Endgames Case Review

Pulmonary nodules in a man with a history of bone marrow transplantation

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1805 (Published 28 April 2016) Cite this as: BMJ 2016;353:i1805
  1. Neil Mendoza, infectious disease fellow1,
  2. Paritosh Prasad, director of transplant and immunocompromised infectious disease1
  1. 1Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York 14642, USA
  1. Correspondence to: P Prasad paritosh_prasad{at}urmc.rochester.edu

Our patient was diagnosed as having Philadelphia chromosome positive pre-B acute lymphoblastic leukaemia with lymphoid blast crisis (blast crisis of chronic myeloid leukaemia) in 2011. Treatment with two cycles of hyper-CVAD (alternating cyclophosphamide+vincristine+doxorubicin+dexamethasone with methotrexate+cytarabine) plus dasatinib resulted in a negative bone marrow biopsy (remission). He had an allogeneic peripheral blood stem cell transplant from a 10/10 HLA matched unrelated donor in 2013. Conditioning was with cyclophosphamide and 1200 cGy total body irradiation. Graft versus host disease prophylaxis was with tacrolimus and methotrexate. Dasatinib was continued after his transplant. In late 2013 he developed relapsed acute lymphoblastic leukaemia. He was treated with fludarabine, cytarabine, and granulocyte colony stimulating factor. Bone marrow biopsy after chemotherapy showed persistent acute lymphoblastic leukaemia, even after he was switched to ponatinib and dexamethasone. Daunorubicin and vincristine were added for one cycle but were discontinued when he was admitted to hospital for cellulitis. Bone marrow biopsy was negative but one three months later showed recurrent acute B lymphoblastic leukaemia. Remission occurred after re-induction with clofarabine in the autumn of 2014; this was followed by 6-mercaptopurine, methotrexate, vincristine, and prednisone maintenance therapy.

He had no history of graft versus host disease and was not taking additional immunosuppressants. After his transplant, both Aspergillus versicolor and A fumigatus were isolated from his sputum, but he had no other evidence of invasive fungal infection. Pneumocystis jirovecii nucleic acid was isolated from his sputum but was thought to represent colonisation rather than infection. He had no evidence of tuberculosis at any time. His prophylactic antimicrobial regimen did not include an antifungal drug (voriconazole was discontinued in 2015 owing to raised liver transaminases) but did include dapsone and aciclovir. About three weeks before admission, pus was noted around his peripherally inserted central catheter (PICC). There was no cellulitis and his PICC was …

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