A 30-year-old male presented with unproductive cough and multiple cervical lymphadenopathy in December 2016. The pathology of the cervical lymph node biopsy revealed T-LBL. Positron emission tomography-computed tomography (PET-CT) revealed multiple lymph node involvements in the neck, mediastinum, bilateral parasternum, and abdomen, the Ann-Arbor stage of the lymphoma reached stage III. The following treatment plan was implemented: 1 cycle of VDLP (vincristine + daunorubicin + L-asparaginase + prednisone) induction chemotherapy, followed by 2 cycles of CAM (cyclophosphamide + A-cytarabine + methotrexate) chemotherapy. After the induction chemotherapy and total body irradiation (TBI)/cyclophosphamide protocol, the patient underwent allo-HSCT with the patient's brothers as donors in July 2017. On the 12th day after transplantation, the CD34+ cell count was 8.33 x 106/kg, the mononuclear cell (MNC) count was 10.15 x 108/kg; the process was uneventful. Forty days after transplantation, the patient developed abdominal pain, diarrhea, and rash across his body. Acute grade three GVHD was considered. The symptoms were relieved after the intravenous administration of methylprednisolone, cyclosporine, and mesenchymal cells. The patient experienced fever during this period, and then the temperature returned to normal after treatment with broad-spectrum antimicrobials, including meropenem and voriconazole. Patients who showed transient BKV, CMV, and hepatitis B virus (HBV) expression levels after transplantation demonstrated improvements after antiviral treatment. The BK DNA level was checked on August 7, 2017, and the result was 4.07 x 107 (copy/ml). The BK DNA level was 1.05 x 105 (copy/ml). A chest CT scan showed diffuse ground-glass opacities (Figs. 1 and 2). An abdominal CT scan revealed enlargement of the spleen (Fig. 3).
The patient underwent tracheoscopy and CMV-DNA was 3 x 106 in BALF and 6 x 103 in blood. The patient also carried out enteroscopy at the same time and his immunohistochemical CMV antigen was positive Then, the patient was diagnosed with CMV pneumonia and enteritis and treated with intravenous ganciclovir (500 mg/d) and high-dose glucocorticoids (80 mg/d). However, the patient continued to have high fever, progressive shortness of breath, and gastrointestinal bleeding. Intubation and invasive mechanical ventilation support were performed. Unfortunately, the condition continued to deteriorate. After 3 weeks, the patient died because of severe hypoxemia and hemorrhagic shock.
Informed consent for the collection of his medical history and blood samples was obtained in compliance with the Declaration of Helsinki and approved by the local ethical committee, and the patient provided informed consent for publication of the case.
High-resolution CT scan showing diffuse multiple nodules in both lungs. Most nodules were 1 to 5 mm in diameter with smooth or irregular edges and were mostly located in the middle and inner lungs. Interlobular septal thickening, a small amount of left pleural effusion, and pleural thickening were observed.