What I would say is sub-therapeutic dosing of boriconazole resulting from a drug-drug interaction, because that's your question, would lead to ineffective treatments of the invasive fungal disease, choice A is correct. You're just hitting them over the head with drug-drug interaction. Yeah, this is a great question. Can you go back up to the stem? And I guess I'm feeling a little naive by asking this, but is it common that the antibiotic susceptibility testing would have been done on the first sample? Is that typical? Not in most places. I mean, in academic centers, it would be, most places around the country wouldn't have a clue about their susceptibilities in the beginning, but it's a reasonable thing to bring it up. I mean, academic center, you would absolutely have it. I guess this is maybe, so maybe a minor adjustment, but could you just say in the second part of the case, she came back and like, maybe she got another bronchoscopy and it was still aspergillus and the susceptibility showed that it was susceptible, but I don't know if that, maybe that makes it too easy, I'm not sure. Jackie, I think you lose the point. She made the discussion that it's rare for resistance to develop that quickly, because I thought that was an important point in your discussion. Yeah. True. Is it, is it, does it have face value to say that when she represents, they go back and test the original isolate and find that that original isolate was susceptible? Right. Yeah. Just because she got sicker. So they would want to. Got sicker. So they tested. Yeah. As opposed to testing upfront. That's a realistic thing that would happen. Yeah. And you can do that, right? Yeah. Yeah. That one you could do. Yeah. That that's a very, that'd be a realistic way to say it. Okay. So they, so when he got readmitted, they test the initial isolate and it turns out to be susceptible. Okay. Yeah. So they could still think like, Oh, did it develop resistance? And then your point about how that's on, correct. Why are you saying this? If it didn't change. This is sort of nitpicking, but like, as I was reading it, I felt like, like the suspension of disbelief that she's sick enough to be intubated in an ICU. Like from that, like, is she in respiratory failure from this image? I was, yes. Yeah. Yeah. I was, you know, kind of using the fevers and lethargy as a way to say that she was encephalopathic because she had a progressive fungal infection, but it is kind of, I guess, extreme to think that that made her so sick that she can protect her airway. But that was the. Do you want to let the, you want to let the EMTs have done that without any particular reason? EMTs intubate her on the scene for, for inability to protect her airway. And she has then, you know, admitted to the ICU. That sounds. Yes. Or Chi-Chi, could you give her some hemoptysis on the basis of her aspergillus and make the blood the reason for the concern about her airway being threatened? Although usually you'd see that more, I think, in like a chronic aspergilloma that has bled. Yeah. At a bunch of the NIH facilities, they use hemoptysis as a trigger to think about aspergillus just because of the angio-invasiveness and the lung infarction. Yeah, yeah, yeah. No, it is true. But like, you usually don't get massive, well, maybe I'm, I don't know, not. It's not, no, it's not massive hemoptysis that they get, but. So you wouldn't really intubate someone unless, or you would hope to not intubate someone with just a little bit of mucus. I think you're better off going with the EMTs. Just say the EMTs did it on the scene, sorry. They did, and now they wind up in your ICU because you didn't feel like extubating them. Yeah, I think the, I agree with Jackie. I think the potential problem that brings up is, if your question is what's the most likely explanation for this clinical presentation, that presentation was with Lethergy. And so the question then is what was causing the Lethergy? Is it a drug-drug interaction or something else? So the Lethergy, the whole time I was, I thought we were getting, you were going to make us interpret a lumbar puncture result or something like that. Yeah. Thankfully not. What about, maybe this is. The worsening of her CT scan, something like that? But if you take out the CT, you can make it sound worse. So take out the picture, keep the read, and make it sound worse in the read that she's had sort of really rapid progression of the CT findings with halo signs and sort of new nodules and make the CT sound bad, instead of saying most likely explanation for the clinical presentation, you could just say like worsening of the respiratory process or something. Or the worsening CT findings could be the, what's the most likely explanation for this worsening CT findings? Yeah. Okay. That all sounds good. Thank you. All right. Well, yeah, I guess just, I'll throw this, just since we're in the discussion mode, given the fact that Aspergillus has the ability to go to brain, did you throw in here that, you know, a CT of the brain shows a nodular lesion, and then that brings up the whole dissemination of Aspergillus. And then that even makes resistance versus drug interaction, maybe a better discussion. Just the lung. Yeah. You can do that. I mean, it's not unreasonable to scan the head and somebody who's presented with lethargy got intubated for airway and the head, there's a nodule it's, you know, et cetera. And then the educational point is it helps people understand the spectrum of Aspergillus being more than just lung and with brain is, I mean, it's only 5%, but it is a site where Aspergillus can go. Yeah. All right. So if you do that, you'll stick a little, you'll have to stick a little bit about that in your discussion. Okay. Thank you.

boriconazole dosing

invasive fungal disease treatment

antibiotic susceptibility testing

Aspergillus dissemination

hemoptysis symptom