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An immunocompromised host with bilateral pulmonary infiltrates.

A 36-year-old man was admitted at our haematology ward in the winter season because of fever and a nonproductive cough for two days. He had a myeloablative allogeneic blood stem cell transplantation ten months earlier for chronic myelogeneous leukaemia in the first chronic phase. The transplantation had been complicated by a treatment-related pneumonitis for which he received immunosuppressive drugs and by Epstein-Barr virus-related lymphoproliferative disease for which he had received a single dose of a humanised mouse anti-CD20 monoclonal antibody (rituximab). On admission he was given ciclosporin and steroids as immunosuppression and claritromycin and valaciclovir as primary prophylaxis. Physical examination revealed crackles over the left lower lung field, a temperature of 39.5C and a peripheral oxygen saturation of 92% at room air. Laboratory examination showed mild anaemia, thrombocytopenia and leucopenia, with a marked neutropenia of 0.55 x 10/l. A radiograph of the chest showed bilateral pulmonary infiltrates in the lower lobes and bilateral shadowing of the frontal sinuses (figure 1). He was treated with broad-spectrum antibiotics (imipenem/ cilastatin) and a bronchial alveolar lavage was performed the next day.