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An 80-year-old man with FLT3-TKD mutation-positive acute myeloid leukemia (AML) relapsed during consolidation therapy with venetoclax/azacitidine and was started on gilteritinib as salvage therapy. On the day after treatment initiation, febrile neutropenia was observed, but the fever resolved promptly after initiation of antimicrobial therapy. On the fifth day after completion of antimicrobial therapy, the patient experienced fever and watery diarrhea over 10 times a day, and a diagnosis of Clostridioides difficile infection (CDI) was made based on stool examination. The patient was treated with intravenous metronidazole, but renal dysfunction, hypotension, and hypoxemia developed, and a CT scan showed pleural and intraperitoneal effusion, significant intestinal wall thickening, and intestinal dilatation. Fidaxomicin was started under general monitoring in the intensive care unit and response was achieved. The patient was discharged from the intensive care unit on the 18th day after the onset of CDI. We report this case not only due to the rarity of fulminant CDI during AML treatment, but also because it is a valuable example of effective treatment of fulminant CDI with fidaxomicin.

Although all-trans retinoic acids (ATRA) are most commonly used as agents in acute promyelocytic leukemia (APL), there are few reports on the administration of ATRAs to patients with liver insufficiency. We report two cases of APL; a 57-year-old man with APL complicated by liver cirrhosis (Child-Pugh class B) and hepatocellular carcinoma who is receiving transcatheter arterial chemoembolization (TACE) and a 50-year-old man with APL complicated by liver cirrhosis (Child-Pugh class B) who is being prepared for receiving a living-donor liver transplantation. Both patients were successfully treated with a normal dosage of ATRA alone during remission-induction therapy. Because the total bilirubin and hepatic transaminases in the two cases were almost at normal levels; the patients received three courses of ATRAs plus a 42%-70% dose of anthracyclines as a consolidation therapy. At 1 year after receiving intermittent ATRA therapy, the patients are maintaining molecular remission. These cases suggest that the administration of ATRA and modifications of doses of chemotherapeutic agents are applicable to APL patients with liver dysfunction.

A 52-year-old female presented with stroke-like symptoms after high-dose methotrexate (HDMTX) therapy and MTX intrathecal injection (IT-MTX) as central nervous system (CNS) prophylaxis for intravascular large B-cell lymphoma (IVLBCL). She had been diagnosed as having IVLBCL without CNS involvement 5 months earlier and had received 6 courses of R-CHOP and 2 courses of HDMTX combined with IT-MTX. She experienced acute-onset right hemiparesis involving the face and arm, along with dysarthria, 7 days after the second HDMTX infusion. Brain magnetic resonance imaging (MRI) and cerebrospinal fluid results were normal and suggested neither stroke nor CNS infiltration. Her symptoms gradually resolved within 4 days and follow-up neurologic examination showed no abnormalities. MRI on day 2 (after the onset) showed an area of hyper-intensity on diffusion weighted imaging (DWI). Follow-up MRI performed on day 38 showed resolution of the DWI intensity, while the T2 and FLAIR signals became more evident. Based on her clinical course and these MRI findings, she was diagnosed as having MTX-induced subacute encephalopathy. This syndrome has been reported mainly in children with ALL after HDMTX or IT-MTX, but there have been few reports of adult patients. MTX-induced subacute encephalopathy should be taken into account as a possible cause of neurologic manifestations because early differentiation from stroke and CNS infiltration is essential to successful management.

This report describes a 41-year-old patient, who developed herpes simplex virus type 2 (HSV-2)-hepatitis after umbilical cord blood transplantation (CBT). The patient had received allogeneic bone marrow transplantation from an unrelated donor for acute myeloid leukemia (AML) not in remission. AML relapsed 18 months after the first transplantation, and CBT was performed. AML relapsed again 5 months later and the patient was given chemotherapy. Although there was no active chronic graft-versus-host disease, liver dysfunction appeared, and one week later, progressed to acute liver failure. Viral screening of blood by PCR including hepatitis B and C viruses, human immunodeficiency virus, Epstein-Barr virus, cytomegalovirus, herpes simplex virus type 1 and HSV-2 revealed elevation of HSV-2 (2.34 × 10⁴ copies/ml). We diagnosed the patient as having HSV-2 acute hepatitis, and initiated treatment with antiviral drugs (acyclovir, foscarnet) and plasma exchange. However, liver functions deteriorated rapidly, and the patient died on day 6 after the onset of acute liver failure. Although HSV hepatitis is very rare after allogeneic stem cell transplantation, it is rapidly progressive and associated with a high mortality rate. Thus, early diagnosis with prompt antiviral intervention is recommended.