A 13-year-old girl with a history of relapsed acute lymphoblastic leukemia (ALL) underwent an UCT 6 months ago. She is engrafted without evidence of GVHD and is no longer receiving immunosuppression. She presents to the emergency department with a fever of 40.1°C and tachypnea. Her saturations are 88% while breathing room air so she is placed on low flow oxygen via nasal cannula. On examination, she is in obvious distress with increased work of breathing and decreased breath sounds in the left lower lung base with rhonchi. A chest radiograph is obtained which shows a large opacity in the left lower lung field with air-bronchograms and trace pleural effusion. Question: What vaccine-preventable infection should be considered? Answer:\nStreptococcus pneumoniae.
A 2-year-old boy with a history of severe aplastic anemia (SAA) is undergoing pre-transplant infectious surveillance in anticipation of a myeloablative BMT. He initially presented with autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) following a viral illness and was treated for AIHA and ITP with intravenous IVIG, rituximab, and steroids. Due to the presence of autoimmune hepatitis, he was also being treated with azathioprine. His cytopenias progressed despite therapy over the next several months. He eventually developed pancytopenia leading to his diagnosis of SAA after BM biopsy showed cellularity of <5% (normal for age 90–95%). Pre-transplant infectious disease surveillance was unremarkable except for an abnormal chest CT. A 2.1 × 1.5 cm round subpleural mass was noted in the left lower lobe with ground-glass attenuation in the left perihilar region. On physical examination, the patient was afebrile, breathing comfortably in room air with a normal respiratory rate and oxygen saturation. Question: How should this patient be managed? Answer: HCT should be delayed while diagnostic procedures can be performed (bronchoscopy with bronchoalveolar lavage) and the patient receives applicable treatment for possible fungal pneumonia.