Antineoplastics
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Reactions 1172 - 6 Oct 2007 S Antineoplastics Immunological disorders leading to infectious arthritis: case report A 28-year-old man developed hypogammaglobulinaemia and B-cell aplasia, with subsequent infectious arthritis due to Ureaplasma urealyticum, after receiving antineoplastics for large B-cell lymphoma. [Dosages and duration of treatment not stated for all drugs except rituximab.] The man was treated with eight cycles of cyclophosphamide, doxorubicin, vincristine and prednisone, plus radiotherapy. After pulmonary relapse 3 months later, he received two cycles of etoposide, methylprednisolone, cytarabine and cisplatin and underwent surgical tumour debulking. He received rituximab 375 mg/m 2 postoperatively in four weekly doses. One week after the last rituximab dose, he received further chemotherapy: etoposide, carmustine, cytarabine and melphalan, followed 1 month later by reduced intensity haematopoietic stem cell transplantation (HSCT) using fludarabine and radiation. Despite receiving methotrexate and ciclosporin A for prophylaxis, he developed graft versus host disease (GVHD), which was treated with corticosteroids. Possible pulmonary aspergillosis was treated with voriconazole, and cytomegalovirus (CMV) infection was treated with ganciclovir. One hundred days after HSCT he developed extensive and moderately severe GVHD. At 8 months post-transplantation, he presented with joint pain, left elbow tender swelling and redness. This spread to other joints and was accompanied by generalised erythema. He was initiated on piperazillin/tazobactam. There was no improvement 5 days later and he was noted to have lymphopenia with complete B-cell aplasia and agammaglobulinaemia. Treatment was changed to doxycycline and IV immunoglobulin (IVIG). Polymerase chain reaction testing of joint fluid was positive for U. urealyticum, and septic arthritis due to U. urealyticum was diagnosed. He experienced a reactivation of his CMV, RSV-pneumonitis and acute renal failure necessitating haemodialysis. His infections were treated and he recovered from the arthritis and other complications. He remained in complete remission 4.5 years post-transplant. Lack of immunoglobulin production persisted, and IVIG was continued. Author comment: "[T]he combination of multiple lymphocytotoxic therapies. . .(intensive chemotherapy in combination with rituximab, intensive conditioning regimen including fludarabine and total body irradiation, allogeneic HSCT, GVHD and its treatment with corticosteroids) led to impaired immune reconstitution post transplant, which resulted in complete and long-lasting B-cell aplasia and agammaglobulinemia." Arber C, et al. Septic polyarthritis with Ureaplasma urealyticum in a patient with prolonged agammaglobulinemia and B-cell aplasia after allogeneic HSCT and rituximab pretreatment. Bone Marrow Transplantation 40: 597-598, No. 6, Sep 2007 - Switzerland 801091537 1 Reactions 6 Oct 2007 No. 1172 0114-9954/10/1172-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Transcript of Antineoplastics
Reactions 1172 - 6 Oct 2007
SAntineoplastics
Immunological disorders leading to infectiousarthritis: case report
A 28-year-old man developed hypogammaglobulinaemiaand B-cell aplasia, with subsequent infectious arthritis due toUreaplasma urealyticum, after receiving antineoplastics forlarge B-cell lymphoma. [Dosages and duration of treatment notstated for all drugs except rituximab.]
The man was treated with eight cycles ofcyclophosphamide, doxorubicin, vincristine and prednisone,plus radiotherapy. After pulmonary relapse 3 months later, hereceived two cycles of etoposide, methylprednisolone,cytarabine and cisplatin and underwent surgical tumourdebulking. He received rituximab 375 mg/m2 postoperativelyin four weekly doses. One week after the last rituximab dose,he received further chemotherapy: etoposide, carmustine,cytarabine and melphalan, followed 1 month later by reducedintensity haematopoietic stem cell transplantation (HSCT)using fludarabine and radiation. Despite receivingmethotrexate and ciclosporin A for prophylaxis, he developedgraft versus host disease (GVHD), which was treated withcorticosteroids. Possible pulmonary aspergillosis was treatedwith voriconazole, and cytomegalovirus (CMV) infection wastreated with ganciclovir. One hundred days after HSCT hedeveloped extensive and moderately severe GVHD. At8 months post-transplantation, he presented with joint pain,left elbow tender swelling and redness. This spread to otherjoints and was accompanied by generalised erythema. He wasinitiated on piperazillin/tazobactam. There was noimprovement 5 days later and he was noted to havelymphopenia with complete B-cell aplasia andagammaglobulinaemia. Treatment was changed todoxycycline and IV immunoglobulin (IVIG). Polymerase chainreaction testing of joint fluid was positive for U. urealyticum,and septic arthritis due to U. urealyticum was diagnosed. Heexperienced a reactivation of his CMV, RSV-pneumonitis andacute renal failure necessitating haemodialysis.
His infections were treated and he recovered from thearthritis and other complications. He remained in completeremission 4.5 years post-transplant. Lack of immunoglobulinproduction persisted, and IVIG was continued.
Author comment: "[T]he combination of multiplelymphocytotoxic therapies. . .(intensive chemotherapy incombination with rituximab, intensive conditioning regimenincluding fludarabine and total body irradiation, allogeneicHSCT, GVHD and its treatment with corticosteroids) led toimpaired immune reconstitution post transplant, whichresulted in complete and long-lasting B-cell aplasia andagammaglobulinemia."Arber C, et al. Septic polyarthritis with Ureaplasma urealyticum in a patient withprolonged agammaglobulinemia and B-cell aplasia after allogeneic HSCT andrituximab pretreatment. Bone Marrow Transplantation 40: 597-598, No. 6, Sep2007 - Switzerland 801091537
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Reactions 6 Oct 2007 No. 11720114-9954/10/1172-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
