Scope on the Scalp: A Case of Pulmonary Infiltrates and a Scalp Lesion in a Neutropenic Host

This is the authors' abstract. We don't add key points for this paper.

A 59-year-old male with a history of relapsed refractory chronic lymphocytic leukemia (CLL) presented to our institution with neutropenic fevers, a new parietal scalp skin lesion, and progressive pulmonary infiltrates. The patient was from Minnesota, where he worked on a hobby farm cleaning chicken coops, mowing grass, and working with soil and mulch. He had not travelled outside of Minnesota and denied sick contacts. Seven weeks before the index presentation, the patient had presented with neutropenic fever and pneumonia, shortly after starting combination chemotherapy with rituximab, etoposide phosphate, vincristine sulfate, cyclophosphamide, and doxorubicin. Work-up was remarkable for new pulmonary nodules and positive Aspergillus antigen from bronchoalveolar lavage (BAL). Additional workup included negative bacterial and fungal cultures from blood and a BAL specimen, negative serum and Aspergillus antigen, negative Pneumocystis carinii polymerase chain reaction and cryptococcal antigen from BAL, negative serological testing for endemic fungi, and a serum (1,3)-β-D-glucan of 124 pg/mL (reference range < 60 pg/mL). A diagnosis of probable invasive aspergillosis was made, and posaconazole was started. Follow-up computed tomography of the chest performed 4 weeks into therapy showed improvement of nodules. Around that time, he was also started on idelalisib for refractory CLL. To avoid the significant drug interactions between idelalisib and triazole therapy, posaconazole was switched to caspofungin.