Infectious complications during immunochemotherapy of posttransplantation lymphoproliferative disease–can we decrease the risk? Two case reports and review of literature

BACKGROUND Post-transplant lymphoproliferative disease(PTLD)is a heterogeneous group of diseases that develop after solid organ and hematopoietic stem cells transplantation related to intensive immunosuppression regimen,T-cell depletion and Epstein-Barr virus infection.Despite the improvement in the management of PTLD,the prognosis remains poor.Here we report the management of two transplanted patients with PTLD and infections during immunochemotherapy(ICTH).CASE SUMMARY Of 65-year-old woman 11 years after kidney transplantation(first case)presented with diffuse large B-cell lymphoma(DLBCL)CS III and started ICHT according to R-CHOP protocol.Despite the secondary prevention of neutropenic fever,the patient developed grade 4 neutropenia with urinary and pulmonary tract infections after the fifth cycle.ICTH was continued in reduced doses up to 7 cycles followed by involved-field radiation therapy of the residual disease.The second case presents a 49-year-old man,8 years after liver transplantation due to cirrhosis in the course of chronic hepatitis B,who started ICTH for DLBCL Burkitt-like CS IV.The patient received four cycles of ICTH according to RCODOX/R-IVAC protocol,with reduced doses.In both cases initially undertaken reduction of immunosuppression was ineffective to prevent infectious complications.Despite one incomplete ICHT treatment due to recurrent infections,both our patients remain in complete remission.CONCLUSION Reduction of immunosuppression and the doses of chemotherapeutics may be insufficient to prevent infectious complications during ICTH in PTLD patients.

Transplanted kidney loss during colorectal cancer chemotherapy:A case report

BACKGROUND The overall risk of de novo malignancies in kidney transplant recipients(KTRs)is higher than that in the general population.It is associated with long-lasting exposure to immunosuppressive agents and impaired oncological vigilance due to chronic kidney disease.Colorectal cancer(CRC),frequently diagnosed in an advanced stage,is one of the most common malignancies in this cohort and is associated with poor prognosis.Still,because of the scarcity of data concerning adjuvant chemotherapy in this group,there are no clear guidelines for the specific management of the CRCs in KTRs.We present a patient who lost her transplanted kidney shortly after initiation of adjuvant chemotherapy for colon cancer.CASE SUMMARY A 36-year-old woman with a medical history of kidney transplantation(2005)because of end-stage kidney disease,secondary to chronic glomerular nephritis,and long-term immunosuppression was diagnosed with locally advanced pT_(4A)N_(1B) M_(0)(clinical stage Ⅲ)colon adenocarcinoma G2.After right hemicolectomy,the patient was qualified to receive adjuvant chemotherapy that consisted of oxaliplatin,leucovorin and 5-fluorouracil(FOLFOX-4).The deterioration of kidney graft function after two cycles caused chemotherapy cessation and initiation ofhemodialysis therapy after a few months. Shortly after that, the patient started palliativechemotherapy because of cancer recurrence with intraperitoneal spread.CONCLUSIONInitiation of adjuvant chemotherapy for colon cancer increases the risk of rapid kidney graft lossdriven also by under-immunosuppression。

Low symptomatic COVID-19 in an elderly patient with follicular lymphoma treated with rituximab-based immunotherapy:A case report

BACKGROUND Follicular lymphoma is an indolent lymphoma that may progress to a highly aggressive form requiring immunochemotherapy.Most regimens utilize rituximab,an anti-CD20 monoclonal antibody,which may affect the clinical course of novel coronavirus,severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infections[coronavirus disease 2019(COVID-19)].Here we describe the first case of mild COVID-19 during ongoing oncological treatment without significant deterioration after rituximab administration.CASE SUMMARY A 74-year-old female with an enlargement of her right palatine tonsil was diagnosed with follicular lymphoma following tonsillectomy and started immunochemotherapy according to the rituximab,cyclophosphamide,vincristine,prednisone regimen.At home before the fourth cycle,she developed nonspecific symptoms(excessive fatigue,loss of appetite and nausea),misdiagnosed as adverse effects of chemotherapy.Unexpectedly,interim positron emission tomography-computed tomography scan,performed shortly before rituximab administration,revealed previously nonexistent pulmonary changes,potentially of infectious etiology.SARS-CoV-2 infection was confirmed by a nasopharyngeal swab(with reverse transcriptase polymerase chain reaction test)performed the following day.Despite rituximab infusion,the patient remained oligosymptomatic and was discharged home for self-isolation.Having reached a negative SARS-CoV-2 status before the subsequently scheduled regimen,the patient successfully received six cycles of rituximab,cyclophosphamide,vincristine,prednisone and obtained complete remission by positron emission tomographycomputed tomography.CONCLUSION Our case shows that rituximab-based immunotherapy due to follicular lymphoma may have no evident negative effect on the COVID-19 clinical course.