A 55-year-old male, with multiple myeloma, was admitted with a fever up to 38.5 C and cervical lymph node enlargement 70 days after an allogeneic HSCT from an unrelated donor with human leukocyte antigen DQB1 mismatch (9/10 matched), for early progression after an autologous HSCT. After reduced intensity conditioning with fludarabine (40 mg/m2 4 days), melphalan (70 mg/m2 1 day), and thymoglobulin (2.5 mg/kg 3 days), he received a T-cell-replete peripheral blood allograft containing 5.7 x 106 CD34+ cells/kg. Graft-versus-host disease prophylaxis consisted of tacrolimus (from day 1) and methotrexate (on days +1, +3, and +6). He received acyclovir as anti-infective prophylaxis and was isolated in a HEPA filtered room during the severe neutropenia period. The patient denied previous exposure or infection by M. tuberculosis. Bacillus Calmette-Guerin vaccination status was unknown and tuberculin skin test (TST) is not routinely performed to HSCT candidates at our hospital.
At admission, a contrast-enhanced computed tomography (CT) showed right laterocervical lymph node enlargement (Figure 1A) and a high-resolution chest CT revealed old pulmonary scar lesions in the right upper lobe but no signs of active infection (Figure 1B). Quantitative polymerase chain reaction (qPCR) in the peripheral blood-detected epstein-barr viral (EBV) replication (820 copies/mL) and a first cervical biopsy was not diagnostic. Tacrolimus taper was started, and the patient was discharged afebrile with oral antibiotherapy.
On day +90, fever was noted again, and the biopsy wound presented purulent suppuration (Figure 2), which was sent for culture. EBV replication was no more detected during the follow-up. Histologic exam of a second biopsy showed caseating granulomas (Figure 3). PCR analysis of the lymph node demonstrated the presence of M. tuberculosis consensus sequences, which was confirmed by microbiological cultures isolating M. tuberculosis complex. Combined treatment with rifampicin, isoniazid, and pyrazinamide was initiated with a quick recovery of all infectious symptoms. Antituberculosis therapy was maintained for 9 months with a complete resolution of tuberculosis (TB).
(B) Highresolution chest CT revealed old pulmonary scar lesions with pleural thickening in the right upper lobe.