Correct!
4. 1 and 3
Blood cultures are a standard of care for febrile immunocompromised patients. They can provide additional evidence to separate a contaminant or colonizing organism from an invasive organism, especially when the BAL cultures show multiple organisms. Another source of information can be quantitative cultures.
The patient had a positive blood culture E. coli and Enterococcus faecium. Unfortunately, the E.coli in both the BAL and blood was an extended-spectrum beta-lactamase (+ESBL) organism and ampicillin would likely be ineffective. Usually, a macrolide (azithromycin, erythromycin, clarithromycin, etc.) is the drug of choice for Legionella although other drugs such as the tetracyclines and flouroquinolones can be used.
The patient also had a positive blood culture for adenovirus. Quantitative PCR of the blood showed >2,000,000 copies/ml. Cidofovir is an injectable antiviral medication. It suppresses viral replication by selective inhibition of viral DNA polymerase. Cidofovir is the most commonly prescribed drug for adenovirus infection although no controlled trials have been performed (2).
At about this time, the patient was noted to have increasing alanine aminotransferase (ALT) and aspartate aminotransferase (AST), both rising to >5000 units/L. Hepatology was consulted and a liver biopsy was performed (Figure 3).
Figure 3. H & E stains of liver biopsy.
What is the likely cause of the abnormal liver enzymes?