1. ENT Case Serviço de Otorrinolaringologia Hospital de Clinicas de Porto Alegre R3 Raphaella Migliavacca MD R2 Suzie Kang MD Dr Otavio Piltcher MD

2. ELS, female, 12 years old, Acute Myeloid Leukemia M6 Chemotherapy – AML 2002 Protocol since Oct 2008 First consolidation Dec 2008 Second consolidation Jan 2009 Complete remission after the second consolidation, 4% blasts Admission in Jan 19 th, 2009, with high fever and neutropenia

3. - Cefepime until Jan 31 - Vancomycin since Jan 30 - Pipe/Tazo since Jan 31 - Fluconazole since Feb 1 - Imipenem since Feb 3 - Amphotericin B since Feb 7 - Voriconazole since Feb 10 Clinical treatments

4. All blood cultures negative Persistent Fever  Chest and Sinuses CT ENT evaluation in Feb 10 th Hb7,7 Leukocytes880 Platelets1700

5. Feb 9 th -Hyperdense soft tissue in left esphenoid, etmoidal cells and frontal

6. Feb 9 th -Mucoperiostal thickening of the left maxilary sinus Chest CT Bilateral pleural effusion 1,5 cm cavitation in left lower lobe

7. These videos can be best viewed These videos can be best viewed from the clinical video library collection. Nasal endoscopy (Feb 10 th )

8. Surgery (Feb 10 th )

9. Nasal biopsy: – Middle turbinate with suppurative acute inflammatory findings and angioinvasive fungal structures, compatible with aspergillosis – Other specimens: respiratory mucosa with edema and vascular congestion Culture: – Aspergillus flavus

10. Revisional Surgery (Feb 16 th )

11. Nasal biopsy: - Necrosis and hemorrhage in mucosa - Negative for fungi

12. April 6 th: Nasal Endoscopy

13. - Follow 12 weeks treatment with Voriconazole (Feb 2009 until May 2009) Third consolidation chemotherapy in March 2009 Complete remission (July 24 th 2009 review)