Disseminated Invasive Aspergillosis in a Patient with Chronic Lymphocytic Leukemia

A 43-year-old male with relapsed chronic lymphocytic leukemia (CLL) was admitted for hypercalcemia.He had a prior history of B-cell non-Hodgkin lymphoma treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and rituximab, etoposide, methylprednisolone, cytarabine, and cisplatin (R-ESHAP), followed by autologous stem cell transplantation.Due to disease progression, the patient was diagnosed with CLL and started on rituximab-bendamustine (R-BENDA).On day 3 of chemotherapy, he developed neutropenia (absolute neutrophil count 820/L).By day 9, he became febrile and hypotensive, and broad-spectrum antibiotics were initiated.Chest CT showed patchy consolidations in the right upper and middle lung zones (Figure 1), raising suspicion for fungal infection.Antifungal therapy with voriconazole was initiated and later switched to liposomal amphotericin B due to QT prolongation.Initial cranial MRI was unremarkable; however, the patient developed progressive confusion and ataxia, prompting repeat imaging on day 17 demonstrated new ring-enhancing lesions in both cerebellar hemispheres, suggestive of fungal abscesses (Figure 2).Bronchoscopy revealed widespread fungal plaques in the central airways (Figure 3).Bronchoalveolar lavage culture confirmed Aspergillus fumigatus, and galactomannan index was markedly elevated (index value 10.4).Despite targeted antifungal therapy, the patient's condition worsened and he succumbed to septic shock in the intensive care unit.Patients with CLL are prone to neutropenia from marrow infiltration and chemotherapy, increasing susceptibility to invasive aspergillosis.Recent reports also highlight the increased incidence of invasive aspergillosis in CLL patients receiving Bruton tyrosine kinase inhibitors such as ibrutinib.While Aspergillus species are harmless in healthy hosts, they can cause severe infections in immunocompromised patients [1,2].