Correct!
5. Begin fluconazole
The small budding yeast is most consistent with Histoplasma capsulatum (2). Fungal blood culture, bone marrow tissue culture, and urinary antigen later confirmed Histoplasma capsulatum. In Arizona where Valley Fever is endemic a Coccidioides serology is indicated. The patient is gravely ill and when faced with a life-threatening illness, most infectious disease specialists begin amphotericin B rather than other antifungals because of presumed superior efficacy (2).
Amphotericin B was initiated on hospital day 3. Multisystem organ dysfunction ensued by day 5 necessitating mechanical ventilation and continuous renal replacement therapy. The patient continued to be pancytopenic and other areas of the bone marrow biopsy showed hematophagocytosis (Figure 5) and a diagnosis of hemophagocytic lymphohistiocytosis (HLH) was made.
Figure 5. Bone marrow biopsy showing hematophagocytosis (Panels A & B) and intracellular yeast (Panel B).
Regarding hemophagocytic lymphohistiocytosis (HLH) which of the following is indicated?