Case presentation
A 55 years old woman with multiple myeloma. She has been treated with
six cycles of VCD (bortezomib/cyclophosphamide dexamethasone) scheme
chemotherapy. After 6 cycles she had no major toxic events and achieved
partial response according to the uniform response criteria of the
International Multiple Myeloma Working Group (IMWG). She was proposed
for autologous hematopoietic stem cell transplantation, that was
performed in our center.
On admission was WBC 5.8x109/l, C-reactive protein
5.22 mg/l (normal range below 5.0). Mobilization of hematopoietic stem
cells started on November 8-th 2019. The patient tolerated well the
administration of drugs and remained clinically stable. The first count
of CD 34 was planned on November 18-th 2019. On10-th day after
hematopoietic stem cell mobilization initiation patient condition
worsened. Patient was transferred to intensive care unit for further
treatment. On admission to ICU body temperature 40oC,
SpO2 - 88-90% without oxygen, with oxygenation was 96-97%, respiratory
rate is 30-35/minute, hemodynamically stable, leucocyte count
15.1x109/hemoglobin 97 g/l, platelet-34 x
103/mkl, C-reactive protein 404.45 mg/l (normal range
below 5.0). Antibacterial therapy (cefepim 2.0g), noninvasive mechanical
ventilation (CIPAP, FiO 35 %, Vt-450 ml PEEP-5. Pasb-12 every 3-4 hours
for 1 hour) and High Flow therapy (FiO2- 50-60%,40-50l/min) was
initiated.
Chest computed tomography (CT) showed bilateral pneumonia, bilateral
exudative pleuritis, multiple foci of chest bone destruction (myeloma
disease). In comparison with CT study dated 31.10.2019 increase in
infiltration in the lower lobe of the left lung and the development of
bilateral pleuritis. (Figure 1)
Patient condition showed no improvement, body temperature was
38-39o C, leucocyte count 14.9
x109/l C-reactive protein 417.78 mg/l. Additional
therapy: cefepim was changed to alpitoz 4.5g, antifungal (Kansidas 50
mg). Despite the therapy patient’s condition kept on worsening (Table
1). Based on clinical manifestation of unknown pneumonia, it was decided
to make an express test for Legionellesis I serotype in urine (BinaxNOW
Legionella Control Swab Pack, Manufacturer: Alere Inc., USA), the result
was positive L pneumophila serogroup 1. Moxifloxacin 400 mg was added to
the therapy. Following day, the patient’s respiratory status gradually
improved, body temperature, the breath rate (22-26) C reactive protein
normalization was detected (Table 1). Respiratory support High Flow
therapy and CIPAP were also discontinued on the fourth day of
moxifloxacin treatment. Saturation was 98 % without oxygen therapy.