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Failure of haematopoietic recovery overcome by SCT despite invasive mucormycosis infection

Bone Marrow Transplantation volume 47, pages 591–592 (2012)Cite this article

Persistent aplasia is a rarely reported complication after intensive chemotherapy for AML and is associated with high morbidity and mortality. A small number of reports have treated persistent aplasia after chemotherapy for AML with allogeneic haematopoietic SCT (HSCT).1 In the current report, we describe a case of invasive fungal infection (IFI) necessitating simultaneous pneumonectomy and allogeneic HSCT as a result of severe iatrogenic aplasia.

The patient had progressive IFI. Simultaneous non-myeloablative haematopoietic HSCT and left pneumonectomy were proposed as salvage therapy. The almost certain mortality that would have ensued with the use of systemic immunosuppression for treatment of GVHD lead to the decision to proceed with a highly T-cell-depleted graft. A fully matched sibling (HLA-A, -B, -C, -DR and -DQ) was available. On day 81, conditioning with fludarabine (30 mg/m2 (three doses)) and antithymocyte globulin (30 mg/kg (five doses)) was commenced, followed by infusion of G-CSF-mobilised T-cell-depleted PBSCs (in vitro CD34+ selection/T-cell depletion using CliniMACS system, Miltenyi Biotec GmbH, Bergisch Gladbach, Germany) on day 85. The dose of CD34+ stem cells infused was 7.22 × 106/kg. On day 88, a left pneumonectomy was performed. The patient was transplanted on a ventilator and extubated after the pneumonectomy. Given that neutrophil engraftment and avoidance of further immunosuppression were critical to control the progressive infection, and the knowledge that CD3+ depletion achieved by magnetic separation is >95% along with lymphocytotoxic concentrations of antithymocyte globulin persisting for >4 weeks, no post-transplant immunosuppression was given. No acute GVHD was detected by day 100, and limited skin GVHD was detected at 1 year. Engraftment was prompt, with a neutrophil count of >500/μL on day 10 and platelet transfusion independence on day 13 after allogeneic HSCT. The patient was subsequently discharged from the ICU on day 123, with no radiological evidence of ongoing fungal infection (Figure 1c) and maintained on posaconazole until day 500.

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Authors and Affiliations

  1. Department of Clinical Haematology, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia

    G Grigoriadis, P Walker, S Patil, S Avery & A Spencer

  2. Department of Medicine, Infectious Diseases Unit, Alfred Health and Monash University, Melbourne, Victoria, Australia

    C C Chang & O Morrissey

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  1. G Grigoriadis
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  2. C C Chang
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  3. P Walker
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  4. S Patil
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  5. S Avery
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  6. O Morrissey
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  7. A Spencer
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Correspondence to G Grigoriadis.

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Grigoriadis, G., Chang, C., Walker, P. et al. Failure of haematopoietic recovery overcome by SCT despite invasive mucormycosis infection. Bone Marrow Transplant 47, 591–592 (2012). https://doi.org/10.1038/bmt.2011.116

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