SCT Question 12

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Question 12

A 35-year-old patient who was transplanted with a HLA matched, DPB1 non-permissive mismatched donor (CMV recipient seroneg, donor CMV sero pos) one year ago presents with a four weeklong history of persistent cough and now shortness of breath on exertion over the past week. The patient had parainfluenza type 3 virus infection one month ago and has had a cough since then. His conditioning was with 12 Gy TBI and CY, with ATG, Tacrolimus and MTX for GVHD ppx. Lung shielding was applied at 750 cGy. Tacrolimus has been off for six months. He is on atovaquone. There are no stigmata of chronic GVHD, except for mild dry mouth and dry eyes. On exam he is tachycardic, SaO2 is 96% on RA at rest and drops to 93% on ambulating in the clinic, breath sounds are diminished. Today nasopharyngeal swab comes back negative for parainfluenza type 3 and other respiratory pathogens. Hi resolution CT scan of the lung shows air trapping on expiratory images and scattered ground glass opacities. WBC ct is normal, and diff has mild eosinophilia but is unremarkable otherwise. IV IGG is 700 mg/dL.

What is the most likely successful treatment

1. FAM therapy

2. Bactrim

3. Levofloxacin

4. Prednisone

5. Posaconazole


Option 1. This is a case of bronchiolitis obliterans in a patient who underwent a transplant from a donor with a DPB1 non-permissive mismatched donor. The risk of GVHD is higher with these donors. Myeloablative total body irradiation also increases lung GVD risk, even though lung shielding is universally used. The antecedent viral infection is the likely trigger for this onset of what is likely BO as indicated by air trapping on chest CT. Mild eosinophilia may be seen in chronic GVHD. The symptoms are mild to moderate and hypoxia is relatively mild. In this setting FAM will likely be adequate therapy. There is little to suggest active infection.


Medicine and Health Sciences


Department of Medicine

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