A Rare Case of Hemorrhagic Cystitis in Allogeneic Hematopoietic Stem Cell Transplant Patient

Abstract

Post bone marrow transplant patients are susceptible to atypical infections, especially viral pathogens. The risk increases many folds in cases of allogeneic transplantation, which also receive GVHD prophylaxis. Viral pathogens like cytomegalovirus and herpes are the common ones encountered during follow-up period. However, in recent times there have been reports of a variety of disease manifestations of rare viruses like polyoma virus and adenovirus. These viral infections may play a crucial role in morbidity and mortality in immunocompromised patients. We hereby elaborate the follow-up course of a 36-year-old post allogeneic transplant patient of acute myeloid leukemia who developed adenovirus related haemorrhagic cystitis. Treatment with oral ribavirin lead to dramatic improvement in symptomatology within a week. This cases re-emphasizes the fact that after ruling out the commoner pathogens, it's of utmost importance to strongly consider the atypical pathogens in such cases. Case-ReportA 36-year-old gentleman, known case of acute myeloid leukemia (FAB-M2) was admitted on Day ?380 of allogeneic stem cell transplant with 7 days history of lower urinary tract symptoms (LUTS), dysuria, increased urine frequency, urgency of urine, and haematuria. In the background, patient received inj. busulphan (0.8 mg/kg every 6 h for 4 days) and inj. cyclophosphamide (60 mg/kg/day for 2 days) as conditioning regimen. Peri-transplant period was unremarkable for any complication. No features of high dose cyclophosphamide induced cystitis or acute graft versus host disease (aGVHD) was noted. He received cyclosporine-A (5 mg/m 2 ) and methotrexate 15 mg/m 2 on Day ?1 and 10 mg/m 2 on Day ?3, ?6 and ?11 as prophylaxis for GVHD (Fig. 1). Tapering of immunosuppression was started on Day ?80 onwards and patient did not have any evidence of GVHD till Day ?256. Following which he developed lichenoid changes in the oral mucosa, dryness of eyes and hypopigmented patches over the face and upper trunk involving \25 % of body surface (Fig. 2). Liver function tests showed total bilirubin levels-1.2 g/dL, SGOT, SGPT and SALP of 92, 139, 392 IU/mL, respectively. After clinical examination, laboratory evaluation and liver?skin biopsy he was diagnosed as moderate cGVHD (Table 1). As a result additional immunosuppressive medications in the form of mycophenolate (1000 mg BD) along with oral prednisolone was started. He also received topical cyclosporine eye drops (0.05 %) for conjunctival GVHD. Following immunosuppressive therapy symptoms related to GVHD started improving (Fig.

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