CASE REPORT article
Front. Med.
Sec. Infectious Diseases: Pathogenesis and Therapy
Hemophagocytic Syndrome Caused by Epstein-Barr Virus and Cytomegalovirus Infection During Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Case Report
Kou Kanesada
Kazuhiko Yoshimatsu
Shuya Yano
Masaharu Higashida
Toshimasa Okada
Shunji Endo
Yoshinori Fujiwara
Tomio Ueno
Kawasaki Medical School, Kurashiki, Japan
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Abstract
Background: Immune dysregulation and excessive inflammatory responses can lead to hemophagocytic syndrome (HPS) involving autologous blood cell phagocytosis, with fatal outcomes occurring in some cases. This case report describes an 80-year-old man who was simultaneously diagnosed with diffuse large B-cell lymphoma (DLBCL) and rectal cancer and developed HPS during neoadjuvant chemotherapy for the latter. Case Description: Treatment for DLBCL was initiated first, and six courses of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) therapy were administered, which led to a clinical complete response of the lymphoma lesions. Following the completion of DLBCL treatment, preoperative chemoradiotherapy with tegafur–uracil/leucovorin (UFT/UZEL) was initiated for rectal cancer. On Day 18, a fever of 38.3 °C developed. Blood tests conducted on Day 24 revealed Grade 4 neutropenia and Grade 4 thrombocytopenia. Granulocyte colony-stimulating factor (G-CSF) preparation, antibiotic therapy, and recombinant human soluble thrombomodulin (rTM) were initiated as disseminated intravascular coagulopathy (DIC) therapy. A poor therapeutic response was achieved, and acute respiratory distress syndrome (ARDS) developed on Day 34. Imaging of the biopsied bone marrow confirmed that hemophagocytosis by macrophages was occurring. The patient was ultimately diagnosed with HPS. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections were identified, and treatment to combat the infections was initiated; however, the patient passed away on Day 37. Conclusions: It is important to consider the possibility of HPS, and diagnosis and treatment initiation should occur in a timely manner when fever of an unknown origin and decreased blood cell counts are observed during malignant disease treatment.
Summary
Keywords
Cytomegalovirus infection, Epstein-Barr virus, Hemophagocytic syndrome, Neoadjuvant chemoradiotherapy, rectal cancer
Received
14 October 2025
Accepted
20 February 2026
Copyright
© 2026 Kanesada, Yoshimatsu, Yano, Higashida, Okada, Endo, Fujiwara and Ueno. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Kazuhiko Yoshimatsu
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