SCT Question 18

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Question 18

A 65-year-old patient is 88 days post unrelated donor PBSC transplant. Conditioning was with Bu-Flu and ATG was given from day -9 to day -7, followed by tacrolimus and MMF. Grade III skin/GI GVHD developed after withdrawal of MMF and was treated with MP and eventually ruxolitinib due to steroid refractoriness. Ruxolitinib yields a good response and now the patient is asymptomatic and presents too the clinic for a routine visit. Current immune suppression is with ruxolitinib, tacrolimus and steroids are being tapered. EBV titer last week was detectable but not quantifiable. Today the titer is 500 copies/mL. There is no fever or lymphadenopathy, LDH is normal, and no atypical lymphocytosis is observed. He is HLA-A2 positive. Next treatment options are

  1. Continue 3 agent immunosuppression and repeat EBV in one week
  2. Taper immunosuppression over two weeks and repeat EBV
  3. Administer rituximab and taper steroids over two weeks
  4. Administer EBV specific, HLA-A2 cytotoxic CTL
  5. Administer IV IGG


Option 3. This patient has had in vivo T cell depletion utilizing ATG and is now on three agent immunosuppression with steroids, ruxolitinib and CNI for management of steroid refractory GVHD. The EBV titer has risen significantly and with this background is likely to continue going up exponentially and thus requires therapy. Rapid tapering of immune suppression risks a flare of severe GI GVHD and IV IGG is ineffective.


Medicine and Health Sciences


Department of Medicine

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