This is a case of a 65-year-old Filipino man with multiple myeloma, post-autologous stem cell transplant (2019). He was referred to the urgent care center (UCC) of Memorial Sloan Kettering Cancer Center (MSK) after a telehealth visit with his primary oncologist where he admitted to having persistent cough, intermittent fevers and shortness of breath for the past 2 months. He had no recent travel history.

At the UCC, he presented with dyspnea (SpO2 89-94%) and neutropenic fever (Tmax 101.3 F). A nasopharyngeal swab was collected at the time of presentation and tested positive by nucleic acid amplification test (NAAT) for SARS-CoV-2. Urine was also collected for a Streptococcal group A antigen test and returned positive. 

At that time, he was admitted to MSK, transferred to pulmonary service and started on piperacillin/tazobactam, azithromycin, remdesivir and dexamethasone. While admitted, a chest X-ray was performed and revealed a new cavitary lesion of the left lung. A tissue specimen was sent to the microbiology laboratory for acid-fast bacilli, fungal and bacterial culture. Concomitantly, a serum specimen was sent to an outside laboratory for a beta-D-glucans detection assay. The culture was positive for yeast, 3 days after collection, and the beta-D-glucans returned as positive. Micafungin was started, and the infectious disease service was consulted for further recommendations. Per consulting ID physician, micafungin was discontinued in favor of fluconazole. In addition, piperacillin/tazobactam and azithromycin were discontinued in favor of ceftriaxone and sulfamethoxazole/trimethoprim. 

Over the next 3 days, the patient’s oxygen saturation continued to improve, and he was no longer febrile. Given the patient’s neutropenia, positive beta-D-glucans and respiratory culture results, a lumbar puncture was performed to rule out meningitis. In the microbiology laboratory, the CSF specimen was set up for acid-fast bacilli, mycology and bacterial culture. Additionally, a NAAT was performed.

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Author Information

Ashton Creasy-Marrazzo, Ph.D., Memorial Sloan Kettering Cancer Center

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