Introduction:
Aplastic anemia is a rare & serious blood disease characterized by a failure of the bone marrow to produce mature blood cells. There is destruction of hematopoietic stem cells in the bone marrow that, in most cases, is caused by an autoimmune reaction. Patients with aplastic anemia are treated with immunosuppressive drugs & some of them, with a donor available, can be successfully treated with hematopoietic stem cell transplantation (HSCT). We report here a rare case of aplastic anemia in a renal transplant recipient.
Methods:
A young girl of Maldivian ethnicity, who developed ESRD at the age of 3 years (hypo-dysplastic kidneys), underwent living related renal transplantation at our centre at 5 years’ age (donor – mother, haplomatched). The child was on triple immune-suppression with Tacrolimus, Mycophenolate mofetil (MMF) & Prednisolone. She had been doing well for over 4 years after renal transplantation, apart from a few episodes of UTI. Graft function was stable. She had an episode of diarrhea & AKI in Jan 2024. Upon evaluation, she was found to have amoebiasis & CMV infection. MMF dose was reduced, & she was treated with IV Gancyclovir for 3 weeks followed by oral Valgancyclovir prophylaxis. Her graft renal function recovered completely.
The child developed a febrile illness in mid – July 2024, & dengue serology was positive. The child was hospitalized & treated for dengue fever. A week following hospitalization, the child had a drop in all her blood counts. She also had shock & AKI, which was treated in the Maldives, & recovered. MMF & Valgancyclovir were stopped in view of pancytopenia. However, the child had severe bone-marrow suppression & pancytopenia requiring packed cell & platelet transfusion. She was also treated for sepsis & GI bleed.
In view of persistently low blood counts, cough & loose stools, she was referred to our hospital. Graft function was stable, & all cultures were negative. A febrile neutropenia panel detected only EBV infection. CSF study was normal, & imaging showed evidence of right sided pneumonia on CT chest. CT brain, neck & abdomen were normal. CMV DNA was barely detectable, & parvovirus B19 PCR was negative. However, the child had extremely low Hb, WBC & platelet counts requiring multiple transfusions. She was treated with broad spectrum antibiotics & anti-fungals. She was treated with IV steroids. MMF was withheld & Tacrolimus dose was reduced. Strict barrier nursing was provided. Her bone marrow study showed severe pancytopenia with only 10% marrow cellularity. There were no atypical cells. G-CSF & Eltrombopag were started & doses were optimized. She also received IVIg. She was treated with antibiotics for her pneumonia & diarrhea (suspected pseudo-membranous colitis).
The child continued to have pancytopenia requiring regular packed cell & platelet transfusions. A HSCT was considered, with one of the parents as prospective donor. However, after over 4 weeks of marrow failure, her WBC counts improved to the normal range, & her infections recovered. The child is currently asymptomatic, with stable WBC counts & renal function. She continues to require platelet transfusions, although the frequency of transfusions has decreased.
Results:
This child had a very unusual cause of bone-marrow failure, probably secondary to dengue/ EBV infection. With appropriate supportive treatment, she is making good recovery.
Conclusions:
More studies are required on dengue fever causing bone-marrow failure & aplastic anemia in renal transplant recipients.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.