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Aspergillus tracheobronchitis after allogeneic bone marrow transplantation

Bone Marrow Transplantation volume 26, pages 1131–1132 (2000)Cite this article

Recently Machida et al1 presented in this journal a case of a patient with an Aspergillus tracheobronchitis after allogeneic BMT together with a review of the literature of this serious complication after BMT. We would like to add our recent experience and comment on the role of galactomannan antigen testing in establishing the diagnosis of this Aspergillus infection.

A 56-year-old female patient underwent allogeneic BMT in our center after induction of first complete morphological and cytogenetic remission of acute myeloid leukemia. After conditioning with idarubicin, cyclophosphamide and busulfan, bone marrow-derived stem cells from her histocompatible sibling were infused. She developed grade II acute GVHD of the skin, for which she was treated with prednisone. Later on she experienced grade IV chronic GVHD of the gastro-intestinal tract and three episodes of CMV-colitis. Treatment with high-dose corticosteroids, cyclosporin, ganciclovir and CMV-hyperimmunoglobulins was given with limited success. On day 193 after BMT she was admitted to our hospital because of severe dyspnea, inspiratory wheezing and hoarseness. Temperature was not raised and persistent severe diarrhea was still present. Physical examination showed severe respiratory distress with use of accessory respiratory muscles and extreme inspiratory wheezing, and on auscultation her breath sounds were hardly audible. Chest X-ray and high-resolution CT scan were unremarkable. Lung function examination demonstrated extreme inspiratory and expiratory obstruction. Yellowish plaques, ulcerations and pseudomembranes were seen on bronchoscopy performed immediately and there were mucus plugs that almost completely obstructed the trachea and bronchi. Microscopic examination of the obstructing material showed hyphae and cultures yielded Aspergillus fumigatus. Biopsy was considered impossible because of the low platelet count. Daily bronchial flushing and treatment with high-dose amphotericin B (1 mg/kg/day, 45 mg daily) and nebulized amphotericin B was started with only temporary improvement. Liposomal amphotericin B 200 mg daily and itraconazole (200 mg, twice daily for 2 days, followed by 200 mg daily) as well as G-CSF (300 μg daily) were added without any improvement. Our patient became ventilator-dependent and could no longer cope with this regime. For this reason it was decided to abstain from further treatment and she died of respiratory failure the same day, 37 days after admission. Permission for autopsy was denied.

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References

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Haematology, University Medical Center/St Radboud, PO Box 9101, Nijmegen, 6500 HB, The Netherlands

    S van Assen, JP Donnelly & JMM Racemakers

  2. Department of Internal Medicine, Division of Pulmonary Medicine, University Medical Center/St Radboud, PO Box 9101, Nijmegen, 6500 HB, The Netherlands

    GP Bootsma

  3. Department of Internal Medicine, Department of Medical Microbiology, University Medical Center/St Radboud, PO Box 9101, Nijmegen, 6500 HB, The Netherlands

    PE Verweij

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  1. S van Assen
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  2. GP Bootsma
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  4. JP Donnelly
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van Assen, S., Bootsma, G., Verweij, P. et al. Aspergillus tracheobronchitis after allogeneic bone marrow transplantation. Bone Marrow Transplant 26, 1131–1132 (2000). https://doi.org/10.1038/sj.bmt.1702679

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