SCT Question 6
Publication/Presentation Date
7-2023
Published In/Presented At
Question 6
A 45 Y/F allogeneic SCT recipient presents to the ED with abdominal pain and diarrhea. She is 85 days post transplant and had ATG, Fludarabine and Melphalan for conditioning. The donor was HLA matched sibling; Donor and recipient are both sero-positive for CMV. Post transplant course has been complicated by grade I skin graft vs. host disease for which she received short course steroids, and multiple courses of broad-spectrum antibiotics for line associated and lung infections. She remains on tacrolimus (therapeutic level), letermovir and acyclovir, as well as bactrim and voriconazole. On exam she has low grade fever, mild tachycardia and orthostatic hypotension. There is faint erythema over the upper chest and shoulders. Abdomen is diffusely tender, with minimal rebound. An AXR shows mild colonic distension, with diminished haustra. CBC shows leukocytosis with neutrophilia. CRP is 3xULLN and lactate is 2xULN. Creatinine is 1.5xULN.
The most likely diagnosis is
1. Acute GI GVHD
2. CMV colitis
3. C difficile colitis
4. Adenovirus enteritis
5. Malabsorption
Answer
Option 3. This patient most likely has severe C diff colitis, she has had recurrent courses of antibiotic therapy for bacterial infection. Neutrophil leukocytosis with low grade fever, suggests an infectious etiology, although it does not exclude GVHD, which is the next most likely etiology of severe diarrhea, in this instance if the C diff assay comes back negative. The AXR findings are ominous and portend progression to toxic megacolon, which in rare instances may be severe enough to require colectomy if accompanied by septic shock. This was a HLA matched related donor transplant with ATG used in the GVHD ppx, making severe GI acute GVHD a little less likely, particularly in view of well controlled skin GVHD off steroids and therapeutic tacrolimus. owever, patients who get C diff colitis may be at greater risk of developing subsequent GI GVHD, likely secondary to dysbiosis and gut inflammation. Letermovir in CMV D+/R+ situation makes CMV colitis less likely. Osmotic diarrhea from malabsorption would not be associated with the pain, fever and leukocytosis. Adenovirus enteritis is usually a severe illness and often rapidly progressive, with multiorgan involvement, including lungs.
Disciplines
Medicine and Health Sciences
Department(s)
Department of Medicine
Document Type
Research