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Bone Marrow Transplant

 

 

Early Complications

Infection

Patients are at risk of life threatening infections immediately after transplant due to prolonged neutropenia.

Most severe infections present as fever with signs of systemic inflammatory response syndrome. For example:

  • Hypotension
  • Tachycardia
  • Respiratory distress
  • Edema
  • Encephalopathy 

Admission to intensive care is not uncommon.

Common infections (bacterial, viral, fungal) during the aplastic phase include:

Infectious Agent

Risk Factors

Gram-Negative Bacteria
  • aGvHD of Gut
  • Chemotherapy / XRT causing mucositis of lower GI tract
  • Constipation

Staphylococcus epidermidis
  • Central Line
Viridans Streptococci
  • Oral mucositis
  • Poor oral hygiene

RSV, Parainfluenza and Other Respiratory Viruses
  • Visitors and Staff (including doctors and nurses) who are sick around patient or don’t properly wash hands.

Clostridium difficile diarrhea
  • Frequent use of antibiotics

Candida species
  • Colonization before transplant
  • Central line
  • Total Parenteral Nutrition

Aspergillus
  • Prolonged neutropenia
  • Construction outdoors with high airborne spore count.
  • Total Parenteral Nutrition

Herpes Simplex Virus
  • Previous exposure to HSV

Most patients receive prophylaxis with :

  • Acyclovir (if they were previously exposed to HSV)
  • An anti-mold azole (e.g. itraconazole, voriconazole). 

Antibiotic prophylaxis is controversial.

Fever in the HSCT patient is a medical emergency and requires prompt attention including

  • Full patient assessment
  • Blood cultures
  • Broad-spectrum antibiotics (usually pipercillin-tazobactam with an aminoglycoside such as gentamicin but this will differ by institution)

Anti-fungal agents (usually liposomal amphotericin) are added if fevers continue for more than 3-5 days and an evaluation by computed tomography of the chest to look for pulmonary aspergillosis is undertaken.

Figure: Bilateral pulmonary aspergillosis in a patient two weeks after an allogeneic unrelated HSCT.  Note the presence of the “halo sign” on the CT scan.  Patient had been having fevers for 4 days and increasing respiratory distress.

 

 

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