Allogeneic hematopoietic stem cell transplantation (HSCT) is the definitive therapy for severe aplastic anemia (SAA)(1,2). The major factors that limit the success of HSCT are graft rejection and graft-versus-host diseases (GVHD)(3,4). Engraftment depends on the conditioning regimen, GVHD prophylaxis, number of donor marrow cells infused and alloimmunization of the patient(3,4). Taking an aplastic anemia with septicemia for transplant is a very high-risk proposition.

A 11-year-old boy was diagnosed to have aplastic anemia and treated with ATG followed by Cyclosporin for 6 months. He was admitted at our center with high-grade fever of one week’s duration with pancytopenia. Blood culture grew E. coli on two occasions and Klebsiella on one occasion. Staphylococcus aureus was grown from central line tip on two occasions. He was started on meropenem and teicoplanin for 3 weeks, when he developed maxillary sinusitis, for which he was started on amphotericin B. He continued to have intermittent fever. He was also given granulocyte infusions for one week. Blood culture was sterile after 3 weeks when a Hickman catheter insertion was done. During this time HLA typing of his 3-year-old sister was done and found to be 6 antigens matched. During the afebrile period patient was started on conditioning with fludarabine (30 mg/m2 IV daily on day 2-4 busulfan (4 mg/kg/d q6h on day 5,6) and cyclophosphamide. 350 mg/m² IV daily on day 2-4. A peripheral blood stem cell (PBSC) harvest was done from the donor after 5 days of G-CSF at 10 mcg/ kg/d. A volume of 110 mL was collected with an MNC of 3.65 × 108 cells/kg. The CD 34 cell dose was 1.34 × 106 cells/kg. GVHD prophylaxis was IV cyclosporin (CsA) at a dose of 3.0 mg/kg/d. G-CSF was started from Day +7 at 5 mcg/kg/d. CsA was changed to the oral route on Day + 13. An absolute neutrophil count >500/mm³ was attained on day +9 and an unsupported platelet count >20000/mm3 was achieved on day +30. Chimerism analysis on day +24 by XY analysis revealed 100% donor cells. Patient was discharged on day +31. Patient is well at last follow up on day +140.

Taking a patient with aplastic anemia with sepsis for bone marrow transplant has a mortality close to 100%. Our patient was successfully transplanted using a conditioning regimen, which was not very highly immunosuppressive but enough to achieve engraftment. PBSC was preferred to bone marrow for faster engraftment. Busulfan along with Cyclophosphamide has been used for conditioning in SAA(5). Busulfan is cheaper than TBI and ATG. Hence, we recommend this conditioning as one option in patients with aplastic anemia especially with infection.

Sharat Damodar,
Sreedhar Murthy,
Emami National Institute for Bone Marrow Transplantation,
Narayana Hrudayalaya,
Anekal Taluk, Bangalore 560099, India.
E-mail: [email protected]

1. Bacigalupo A, Brand R, Oneto R, Bruno B, Socie G, Passweg J, et al. Treatment of acquired severe aplastic anemia: bone marrow transplantation compared with immuno-suppressive therapy. The European group for Blood and Marrow Transplantation experience. Semin Hematol 2000; 37: 69-80.

2. Horowitz MM. Current status of allogenic bone marrow transplantation in acquired aplastic anemia. Semin Hematol 2000; 37: 30-42.

3. Stucki A, Leisenring W, Sandmaier BM, Sanders J, Anasetti C, Storb R. Decreased rejection and improved survival of first and second marrow transplant for severe aplastic anemia (a 26-year retrospective analysis). Blood 1998; 92: 2742-2749.

4. Deeg HJ, Leisenring W, Storb R, Nims J, Flowers ME, Witherspoon RP, et al. Long- term outcome after marrow transplantation for severe aplastic anemia. Blood 1998; 91: 3637-3645.

5. Dulley FL, Vigorito AC, Aranha FJ, Sturaro D, Ruiz MA, Saboya R, et al. Addition of low dose cyclophosphamide in aplastic anemia patients prior to allogeneic bone marrow transplantation to reduce rejection. Bone Marrow Transplant 2004; 33: 9-13.