Reactions 1680, p170 - 2 Dec 2017 Disseminated coccidioidomycosis: case report A 65-year-old man developed disseminated coccidioidomycosis following immunosuppresive therapy with carmustine [BCNU], cyclophosphamide, doxorubicin, vincristine, ifosfamide, carboplatin, cytarabine [Ara-C], etoposide, fludarabine, methotrexate, prednisone and rituximab [routes not stated; not all dosages stated]. The man was diagnosed with stage IVA composite follicular lymphoma/diffuse large B-cell lymphoma in September 2008. Subsequently, he received eight cycles of R-CHOP chemotherapy, which consisted of rituximab, prednisone, cyclophosphamide, doxorubicin and vincristine. The chemotherapy resulted in first complete remission (CR) in 2009. However, due to disease relapse December 2009, he received three cycles of salvage rituximab, etoposide, ifosfamide and carboplatin, which was followed by radiation therapy. In March 2010, he underwent a high-dose consolidation with auto-haematopoietic stem cell transplant (HSCT) rescue using conditioning regimen with combination carmustine, cyclophosphamide, etoposide and cytarabine. In October 2010, the disease relapsed once again. He was treated with rituximab [Rituxan], cytarabine and methotrexate in December 2010. In February 2011, he underwent an allo- HSCT using conditioning with rituximab and total body irradiation. In August 2011, he achieved CR for the third time. However, he developed skin and oral chronic graft versus host disease (GVHD). In February 2012, the disease relapsed again, and he also experienced a flare of skin and oral chronic GVHD. Both, chronic GVHD and relapse were treated with prednisone and rituximab four doses weekly. In August 2015, he was enrolled in a clinical trial for treatment with CD19 directed CAR T-cells (off label therapy for the treatment of NHL). He underwent apheresis for T-cell collection. He received preparatory three day cytoreductive chemotherapy with fludarabine 25 mg/m and lymphodepleting cyclophosphamide [Cytoxan] 60 mg/kg. Thereafter, in December 2015, a fine needle aspiration demonstrated spherules, indicating disseminated coccidioidomycosis. Prolonged history of immunosuppresive therapy and the use of CD20 targeting antibody rituximab, were considered possible risk factors for the disseminated coccidioidomycosis. Hence, the man was treated with fluconazole. In February 2016, a repeat PET showed resolving infectious/ inflammatory process. In July 2017, his bronchoscopy and fine needle aspiration of lymph node revealed recurrence of disseminated coccidioidomycosis. As of August 2017, he was on re-treatment for disseminated coccidioidomycosis [outcome not stated]. Author comment: "[P]ossible risk factors in this case include . . . history of immunosuppressive therapy with allo- HSCT, chronic GVHD and prior therapies like the use of CD20 targeting antibody Rituximab." Zahid U, et al. Coccidioidomycosis, immunoglobulin deficiency: Safety challenges with CAR T cells therapy for relapsed lymphoma. Immunotherapy 9: 1061-1066, No. 13, Oct 2017. Available from: URL: http://doi.org/10.2217/imt-2017-0070 - USA 803284427 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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