A three-year-old female presented with a one-week history of diarrhea and vomiting. She was pale with bruising, petechie, abdominal distension, and a palpable spleen. Bone marrowaspirate biopsy revealed elevated monocytes (23.8%) and blasts (20.2%). AML (inversion 16, trisomy 8, CNS3 positive) was diagnosed and the patient received chemotherapyaccording to protocol AML0531. She received fluconazole prophylaxis for her first cycle of chemo- therapy (intrathecal [IT] cytarabine, followed by intravenous [IV] cytarabine, etoposide, and daunorubicin) that was briefly changed to caspofungin during a period of febrile neutropenia. Chemo- therapy and antifungal prophylaxis were the same for cycle two, which was complicated by febrile neutropenia on day 10, and piperacillin-tazobactam was initiated. Due to persistent fever, vancomycin was added on day 19 and fluconazole prophylaxis was changed to amphotericin B on day 22. Chest computed tomography (CT) on day 26 revealed bilateral lung nodules with a “buds on a tree” pattern suggestive of fungal disease (Fig. 1A and B). Ampho- tericin B was switched to voriconazole. Urine cultures obtained on day 26 and a broncho-alveolar lavage performed on day 27 were both positive for C. krusei. Voriconazole was continued with ther- apeutic drug monitoring (TDM) target 1e5 mg/L (see Fig. 2).
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