SESSION TYPE: Cancer Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We describe a case of Engraftment syndrome (ES) following donor lymphocyte infusion (DLI) for AML.
CASE PRESENTATION: A 55 year-old female with history of allogeneic HSCT for AML nine months ago, was admitted to the ICU with neutropenic fever for seven days and respiratory distress, with recent relapse requiring DLI (total cell dose of 1.02x10^7 CD3/kg) eleven days prior to presentation. Her symptoms consisted of dyspnea, fevers and new non-pruritic rash; she denied headaches, chest pain, cough, abdominal pain or diarrhea. Her vital signs were 39.2C, HR 115, BP 130/70, RR 40, and saturations of 97% on 2L NC. Exam: significant for respiratory distress, tachycardia, diffuse rales, soft, non-distended abdomen, no edema and an erythematous, non-blanching maculopapular rash over her malar eminence and upper body. WBC=500, ANC=400, AST=26, ALT=22, tbili=2.4, and creatinine=0.92. Chest radiograph revealed diminished vascular clarity and perihilar airspace opacities consistent with pulmonary edema. BAL revealed colorless fluid with 1010 RBCs, 95 WBCs; 49% lymphocytes and 45% macrophages. Her condition deteriorated on broad spectrum anti-infective therapy while pan-body fluid cultures remained negative; symptoms progressed to include diarrhea, hypoxia requiring 15L high-flow NC, delirium and by day 4 of ICU admission her labs were: WBC=4,700, ANC=4,000, AST=195, ALT=64, t-bili=5.2 and creatinine=2.0. Methylprednisolone and etanercept were initiated for working diagnosis of ES with rapid (within 48 hours) resolution of her hypoxia, fever, rash, diarrhea, transaminitis, and stabilization of renal function.
DISCUSSION: Engraftment Syndrome occurs in the peri-engraftment period of HSCT. While it is most often described following autologous HSCT, it can also occur after allogeneic HSCT and in this population is difficult to distinguish from hyper-acute GVHD. Two different diagnostic criteria have been proposed. The Maiolino criteria requires non-infectious fevers plus: skin rash, pulmonary infiltrates or diarrhea occurring 24 hours before or any time after the first appearance of neutrophils. Other common findings of ES included in the Spitzer criteria are hepatic dysfunction, renal failure, transient encephalopathy and weight gain >2.5% of body weight. Our patient fulfilled both diagnostic criteria for ES.
CONCLUSIONS: To our knowledge, this is the first documented case of ES following DLI. Recognition of ES as a pulmonary complication of HSCT is important as it historically carries a high mortality rate, but can respond dramatically to steroid and anti-TNF therapy.
1) Carreras, E et al. Engraftment Syndrome after Auto-SCT: analysis of diagnostic criteria and risk factors in a large series from a single center. Bone Marrow Transplantation 2010; 45:1417-1422.
DISCLOSURE: The following authors have nothing to disclose: Joseph Pitcher, Harold Chung, Amir Toor, Catherine Grossman
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