A 63-year-old male underwent allogeneic stem cell transplant for chronic myelogenous leukemia 120 days
ago. He has had multiple episodes of acute graft-versus-host disease, for which he received multiple pulses
of corticosteroids and remains on maintenance cyclosporine. His absolute neutrophil count hovers
between 750 and 1000 cell/μL. He is receiving prophylactic doses of trimethoprim-sulfamethoxazole.
The patient developed a fever, patchy pulmonary infiltrates and hypoxia. He is intubated and undergoes
bronchoscopy. The micro lab reports that branched hyphae are present on wet mount of the BAL. No
pneumocystis was seen. PCR on the BAL is positive for CMV. Liposomal amphotericin (5 mg/kg/day) is
started.
Five days later, the lab reports that the BAL culture is growing Scedosporium apiospermum. PCR of
peripheral blood for CMV is undetectable. The patient is still febrile and the pulmonary status has
deteriorated.
At this point, you would recommend:
A. Raise the dose of liposome amphotericin B to 10 mg/kg
B. Add ganciclovir
C. Switch to fluconazole
D. Switch to voriconazole
E. Add caspofungin
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