. A 39-year-old male who underwent a haploidentical allogeneic hematopoietic stem cell…

. A 39-year-old male who underwent a haploidentical allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia 2 years ago is admitted to the ICU with acute hypoxic respiratory failure requiring supplemental oxygen through a highflow nasal cannula. His HSCT was complicated by graft-versus-host disease (GVHD) of the skin and gastrointestinal tract 6 weeks ago for which he was treated with pulse dose steroids. He was recovering from an upper respiratory tract infection caused by rhinovirus (nasopharyngeal swab PCR positive) 3 weeks ago when he started to experience

. A 39-year-old male who underwent a haploidentical allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia 2 years ago is admitted to the ICU with acute hypoxic respiratory failure requiring supplemental oxygen through a highflow nasal cannula. His HSCT was complicated by graft-versus-host disease (GVHD) of the skin and gastrointestinal tract 6 weeks ago for which he was treated with pulse dose steroids. He was recovering from an upper respiratory tract infection caused by rhinovirus (nasopharyngeal swab PCR positive) 3 weeks ago when he started to experience shortness of breath that progressively worsened. His WBC count was 4.5 cells/L with 80% neutrophils on admission. His creatinine was elevated at 2.1 mg/dL (baseline: 1 mg/dL). A CT scan of the chest without contrast revealed multifocal nodular opacities with right-sided predominance. Blood cultures, urine histoplasma antigen, serum cryptococcal antigen, and serum Aspergillus galactomannan were negative. His serum _1,3-d-glucan assay was positive. The patients sputum culture grew normal respiratory flora. He was started on intravenous vancomycin and piperacillintazobactam, but his respiratory status continued to decline eventually requiring intubation 2 days into his admission. Bronchoscopy was performed with bronchoalveolar lavage (BAL). Initial stains on the BAL fluid showed nonpigmented, septate hyphae branching at right angles. What is the NEXT step in the antimicrobial management of this patient? A. Add IV micafungin B. Add PO voriconazole C. Add IV voriconazole D. Start IV amphotericin B E. Continue current management and wait for final pathogen identification

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