Double pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.

Bortezomib, lenalidomide, and dexamethasone induction chemotherapy (VRd), followed by autologous stem cell transplantation (ASCT), are the standard of care for patients with newly diagnosed multiple myeloma (NDMM). Pomalidomide is currently approved for relapsed-refractory multiple myeloma. This single-arm, open-label, phase 2 study was the prospective evaluation of the efficacy and safety of bortezomib, pomalidomide, and dexamethasone (VPd) induction for NDMM. We used Fleming’s two-stage design for sample size calculation. We included transplant-eligible and ineligible patients aged 18–75 years in the study. The patients received four cycles of VPd induction followed by response assessment. Thirty-four patients were included in the study, of which 31 completed all four cycles of induction. The median age was 52 years (32–72). Thirty (91%) patients had multiple myeloma, and three had multiple plasmacytomas with less than 10% bone marrow involvement. Nine (27%) had ISS-I, 9 (27%) had ISS-II, and 15 (46%) had ISS-III myeloma. Three patients had high-risk cytogenetic abnormalities. After four cycles of VPd induction, ten patients (32%) achieved stringent CR, nine had CR (29%), eight (26%) had VGPR, and 4 (13%) had PR. Fifteen (48%) had a complete metabolic response (CMR) on PET-CT. Two patients developed SAEs. Anemia was the most common hematological toxicity. Peripheral neuropathy and constipation were the most common non-hematological toxicities. Patients with ≥VGPR had significantly better 12-month PFS than those with PR. Patients with ≥VGPR and CMR on PET-CT had significantly better 12-month OS. Our study showed VPd induction is safe and efficacious in NDMM. Further Phase 3 studies are necessary to establish the superiority and survival benefits.

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Cytomegalovirus (CMV) retinitis is one of the common complications in profoundly immunosuppressed patients such as those with acquired immune deficiency syndrome. It has been rarely reported in patients with lymphoma on aggressive chemotherapy. We encountered a patient with bilateral CMV retinitis who developed this vision-threatening complication while on low-dose palliative metronomic chemotherapy with oral drugs (cyclophosphamide, procarbazine, etoposide, and prednisolone). Though the infection resolved with treatment, there was residual vision loss. This case is presented to sensitize clinicians to the possibility of unusual infections in patients on long-term oral chemotherapies.