Ibrutinib
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CNS Aspergillosis: case report A 37-year-old man developed CNS Aspergillosis during treatment with ibrutinib for CNS relapse of mantle cell lymphoma. [route, dosage, duration of treatment to reaction onset and outcome not stated]. The man presented with non-painful, persistent left-axillary lymphadenopathy. After investigations following hospital admission, a diagnosis of aggressive mantle cell nonHodgkin’s lymphoma with bone marrow infiltration was made. Then, he started receiving various chemotherapy agents. Subsequently, he underwent an autologous bone marrow transplant. Later, he was discharged with prophylactic treatment of aciclovir, cotrimoxazole [trimethoprimsulfamethoxazole] and cannabis for chronic pain relief. After one month, he presented with diarrhoea and vomiting. Stool cultures were positive for Campylobacter infection. Thus, he was treated with azithromycin. After investigations, a differential diagnosis of CNS relapse of mantle cell lymphoma was made. Therefore, he was treated with combination of intrathecal chemotherapy, whole-brain radiation and unspecified high-dose steroids. He continued therapy with anti-seizure medication and prophylactic aciclovir and cotrimoxazole. Subsequently, he started receiving ibrutinib [Imbruvica] due to the recurrence and aggressive nature of the mantle cell lymphoma. However, after less than a month, he was again admitted due to signs and symptoms of pneumonia and generalised seizure. An MRI of the brain showed multiple bilateral brain lesions which were suggestive of toxoplasmosis. A lumbar puncture revealed a slight increase in the WBC count. A stereotactic brain biopsy culture detected Aspergillus fumigatus. Thus, a diagnosis of CNS aspergillosis was made and toxoplasmosis was ruled out. The man’s ibrutinib therapy was discontinued, and he was treated with voriconazole and amphotericin B. Despite this therapy and an apparent improvement on CNS imaging, his condition continued to slowly deteriorate. His brain lesions did not enlarge, but he became neurologically crippled with frontal lobe behaviour, and required assistance with all his activities of daily living. A few months later, he died [an immediate cause of death not stated]. Author comment: "This case highlights the importance of a high clinical suspicion of opportunistic infections in patients receiving small molecule kinase inhibitors." Schamroth Pravda M, et al. The Muddied Waters of Ibrutinib Therapy. Acta Haematologica 141: 209-213, No. 4, May 2019. Available from: URL: http:// 803434576 doi.org/10.1159/000496555 - Israel
0114-9954/19/1780-0001/$14.95 Adis © 2019 Springer Nature Switzerland AG. All rights reserved
Reactions 23 Nov 2019 No. 1780
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