Case 11--Late Onset Pulmonary Syndrome after Bone Marrow Transplantation

Clinical summary: This 46-y-old man presented in 5/97 for 3 days of nausea and vomiting, and worsening RUQ discomfort since March. Two years before, he was admitted for the acute onset of left arm and leg swelling. He had generalized peripheral, retroperitoneal, and mediastinal adenopathy. Biopsies showed mantle cell lymphoma, blastic variant, that involved the bone marrow (stage IV). Chemotherapy (CHOP: cyclophosphamide, doxorubicin, vincristine, prednisone) produced a complete remission. Relapses at 10 and 15 months were treated with chemotherapy (ESHAP: etoposide, methylprednisolone, cytarabine, cisplatin) and local radiation. Eight months before the current admission, he received an allogeneic bone marrow transplant (preceded by VP-16, cyclophosphamide, and total body radiation conditioning) from a sibling. Following transplantation, he had abdominal pain, poor oral intake, and persistently abnormal liver function tests. Although graft versus host disease (GVHD) was suspected, it could not be documented by upper or lower gastrointestinal endoscopy and biopsy. He did not use tobacco, alcohol, or illicit drugs. On admission, heart rate was 82/min and blood pressure 82/50. Lungs were clear, and the remainder of the examination was normal. White count was 4.0 k/µl (absolute PMNs 2,500), hct 35%, and plt 138 k/µl. Oxygen saturation was 91% on room air, and ABG showed pH 7.32, pCO2 48 mm Hg, and pO2 61 mm Hg. A chest film showed a RUL opacity that was new since March. CT showed, in addition, bibasilar nodules. Bronchoscopy yielded aspergillus and CMV by culture, but no cytologic evidence of CMV and no evidence of tuberculosis. He was treated with itraconazole for the aspergillus and gancyclovir and intravenous gamma globulin for the CMV. Prednisone and cyclosporine were discontinued. The opacities progressed; and DHPG, acyclovir, and amphotericin were added. He developed a mild, non-productive cough but remained afebrile. Suspicion of infection and progression of radiographic opacities prompted a thoracoscopic biopsy of the RUL on 6/24.

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