Age 35 Years, Acute Leukemia
Contributed By: Dr. Imtenan Sharif
Mrs. Saima Mehdi, was 35 years of age when, in Oct 2013, she was transferred to AFBMTC with Acute Leukemia. Bone marrow examination demonstrated findings of AML M5a. Immunophenotyping was consistent with AML M2 and cytogenetics revealed 45XX with monosomy 8. She achieved remission after 2 courses of induction with D3A7. Being a high-risk case, upfront allogeneic HSCT from HLA matched brother was offered. Patient proceeded to USA for second opinion and reported back after 2 months without any treatment. Her bone marrow was still in remission. Consolidation was given with high dose Cytarabine. Pretransplant conditioning was with Bu16/ Cy200. Allogeneic HSCT was done on 9/5/2014. Engraftment was prompt and patient was discharged on Day+15. Patient was readmitted on Day+19 with complaints of vomiting and diarrhea. Upper GI endoscopy was normal. Positive PCR confirmed CMV reactivation which was treated with ganciclovir. Soon afterwards transplant associated microangiopathy (TMA) developed; cyclosporine was replaced with mycophenolate. There were multiple episodes of melena. A repeat endoscopy revealed erosive gastritis requiring intensive treatment. On Day+68 Mrs. Mehdi developed respiratory failure requiring mechanical ventilation. She was weaned off ventilator after 76 hours. CMV reactivated in Jul 2014 & responded to ganciclovir. In Nov 2014 the patient was admitted with shock and respiratory distress. Clinical and radiological findings were consistent with Invasive Aspergillosis which was treated with Amphotericin B. Immunosuppression was stopped at 6 months post-transplant. At 8½ months post BMT, PCR for HCV RNA came up positive. At the same time Herpes Zoster Opthalmicus developed. Treatment for HCV was postponed and patient was treated for HZ and post-herpetic neuralgia for months. Later Sofosbuvir and Ribavirin were started and PCR for HCV RNA became negative. Despite this turbulent course, donor chimerism remained more than 90% and lymphocyte subset analysis demonstrated good immune reconstitution. Mrs. Mehdi is now almost 3 years post-transplant. There is no sign of leukemia. She is off all medications and enjoying good quality of life with her family.