S Methylprednisolone
Aspergillus fumigatus infection and pulmonary aspergillosis leading to constrictive Aspergillus pericarditis: case reportA 3-year-old girl developed Aspergillus fumigatus infection and pulmonary aspergillosis leading to constrictive Aspergillus pericarditis following treatment with methylprednisolone for autoimmune-mediated gastric outlet obstruction.The girl, who was diagnosed with homozygous X-linked chronic granulomatous disease, had been receiving treatment with interferon γ-1b. She was admitted to the emergency service with shortness of breath and fever. Her medical history was significant for autoimmune-mediated gastric outlet obstruction, for which she had been receiving treatment with oral methylprednisolone 20mg daily; however, 1 month prior to the current admission, her methylprednisolone had been stopped. On admission, physical examination showed fever, tachypnoea, tachycardia, narrow pulse pressure and tender hepatomegaly and distended neck veins. She was in New York Heart Association (NYHA) class II-III. Additionally, peripheral oxygen saturation was found to be 87% in ambient air. A chest X-ray showed bilateral pneumonic infiltrations. Laboratory findings revealed anaemia, leucocytosis and elevated CRP level. Polymerase chain reaction was positive for coronavirus of an unknown aetiology. Serological assay of galactomannan was positive. Contrast-enhanced chest CT showed bilateral diffuse lung infiltrates along with alveolar condensation. Additionally, pericardial thickening with abscess formations at the diaphragmatic surface of the heart and around the right atrium was observed. Constrictive Aspergillus pericarditis was considered. Subsequently, a diagnosis of congestive heart failure and pneumonia was made, and she was admitted to the hospital.The girl was treated with empirical wide-spectrum antibiotherapy with linezolid, meropenem, cotrimoxazole [trimethoprim/ sulfamethoxazole], ganciclovir [Cymevene] and caspofungin in addition to an anti-congestive regimen. Trans-thoracic echocardiography demonstrated no pericardial effusion; however, hyperechogenic formations at the apex and undersurface of the heart with approximately 4-6mm of pericardial thickening were observed. Left ventricular ejection fraction was found to be 65%. Additionally, tethering of the right ventricular free wall with interventricular septal bouncing was noted. A pulsed-wave doppler recording through the apical window at the tricuspid level showed inspiratory decrease and expiratory increase in early inflow velocity along with E/A >1. Therefore, diastolic dysfunction was considered. During the hospitalisation stay, her interferon-γ-1b therapy was continued, and she intermittently received granulocyte colony stimulating factors. Subsequently, she underwent a sternotomy and the pericardium was dissected free from one phrenic nerve to the other until the right ventricle was completely clear and the left ventricle was partially liberated. Additionally, several islands of thick, loculated, firm-walled, fibrinous...
