillin-tazobactam and levofloxacin for 2 days
without clinical improvement, and his body temperature was still high.
Then he came to our hospital for further diagnosis and treatment. The
laboratory findings showed the white blood cell count was
5.75×109·L-1 and the neutrophils(%)
was 83.2%, the CRP was 140.7 mg·L-1,the
procalcitonin(PCT) was 0.65 ng·mL-1. Then he was
admitted to the hospital diagnosed with pulmonary infection. The patient
was in good health in the past with no smoking and drinking habits, no
history of food and drug allergies, no history of living in a humid
environment, and no history of contacting with poultry and animals. His
occupation was a building worker and he had a history of second-hand
smoke exposure. Physical examination revealed body temperature was 38.3
℃, the pulse was 77 times per minute, the respiratory rate was 20 times
per minute, the blood pressure was 126/86 mmHg, and his body weight was
69 kg. Breath sounds were clear in both lungs, and no dry or wet rales
were heard. Lung CT was conducted again and revealed pneumonia and
scattered lung air sacs in both lungs, and local thickening of the
pleura on both sides. He still had fever after anti-infection therapy
with moxifloxacin, cefoperazone sodium and sulbactam sodium and
oseltamivir. The highest temperature was 39.8°C, and the routine
etiological screening was negative. The bronchoscopy was performed in
the third day and founded the both bronchi were unobstructed, and no new
creatures. Moderate amount of septate hyphae were founded by
immunofluorescence staining (fungi). Moderate amount of S.
apiospermum were founded with BAL culture and the NGS of BAL also
founded Scedosporium (sequence number 238), Scedosporiumboydii (sequence number 179). Treatment was performed with
voriconazole intravenously (400mg daily) for 10 days. This treatment
resulted into remission of the radiological findings and clinical
improvement. The laboratory findings including white blood cell count
(8.94×109·L-1), CRP (6.56
mg·L-1) and PCT (0.13ng·mL-1) were
all normal. TDM of voriconazole was 1.1μg·mL-1. He was
discharged from the hospital on the 12th day. Oral
voriconazole (400mg daily) was continued for 3 months, complete
remission of the pneumonia and improvement of the clinical situation was
received, and voriconazole was discontinued.