A 16-year-old girl had been undergoing intensive chemotherapy (ALL 2009) for Early T -cell precursor acute lymphoblastic leukemia (ETP). At 22:00 of the 26th day of induc-tion phase IA, she was found to have developed febrile neutropenia. After blood cul-tures were obtained, empirical therapy with ceftriaxone and amikacin was initiated, according to internal protocol. Clinical condition improved and she remained afebrile for 24 hours. The following day, at 04:00, she suddenly developed a cough with hemoptysis. At this time, fibrinogen was 167 mg/dL, and platelets 35000/uL. A chest X-ray showed thickening in the middle of the right lower zone, and a chest CT scan showed a nodule with central hypodense area (necrotic-colliquative evolution of the infiltrate). In spite of supplementation with platelets, red blood cells, plasma, fibrinogen, antithrombin, and activated factor VII, the patient's clinical condition worsened rapidly and the pulmonary hemorrhage became uncontrollable. She died at 12:00. Blood cultures yielded a strain of Pseudomonas aeruginosa, with reduced sensitivity to antibiotics. Aspergillosis is the most frequent infectious cause of massive pulmonary hemorrhage in pediatric leukemias, while bacterial pneumonia or TBC are by far less frequent. As-pergillus requires the presence of neutrophils to cause hemoptysis or cavitation, while bacteria (Gram-positive or -negative) can cause pulmonary necrosis also in patients with neutropenia.
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