Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Human polyomavirus infection, IL-2 receptor assay, Immunoglobulin therapy, Impaired work ability, Magnetic resonance imaging hepatobiliary
Clinical narrative: I presented to hospital initially on 11/22/2023 with fever, rigors, malaise, fatigue, and pancytopenia. I was treated with steroids and improved. I was discharged on 11/25/2023. The steroids were tapered and the symptoms returned by 12/7/2023. The pancytopenia returned. I was restarted back on the steroids. I progressed and was readmitted on 12/17/2023 with fever, chills, fatigue, weight loss,shock, pancytopenia, high ferritin, and liver function abnormalities. I was treated with IV antibiotics, IV fluids, steroids, and immune globulin. I had a liver biopsy showing Hemophagocytic Lymphohistiocytosis (HLH). I was treated with IV steroids, Retuxan, Jakafi, and anakinra IV. I improved but then recurred with a pancytopenia. My course at hospital was also complicated by neutropenic sepsis with a terminal ileitis. I was transferred to center by 1/11/2024. A follow up bone marrow biopsy revealed the presence of the HLH in the bone marrow. As I failed the first round of treatment, my hematologists changed therapy to etoposide. The HLH responded by an improvement in the cell counts and ferritin but I was developing complications of the chemotherapy with alopecia and progressive anemia. This was in addition to the pedal edema and proximal muscle weakness I developed from the steroids. Of note, during the HLH illness from 11/2023 to 1/2024, I had lost about 45 lbs. I was discharged from center on 1/25/2024. I was tapered off the steroids, Rituxan, anakinra, and Jakafi after discharge. It was felt that my HLH was due to the vaccine. Other case reportes were noted in the literature at that time. My lymphoma is not known to be complicated by HLH and I did not have the genetic propensity as gene testing was negative. It was decided that as I could not be on prolonged etoposide nor could I tolerate a third recurrence, I underwent a stem cell transplant on 2/28/2024. This occurred after the conditioning chemotherapy of cyclophosphamide and fludarabine and total body radiation. My course was complicated by neutropenic fever, severe anorexia, ongoing weight loss, wound infections, pneumonia, pericardial effusion, BK viral UTI, superficial phlebitis, pancytopenia, and deconditioning. I received IV antibiotics, blood and platelet transfusions, immune globulin, wound care, and IV fluids. I was transferred to acute rehab in the system and was discharged home on 4/14/2024. Since then, I had persistent chills without fever while on immunosuppressives with a negative work up. I had persistent pedal edema of unclear cause managed by wraps. I have had a persistent pericardial effusion of unclear etiology, possibly due to graft versus host disease (GVHD). I had a period of severe anemia to a hb of 7 in 7/2024 which has slowly improved. I had recurrent episodes of nausea, vomiting and diarrhea from the end of 7/2024 into the beginning of 8/2024 with nonspecific biopsies of the upper and lower GI tracts for GVHD. I was weaned off of Jakafi by the end of 8/2024. I have slowly improved since then but still have a mild anemia, deconditioning and improved but present upper extremity weakness. I was receiving physical therapy all along with an interruption during the time I was transplanted. It ended on 12/4/2024. Please note that I have been out of work since 12/11/2023.