Pericarditis is an uncommon complication in patients receiving bone marrow transplantation (BMT). Bacterial and fungal pericarditis have been reported in post transplant recipients. Braverman et al1 reported that high-dose cyclophosphamide (CY) in preparative regimen also caused cardiotoxicity including pericarditis and congestive heart failure. Pericardial effusion with or without clinical pericarditis was observed within 2 weeks post-CY therapy. This condition resolved without therapeutic intervention. Interestingly, benign idiopathic acute pericarditis has been observed in young adult or older splenectomized thalassemic patients.2 The explanation for this finding has been obscure. In this article, we report a thalassemic child undergoing unrelated BMT who developed acute pericarditis during pre-engraftment period.
An 11-year-old boy with splenectomized homozygous beta-thalassemia (Pesaro class 2) underwent HLA-matched unrelated donor BMT. Pre-transplant electrocardiogram (ECG) and echocardiogram showed no abnormalities. Preparative regimen consisted of oral busulfan 4 mg/kg/day divided into four doses on day −10 to −7, intravenous cyclophosphamide 50 mg/kg once daily on day −6 to −3, and intravenous rabbit antithymocyte globulin 10 mg/kg once daily on day −4 to −1. Graft versus host disease (GVHD) prophylaxis used was tacrolimus starting on day −4, and mycophenolate mofetil on day +1 to +45. Tacrolimus trough level was maintained between 5 and 15 ng/ml. The child received unrelated bone marrow with 1.96 × 106 CD34+ cells/kg. On day +5, the patient developed fever, erythematous rash over the body, mild abdominal distention, and had gained weight by 5%. He was treated with intravenous meropenem after blood culture was obtained. On the next day, he complained of severe chest pain and difficult breathing. Physical exam revealed temperature of 39.6°C, sinus tachycardia of 130 beats/min, blood pressure of 90/60 mmHg, normal pulses, and pericardial friction rub over left precordium. ECG showed sinus tachycardia 130 beats/min, ST elevation in leads I, II, aVL, and V3-6. Echocardiogram demonstrated clear nonloculated pericardial effusion of 1 cm thickness without signs of cardiac tamponade. There was neither abnormality of cardiac valves nor intramyocardial abscess. The ventricular systolic function was normal. Blood cultures for bacteria and fungus showed no growth. There was no history of either chronic cough or exposure to tuberculosis. Gastric washes for acid-fast bacilli and culture for Mycobacterium tuberculosis showed negative results. In addition, CMV and EBV viral loads were undetectable. Intravenous methylprednisolone 2 mg/kg/day was given. He had no fever, chest pain, nor signs of pericarditis on the second day after methylprednisolone was started. Methylprednisolone was gradually tapered off. The pericardial effusion was completely resolved on the follow-up echocardiogram 2 weeks later. He achieved neutrophil and platelet engraftment on day +10 and +16, respectively. The patient developed grade II acute GVHD of skin on day +26. At the first year evaluation, echocardiogram showed normal ventricular contractility without pericardial effusion. Otherwise, he had recovered well without disease for the following 19 months.
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