A 68-year-old man with T-PLL (leukocyte count 174.5 × 109/L, 96% lymphoid cells) was treated with chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, and prednisolone every 2 weeks (CHOP14), in combination with alemtuzumab 30 mg subcutaneously on days 1, 5, and 9 of each cycle. This combined therapy was well tolerated. Complete cytologic and immunohistochemical remission was confirmed by blood and bone marrow examination 2 weeks after the latest chemotherapy treatment. Ten weeks later, the patient experienced flu-like symptoms and had a fever of 38.9°C. One week earlier, the antimicrobial prophylaxis, which consisted of valacyclovir, 500 mg 2 times/day, and trimethoprim-sulfamethoxazole, 960 mg 3 times/week, had been stopped, although the alemtuzumab-induced lymphocytopenia was still present (leukocytes 7.2 × 109/L, 84% neutrophils, 0.6% lymphocytes). Outpatient evaluation showed 2 lung abscesses. From 3 consecutive blood cultures and from the bronchoalveolar lavage fluid, a gram-positive bacillus with mucoid growth was isolated and identified as R. equi (API Coryne, bioMérieux, Marcy l’Etoile, France). The isolated strain was resistant to β-lactam antimicrobial drugs and trimethoprim-sulfamethoxazole and susceptible to aminoglycosides, tetracyclines, fluoroquinolones, glycopeptides, erythromycin, and rifampin. Treatment with moxifloxacin and rifampin was begun. After 3 weeks of treatment, fever developed in the patient again. Blood cultures grew R. equi. The patient was admitted to the hospital for intravenous treatment with imipenem/cilastatin, 500 mg/500 mg 3 times/day, and vancomycin, 1.5 g once a day. A computed tomographic scan of the chest showed progression of the pulmonary abscesses and mediastinal lymphadenopathy. Clarithromycin, 500 mg 2 times/day, was added, and the vancomycin was increased to 2 g once a day, which resulted in clinical improvement. Purple, subcutaneous, oval lesions, 2–3 cm in diameter and not painful to palpation, were seen on the upper portion of both legs. Pathologic examination of these lesions after biopsy showed suspected localization of T-PLL. R. equi could not be demonstrated in these skin lesions by either pathologic or microbiologic examination. After 2 weeks of receiving intravenous antimicrobial drugs, the patient was discharged with oral rifampicin, 600 mg once a day; ciprofloxacin, 750 mg twice/day; and azithromycin, 500 mg once a day.
He was readmitted to our hospital 9 weeks later because he had become dyspneic and febrile. Evaluation showed pleural effusion on the right side. Progression of the T-PLL was also diagnosed. After 1 week’s incubation of the pleural fluid, mucoid nonpigmented colonies were growing, consisting of gram-positive coccoid rods, which were catalase positive. Rhodococcus infection was suspected and confirmed by 16S rDNA sequencing without further conventional identification. The isolate showed intermediate susceptibility to ciprofloxacin (MIC 0.75 mg/L), moxifloxacin (MIC 0.5 mg/L), and erythromycin (MIC 1.5 mg/L). Drainage of the pleural fluid resulted in a trapped lung due to pleural thickening. A pleurectomy was considered but was refused by the patient, considering his poor overall prognosis based on the relapse of T-PLL. On his request, the antimicrobial drugs were stopped, and he went home with palliative treatment consisting of morphine and prednisone. He died 3 months later. Overall, he had been treated with antimicrobial agents for 19 weeks.