BMTCN C
T.R. is a 28-year-old woman with acute myeloid leukemia in her second complete remission who is
admitted for a matched unrelated allogeneic stem cell transplantation. Her conditioning regimen is as
follows:
Myeloablation (busulfan/cyclophosphamide) and immunosuppression with tacrolimus and
methotrexate (5 mg/m2 on days +1, +3, +6, and +11).
She did not receive methotrexate on day +11 because of severe mucositis. Her transplant course was
complicated by mucositis, neutropenic fever, and Clostridium difficile diarrhea. T.R. had no symptoms of
graft-versus-host disease (GVHD) during the hospital course. Her blood counts recovered, and she was
discharged to home. Day +30 bone marrow showed 100% donor. A clinic visit on day +50 revealed a new
maculopapular rash covering 40% of T.R.'s body. She is staged as grade 2. The skin biopsy is consistent
with GVHD. What is the initial management?
A. Check tacrolimus level.
B. Start systemic steroids.
C. Start topical steroids.
D. A and C correct answerD. A and C
The patient's immunosuppressive drugs need to be at a therapeutic level. Try to use as little additional
immunosuppression as is necessary to control GVHD so as to maintain allo- effect of the transplant
against any residual leukemia. Often, grade 1 or 2 skin GVHD responds to topical steroids.
T.R.'s tacrolimus level is therapeutic at 11. One week later, at the scheduled clinic visit, her rash has
decreased to grade 1. T.R. reports "watery diarrhea" five times per day. She is admitted to the hospital
for further evaluation and treatment. How should the patient be managed?
(1) Continue PO medications.
(2) Add antidiarrheal agents.
(3) Rule out infectious etiology of diarrhea.
(4) Change medications from PO to IV.
, (5) Request gastrointestinal (GI) consult.
(6) Obtain accurate measurement of stool volume.
A. 1,2,5
B. 1,3,6
C. 2,3,4,5,6
D. 2,3,4,5 correct answerC. 2,3,4,5,6
Infectious etiology must always be ruled out (e.g., Clostridium difficile [C. difficile], rotavirus).
Medications should be changed from PO to IV to ensure absorption. GI consult to follow and assess need
for colonoscopy. GI GVHD grading is based on volume of stool, so an accurate assessment of amount of
diarrhea is important. Once C. difficile is ruled out, antidiarrheal agents may be started.
T.R.'s tacrolimus level remains therapeutic at 11. The volume of diarrhea in 24 hours is 1,000 ml.
Infectious etiology workup is negative. Colonoscopy was obtained, and the report describes erythema
and ulcerations. Cytomegalovirus (CMV) and other viral strains are negative. The formal interpretation
of biopsy shows consistency with GVHD. T.R. is therefore diagnosed with stage 2 acute GVHD. How
should the patient be managed?
A. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
B. Add mycophenolate.
C. Treat with infliximab.
D. Treat with antithymocyte globulin (ATG).
E. Add cyclosporine. correct answerA. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
One week later, T.R.'s volume of diarrhea has increased to 3,000 ml per day. How should the patient be
treated?
A. Increase steroids.
B. Add infliximab or ATG and attempt to taper steroids.
C. Continue same treatment and wait.
D. Start clear liquids PO to replace GI fluid loss. correct answerB. Add infliximab or ATG and attempt to
taper steroids.
T.R. is a 28-year-old woman with acute myeloid leukemia in her second complete remission who is
admitted for a matched unrelated allogeneic stem cell transplantation. Her conditioning regimen is as
follows:
Myeloablation (busulfan/cyclophosphamide) and immunosuppression with tacrolimus and
methotrexate (5 mg/m2 on days +1, +3, +6, and +11).
She did not receive methotrexate on day +11 because of severe mucositis. Her transplant course was
complicated by mucositis, neutropenic fever, and Clostridium difficile diarrhea. T.R. had no symptoms of
graft-versus-host disease (GVHD) during the hospital course. Her blood counts recovered, and she was
discharged to home. Day +30 bone marrow showed 100% donor. A clinic visit on day +50 revealed a new
maculopapular rash covering 40% of T.R.'s body. She is staged as grade 2. The skin biopsy is consistent
with GVHD. What is the initial management?
A. Check tacrolimus level.
B. Start systemic steroids.
C. Start topical steroids.
D. A and C correct answerD. A and C
The patient's immunosuppressive drugs need to be at a therapeutic level. Try to use as little additional
immunosuppression as is necessary to control GVHD so as to maintain allo- effect of the transplant
against any residual leukemia. Often, grade 1 or 2 skin GVHD responds to topical steroids.
T.R.'s tacrolimus level is therapeutic at 11. One week later, at the scheduled clinic visit, her rash has
decreased to grade 1. T.R. reports "watery diarrhea" five times per day. She is admitted to the hospital
for further evaluation and treatment. How should the patient be managed?
(1) Continue PO medications.
(2) Add antidiarrheal agents.
(3) Rule out infectious etiology of diarrhea.
(4) Change medications from PO to IV.
, (5) Request gastrointestinal (GI) consult.
(6) Obtain accurate measurement of stool volume.
A. 1,2,5
B. 1,3,6
C. 2,3,4,5,6
D. 2,3,4,5 correct answerC. 2,3,4,5,6
Infectious etiology must always be ruled out (e.g., Clostridium difficile [C. difficile], rotavirus).
Medications should be changed from PO to IV to ensure absorption. GI consult to follow and assess need
for colonoscopy. GI GVHD grading is based on volume of stool, so an accurate assessment of amount of
diarrhea is important. Once C. difficile is ruled out, antidiarrheal agents may be started.
T.R.'s tacrolimus level remains therapeutic at 11. The volume of diarrhea in 24 hours is 1,000 ml.
Infectious etiology workup is negative. Colonoscopy was obtained, and the report describes erythema
and ulcerations. Cytomegalovirus (CMV) and other viral strains are negative. The formal interpretation
of biopsy shows consistency with GVHD. T.R. is therefore diagnosed with stage 2 acute GVHD. How
should the patient be managed?
A. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
B. Add mycophenolate.
C. Treat with infliximab.
D. Treat with antithymocyte globulin (ATG).
E. Add cyclosporine. correct answerA. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
One week later, T.R.'s volume of diarrhea has increased to 3,000 ml per day. How should the patient be
treated?
A. Increase steroids.
B. Add infliximab or ATG and attempt to taper steroids.
C. Continue same treatment and wait.
D. Start clear liquids PO to replace GI fluid loss. correct answerB. Add infliximab or ATG and attempt to
taper steroids.
