CASE DESCRIPTION

JP is a 52-year-old man with a history of mixed histiocytic–lymphocytic lymphoma of the stomach, diagnosed in 1975. He was treated with surgical excision and postoperative radiotherapy and had no clinical evidence of recurrence five years later. In the spring of 1980, four months prior to the present admission, he developed fatigue and pallor. Hematologic evaluation resulted in the diagnosis of acute myelogenous leukemia.

On the day of admission, the patient developed fever and chills. Physical examination was remarkable only for a temperature of 39°C and general pallor. Laboratory evaluation revealed a hemoglobin level of 8.5 g per deciliter, a white blood cell count of 35,000 per cubic centimeter with 35% myeloblasts, and a platelet count of 108,000 per cubic centimeter. Tobramycin and ticarcillin were administered. Subsequently, two blood cultures were positive for Staphylococcus epidermidis; oxacillin was also administered. On the second hospital day, antileukemic therapy with cytosine arabinoside and daunorubicin was begun. Cotrimoxazole was given prophylactically.

After an initial defervescence, the patient developed severe dysphagia and recurrent fever. Barium swallow suggested the presence of esophageal ulcers, consistent with, but not diagnostic of, Candida esophagitis. At that time, all other clinical and laboratory data failed to disclose a source of infection. The patient's white blood cell count during this episode was 6,000 per cubic centimeter with 8% polymorphonuclear leukocytes, 50% lymphocytes, and 40% blast forms.