First Case of Concurrent Cytomegalovirus and Aspergillus tamarii Pulmonary Infections in a Mantle Cell Lymphoma Patient: A Case Report and Literature Review.

Patients with mantle cell lymphoma (MCL) who undergo chemotherapy are at high risk of developing opportunistic pulmonary infections. Concurrent infection with cytomegalovirus (CMV) and the rare pathogen Aspergillus tamarii (A. tamarii) has never previously been reported in MCL patients. In this case report, we present the first documented instance of concurrent CMV and A. tamarii pneumonia in a MCL patient. A 69-year-old man with MCL developed a cough, chills, exertional dyspnoea, and hypoxemia after five cycles of rituximab-bendamustine (R-Benda) chemotherapy. Chest computed tomography (CT) showed bilateral ground-glass opacities. Metagenomic next-generation sequencing (mNGS) of the blood and bronchoalveolar lavage fluid (BALF) simultaneously revealed CMV and A. tamarii infections. The patient initially achieved rapid clinical improvement with ganciclovir and voriconazole. However, the infection relapsed following unauthorised premature discontinuation of ganciclovir and voriconazole without medical advice. Long-term oral voriconazole with regular TDM and close monitoring of ganciclovir-related myelosuppression resulted in sustained remission. This is the first reported case of concurrent CMV and A. tamarii pulmonary coinfection in a MCL patient, and mNGS enables the rapid and accurate diagnosis of mixed rare infections. Voriconazole is effective against A. tamarii; TDM and full-course treatment are essential for preventing relapse. We present a practical workflow for managing immunocompromised patients with rare mixed pulmonary infections to improve outcomes.