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Paradoxical embolism after peripheral blood stem cell infusion

Bone Marrow Transplantation volume 36, pages 561–562 (2005)Cite this article

There are two case reports of a paradoxical embolus to the brain following bone marrow infusion.1 We describe a similar case following infusion of peripheral blood hematopoietic stem cells.

A 62-year-old man had been diagnosed with classical Hodgkin's lymphoma 5.2 years prior to admission. He was initially treated with ABVD chemotherapy, and achieved complete remission. He relapsed with neck and mediastinal lymphadenopathy 4 years later and was treated with ICE/rituximab. Although initially thought to be disease-free following ICE/rituximab, he developed recurrent lymphadenopathy 3 months later, and was treated with gemcitabine-based salvage chemotherapy with good response. He was then mobilized with cyclophosphamide+granulocyte colony-stimulating factor (G-CSF) and underwent two apheresis procedures to collect autologous hematopoietic stem cells (HSC) with a yield of 3.09 × 106 CD34+ cells per kilogram of patient weight, which were cryopreserved in 10% dimethyl sulfoxide (DMSO), human serum albumin, and Plasmalyte-A media. Following conditioning with cyclophosphamide, BCNU and etoposide, while being reinfused with the first thawed HSC product several weeks later, he suddenly felt nauseated and complained of abdominal pain. He decided not to volunteer these symptoms and continue with the infusion. At the end of the 220 ml infusion, he had a ‘scratchy sensation’ in his throat, which prompted him to cough repetitively. Subsequently, his nurse noticed a new right facial droop. He also complained of tingling in the index finger of his left hand. The patient denied a history of hypertension or previous strokes. He denied headache, chest pain, shortness of breath, palpitations, calf pain, dyspnea, or urticaria. Physical examination was remarkable for a central right facial nerve palsy and dysarthria. His body temperature remained unchanged at 36.8°C throughout the transfusion. His heart rate remained approximately 90/min and his blood pressure ranged from 100/60 mmHg prior to infusion to 124/92 mmHg after its completion. With supportive care, his symptoms improved substantially over the first hour, with ongoing improvement over the subsequent 48 h. Computed tomography (CT) with angiography was performed immediately, followed by magnetic resonance imaging (MRI) approximately 12 h later; results were normal for both studies. Since he had only received 1.65 × 106 CD34+ cells/kg with the first infusion, the decision was made to infuse a second banked autologous HPSC product. The second product was washed, filtered, and caused no further reactions. Transthoracic echocardiography with bubble injection demonstrated intracardiac shunting suggestive of a small aortic septal defect or a patent foramen ovale (PFO). There was no evidence of deep vein thrombosis in the bilateral lower extremities by duplex ultrasound with Doppler study. The remainder of his hospital course was uncomplicated and to date he remains free of recurrent neurologic symptoms.

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References

  1. Moore TB, Chow VJ, Ferry D et al. Intracardiac right-to-left shunting and the risk of stroke during bone marrow infusion. Bone Marrow Transplant 1997; 19: 855–856.

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Authors and Affiliations

  1. Harvard University Joint Program in Transfusion Medicine and Blood Transfusion Service, Massachusetts General Hospital, 55 Fruit Street, GRJ-148, Boston, 02114, MA, USA

    K Darabi

  2. Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA

    J R Brown

  3. Connell & O’Reilly Families Cell Manipulation Core Facility, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA, USA

    G S Kao

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  1. K Darabi
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  2. J R Brown
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  3. G S Kao
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Darabi, K., Brown, J. & Kao, G. Paradoxical embolism after peripheral blood stem cell infusion. Bone Marrow Transplant 36, 561–562 (2005). https://doi.org/10.1038/sj.bmt.1705088

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