Risk Factors

A 60 year old patient with diabetes, COPD, AML s/p chemotherapy with ongoing neutropenia, history of cholecystectomy, and inguinal hernia presents with a COPD exacerbation. He is treated with nebulizers, high dose steroids, and broad spectrum antibiotics. He slowly improves, but then develops a small bowel obstruction. The surgeons recommend nonoperative management; an NG tube is placed. Because he is slow to improve, a PICC line is ordered and total parenteral nutrition is started. On hospital day 7, he becomes febrile, hypotensive, and tachycardic. He complains of chills and blurry vision. His antibiotics are broadened to cover extended spectrum beta lactamase organisms. He continues to deteriorate clinically.

Fundoscopic exam is shown below:

Challenge: What are you worried about?

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