The patient is treated with predinisone, 40mg/d, azithromycin, ceftriaxone, and oseltamivir for presumed influenza infection. On hospital day 3, her symptoms of wheezing worsen, and she receives increased methlyprednisolone, 60 mg q8h. Urine culture reveals yeast. Her respiratory symptoms continue to worsen with wheezing, increased sputum production, and hypoxemia (pulse oxygen saturation of 85% on 40% fraction of inspired oxygen). Her WBC count initially was 4,600 cells/μL but continues to increase as high as 23,300 cell/μL with persistent lymphopenia < 1,500/μL. Hospital day 11 reveals thick, yellow-green sputum, and cultures grew mold. The patient requires intubation by hospital day 17. Chest radiography reveals worsening interstitial and alveolar infiltrates (Fig 1
). She is febrile to 38.8°C. Her pulmonary infiltrates continue to worsen, and a new heart murmur develops. By hospital day 20, she is hypotensive, with a WBC count of 2,100 cells/μL and worsening mental status. By the evening, she no longer has evidence of pupillary, corneal, or gag reflexes. A CT of her head reveals multiple (n = 25) hypodense lesions in the supratentorial and infratentorial brain parenchyma (Fig 2
). The family wishes to withdraw care, and the patient dies on hospital day 25. An autopsy is performed.