An immunocompromised patient on prolonged high-dose corticosteroids develops fever unresponsive to antibiotics and a new pulmonary infiltrate. Bronchoalveolar lavage (BAL) galactomannan index is 2.8. What is the most likely diagnosis and the recommended first-line treatment?
- A Pneumocystis jirovecii pneumonia (PCP); IV co-trimoxazole
- B Pulmonary mucormycosis; liposomal amphotericin B
- C Candida pneumonia; IV fluconazole
- D Invasive pulmonary aspergillosis (IPA); voriconazole IV/oral ✓
Explanation
A BAL galactomannan (GM) index ≥1.0 is diagnostic for invasive pulmonary aspergillosis (IPA) per EORTC/MSG revised criteria. Galactomannan is a polysaccharide component of the Aspergillus cell wall released during hyphal growth; BAL GM has superior sensitivity (90%) over serum GM for IPA. Voriconazole IV or oral is the first-line treatment for IPA (superior to amphotericin B in a landmark RCT). Isavuconazole is a non-inferior alternative. Mucormycosis does NOT produce galactomannan (hence negative GM is used to distinguish mucormycosis from aspergillosis). PCP is diagnosed by silver stain/IFT on BAL.
Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
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