Figure 1 Perfusion lung Scan: Multiple segmental perfusion defects compatible with the presence of pulmonary thromboembolism. She started receiving warfarin aiming at an international normalized ratio (INR) of 3 to 4. The measurement of serum levels of antiphospholipid antibodies was repeated on the occasion of deciding about immunosuppressive therapy. Assuming the presence of multiple deep vein thrombosis, pulmonary thromboembolism, progressive pulmonary hypertension and positive antiphospholipid antibodies, prednisolone (60 mg/day) and azathioprine (50 mg twice a Inhibitors,research,lifescience,medical day) started hoping

to prevent more catastrophic events. She was on treatment with warfarine, azathioprine and prednisolon for 12 months, after which corticosteroid was tapered and discontinued because of hyperglycemia. The patient then continued to receive azathioprine, warfarine and oral glucose lowering agents, and felt well until recently. Last year, she suffered from several attacks of paroxsismal atrial tachycardia; therefore, she was admitted to the hospital. Because Inhibitors,research,lifescience,medical of poor compliance, glycemic control was poor. There was

no history of any serious infection during the last four years, and serial assays for complete blood count was normal. At the last presentation, the laboratory findings were as follows: urea; 55 mg/dl, creatinine; 1.1 mg/dl, glucose; 350 mg/dl, prothromobine time; 25 seconds, INR; 4.4, WBC; 10000/μl/with 75% segment and 20% lymphocyte. Microscopic Inhibitors,research,lifescience,medical examination of urine showed: WBC; 4-5/high power field, RBC; 4-5/high power field and negative for bacteria. Dipstick urine tests showed positive for protein and glucose. Blood O2 saturation was 93%. Chest radiography demonstrated bilateral infiltrations Inhibitors,research,lifescience,medical and cavitations (figure 2). Figure 2 Chest radiography demonstrating two lung cavitations (arrows) and an enlarged heart.  Chest computer tomography (CT) scan showed Inhibitors,research,lifescience,medical cavity in the medial segment of left lower lobe and a cavity in the apical segment of right lower lobe (figure 3). Blood culture for bacterial infections, and sputum

smear for acid fast bacillus (AFB) were negative. Fungal stain showed elements of sporotricosis. The patient was GBA3 in poor condition, and semi invasive or invasive procedures were not performed. Liposomal amphotricine was not available; therefore, amphotricin B started empirically for possible invasive fungal infection of lung, and azathioprine was discontinued. Blood glucose remained in an acceptable range by regular insulin therapy. At the end of the first week, the patient continued to be much better, and blood sugar, urea and creatinine were remained in acceptable range. After two weeks of treatment, the patient was discharged and amphotricine was replaced by oral itraconasol. Because of recurrent paroxysmal atrial tachycardia, the patient was readmitted on day 7 after discharge. At this admission, the patient succumbed to severe dyspnea, this website increased urea (192 mg/dl) and creatinine (4.