JM is a 44-year-old female who is currently day + 8 following an HSCT from a full HLA-matched sibling for AML in first complete remission. Her preparative regimen consisted of busulfan and cyclophosphamide; tacrolimus and methotrexate are being administered for GVHD prophylaxis. She is currently receiving fluconazole 400 mg daily and acyclovir 400 mg three times daily for infection prophylaxis. She is currently day 4 of cefepime 2 g IV every 8 hours and vancomycin 1,000 mg (15 mg/kg) IV every 12 hours for neutropenic fever; all cultures remain negative. Her ANC today is 20 cells/mm3 (0.02 x 109/L). She remains persistently febrile. Her latest vital signs reveal a temperature of 38.9°C, (102°F), blood pressure 106/70 mm Hg, heart rate 112 bpm, respiration rate of 20 breaths per minute, and an oxygen saturation of 95% on room air. She has no other complaints other than she is experiencing grade II mucositis.
What diagnostic measures are needed to address JM's current signs and symptoms?
Are any changes to JM's anti-infective regimen warranted? What options are available in terms of medication management and what monitoring parameters are necessary with each medication?
HSCT survivors are at higher risk for secondary malignant neoplasms. Long-term impairment of end-organ function, including kidney, liver, and lungs, may be due to the preparative regimen, infectious complications, and/or post-transplant immunosuppression. Many HSCT recipients experience endocrine dysfunction, such as hypothyroidism from TBI, adrenal insufficiency from long-term corticosteroids to treat GVHD, and infertility from radiation and/or high doses of alkylating agents in my-eloablative preparative regimens. Osteopenia has been found in over half of HSCT recipients, most likely from gonadal dysfunction and/or corticosteroid administration.
Close monitoring of HSCT recipients for infections is necessary because recovery of immune function is slow, sometimes requiring over two years, even in the absence
of immunosuppressants. Fevers should be assessed and treated rapidly to minimize the likelihood of a fatal infection. HSCT recipients—both autologous and allogeneic—lose protective antibodies to vaccine-preventable diseases; the CDC and the European Group for BMT have issued recommendations for reimmunization for HSCT recipients.49
HSCT survivors should be monitored routinely for signs of relapse and, if an allogeneic graft was used, chronic GVHD. They should be advised regarding revaccination and obtaining prompt medical care for fevers or signs of infection. Routine evaluations of organ function (i.e., renal, hepatic, thyroid, and ovarian) and osteopenia should occur and the appropriate management strategies initiated if necessary.
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