SCT Question 11
A 65 Y male presents for a clinic visit and reports slowly progressive dyspnea on exertion, with cough evolving over the last week. SaO2 on RA is 88% and drops to 82% with walking, with a 30 beats per minute increase in HR. SaO2 returns to baseline over two minutes upon coming to rest. He underwent a HLA-A antigen mismatched unrelated donor transplant using a reduced intensity conditioning regimen for high-risk AML in CR2, four months ago. GVHD ppx was with PT CY followed by MMF and tacrolimus, early post-transplant course was complicated by asymptomatic CMV viremia which was treated with oral valganciclovir. Because of high-risk disease tacrolimus was stopped at day 90 post-transplant. Lung exam reveals crackles in bilateral bases. There is no JVD or peripheral edema. Heart sounds are normal. There is no skin rash. CT of the chest without contrast demonstrates scattered bilateral areas of consolidation. Galactomannan assay is negative. CRP is 4xULN.
What is the most likely successful treatment
1. FAM therapy
Option 4. This is a case of organizing pneumonia in a patient who has had an HLA mismatched unrelated donor transplant, with early withdrawal of immune suppression to provoke a graft vs. leukemia effect in relapsed high-risk AML. The clinical course was complicated by CMV viremia which further increases the risk for alloreactive response in an already fraught setting. Several weeks later he has progressive dyspnea and severe hypoxia with hemodynamic consequences, elevated CRP and has consolidation on chest CT scan. This situation requires systemic corticosteroids. FAM will be inadequate therapy given consolidative changes. In practice the CT findings merit antibiotic therapy to be commenced as well. This measure of hypoxia will usually be seen in more advanced fungal disease. Nevertheless, BAL is a necessary part of the work up. Foscarnet administration will need evidence of active CMV infection. At day 100 off tacrolimus CMV pneumonia is less likely.
Published In/Presented At
Toor, A. (2023). SCT Question 11. LVHN Scholarly Works. Retrieved from https://scholarlyworks.lvhn.org/medicine/6043
Medicine and Health Sciences
Department of Medicine