Our patient is a 17-year-old male who was diagnosed with FA at 13 years of age when he presented with bruising, fatigue, and pancytopenia. Physical stigmata of FA included hypopigmented skin lesions, short stature (below 3rd percentile), micrognathia, and hearing loss. Diepoxybutane (DEB) testing revealed increased chromosomal breakage. FA complementation grouping was not performed. Two years later, at the age of 15, the patient experienced bruising, epistaxis, and fatigue and was diagnosed with T-cell ALL. T-cell ALL markers included CD1+, TdT+, CD2+, CD3+, CD4+, CD5+, CD7+ and CD 8+; however, cytogenetic markers were not available. He was treated with standard 4-drug induction therapy and received vincristine, prednisone, PEG-asparaginase, and 2/4 doses of daunorubicin at an outlying hospital as per Children's Oncology Group Protocol AALL0434. His clinical course was complicated by prolonged neutropenia (ANC < 500) lasting greater than 2 months and bacterial sepsis. He developed grade IV vincristine-related neuropathy by the Balis scale grading system. Within weeks of initiating vincristine dosed at 1.5 mg/m2/dose, the patient became immobile and wheel-chair bound. He remained immobile for 12 months after vincristine therapy was terminated. He received cytarabine dosed at 125 mg/m2/dose via continuous infusion for 3 consecutive days after which the patient developed fever and profound myelosuppression. Because of new onset respiratory symptoms, a chest X-ray was obtained that revealed a right middle lobe infiltrate. CT scan of the chest showed a cavitary lesion consistent with fungal infection and he was placed on voriconazole.
 Five months after the diagnosis of T-cell ALL, the patient was referred to our center for evaluation for bone marrow transplant. Pretransplant bone marrow aspiration and cerebral spinal fluid showed no evidence of malignant cells. MRI of the brain revealed a left parietooccipital abscess and CT scan of the chest showed enlargement of the right middle lobe cavitary lesion and small bilateral nodules consistent with fungal infection (Figures 1 and 2). CT scan of abdomen and pelvis showed multiple soft tissue abscesses of the upper thighs which were drained and found to be sterile. Antifungal therapy was initiated. The patient underwent complete surgical resection of the left parietooccipital lesion and partial resection of the lung lesion. Hyphae consistent with Aspergillus were identified on histopathologic studies from lung and brain lesions. Aspergillus species was cultured from brain tissue.
 Hematologic remission was sustained with modified dosing of cytarabine and intrathecal methotrexate. Our patient received an approximately 50% dose reduction of cytarabine (60 mg/m2/dose) from the initial 125 mg/m2/dose he had received previously. Cytarabine was administered over 15 minutes for 3 consecutive days instead of a 24 hour infusion in order to reduce cell exposure to chemotherapy. Reduced dose of intrathecal methotrexate (50% reduction of age-based dosing) was given followed by leucovorin rescue. Twenty-four hours after the completion of chemotherapy, filgrastim (5 mcg/kg) was started. The patient tolerated these agents well, neutrophils recovered within 12 days, and there was no progression of aspergillosis or leukemia.
 One month after partial pulmonary aspergilloma resection and 4 months after complete parietooccipital aspergilloma resection, the patient underwent a 10/10 matched unrelated donor bone marrow transplant using a modified reduced-intensity preparative regimen. The patient received voriconazole 200 mg orally daily and micafungin 100 mg IV daily for 4 months prior to BMT. Galactomanman levels remained negative, and radiographic studies of the brain and chest showed improvement and no new fungal foci. The BMT preparative regimen included fludarabine 140 mg/m2, cyclophosphamide 40 mg/kg, thymoglobulin 6 mg/kg (total doses), and 450 cGy TBI. 3 x 106 CD34+ stems cells were obtained from the donor's bone marrow. T-cell depletion was achieved using rabbit ATG. GVHD prophylaxis included tacrolimus and mycophenolate. Neutrophils engrafted by day 14. There were no acute transplant-related complications. He received voriconazole for 6 months after BMT. At the time of this writing, 30 months after BMT the patient is without evidence of recurrent aspergillosis or leukemia, and continues to do well.