An open-label, randomized controlled trial of sulfamethoxazole-trimethoprim for Pneumocystis prophylaxis: results of 52-week follow-up

Objectives

The aim was to investigate the long-term prophylactic efficacy, drug retention and safety of low-dose sulfamethoxazole–trimethoprim (SMX/TMP) prophylaxis against Pneumocystis pneumonia (PCP).

Methods

Adult patients with rheumatic diseases receiving prednisolone ≥0.6 mg/kg/day were randomized into the single-strength group (SS; SMX/TMP 400/80 mg daily), the half-strength group (HS; 200/40 mg daily) or the escalation group (ES; starting at 40/8 mg and increasing incrementally to 200/40 mg daily) and treated for 24 weeks, then observed for 52 weeks. The primary endpoint, the PCP non-incidence rate (non-IR) at week 24, has been reported previously. The secondary endpoints were the PCP non-IR at week 52, treatment discontinuation rate and adverse events.

Results

Fifty-eight, 59 and 55 patients in the SS, HS and ES, respectively, received SMX/TMP. PCP did not develop in any of the patients by week 52. The estimated PCP non-IR in patients receiving SMX/TMP 200/40 mg daily (HS and ES) was 96.8–100%. Throughout the 52-week observation period, the overall discontinuation rate was significantly lower in HS than in SS (22.7 vs 47.2%, P = 0.004). The discontinuation rates attributable to adverse events were significantly lower in HS (19.1%, P = 0.007) and ES (20.3%, P = 0.007) than in SS (41.8%). The IRs of adverse events requiring SMX/TMP dose reduction before week 52 differed among the three groups, with a significantly higher IR in SS than in HS or ES (P = 0.007).

Conclusion

SMX/TMP 200/40 mg had a high PCP prevention rate and was superior to SMX/TMP 400/80 mg in terms of drug retention and safety.

Trial registration

University Hospital Medical Information Network Clinical Trials Registry, UMIN000007727.

P1912Incidence of silent cerebral thromboembolism in catheter ablation for atrial fibrillation under the use of DOAC: Comparison of cryoballoon versus radiofrequency ablation system

Background

Silent cerebral thromboembolism (CE) in catheter ablation for atrial fibrillation (AF) is not rare. Prior our study has reported lower incidence of silent CE in AF radiofrequency (RF) ablation using irrigated-tip catheter than conventional 4 or 8mm-tip catheter. In addition, the incidence of silent CE in AF ablation under direct oral anticoagulant (DOAC) was equivalent to continuous therapeutic warfarin. Recently pulmonary vein isolation (PVI) using cryoballoon (CB) has emerged as an alternative technique to RF ablation because some studies suggested that the efficacy for PVI by CB was equivalent to RF. However, incidence of silent CE in CB ablation under the use of DOAC is unknown.

Objective

We aimed to evaluate the incidence new silent CE in AF ablation using CB system compared with irrigated RF system under the use of DOAC.

Methods

322 consecutive patients with paroxysmal or persistent AF (155 using CB system, 167 using RF system) who underwent the first AF ablation were taking DOAC more than one month prior to the procedure. Throughout AF ablation procedure, heparin was administered to maintain activated clotting time (ACT) between 300 and 400 seconds. Head MRI was performed in all patients within 24 hours after the procedure.

Results

In 14 (9.0%) patients using CB and in 20 (12.0%) patients using RF, head MRI showed new embolic lesions without neurological symptom (P=0.469). Although the amount of heparin during the procedure in group CB was significantly less than in group RF (16134±3125 U vs. 18689±5222 U; P<0.0001), amount of heparin per hour in group CB was more than in group RF (8335±1955 U/h vs. 6143±1918 U/h; P<0.0001) because procedure time in group CB was shorter than in group RF (121.3±34.1 min vs. 189.5±47.4 min; P<0.0001). Mean ACT in both groups was maintained high level (3367±25.3 sec. vs. 338.6±23.5 sec.; P=0.479). In univariate analysis, minimum ACT during procedure, as before puncture of interatrial septum, were significantly correlated with the incidence of silent CE (P=0.027).

Conclusions

The incidence of silent CE in AF ablation using CB system was lower than RF system, although it was not a significant difference between different ablation techniques for AF. In AF ablation, the use of CB may be preferred rather than RF as ablation system in regard to risk reduction of thromboembolic complications.

Two cases of type 2 diabetes mellitus in elderly patients successfully treated with monthly exenatide long-acting release

Two elderly patients with poorly controlled type 2 diabetes mellitus had difficulty self-managing their medications. Exenatide long-acting release (LAR), with an extended administration interval of 1 month, maintained hemoglobin A1c (HbA1c) level in the 7% range. Monthly administration of exenatide-LAR may be considered for use in carefully selected elderly individuals.

Development of a Hybrid Artificial Liver using a Polyurethane Foam/Hepatocyte-Spheroid Packed-Bed Module

Primary dog hepatocytes spontaneously formed spheroids in the pores of polyurethane foam (PUF) within 1–2 days of stationary culture. The spheroids, about 100–150 μm in diameter, partly attached to the surface and immobilized inside these pores.

The lidocaine disappearance rate decreased to about 4 μg/105 viable cells/day for 10 days, while in the PUF/spheroid culture the rate was maintained at almost the initial level of 8 μg/105 viable cells/day for 10 days. Then, two scales of PUF packed-bed modules were designed. A small module (PUF volume; 14.5 cm3) was used for in vitro culture to investigate optimum culture conditions, and a large module (PUF volume; 300 cm3) was designed for dog experiments. Hepatocytes inoculated in these modules also formed spheroids and maintained almost the same activity of albumin secretion rate (111 μg/cm3 PUF/day in the small module and 87.7 μg/cm3 PUF/day in the large module). These results indicate that the PUF packed-bed module containing hepatocyte-spheroids is promising as a hybrid artificial liver

Conditions Required for a Hybrid Artificial Liver Support System using a PUF/Hepatocyte-Spheroid Packed-Bed Module and it's use in Dogs with Liver Failure

We studied the effects of a hybrid artificial liver support system we developed on dogs with hepatic failure. The system consisted of a multi-channel polyurethane foam packed-bed culture module, including primary dog hepatocyte spheroids.

Blood ammonia was well metabolized by 20 g hepatocytes, but the other functions such as glucose concentration, total bile acid concentration, and survival time required 30 g hepatocytes to improve conditions. We found that we should use a culture substratum that easily forms spheroids, and that an artificial liver module should be used as soon as possible after spheroid formation by hepatocytes in the module.

Optimal regimens of sulfamethoxazole-trimethoprim for chemoprophylaxis of Pneumocystis pneumonia in patients with systemic rheumatic diseases: results from a non-blinded, randomized controlled trial

Background

Sulfamethoxazole-trimethoprim (SMX/TMP) is a standard drug for the prophylaxis of Pneumocystis pneumonia (PJP) in immunosuppressed patients with systemic rheumatic diseases, but is sometimes discontinued due to adverse events (AEs). The objective of this non-blinded, randomized, 52-week non-inferiority trial was to quest an effective chemoprophylaxis regimen for PJP with a low drug discontinuation rate. Results at week 24 were reported.

Methods

Adult patients with systemic rheumatic diseases who started prednisolone ≥0.6 mg/kg/day were randomized into three dosage groups: a single-strength group (SS, SMX/TMP of 400/80 mg daily), half-strength group (HS, 200/40 mg daily), and escalation group (ES, started with 40/8 mg daily, increasing incrementally to 200/40 mg daily). The primary endpoint was non-incidence rates (non-IR) of PJP at week 24.

Results

Of 183 patients randomly allocated at a 1:1:1 ratio into the three groups, 58 patients in SS, 59 in HS, and 55 in ES started SMX/TMP. A total of 172 patients were included in the analysis. No cases of PJP were reported up to week 24. Estimated non-IR of PJP in patients who received daily SMX/TMP of 200/40 mg, either starting at this dose or increasing incrementally, was 96.8–100% using the exact confidence interval as a post-hoc analysis. The overall discontinuation rate was significantly lower with HS compared to SS (p = 0.007). The discontinuation rates due to AEs were significantly lower with HS (p = 0.006) and ES (p = 0.004) compared to SS. The IR of AEs requiring reduction in the dose of SMX/TMP (p = 0.009) and AEs of special interest (p = 0.003) were different among the three groups with significantly higher IR in SS compared to HS and ES.

Conclusions

Although there were no PJP cases, the combined group of HS and ES had an excellent estimated non-IR of PJP and both were superior in safety to SS. From the perspective of feasibility and drug discontinuation rates, the daily half-strength regimen was suggested to be optimal for prophylaxis of PJP in patients with systemic rheumatic diseases.

Trial registration

The University Hospital Medical Information Network Clinical Trials Registry number is UMIN000007727, registered 10 April 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1206-8) contains supplementary material, which is available to authorized users.

DNA synthesis and intracellular calcium elevation in porcine cerebral arterial smooth muscle cells by cerebrospinal fluid from patients with subarachnoid haemorrhage

To understand the molecular mechanism of the pathogenesis of cerebral vasospasm following subarachnoid haemorrhage, we analysed the effect of cerebrospinal fluid from patients with subarachnoid haemorrhage on DNA synthesis and cytosolic-free calcium elevation in cultured porcine cerebral smooth muscle cells. Cerebrospinal fluid from patients on day 2 after subarachnoid haemorrhage induced transient elevation in cytosolic-free calcium levels. In contrast, the maximal elevation of cytosolic-free calcium levels induced by cerebrospinal fluid from control patients (without subarachnoid haemorrhage) was significantly lower than that induced by cerebrospinal fluid from patients with subarachnoid haemorrhage. In cultured porcine cerebral arterial smooth muscle cells, cerebrospinal fluid from patients with subarachnoid haemorrhage promoted levels of [3H]-thymidine incorporation (DNA synthesis) more than 2.5-fold higher than that promoted by cerebrospinal fluid from control patients without subarachnoid haemorrhage. However, in cultured aortic smooth muscle cells, there was no significant difference in [3H]-thymidine incorporation between cerebrospinal fluid from patients with subarachnoid haemorrhage and that by control cerebrospinal fluid. From these results in cerebral arterial smooth muscle cells, cerebrospinal fluid from patients following subarachnoid haemorrhage may play not only constrictive functions, evidenced by cytosolic-free calcium elevations, but also proliferative functions, demonstrated by promotion of [3H]-thymidine incorporation. The relevance of these factors to vasospasm will be discussed.

Successful treatment of glucocorticoid and cyclosporine refractory adult-onset Still's disease complicated with hemophagocytic syndrome with plasma exchange therapy and tocilizumab : a case report

A 35-year-old woman was admitted to a hospital because of fever, sore throat, cervical lymph node swelling, and skin rashes. Laboratory data revealed leukocytosis and elevated C-reactive protein (CRP), aspartate aminotransferase, alanine aminotransferase, and ferritin levels. No antinuclear antibody or rheumatoid factor was found. She was diagnosed as having adult-onset Still's disease (AOSD). Although treatment with high-dose glucocorticoid (GC) and cyclosporine (CsA) was started, her condition did not improve because of complication with severe hemophagocytic syndrome (HPS). Therefore, she was transferred to our hospital. Immediately after admission, GC pulse therapy was started again, and treatment with CsA was replaced with tacrolimus (TAC), in addition, plasma exchange therapy was initiated. After treatment, her condition improved. However, 1 week after plasma exchange was discontinued, her condition deteriorated slightly with a slight fever and elevation of CRP level. This indicated that her condition could not be managed with GC and TAC, therefore, tocilizumab (TCZ) was added to her treatment, which improved her symptoms and enabled reduction in GC and TAC doses. Although many reports have indicated that biological agents are effective for refractory AOSD, their safety and efficacy in cases of AOSD complicated with HPS are controversial as these agents may exacerbate HPS. Our present case indicates that TCZ can be used after control of the disease activity by plasma exchange against refractory AOSD complicated with HPS.

Eosinophilia with organ involvement in 3 siblings

We describe 3 siblings who suffered from marked eosinophilia with organ involvement. One sibling, who experienced cervical lymphadenopathy and peripheral neuropathy with eosinophilia (5,834 cells/μL) following bronchial asthma, was diagnosed with Churg-Strauss syndrome (CSS) according to the criteria of the American College of Rheumatology. Another sibling, who suffered from severe asthma with persistent polyarthritis and eosinophilia (2,496 cells/μL), was also diagnosed with CSS according to the criteria of the Japanese Ministry of Health, Labour and Welfare. The remaining sibling, who had eosinophilic pleuritis with peripheral blood eosinophilia (699 cells/μL), did not fulfill the widely used criteria for CSS or hypereosinophilic syndrome (HES) ; however, he fit the newly proposed criteria for HES. Glucocorticoid treatment relieved their symptoms. Although the diagnoses and the criteria used for diagnosis differed between the siblings, all 3 patients showed common features such as eosinophilia with organ involvement that required treatment, indicating the possibility of familial eosinophilia (FE). Furthermore, the clinical features observed differed substantially from those of previously reported FE patients, therefore, these 3 siblings may be affected by a type of FE distinguishable from those previously described.

Superconducting pairing and the pseudogap in the nematic dynamical stripe phase of La2-xSrxCuO4

Fully absorption coefficient corrected Raman spectra were obtained in La2-xSrxCuO4. The B1g spectra have a Fleury-Loudon type two-magnon peak (resonant term) whose energy decreases from 3180 cm(-1) (394 meV) to 440 cm(-1) (55 meV) on increasing the carrier density from x = 0 to 0.25, while the B2g spectra have a 1000-3500 cm(-1) (124-434 meV) hump (hill) whose lower-edge energy increases from x = 0 to 0.115 and then stays constant to x = 0.25. The B2g hump is assigned to the electronic scattering (non-resonant term) of the spectral function with magnetic self-energy. The completely different carrier density dependence arises from anisotropic magnetic excitations of spin-charge stripes. The B1g spectra were assigned to the sum of k ∥  and k⊥ stripe excitations and the B2g spectra to k⊥ stripe excitations according to the calculation by Seibold and Lorenzana (2006 Phys. Rev. B 73 144515). The k ∥  and k⊥ stripe excitations in fluctuating spin-charge stripes were separately detected for the first time. The appearance of only k⊥ stripe excitations in the electronic scattering arises from the charge hopping perpendicular to the stripe. This is the same direction as the Burgers vector of the edge dislocation in metal. The successive charge hopping in the Burgers vector direction across the charge stripes may cause Cooper pairs as predicted by Zaanen et al (2004 Ann. Phys. 310 181). Indeed, this is supported by the experimental fact that the superconducting coherent length coincides with the inter-charge stripe distance in the wide carrier density range. The one-directional charge hopping perpendicular to the stripe causes the flat Fermi surface and the pseudogap near (π,0) and (0,π), but the states around (π/2,π/2) cannot be produced. The low-energy Raman scattering disclosed that the electronic states at the Fermi arc around (π/2,π/2) are coupled to the A1g soft phonon of the tetragonal-orthorhombic phase transition. This suggests that the Fermi arc is produced by the electron-phonon interaction. All the present Raman data suggest that Cooper pairs are formed at moving edge dislocations of dynamical charge stripes.

Correlation between Raman sum and optical conductivity sum in La(2-x)Sr(x)CuO4

In a strongly correlated electron system, the single-particle spectral function changes into a coherent peak and incoherent humps which extend over 1 eV. The incoherent parts lose the symmetry and k dependence, so that the Raman spectra with different symmetries become identical and they are expressed by the optical conductivity. We found that the B1g and B2g spectra in La(2-x)Sr(x)CuO4 become identical above 2000 cm(-1) in the underdoped phase, if Fleury-Loudon type B1g two-magnon scattering is removed. The first Raman susceptibility moment correlates with the generalized optical conductivity moment. The good correlation arises from the incoherent states of a hump from 1000 to 4000 cm(-1). The hump is the only structure of the incoherent electronic states in the mid-infrared absorption spectra below 1.4 eV at low carrier densities. The energy is twice the separated dispersion segments of the spin wave in the k(perpendicular) stripe direction. The incoherent state is formed by the magnetic excitations created by the hole hopping in the antiferromagnetic spin stripes in the real space picture.

Evaluating the association between histological manifestations of cord colitis syndrome with GVHD

Cord colitis syndrome (CCS) is a recently proposed clinical entity characterized by a persistent diarrheal illness after cord blood transplantation (CBT), which is not caused by GVHD or CMV colitis. CCS is histologically characterized by chronic active colitis with granulomatous inflammation and Paneth cell metaplasia suggesting chronicity. However, the specificity of these pathological features to CCS remains to be validated. We conducted a retrospective study of 49 patients who had diarrhea and underwent diagnostic colonoscopy with biopsy following allogeneic hematopoietic SCT. None of the patients met the clinical criteria for CCS. Chronic active colitis with granulomatous inflammation and Paneth cell metaplasia was present in 12/33 (36%) patients with biopsy-proven GVHD, 4/6 (67%) patients with CMV colitis and 2/15 (13%) patients with nonspecific colitis. In patients with GVHD and/or CMV colitis, these pathological features were present in 4/8 (50%) patients after CBT and in 11/26 (42%) patients undergoing BMT or PBSCT. These results demonstrate that chronic active colitis with granuloma and Paneth cell metaplasia is not only a specific feature of CCS but also is present in GVHD and CMV colitis, irrespective of stem cell source.

Formation of porcine hepatocyte spherical multicellular aggregates (spheroids) and analysis of drug metabolic functions

Porcine hepatocytes are used in the hybrid artificial liver support system that we are developing because of their high level of liver functions in vitro and because human hepatocytes can not be used in Japan for ethical reasons. Spherical multicellular aggregates or spheroids have been found to be effective in vitro for long-term maintenance of liver functions. Therefore, we formed spherical multicellular aggregates (spheroids) of primary porcine hepatocytes using a polyurethane foam (PUF) as a culture substratum and analyzed their drug metabolic functions in vitro. Primary porcine hepatocytes inoculated into the pores of a flat PUF plate (25 x 25 x 1 mm), spontaneously formed spheroids within the range of 100 to 150 mum in diameter 24 to 36 h after inoculation. The formed spheroids were attached to the bottom surface of the PUF pores, and their morphology and viability were maintained for more than 12 days. The P-450 activity in the spheroids of porcine hepatocytes was demonstrated by detecting production of monoethylglycinexylidide from lidocaine. In addition, the conjugation enzyme activity was demonstrated by detecting glucuronidation and sulfation of acetaminophen. These activities were maintained for 12 days at a level twice as high as in the monolayer culture. This result shows that the porcine hepatocyte spheroids formed by using PUF can maintain the drug metabolic functions important in a hybrid artificial liver device. Consequently, culturing porcine hepatocyte spheroids using PUF seems to be promising for development of a hybrid artificial liver.

A dose-escalation regimen of trimethoprim-sulfamethoxazole is tolerable for prophylaxis against Pneumocystis jiroveci pneumonia in rheumatic diseases

OBJECTIVE

To investigate the safety and efficacy of a dose-escalation regimen of trimethoprim-sulfamethoxazole (TMP/SMX) for prophylaxis against Pneumocystis jiroveci pneumonia (PCP) in rheumatic diseases.

METHODS

Data from 41 patients, who received glucocorticoids with or without immunosuppressive agents and prophylactic use of TMP/SMX, were retrospectively analyzed. Thirteen patients were started on a daily dose of 10% of single-strength (SS) TMP/SMX, which was increased gradually (dose-escalation group), while 28 patients were started on 1 SS tablet daily (routine group).

RESULTS

In the dose-escalation group, the retention rate was 100% at 6 months. In the routine group, 5 patients discontinued TMP/SMX; the retention rate was 82.1%. Moreover, the retention rate when taking a daily dose of 50% or more of SS TMP/SMX, or 1 SS tablet thrice-weekly, was significantly higher in the dose-escalation group (100 versus 71.4%, P = 0.032). No PCP was observed in the dose-escalation group; however, 1 patient in the routine group, who had discontinued TMP/SMX, developed PCP. The rate of adverse effects was less, although nonsignificant, in the dose-escalation group (30.8 versus 46.4%, P = 0.344).

CONCLUSIONS

In rheumatic diseases, a dose-escalation regimen of TMP/SMX resulted in a higher retention rate and was safer than the routine regimen.

[Polymyositis in a father and his son ; a case report]

A 73-years-old man, who was a farmer, developed fever, fatigue, and muscle weakness. His serum creatine kinase (CK) level was found to be high. Computed tomography showed the presence of bibasilar subpleural interstitial infiltrates. He was therefore clinically given a diagnosis of polymyositis. After high-dose glucocorticoid (GC) and GC-pulse therapies were started, his symptoms improved, and the CK level decreased. The patient's son was 44-years-old. He moved back into his parent's home, quit his corporate job and started working in the agricultural field. He then developed fever, myalgia, and muscle weakness. His serum CK level was high. Therefore, he also was given a diagnosis of polymyositis. After high-dose GC and immunosuppressive therapies were stared, his symptoms improved and CK level decreased. Polymyositis may be triggered by specific environmental exposures in genetically susceptible individuals. The son developed the disease immediately after he moved into his parent's home and changed his profession to farming which was same as his father's profession. Moreover, the father and his son may have had common genetic factors. We believe that some environmental factors triggered the onset of polymyositis in the father and his son.

[Lung cancer accompanied by active pulmonary tuberculosis]

We report 2 patients with lung cancer accompanied by active pulmonary tuberculosis. Case1 was a 82-year-old woman with stage I A bronchioloalveolar carcinoma and tuberculosis in right upper lobe. Right upper lobectomy was performed after the histological diagnosis of lung cancer by intraoperative frozen section. Case2 was a 69-year-old man with papillary adenocarcinoma in right lower lobe and tuberculosis in bilateral upper lobe. Partial resection in right lower lobe was performed for diagnosis of lung cancer. Smear-positive tuberculosis was diagnosed by sputum examination after the operation. Post-operative anti-tuberculosis chemotherapy was added in both patients.

A case of IgG4-related disease with features of Mikulicz's disease, and retroperitoneal fibrosis and lymphadenopathy mimicking Castleman's disease

A 51-year-old man developed painless enlargement of the bilateral submandibular and lacrimal glands without xerostomia or xerophthalmia in the absence of autoantibodies to SS-A (Ro) and SS-B (La). In a few years, he developed generalized lymphadenopathy, with markedly elevated serum IgG4, and a computed tomography scan revealed soft-tissue-density lesions around the abdominal aorta, a finding consistent with retroperitoneal fibrosis. Biopsy of the cervical lymph node showed an expansion of the interfollicular area by heavily infiltrating plasma cells, consistent with multicentric Castleman's disease. Immunohistochemical analysis revealed that the IgG4-positive/IgG-positive plasma cell ratio was 80%, leading us to a single diagnosis of IgG4-related disease. High-dose corticosteroid treatment resulted in prompt resolution of the physical, serological, and imaging abnormalities. Although IgG4-related disease can mimic multicentric Castleman's disease, as in our patient, the two diseases have effective but distinct treatments, and thus measurement of serum IgG4 levels and specific immunohistochemical analysis for determining the IgG4-positive/IgG-positive plasma cell ratio are recommended if IgG4-related disease is suspected.

Evidence for a correlated insulator to antiferromagnetic metal transition in CrN

We investigate the electronic structure of chromium nitride (CrN) across the first-order magnetostructural transition at T(N)∼286  K. Resonant photoemission spectroscopy (PES) shows a gap in the 3d partial density of states at the Fermi level and an on-site Coulomb energy U∼4.5  eV, indicating strong electron-electron correlations. Bulk-sensitive high-resolution (6 meV) laser PES reveals a clear Fermi edge indicating an antiferromagnetic metal below T(N). Hard x-ray Cr 2p core-level PES shows T-dependent changes across T(N) which originate from screening due to coherent states as substantiated by cluster model calculations using the experimentally observed U. Electrical resistivity confirms an insulator above T(N) (E(g)∼70  meV) becoming a disordered metal below T(N). Thus, CrN transforms from a correlated insulator to an antiferromagnetic metal, coupled to the magnetostructural transition.

Local lattice distortion in the giant negative thermal expansion material Mn3Cu1-xGexN

Giant negative thermal expansion is achieved in antiperovskite manganese nitrides when the sharp volume change associated with magnetic ordering is broadened by substitution. In this Letter, we address the unique role of the ''magic" element, Ge, for such broadening in Mn3Cu1-xGexN. We present evidence for a local lattice distortion well described by the low-temperature tetragonal (T4) structure of Mn3GeN for a range of x, where the overall structure remains cubic. This structural instability shows a strong correlation with the broadness of the growth of the ordered magnetic moment and, hence, is considered to trigger the broadening of the volume change.

Disseminated tuberculosis following second unrelated cord blood transplantation for acute myelogenous leukemia

Here we report the case of a 43-year-old Japanese woman with acute myelogenous leukemia who underwent 2 unrelated cord blood transplantations (UCBT), terminating in fatal disseminated tuberculosis (TB). The patient did not achieve remission despite intensive chemotherapy, and subsequently underwent UCBT with a standard conditioning regimen. However, engraftment was not achieved. Fifty days after the first UCBT, the patient underwent a second UCBT with a reduced-intensity conditioning regimen. She developed a pre-engraftment immune reaction, which responded well to prednisolone, and engraftment was documented. However, 50 days after the second UCBT, the patient presented with high fever and developed pneumonia despite antibiotic and antifungal treatments. Thereafter, Mycobacterium tuberculosis was detected in blood cultures and specimens of bronchoalveolar lavage, thus indicating disseminated TB. Despite anti-tuberculous treatment, she died on day 85. TB should always be considered as a possible diagnosis when treating febrile immunocompromised patients.