A 2-year-old boy with a history of severe aplastic anemia (SAA) is undergoing pre-transplant infectious surveillance in anticipation of a myeloablative BMT. He initially presented with autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) following a viral illness and was treated for AIHA and ITP with intravenous IVIG, rituximab, and steroids. Due to the presence of autoimmune hepatitis, he was also being treated with azathioprine. His cytopenias progressed despite therapy over the next several months. He eventually developed pancytopenia leading to his diagnosis of SAA after BM biopsy showed cellularity of <5% (normal for age 90–95%). Pre-transplant infectious disease surveillance was unremarkable except for an abnormal chest CT. A 2.1 × 1.5 cm round subpleural mass was noted in the left lower lobe with ground-glass attenuation in the left perihilar region. On physical examination, the patient was afebrile, breathing comfortably in room air with a normal respiratory rate and oxygen saturation. Question: How should this patient be managed? Answer: HCT should be delayed while diagnostic procedures can be performed (bronchoscopy with bronchoalveolar lavage) and the patient receives applicable treatment for possible fungal pneumonia.
An 8-year-old boy, with a history of relapsed acute myeloid leukemia (AML) after an UCT, is admitted to the hospital to begin preparation for a second HCT, using a second UCB graft that will be infused in 7 days. On the third day of his myeloablative preparative chemotherapy, 4 days prior to infusion of his second transplant, he develops a temperature of 39.8°C. On examination, he is hypotensive (blood pressure is 64/32 mmHg) and tachycardic at 150 beats/min. His lungs are clear to auscultation. Blood cultures are obtained from his central line, and he is started on broad-spectrum empiric antibacterial antibiotics. He receives multiple fluid boluses and his hemodynamic status improves. Question: What is the likely underlying etiology of his hemodynamic change? Answer: Gram-positive infection of his central venous catheter.