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.