A 67-year-old male with acute myeloid leukemia and an allogeneic hematopoietic stem cell transplant (HCT) from a matched, unrelated donor two and a half months prior was admitted with 10 days of nausea, vomiting, and diarrhea. After his HCT, he had hematopoietic engraftment and was maintained on tacrolimus with trimethoprim-sulfamethoxazole, fluconazole, and valganciclovir prophylaxis. One month prior to admission, he developed graft-versus-host disease (GvHD) of the skin and was started on prednisone (80 mg/day initially and weaned to 20 mg/day). He had emigrated from Colombia to the United States as a teenager but did not have any recent travel. He previously worked at a desk job and was retired. He denied any animal exposures and did not spend significant time outdoors.
On admission, he endorsed early satiety and poor oral intake but denied fevers, chills, or new skin changes. He had mild diffuse abdominal tenderness with hypoactive bowel sounds on examination. Laboratory testing revealed a white blood cell count of 3.9 × 109 cells/liter [normal range, (4.2 to 9.1) × 109 cells/liter] with a normal differential, hemoglobin of 7.7 g/dl (normal, 12.9 to 16.1 g/dl), and platelet count of 70 × 109 cells/liter [normal range, (150 to 400) × 109 cells/liter]. He had normal renal and liver function tests. Admission blood cultures were negative. He was started on methylprednisolone at 2 mg/kg of body weight due to concern for gastrointestinal GvHD. An endoscopy and colonoscopy were performed, and biopsy samples were taken (Fig. 1A). The procedure revealed moderate gastritis, severe duodenitis, and colonic erosions consistent with colitis and diverticulosis. During his hospitalization, he developed progressive hypoxic respiratory failure requiring up to 5 liters of oxygen, and a chest computed tomography showed diffuse nodular and groundglass opacities with interstitial thickening. A sputum sample was obtained and sent for routine bacterial culture (Fig. 1B).
FIG 1.
(A) Gastric biopsy sample stained by hematoxylin and eosin stain (magnification, ×100) and (B) sputum culture plated to chocolate agar.
For answer and discussion, see https://doi.org/10.1128/JCM.01317-20 in this issue.