A 64-year-old Italian man was admitted in March 2005 for severe headache, continuous fever and pancytopenia. His history showed that he was suffering from NHL type B grade II (Real) already treated with chemotherapy according to the CHOP-R scheme and then with high doses of cyclophosphamide in order to mobilise the stem cells in anticipation of an autologous transplant, which was never carried out. A recent total body CT scan showed remission of the lymphomatous disease, while the osteomedullary biopsy revealed secondary myelodysplasia in the absence of neoplastic infiltration.
On admission to hospital, the physical examination revealed a fever of 39°C, cutaneous and mucosal pallor and splenomegaly, BP 110/70 mmHg, heart rate 128 beats per minute. The rest of the initial physical examination is compatible with normality.
Complementary examinations. Initial tests showed, among other things, pancytopenia with neutropenia of 830/ul. Virological examinations (negative) and serial blood cultures were performed. A CT scan of the skull showed no acute focal lesions or signs of cerebral hypertension. The patient was treated with supportive therapy, granulocyte growth factors, antifungals and broad-spectrum antibiotics, with remission of the haematological picture and resolution of fever. Due to the persistence of headache and the successive appearance of meningeal signs, a diagnostic lumbar puncture was performed. Microscopic analysis of the CSF showed an increase in the total number of cells, consisting of a large number of neutrophils, megakaryocytes and myeloid cells with intermediate maturation; a picture representative of a medullary population. Immunohistochemical cytological analysis was compatible with myeloid metaplasia: factor VIII and myeloperoxidase positive in morphologically compatible elements. The repeated analysis of CSF compared to peripheral blood and the fact that no spinal tap was traumatic or difficult to perform excludes contamination. In the meantime, the blood culture was positive for Sterotrophomonas maltophilia, which was sensitive to antibiotic treatment. Two weeks after admission, the patient's neurological condition worsened, he went into a cerebral coma and died.