MED-11. Disseminated aspergillosis in a patient with two different types of cancer.

A 73-year-old white male presented to the ED with high fever, confusion, agitation, and weight loss. He has a history of HTN, CHF, multiple sclerosis, dementia, and prostate cancer status post brachytherapy. He had been on prophylactic macrodantin for recurrent UTI since the prostatic procedure. He was febrile but WBC remained normal. Cefepime was started for urine culture positive for Pseudomonas Aeruginosa. The patient continued to have low grade fever despite treatment, but blood cultures remained negative and transesophageal echocardiogram was negative for endocarditis. The patient also had more than 6 months history of ulceration on the right heel progressed to a black eschar but without evidence of osteomyelitis. Although the patient was discharged to a nursing home based on clinical improvement, he came back to the ED 1 week later with fever 39.5, confusion, agitation and vomiting. WBC was again normal (8,400) but neutrophile count was high 86.5%. Blood cultures from the previous admission came back after 2 weeks to show Aspergillus fumigatus and Caspofungin IV was started. CT imaging to look for the source of aspergillosis showed inflammatory mucosal thickening of ethmoidal air cells bilaterally, 1 cm low density lesion in right lobe of the liver, and multiple nodules in right lung. Although soft tissue biopsy of the heel lesion was negative for Aspergillus, it showed a nodular ulcerated malignant melanoma, extending more than 3 mm in depth. The patient tolerated Caspofungin well and remained afebrile after 3 days of treatment. Repeated blood cultures were negative. Aspergillus cultured directly from the bloodstream is a rare clinical entity. This case is even more remarkable in that no clear primary source of invasive aspergillus infection was found. The nodules were thought to be aspergillomas, but further work up to differentiate them from metastases was withheld, as the family made the patient DNR and refused the lung biopsy.

Diana Wagner, MD, and Nayef El-Daher, MD, PhD. Department of Medicine, Unity Health System, Rochester, NY.