Name:
A 56-Year-Old Post Bone Marrow Transplant Patient
Description:
A 56-Year-Old Post Bone Marrow Transplant Patient
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Duration:
T00H05M45S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to episode 68, a 56-year-old patient post bone marrow transplant.
DR. WIENER: Hi Cathy. So, the question begins, a 56-year-old woman undergoes a haploidentical allogeneic bone marrow transplant from her 20-year-old daughter to treat poor risk acute myeloid leukemia.
DR. HANDY: That would be standard treatment after induction chemotherapy and it represents an allogeneic transplant. So, if we just want to define terms to begin with, allogeneic transplants are from a donor that is not genetically identical, a haploidentical allogeneic transplant is from someone that is matched at one haplotype, such as a parent or a child. The other type of transplant is an autologous transplant and that involves removal and storage of the patient's own stem cells with subsequent reinfusion after the patient receives high dose myeloablative therapy.
DR. HANDY: In these cases, you need to do the transplant to be able to give the high doses of chemotherapy.
DR. WIENER: Anything else to note that's important as differences between all these transplants?
DR. HANDY: Yeah, in allogeneic transplants because they're not exactly immunologically matched, there may be some graft versus host disease as a side effect, however, that's beneficial because in addition to reacting to the host, the graft will exert a graft-versus-leukemia effect to control the cancer, and that's really why you're doing the transplant in the first place. In an autologous transplant, there is no risk of graft versus host disease or graft rejection, but these lack the graft-versus-tumor effect.
DR. HANDY: The autologous stem cell product may be contaminated with tumor cells as well which could lead to relapse. But, keep going on this case.
DR. WIENER: Okay. So the question is going to be about infections, and the question asks, which of the following infections is an acute, defined as likely to happen within the first 30 days, complication of her allogeneic bone marrow transplant? And the options are, A. Aspergillus; B. Candida; C. cytomegalovirus or CMV; D. encapsulated bacteria; or E. varicella zoster.
DR. HANDY: By the end of one week post-transplant, patients are usually profoundly pancytopenic. Because the risk of bacterial infection is so great, most centers place patients on broad spectrum antibiotics, once the granulocyte count falls below 500. So, I would be worried about bacterial infection in this point, but not the encapsulated bacteria that's mentioned in the question. But early on, because of the neutropenia and mucositis, patients are at high risk of Candida infection, so the answer to this question is B.
DR. WIENER: What about the other infections? When do those typically come about?
DR. HANDY: Aspergillus and CMV infection tend to be a bit later, starting around day 30 through about day 90. Encapsulated bacterial infections and VZV, we worry most about starting around day 90 through the almost one year mark.
DR. WIENER: Okay, well, let's extend this discussion a little bit, let's talk a little bit about vaccines and preventive measures to prevent infections. What can be done to prevent these infections or other infections?
DR. HANDY: For transplant patients in particular, bacterial, fungal and viral prophylaxes are given initially with stopping points that reflect the risk of infection. So for example, bacterial infection prophylaxis can usually be de-escalated or stopped once there's engraftment and the white blood cell counts are recovered, whereas, fungal and some viral prophylaxes will continue for longer periods. Prophylaxis against fungal infections reduces the rate of infection and also improves overall survival.
DR. HANDY: Fluconazole is often used for patients with standard risk while prophylaxis with mold-active agents such as voriconazole or posaconazole should be considered for patients at higher risk, such as those with a prior fungal infection.
DR. WIENER: And what about vaccines?
DR. HANDY: So in general, we advise against live virus vaccines. These patients have a risk of developing disease because of their immune suppression. So, we wouldn't use those. Plus, cancer patients who are undergoing chemotherapy do not respond normally to immunization and titers of antibodies to infectious agents fall more rapidly than in healthy individuals. So, patients will need to be re-vaccinated against Strep pneumonia, H. flu, and Neisseria meningitidis.
DR. HANDY: For those vaccines that are usually also given in childhood, like Tdap, Hep A, Hep B, and HPV, if age appropriate, should also be given. And the polio vaccine should be the inactivated form.
DR. WIENER: What about flu shots? Is that okay to give?
DR. HANDY: Yes, typically we will give it annually with the inactivated vaccine. And, given the COVID-19 pandemic, I will mention that COVID vaccines are currently recommended for immunocompromised patients. The two vaccines that were first approved here in the U.S. are the mRNA vaccines and those are thought to be safe to give, especially when balancing the increased risk of complications from COVID in immunocompromised patients.
DR. WIENER: Okay, great. So, the teaching point in this case is that after a bone marrow transplant within 30 days, bacterial and fungal, particularly Candidal infections are most common. Other infections such as Aspergillus and varicella are later complications. Most vaccines should be repeated post-transplant. And the newest vaccine for COVID-19, the messenger RNA vaccines, generally are recommended, although, of course, more research is being done.
DR. HANDY: And to learn more, I'll direct you to a couple of different chapters that cover these topics. First, the chapter on hematopoietic cell transplantation and also the chapter on infections in transplant recipients. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine.
DR. HANDY: Go to accessmedicine.com to learn more.