A 76-year-old patient was admitted to the intensive care unit (ICU) with respiratory distress. He was of Moroccan descent and had recently been diagnosed with a diffuse large cell B-cell non-Hodgkin lymphoma. He received his second chemotherapy (R-CHOP) 20 days prior to this admission, both times developing profound neutropenia (maximum decline of neutrophilic granulocytes to 0.15 x 109/l). Physical examination showed a tachypnoeic patient using his accessory respiratory muscles to breathe, his respiratory rate was 25/minute, SatO2 95% with 12 litres/ minute oxygen, blood pressure of 140/60 mmHg, heart rate of 95/minute and a tympanic temperature of 35.4 °C. On auscultation of the lungs we noticed some crackles and mild bronchospasm. Blood gas analysis showed metabolic compensated respiratory acidosis (pH 7.36, pCO2 9.2 kPa, HCO3- 39.1 mmol/l, base excess 12.7 mmol/l) and hypoxia (pO2 6.9 kPa, SatO2 83%). CT imaging of the chest showed diffuse bilateral lung consolidation and ground glass opacity.
A bronchoscopy with bronchoalveolar lavage (BAL) was done prior to ICU admission. Due to the immunocompromised status of this patient, broad-spectrum empirical therapy had been commenced, with amoxicillin, ceftazidime, voriconazole and co-trimoxazole. Cultures of the BAL liquid showed high numbers of yeast strings, as shown in figure 1.
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