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LAST MONTH’S CLINICAL CHALLENGE

 

A 44-year-old man with AML in CR2 had a matched unrelated donor PBSC transplant using busulfan and cyclophosphamide conditioning.  The patient and donor were CMV positive.  GVHD prophylaxis was tacrolimus/methotrexate.

 

At Day +23, an erythematous rash on his upper back, shoulders and ears was treated with topical triamcinolone cream and resolved.  At Day +36  (Friday afternoon), he presents with two days of watery diarrhea (four stools; estimated 700 ml per day), nausea and anorexia, and a new erythematous rash over his upper chest, back and arms.  On physical exam, he is afebrile and has a rash.  His abdomen is minimally tender without rebound.  Laboratories are notable for WBC 3400 (ANC 1900), platelets 36,000, creatinine 1.5, total bilirubin 2.4, direct bilirubin 1.9, alkaline phosphatase 195 (nl <150); AST 44 (nl <50). Trough tacrolimus level 10.   CMV DNA PCR showed 850 copies (previously negative <500).   He is taking tacrolimus and fluconazole plus scheduled medications for depression, heartburn, hypertension, edema and hypokalemia.  Skin and GI biopsies are done.

 

What would you recommend?


YOUR RESPONSES

 

·         Start prednisone 2 mg/kg/day along with ganciclovir 5 mg/kg q12 hrs. – 44%

 

·         Start ganciclovir 5 mg/kg q12 hrs.  Add prednisone only if GI biopsy is positive for GVHD. – 29%

 

·         Start prednisone 2 mg/kg/day.  Add ganciclovir only if GI biopsy shows CMV. – 24%

 

·         No therapy until results of skin and GI biopsy are available. – 3%

 

FURTHER DEVELOPMENTS:  After 8 days (Day +44), his diarrhea (850 ml/day) and rash persist and are unchanged. The skin biopsy shows GVHD.  The GI biopsy results are still pending. His total bilirubin is 2.9, creatinine 1.8, repeat CMV DNA PCR is negative.

 

What would you recommend?

 

YOUR RESPONSES

·         Add prednisone 2 mg/kg/day. – 34%

·         Add mycophenolate mofetil. – 26%

·         Add ATG (horse or rabbit). – 9%

·         Add etanercept. – 9%

·         Add other GVHD therapy not listed. – 9%

·         No change in therapy, order liver biopsy. – 5%

·         Continue initial treatment. – 4%

·         Add sirolimus. – 4%

       

Click Here To Read Commentary
by Daniel Weisdorf, MD
University of Minnesota