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Answer 3
  1. P. carinii pneumonia. Alemtuzumab is an anti-CD52 monoclonal antibody that is approved for the treatment of relapsed CLL.3 Alemtuzumab also is a potent T-cell inhibitor and is associated with a very high risk of secondary infections including P. carinii, varicella zoster reactivation, and cytomegalovirus reactivation. Patients receiving alemtuzumab should be treated with prophylactic trimethoprim/sulfamethoxazole and acyclovir and should be monitored for cytomegalovirus reactivation. Patients with CLL are at increased risk for bacterial infections, such as sinusitis and pneumonia, as a result of disease-induced hypogammaglobulinemia and subtle defects in immune function. Despite this, pneumococcal pneumonia is less likely in this patient given the nonproductive cough and lack of a lobar infiltrate. Hypersensitivity pneumonitis can occur with any medication but does not occur this late after receiving alemtuzumab. Pulmonary infiltration from CLL is extremely rare. Histoplasmosis is unlikely given that this patient is from New Hampshire (an area of the country where histoplasmosis is not endemic) and has not traveled.

    3. Rai KR, Freter CE, Mercier RJ, et al. Alemtuzumab in previously treated chronic lymphocytic leukemia patients who also had received fludarabine. J Clin Oncol 2002;20:3891–7.

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