Thanks Emilio for presenting a great case! This was a person who was several weeks out from a matched unrelated donor allogeneic stem cell transplant, on broad-spectrum antibiotics with severe neutropenia who was intubated for acute hypoxic respiratory failure found to have pulmonary aspergillosis.
- ) The differential diagnosis for acute respiratory failure in a BMT patient is broad and includes the following categories to consider: infection (opportunistic infection, nosocomial, seasonal, aspiration), transplant complications (early & late: chemo side effect, PTLD, bronchiolitis obliterans, organizing pneumonia), transfusion reaction, DAH, and ARDS. Here's a great NEJM case that discusses the differential.
- ) Pulmonary aspergillosis has a classic triad of “fever, pleuritic chest pain, and hemoptysis” and associated with transplant patients, esp those with severe/ prolonged neutropenia, GVHD, CMV+, and on TPN; there should be a low threshold in these patients who are profoundly immunocompromised to get cross-sectional lung imaging
- ) The American Society for Blood and Bone Marrow Transplantation has an excellent comprehensive set of guidelines for evaluating infection after BMT
Want to learn more?
Infection in post-BMT patient
- Time periods to think about are the pre-engraftment period, the first 100 days and then later
- Prior to engraftment, bacterial infections predominate (also nosocomial as patients are in the hospital prior to engraftment); as the immune system recovers in the first 100 days (B cells then T cells slowly) patients are at risk for viral and fungal infections still
- Also consider seasonal respiratory infections during this period as well
- Recall that infections will present atypically in patients who lack an immune system, so have a low threshold to consider infection in these patients
- Check out this great video for residents from the National Marrow Donor Program by Dr Miguel-Angel Perales of MSKCC on early complications after BMT
ICU outcomes for BMT patients
- This is an often-cited Journal of Clinical Oncology paper that was a multicenter retrospective sample of ~300 patients after allogeneic SCT admitted to the ICUs in France between 1997-2003. The majority were admitted for respiratory failure and over half needed mechanical ventilation. Of all the patients, 32% were discharged from the hospital, and 21% survived 1 year. Outcomes were worse for those who were intubated.