Bone Marrow Transplantation (2002) 29, 715â716. 2002 Nature Publishing ... Bone marrow suppression, another manifestation of. CMV infection8 has been ...
Bone Marrow Transplantation (2002) 29, 715–716 2002 Nature Publishing Group All rights reserved 0268–3369/02 $25.00 www.nature.com/bmt
Case report Unusual cytomegalovirus complications after autologous stem cell transplantation for large B cell lymphoma: massive gastrointestinal hemorrhage followed by a communicating hydrocephalus Y Cohen1, O Paltiel2, G Amir3, N Da’as1, D Engelhard4 and A Polliack1 1
Department of Hematology Hadassah University Hospital, Jerusalem, Israel; 2Department of Social Medicine, Hadassah University Hospital, Jerusalem, Israel; 3Department of Pathology, Hadassah University Hospital, Jerusalem, Israel; and 4Department of Pediatrics, Hadassah University Hospital, Jerusalem, Israel
Summary: Unusual cytomegalovirus (CMV)-related complications were seen after autologous stem cell transplantation (SCT) in a 50-year-old patient with diffuse large B cell lymphoma. One month after SCT, the patient developed life-threatening upper gastrointestinal tract (GIT) bleeding with several episodes of hemorrhagic shock. Endoscopy and subsequent explorative laparotomy revealed deep-seated bleeding ulcers containing intracellular CMV inclusion bodies distributed extensively in the GIT, from the lower esophagus to the small bowel. Later, she developed gradual loss of consciousness with communicating hydrocephalus which was possibly secondary to CMV-induced ventriculitis. She recovered completely after insertion of a ventriculostomy and subsequent V-P shunt. Bone Marrow Transplantation (2002) 29, 715–716. DOI: 10.1038/sj/bmt/1703519 Keywords: gastrointestinal tract hemorrhage; autologous transplantation; lymphoma; hydrocephalus; CMV
CMV antigenemia is common early after autologous or allogeneic stem cell transplantation (SCT),1 but usually lacks any clinical significance. The lung is the organ most susceptible to invasive CMV infection, although this occurs infrequently after autologous SCT.2 Rare sites of CMV infection post autologous SCT include the gonads3 and the gastrointestinal tract (GIT).4 The following case report describes an unusual clinical course of CMV infection early after autologous SCT. A 50-year-old female who had stage 4B diffuse large B cell lymphoma involving the adrenal glands, uterus, ovaries and abdominal lymph nodes with markedly elevated LDH (4000 IU), achieved complete remission after six cycles of CHOP. She was maintained on a continuous low dose of Correspondence: Dr A Polliack, Head of Lymphoma-Leukemia Unit, Department of Hematology, Hadassah University Hospital, Jerusalem, Israel 91120 Received 2 October 2001; accepted 21 January 2002
Figure 1 Jejunal mucosa showing partial ulceration and granulation tissue (H&E ×5).
prednisone (5 mg daily) because of Addison’s disease caused by adrenal involvement by lymphoma. Four months later, she underwent autologous PBSCT using the TECAM conditioning regimen (etoposide, thiotepa, cytarabine, cyclophosphamide and melphalan) with engraftment on day ⫹25. On day ⫹30 she complained of abdominal pain which was followed by massive upper GIT bleeding. During the following days, several episodes of hemorrhagic shock occurred. Endoscopy and subsequent explorative laparotomy revealed many deep-seated bleeding ulcers along the lower esophagus, stomach and jejunum (Figure 1). Biopsy revealed intracellular CMV inclusion bodies (Figure 2).
Figure 2 Immunohistochemical stain of the granulation tissue shows numerous infected cells (×40).
CMV infection after autologous SCT Y Cohen et al
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tion. Although CMV enteritis occurs occasionally after allogeneic SCT,4–6 massive GIT bleeding from extensive deep-seated ulcers, as described in this case is extremely unusual and has only been reported on one occasion.7 Bone marrow suppression, another manifestation of CMV infection8 has been attributed to coinfection of the transfused CD34⫹ stem cells with CMV.9 Since hydrocephalus is an unusual occurrence after transplant, its presence here after a systemic CMV infection suggests that perhaps CMV-induced ventriculitis was responsible, despite the fact that at the time of diagnosis, CSF examination was normal, without pleocytosis, and PCR for CMV negative. In conclusion, our experience shows that CMV complications are not necessarily limited to the allogeneic SCT setting, and may be seen after autologous SCT in immunocompromised patients. Screening for CMV after autologous SCT is useful under such circumstances.
References
Figure 3 Hydrocephalus showing increase in size of the lateral, as well as the third ventricle.
Blood PCR was also positive for CMV while serology showed evidence of past CMV infection. On day ⫹39 she developed ARDS due to massive aspiration of hematemesis, associated with severe pancytopenia. Intensive blood product support, which included dozens of packed RBC and platelets unit transfusions, resulted in hemodynamic stabilization while treatment with i.v. gancyclovir (10 mg/kg every day) for 2 months achieved control of the viral infection, with disappearance of the antigenemia within the first 2 weeks. However, on day ⫹75, loss of consciousness occurred due to the development of a communicating hydrocephalus (Figure 3). Following ventriculostomy and subsequently V-P shunt insertion, her neurologic disability improved and later disappeared. At the time of diagnosis of the hydrocephalus, CSF examination was normal and PCR for CMV negative. Currently, 2 years after PBSCT, the patient is well and remains in complete remission. Discussion The unusual post-autologous SCT complications that occurred in this patient included CMV-related GIT infec-
Bone Marrow Transplantation
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