Disseminated tuberculosis secondary to polymicrobial co-infection following long-term immunotherapy for sarcomatoid mesothelioma: A case report

Our plain-English summary of Disseminated tuberculosis secondary to polymicrobial co-infection following long-term immunotherapy for sarcomatoid mesothelioma: A case report, by L. Xia, J. Xu, Z. Chen, et al (Respiratory Medicine Case Reports, 2026).

The study

• Authors: L. Xia, J. Xu, Z. Chen, Y. Shen, Y. Zou
• Journal: Respiratory Medicine Case Reports
• Published: 2026;59:102367
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM), particularly its sarcomatoid subtype, is a highly aggressive sarcoma of the pleural lining with a dismal prognosis. Prolonged use of immune checkpoint inhibitors (ICIs), while improving survival in selected patients, can induce profound immunosuppression, increasing susceptibility to life-threatening opportunistic infections. This report describes a 77-year-old male with sarcomatoid MPM who developed fatal disseminated tuberculosis (TB), accompanied by concurrent Aspergillus and herpesvirus infections during extended immunotherapy. The case underscores the critical role of metagenomic next-generation sequencing (mNGS) in enabling rapid diagnosis of atypical TB reactivation in an immunocompromised host, even when conventional cultures are negative. mNGS identified co-infections with Aspergillus flavus and herpesviruses (HHV-5, HHV-4, HHV-1), demonstrating its superiority in polymicrobial infection detection.

© 2026 The Authors.

In plain English

This was a case report from a hospital in Nanchang, China, about a 77-year-old man with sarcomatoid malignant pleural mesothelioma. The article did not describe any asbestos exposure for him. From May 2022 he received immunotherapy (nivolumab with ipilimumab, later sintilimab). He also took the steroid methylprednisolone for over 6 months, which the authors said caused immunosuppression. In early 2025 he had repeated fevers. A fungal culture grew Aspergillus flavus, while sputum smears for tuberculosis were negative. After chemotherapy in March 2025 his blood counts fell severely and he entered intensive care. Gene sequencing of blood and sputum (mNGS) then found Mycobacterium tuberculosis, Aspergillus flavus and three herpesviruses. Another test measured a high tuberculosis load (11,433.4 copies/mL). He died of septic shock and multiorgan failure on March 30, 2025. The authors concluded that patients like him, on long-term immunotherapy with steroids, may have an increased risk of fatal infections. They called for tuberculosis screening before immunotherapy and early use of mNGS. They noted that no autopsy confirmed the spread of tuberculosis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report
• Who was studied: One 77-year-old man with a 2-year history of sarcomatoid malignant pleural mesothelioma (MPM), treated at The Second Affiliated Hospital of Nanchang University, Jiangxi Province, China, from May 2022 until his death in March 2025
• Exposure: The exposure was not asbestos: the article gives no asbestos history for this patient. It describes long-term immune checkpoint inhibitor therapy. This began with nivolumab plus ipilimumab, then nivolumab alone, then sintilimab from June 2024. He also received methylprednisolone for over 6 months, radiotherapy in September 2024, and pemetrexed plus bevacizumab on March 17, 2025.
• Main results:
  • Early tests in this patient did not find tuberculosis. In February 2025, sputum smears for acid-fast bacilli (the stain used to look for tuberculosis bacteria) were negative.
  • On March 9, 2025, a fungal culture grew Aspergillus flavus. Blood culture, serum beta-D-glucan and sputum acid-fast smears were negative at that time.
  • On March 22, 2025, after chemotherapy, the patient had grade IV myelosuppression (severely low blood counts) and a severely low CD4+ T-cell count of 128 per microliter.
  • On March 25, 2025, mNGS of the patient's blood and sputum found the following: Mycobacterium tuberculosis complex (50,595 reads), Enterococcus faecium (21 reads), Aspergillus flavus complex (7 reads), and human herpesviruses 1, 4 and 5 (743, 927 and 60,318 reads).
  • Sequencing found no rifampicin or isoniazid resistance in the tuberculosis.
  • Sputum acid-fast smears then turned positive: 3+ on March 25 and 4+ on March 26, 2025.
  • On March 27, 2025, droplet digital PCR confirmed human-type Mycobacterium tuberculosis in the patient's blood at a high load (11,433.4 copies/mL).
  • Despite changed antimicrobial treatment and supportive care, the patient died on March 30, 2025, of refractory septic shock and multiorgan failure.
• The authors' conclusion: The authors concluded that this case suggests that sarcomatoid MPM patients receiving long-term immune checkpoint inhibitors combined with corticosteroids may have an increased risk of fatal polymicrobial infections. They called TB screening before treatment, infection monitoring, early mNGS and multidisciplinary collaboration critical.
• Limitations the authors state:
  • The authors stated that the single-center retrospective design may restrict how far the findings apply to others.
  • The authors stated that there was no autopsy to confirm the disseminated tuberculosis.

Topics

Medical terms in this study, explained in our Lexicon: Immunotherapy, Sarcomatoid, Mesothelioma, Pleural Mesothelioma, Sarcoma, Prognosis, checkpoint inhibitors, Next-Generation Sequencing (NGS).

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• Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma — A. Nakas, E. von Meyenfeldt, et al. (2012)
• Response to Nivolumab followed by complete cytoreductive surgery with HIPEC resulted in long-term survival in a patient with sarcomatoid-predominant biphasic peritoneal mesothelioma. A case report — P.H. Sugarbaker (2023)
• Sarcomatoid Type Primary Pericardial Mesothelioma with a Long-term Survival after the Onset of Cardiac Tamponade — C. Saisho, H. Ishii, et al. (2016)
• Sarcomatoid diffuse pleural mesothelioma in an 80-year-Old woman with long-term response to nivolumab plus ipilimumab: A case report — Y. Yoshida, H. Mizugaki, et al. (2025)
• A Case of Pulmonary Embolism with Sarcomatoid Malignant Pleural Mesothelioma with Long-Term Pleural Effusion — R. Gu, L. Jiang, et al. (2021)

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