Report opportunistic CMV infection after haploidentical transplantation related to Ph+ ALL.

The 41-year-old man with Ph+ ALL being induced with protocol HIPERCVAD + dasatinib and after a long search for family donors and at REREME we did not succeed, we opted for haploidentico transplantation with daughter (9/12). He hadn't episodes of infectious disease including pulmonary invasive aspergillosis previous transplant. He was CMV-seropositive, but the donor was CMV-seronegative. The conditioning regimen consisted of Baltimore's protocol with Cy post. Peripheral blood mononuclear cells were collected from his daughter without ex vivo manipulation, and infused on day 0. The number of infused CD34 positive cells was 9.24 106 cells/kg of the recipient body weight. Post-transplantation prophylaxis against graft-versus-host disease was performed with continuous infusion of cyclosporine A (3 mg/kg) at D+5 and cyclophosphosfamide at D+3 and D+4. Neutrophil engraftment, defined as the first of 3 consecutive days with an absolute neutrophil count of at least 0.5 109 /L, was documented on day 19. Though febrile neutropenia was observed for 9 days, no bacterial and fungal infection was documented during neutropenia. Acute graft-versus-host disease was not clinically observed. CMV reactivation was first detected on day 29 after transplantation by the PCR -RT CMV during seminal preventive monitoring. However, the patient at the time of reactivation presented joint edema with phlogistic signs in the right knee of sudden onset. The viral load detected was 1,800 copies, and monitoring of the previous week was negative. Thus, after orthopedic evaluation with knee MRI, signs of septic arthritis were found and a patient underwent joint puncture with biochemical, fungic and bacterial analysis of the synovial liquid that was negative. In the same sample, we sent to RT-PCR of CMV and verified 2,300 copies in the synovial sample. Antiviral treatment with intravenous ganciclovir (5 mg/kg twice daily) was initiated with except response after 15 days of use, being requested after negative cao of letemovir viral load as preventive therapy. The level of antigenemia was decreased gradually and the dose of ganciclovir was decreased to 5 mg/kg/day.

Cytomegalovirus (CMV) disease is one of the major complications after allogeneic hematopoietic stem cell transplantation. Since the mortality rate is high, preemptive strategy by monitoring CMV reactivation with antigenemia assay or DNAemia assessed by the polymerase chain reaction have been developed for the management of CMV after hematopoietic stem transplantation cell. The risk factors for CMV disease after allogeneic hematopoietic stem cell transplantation include transplantation from an unrelated donor, the presence of HLA mismatch, the use of T-cell depletion, the development of acute graft-versus-host disease, the use of steroids.

CMV infection in patients undergoing haploidentical transplantation is still a prevalent complication and with forms of atypical presentations due to the severe immunosuppression protocol that these patients are submitted to.