Immunosuppressants

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 26-year-old man developed myelosuppression, febrile neutropenia and COVID-19 infection during treatment with etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab for primary mediastinal large B-cell lymphoma.

The man presented with a large mediastinal mass and was diagnosed with primary mediastinal large B-cell lymphoma. Subsequently, he received 2 cycles of dose-adjusted DA-EPOCH-R regimen consisting etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab [routes and dosages not stated] and during each of the cycles, he developed febrile neutropenia. On 09 January 2020, he was admitted for the administration of the third cycle of DA-EPOCH-R regimen. Investigations demonstrated partial remission. Subsequently, he received the 3^rd cycle of DA-EPOCH-R regimen from 12 January 2020 to 17 January 2020. On 19 January 2020, he had a fever without dyspnea, cough, myalgia or fatigue. His lymphocyte count was 0.68 × 10⁹ cells/L, neutrocyte count 0.89 x 10⁹ cells/L and chest CT revealed no evidence of infection. He received treatment for febrile neutropenia with meropenem, granulocyte colony-stimulating factor and linezolid. However, his fever persisted and he had grade 3/4 neutropenia from 21 January 2020 to 25 January 2020. He also exhibited myelosuppression. On further evaluation, he was confirmed positive for antibodies of Mycoplasma pneumoniae IgM, coxsackie B5 virus IgM and enterovirus RNA, indicating infections by these pathogens.

The man was treated with ganciclovir, azithromycin, oseltamivir and posaconazole. On 27 January 2020, his neutrophil normalised, but he reported sore throat, nausea and fever. A CT scan revealed bilateral pleural effusion, segmental atelectasis, bilateral scattered opacities and consolidation. An RT-PCR test revealed COVID-19 infection. On 30 January 2020, he was transferred to a designated hospital. He was started on an off-label treatment with oral umifenovir [arbidol hydrochloride] 0.2g thrice daily for a week and lianhuaqingwen for 10 days. Subsequently, he tested negative for COVID-19 infection and his CT findings improved. On 17 february 2020, he was considered cured and was discharged. He had not developed pneumonia.