[Acute respiratory failure in a 16-yr-old girl with alveolar soft part sarcoma]

Intensive treatment in oncology often leads to severe complications, including infection and coagulation disturbances. Among the most serious are fungal infections which are often life-threatening, and difficult to recognize and treat. We present a patient with severe pneumonia and pleural effusion, that developed during treatment of a soft tissue sarcoma with pulmonary metastases.

A 16-year-old girl was admitted to the ITU because of marked dyspnoea, bilateral pneumonia and pleural effusion. She was intubated and placed on a ventilator, and bilateral pleural drains were inserted. She also required vigorous inotropic support (dopamine + noradrenaline). CRP was 12.5-19.8 mg dL(-1) and procalcitonin was below 1 ng mL(-1)). Lung metastases and tuberculosis were excluded and fungal infection suspected. Aspergillus DNA was detected in bronchoalveolar lavage, and in blood serum (PCR). Amphotericin B and voriconazole were instituted, but without evident success, The girl was severely distressed, required mechanical ventilation with an F1O2 of 0.6, while her CRP increased to 28.4 mg dL(-1). The amphotericin was stopped and replaced with caspofungin, resulting in rapid improvement in her clinical status. The girl was extubated after 21 days of ventilation, however due to a very severe opioid withdrawal syndrome with extreme agitation, she was re-intubated. After a further two weeks on methadone and sedatives, she was extubated again, this time successfully, One month later she was discharged from the hospital, still on oral voriconazole.

Fungal infection should always be considered in immunocompromised patients with clinical signs of systemic infection. Recognition and treatment of pulmonary aspergillosis is difficult and may require multi drug therapy.