Graft-versus-lymphoma effect in a patient with a refractory low-grade lymphoma.

the blood brain-barrier, trimethoprim/sulphamethoxazole (160/800 mg every 8 hours) and amikacin (500 mg every 12 hours). The patient’s clinical condition slowly deteriorated and the patient died 73 days after the start of the antibiotic treatment. Post-mortem examination confirmed the diagnosis of CNS and pulmonary nocardiosis. Infection remains a major cause of significant morbidity and mortality in patients with advanced CLL.3 N. asteroides is the most frequent species of Nocardia involved in human infection. Although there are rare descriptions of this infection being one of the emerging infectious complications of purine analog-based therapy for CLL and low-grade lymphoma,3 there have been no previous reports of it occurring in patients treated with chlorambucil. The most interesting thing to learn from our case is, however, that CNS involvement can be silent and elusive; in fact, the CNS may have been involved from the onset of the disease but the poor passage of imipenem and amikacin across the blood-brain barrier may have allowed its progression. Clinically, however the first sign of this complication was SIADH which constitutes an interesting and previously undescribed association. In a recently described case a patient who attained apparent control of the infection was later found at autopsy to have an active N. asteroides cerebral abscess.4 Some authors have recommended routine cranial CT scanning in all patients diagnosed as having a nocardial pulmonary infection and no neurologic signs or symptoms;2 in patients with hematologic malignancies, this recommendation should be given even more consideration. Finally, since nocardiosis is prone to relapse following initially successful therapy,1-3 these patients should receive long-term secondary prophylaxis during subsequent courses of chemotherapy.5