The delay in referring patients carrying granulocytopenic Severe Aplastic Anemia (SAA) for transplantation, favors the appearance of disseminated Aspergillosis during transplantation, and this is a fact that still desolates developing countries. Aspergillosis can lead to disseminated intravascular coagulation or even clinical hypercoagulability with normal coagulogram. The DVT treatment can be carried out with potent thrombolytics, but its use is risky in thrombocytopenic patients. E.S.O, 14, male, SAA diagnosed in December 2001, underwent allogeneic BMT from his HLA identical sibling in April 2002. He received during this 4 month period about 20 random transfusions of packed red blood cells and platelets. He was conditioned with cyclophosphamide 50mg/kg/day - 04 days and busulfan 4 mg/kg/day - 01 day. The GVHD prophylaxis included cyclosporine from D-1 and methotrexate on days 1and 3 (in order to reduce aplasia length). Infection prophylaxis included systemic antibiotics and antifungal from aplasia onset until hematological recovery. From D+4 post-BMT he developed fever (38 - 40Â°C) and cough, in addition to serious edema, hyperemia and pain in his left arm. Blood cultures were negative and a chest X-Ray was normal. Echodoppler evidenced thrombosis in left cephalic vein. Coagulogram was normal. Catheter was removed and therapy with low molecular weight heparin was initiated, (Clexane® - 15mg/kg/day). Due to clinical aggravation, 48 hours after starting this treatment, heparin, 100UI/kg/day was administered in continuous venous perfusion associated with Alteplase (Actylise® ) 25mg in 2 hours/day in peripheral vein for 2 days, under irradiated and filtered single-donor platelet transfusion before and after Alteplase. Clinical situation improved and echodoppler normalized about 4 days after this procedure had been started. Complications related to the thrombolytic administration were not observed. Due to difficulty in maintaining intensive treatment through peripheral vein, new central tunneled brachial catheter was inserted in basilic vein. On D+8 post-BMT he presented high fever and coughing, and a thorax CT evidenced suggestive image of pulmonary Aspergillosis. Fungizon® , 1.5mg/kg/day, was administered. Five days later he presented edema, hyperemia and pain in right arm and echodoppler demonstrated thrombosis in right basilic vein, despite heparin still being administered. Actyilise® 25mg 2 hours/day was restarted for 2 days, also under platelet transfusion prior to and after its administration. Clinical improvement and echodoppler normalization were evidenced 3 days after this treatment had been started. Despite the neutrophilic engraftment on D+20 post-BMT, patient deceased on D+23 due to disseminated Aspergillosis . The use of Alteplase demonstrated to be effective on thrombolysis and clearance of catheter on this high risk case. We suggest, on hypercoagulability situations, the use of peripheral veins or a non-central brachial catheter positioned a few centimeters from venous dissection with short tunnelization.
Full conference title:
44th Amercian Society of Hematology Annual Meeting
- ASH 44th (2002)