Case
Allogeneic stem cell transplant is the definitive treatment of severe aplastic anemia. Up-front MSD HSCT for young and adult patients is the treatment of choice for severe AA [1]. Donor, however, should be disease free at the time of stem cell apheresis. Here we present a case of Allogeneic HSCT where stem cell transfusion had to be continued in-spite of donor being infected by varicella zoster.
15-year-old male diagnosed as severe aplastic anemia was planned for allogeneic stem cell transplant. Stress cytogenetics was normal, PNH screen was negative. His younger sibling, 11 years old male child was a 12/12 match and hence after completing necessary investigations, the recipient was admitted in the transplant unit of our Hematology Department. His conditioning regimen consisting of fludarabine for 3 days, cyclophosphamide for 2 days and Horse ATG for 4 days was started on D-7. The donor was admitted for mobilization of stem cell by G-CSF. On day D-5 of the recipient’s conditioning regimen, the donor was found to have blister like lesions on his back. The donor other than the lesion was asymptomatic and afebrile. He had received two doses of Varicella vaccine in his early childhood. A dermatologist opinion was taken who diagnosed it as varicella zoster (Fig. 1). The donor was started on therapeutic oral acyclovir from that day. A medical board constituting of Virologists, Infectious Disease specialist, Transfusion Medicine specialist, Hematologists and Dermatologist was arranged on the next day and varicella was confirmed by all of them. It was not possible to stop the procedure as the recipient was already started on conditioning regimen. If the procedure was stopped at this point, then without stem cell infusion, the recipient would have been exposed to severe myelosuppression and risk of death. Keeping all these in mind, the board members recommended to continue the procedure though there may be risk of transmission of infection from the donor’s product. Although the mode of transmission of varicella zoster is through direct contact and through droplet infection, the chance of spread through blood product cannot be entirely ruled out especially in immunocompromised individuals. The recipient was started on prophylactic acyclovir from that day onwards and conditioning was continued. The donor serum, scab and nasopharyngeal swab was sent for varicella PCR test which came out to be positive. Donor’s blood sample was also sent for IgG antibody, which was detected to be high 352 0.00 mIU/ml (normal < 150 mIU/ml). The recipient received stem cell product from his donor on the stipulated day along with therapeutic acyclovir which was started from the day of stem cell infusion. Recipient blood was sent for varicella PCR after 72 h and it came out to be negative. The recipient did not develop any features of varicella infection post stem cell infusion and also during his entire stay. His neutrophil engrafted on day + 16. Chimerism at D + 30 showed 90% donor chimera. He is under regular follow up and is doing fine 8 months after transplant. He has been kept on prophylactic acyclovir as VZV reactivation occurs frequently after HSCT and carries a high complication rate, warranting prophylaxis [2]. For further confirmation, Varicella IgG of the donor repeated after 1 month was found to be 1496.00 mIU/ml (normal < 150 mIU/ml). A four-fold increase of titer was noted which confirmed varicella infection [3].
Fig. 1.
Varicella lesions on the back of the donor
Till date, that is post 8 months of transplant, there is no incidence of Varicella infection in the recipient. We plan to continue acyclovir prophylaxis till day + 360.
We searched the literature and to the best of our knowledge there is no published data of such case and this was the first case where a successful transplantation was done from a varicella infected donor.
Declarations
Conflict of interest
There was no conflict of interest.
Research involving human or animals participants
Not applicable.
Consent for publication
Consent taken from the patients guardian for publishing the case.
Footnotes
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References
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