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Journal of Clinical Oncology, Vol 22, No 19 (October 1), 2004: pp. 4022-4023 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.12.041
Medical Problems in Patients With MalignancyCASE 3. Ulcerating Cytomegalovirus Bronchitis in a Patient With Relapsed Non-Hodgkin's LymphomaMedical Oncology Department, St Vincent’s University Hospital, Dublin, Ireland A 47-year-old man who was undergoing alemtuzumab (Campath; ILEX Pharmaceuticals, San Antonio, TX) therapy for multiple relapsed follicular non-Hodgkin's lymphoma presented with severe heartburn, odynophagia, oral mucositis, and dry cough. His neutrophil count was 1.0 x 109/L. He had been receiving ciprofloxacin, cotrimoxazole, and valacyclovir prophylaxis. He was treated with proton pump inhibition and intravenous (IV) fluconazole for suspected esophageal candidiasis. He became febrile in hospital and IV acyclovir was added. Subsequent esophagogastroduodenoscopy showed grade 3 esophagitis with longitudinal ulcers. Thrombocytopenia precluded biopsy. Imaging showed an infiltrate in the right lung base, together with bilateral pleural effusions. Fiberoptic bronchoscopy revealed inflamed airways and multiple necrotic ulcers with thick exudates (Figs 1 and 2). Bronchial washings were positive for cytomegalovirus (CMV) by polymerase chain reaction. CMV antigenemia was also demonstrated. Treatment with IV gancyclovir 5 mg/kg twice daily and immunoglobulin (Flebogamma; Instituto Grifolf, Barcelona, Spain) was instituted, and his symptoms resolved. Alemtuzamab treatment was reinstituted, together with oral valgancyclovir as CMV prophylaxis.
CMV causes a variety of infections in immunocompromised patients following transplantation, or in the context of AIDS or immunosuppressive anticancer therapy. Bronchiolitis obliterans can complicate CMV infection in patients who undergo marrow or organ transplantation.1 CMV pneumonia is a rare complication of chemotherapy for solid tumors.2 In an autopsy series of patients who had died following marrow transplant, Yokoi et al3 reported cases with denuding of respiratory epithelium, mural edema, and an inflammation. Several of these patients had CMV infection. There are no distinguishing diagnostic radiologic features of pulmonary CMV infection.4 A ground-glass radiologic appearance is reported.5 Evaluation should include bronchoscopy with lavage. Successful treatment and prophylaxis of CMV infection is possible. IV gancyclovir with immunoglobulin is the standard treatment, with a lower dose given orally as prophylaxis.6 Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Fend F, Prior C, Margreiter R, et al: Cytomegalovirus pneumonitis in heart-lung transplant recipients: Histology and clinicopathologic considerations. Hum Pathol 2:918-926, 1990
2. Breathnach O, Donnellan P, Collins D, et al: Cytomegalovirus pneumonia in a patient with breast cancer on chemotherapy: Case report and review of literature. Ann Oncol 10:461-465, 1999 3. Yokoi T, Hirabayashi N, Ito M, et al: Broncho-bronchiolitis obliterans as a complication of bone marrow transplantation: A clinicopathological study of eight autopsy cases. Nagoya BMT Group. Virchows Arch 431:275-282, 1997[CrossRef][Medline]
4. Shreeniwas R, Schulman LL, Berkmen YM, et al: Opportunistic bronchopulmonary infections after lung transplantation: Clinical and radiographic findings. Radiology 200:349-356, 1996 5. Moon JH, Kim EA, Lee KS, et al: Cytomegalovirus pneumonia: High-resolution CT findings in ten non-AIDS immunocompromised patients. Korean J Radiol 1:73-78, 2000[Medline] 6. Pascual J, Alarcon MC, Marcen R, et al: Cytomegalovirus infection after renal transplantation: Selective prophylaxis and treatment. Transplant Proc 35:1756-1757, 2003[CrossRef][Medline]
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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