A 75-years old man receiving daratumumab-lenalidomide and dexamethasone as first line therapy for an IgAk MM was admitted for fever, hypoxia and decrease in consciousness. Blood tests showed normal neutrophils count (3.4 x109/L), lymphocytopenia (0.5 x109/L) and severe hypogammaglobulinemia (1.3 g/l) that was not present at MM diagnosis. CRP at admission 647 nmol/L (normal value < 47 nmol/L). The patient had no pneumological comorbidities, respiratory function was unremarkable before starting MM-therapy and he was on antibiotics prophylaxis with levofloxacin during the first 3 cycles of therapy. He was treated with 3 cycles of MM-therapy and dexamethasone dosage was reduced at 50% according to age (0.27 mg/kg/day of prednisolone for more than 90 days) achieving a biochemical VGPR.
Meropenem and linezolid were started but 4 days later, the respiratory support was increased with non-invasive ventilation.
CT scan showed bilateral pleural effusion, ground glass areas and parenchymal consolidation areas. Oral posaconazole was added to broad spectrum iv antibiotics ( Figure 3 ) few days before BAL obtaining therapeutic levels on blood. Serum AGASP was persistently negative.
A BAL was performed during antimicrobial therapy with no microbiologically documented infection. Very low copies of cytomegalovirus (CMV) were detectable on BAL sample but there were judged not enough for diagnosis of pulmonary CMV infection. CMV DNA on whole blood was negative and patient was not treated with antiviral therapy. Patient underwent oro-tracheal intubation due to worsening gas exchange. Broad spectrum antibiotics were continued for 10 days while empiric antifungal therapy for almost 2 months.
There was a progressive improvement, with oxygen weaning and suspension of all antimicrobial drugs. Follow up CT scan showed a regression in all ground glass and consolidation areas, lymphocyte count increased > 1.5 x109/L and patient recovered and was able to resume every-day activities. After this favourable evolution, patient was able to safely re-start daratumumab-lenalidomide-dexamethasone 2 months later. He was not on secondary antifungal prophylaxis and the monitored lung CT scan at 4 months from the IFI was negative. Until now, after other 5 cycles of MM-therapy there was no IFI outbreak, patient continued substitutive IVIg according to blood dosage (median IgG 3.2 g/l).