24 August 2024: Articles
Bloodstream Infection in a Lymphoma Patient Undergoing Chemotherapy: A Case Study and Implications for Probiotic Use
Unusual clinical course, Diagnostic / therapeutic accidents, Unexpected drug reaction
Osamu Imataki 1ABCDEFG*, Makiko Uemura 1ABCDEFGDOI: 10.12659/AJCR.944687
Am J Case Rep 2024; 25:e944687
Abstract
BACKGROUND: Fermenting bacilli producing lactic acid, including Bifidobacterium spp., are supposed to have low pathogenicity and no virulence for humans. Probiotics consisting of those fermenting bacilli can prevent and treat symptomatic gastrointestinal conditions, such as diarrhea. We use probiotics even in cancer patients, those who are immunocompromised, because a preferable effect to the intestinal commensal microbiome has been shown in a recent report. Some case reports warn of a rare risk of bloodstream infection caused by probiotics. However, complete prohibition of probiotic use in cancer patients abandons the benefits.
CASE REPORT: A 75-year-old Japanese woman with malignant lymphoma was treated with immune-chemotherapy regimen consisting of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP). The patient had onset of febrile neutropenia during chemotherapy and had Bifidobacterium breve bloodstream infection on day 8 after the eighth R-CHOP treatment. She had usually eaten commercial yogurt every morning. This yogurt was produced from only Lactobacillus bulgaricus and Streptococcus thermophilus. It did not contain Bifidobacterium breve. The bloodstream infection in this case looked like it derived from her food; however, it was not associated with her habitual foods. The patient was treated with meropenem for 8 days and experienced complete remission of the bloodstream infection.
CONCLUSIONS: We speculate that fermenting bacilli can also be a source of bloodstream infection, not necessarily associated with probiotic strains, in cancer patients treated with chemotherapy. Additionally, we recommend that probiotics can alleviate alimentary tract symptoms in immunocompromised patients.
Keywords: Bacteremia, Bifidobacterium breve, Immunocompromised Host, Lymphoma, Probiotics
Introduction
Probiotics are fermented organisms producing lactic acid, which promotes a favorable effect on the intestinal immune system. Clinical trials have demonstrated optimal outcomes with probiotics in cancer patients after chemotherapy [1]. While rare infectious complications associated with probiotics are infrequently reported, a pessimistic study suggests avoiding probiotics in immunocompromised hosts to prevent low-frequency bloodstream infections (BSI) caused by low pathogenic virulence pathogens. However, probiotic-induced BSI is rare, and BSI from other low-virulence organisms occurs in immunocom-promised patients, even without probiotics [2]. Despite these considerations, the overall positive impact of probiotics in patients with cancer remains significant.
Case Report
A 75-year-old Japanese woman with malignant lymphoma (diffuse large B-cell lymphoma) was treated with the rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) regimen. A large mass was found on her left cervical lymph node. Malignant lymphoma had a poor risk status in the revised international prognostic index (IPI) and a high intermediate risk in the NCCN-IPI. She achieved complete remission after 8 courses of R-CHOP. The dosage of the CHOP regimen was adjusted with a 50% reduction in the first cycle, followed by a 20% reduction in the second cycle, and full dose administration after the third cycle. The dose modification was due to the patient’s general condition. At the last course of chemotherapy, she developed febrile neutropenia (white blood cell count of 1900/µL and neutrophil count of 87/ µL) with mild diarrhea on day 8 after the eighth R-CHOP, despite of the use of pegfilgrastim 3.6 mg. This febrile episode marked the patient’s initial occurrence of febrile neutropenia. She was admitted to the hospital for treatment of febrile neutropenia. Blood culture at the onset of febrile neutropenia revealed bacteremia caused by
Discussion
In our field, hematological malignancies, including malignant lymphoma, require several months of constitutive chemoimmunotherapy with the R-CHOP regimen. In these cases, probiotics, such as fermenting bacilli that produce lactic acid, can sometimes be a suspicious preparation drug, causing probiotic-associated BSI [6]. In some cases, probiotics have been used to identify genetic isolates derived from blood cultures and organisms [7]. In other cases, clinical isolates from blood had identically different phenotypes from probiotic strains, using molecular methods [8]. Thus, the consistency or association between probiotic treatment and BSI is not well established. In another view, a neutropenic diet devoid of raw food was not linked to an increased risk of infections and mortality [9,10]. These fermenting bacteria are found in the human gastrointestinal tract. Although microorganisms in the gastrointestinal tract are less pathogenic than bacteria, almost all of them are antimicrobial-resistant. We believe that even if 2 isolates of BSI and probiotics are identified as the same species, this does not always imply that the BSI originated from probiotics. In the present case,
As demonstrated in this case, probiotics, including food and pharmaceutical lactic acid bacteria preparations, do not always cause lactate-producing bacteria translocation in the alimentary tract. In our case, one of the commensal nonvirulent bacteria,
Conclusions
We observed that fermenting bacilli, including
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