Case study

A 61-year-old woman with Rai Stage-III Chronic Lymphocytic Leukaemia (CLL) was initially treated with four monthly cycles of fludarabine. Because of an unsatisfactory response, she then received three cycles of standard chemotherapy followed by radio-immunotherapy (RIT) supported with autologous Peripheral Blood Progenitor Cell (PBPC) rescue.

Two days after her PBPC infusion, the patient was admitted to a local hospital for culture-negative neutropenic fever and treated with IV antibiotics and G-CSF. During this hospitalisation, nonirradiated blood components including 2 units of non-WBC-reduced RBCs and 3 units of WBCreduced single-donor apheresis platelets were transfused over two days. The patient was discharged to home after 7 days in the hospital, afebrile and with a normal WBC count.

Ten days after transfusion of the PBPCs, the patient presented with a 2-day history of recurrent fevers and a new, salmon-coloured, diffuse, maculo-papular rash. On admission, laboratory studies revealed a WBC count of 6.1×109/L with an absolute neutrophil count of 5.4×109/L, an Hb level of 80 g/L, and a platelet count of 16×109/L. Diarrhoea, liver function test elevations, and pancytopenia developed over the next 4 days. Skin biopsy, performed the day of admission, showed a predominantly mononuclear cell infiltration (see Figure) and a marrow biopsy revealed marked hypocellularity.

Figure showing a marked mononuclear cell infiltrate on a skin biopsy.

Based on the above information, provide an initial diagnosis of this condition, further examinations that would be required to confirm the diagnosis and a potential approach to therapy.

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