1239

Abstract

cause of morbidity and mortality in immunocompromised children with highest incidence found in children with Wiskott-Aldrich syndrome and a very low incidence of 0.6% in children with ALL. Aspergillus fumigatus is the most common cause of IA followed by aspergillus flavus, aspergillus niger, aspergillus terreus. Clinical practice guidelines of the Infectious disease society of America does not recommend empirical therapy in shorter duration of neutropenia <10days unless there are findings of invasive fungal infections. Our patient presented with hyperleukocytosis and likely had dysfunctional neutrophil function thus predisposing him to IA. He also progressed to absolute neutropenia in rapid fashion within 3days of initiation of chemotherapy. The most significant risk factor contributing to his development of IA may have been his home environment. The family lived and worked in Avondale Pennsylvania, a suburb of Philadelphia in chester County with close proximity to Kennet Square and its large mushroom farming industry. Kennet Square is noted as "The Mushroom Capital of the World" supplying over 51% of the nation's mushroom crop. Mushrooms as with other fungi, thrive in warm moist dark environment and are frequently fertilized with a soil/ manure compost that is frequently rotated by heavy equipment. This compost rotation releases spores into the air that are harmless when inhaled by immunocompetent individuals. Our patient living in this endemic area was likely exposed to high spore content of pathogenic Aspergillus species environmentally and so rapidly developed brain abscess when chemotherapy was initiated. Our case is unique as he had very rapid onset of CNS aspergillosis, with history of agricultural exposure in the setting of Pre B cell ALL. Given our hospital's geographic location, questions remain whether consideration should be given to initiate empirical antifungal therapy at treatment doses with initiation of chemotherapy.