Colitis secondary to engraftment syndrome post ABMT

1. CORRESPONDENCE
Colitis Secondary to Engraftment Syndrome in a Patient
with Autologous Peripheral Blood Stem Cell Transplant
Amer A. Alkhatib Æ Kathleen K. Boynton Æ
Ahmed M. Badheeb
Published online: 5 June 2009
Ó Springer Science+Business Media, LLC 2009
To the Editor,
More than 30,000 autologous bone marrow transplanta-
tion are done annually worldwide [1]. Two-thirds of these
bone marrow transplantations are done for multiple mye-
loma and non-Hodgkin’s lymphoma [1]. Other indications
for autologous transplantation are Hodgkin’s lymphoma,
acute myeloid leukemia, neuroblastoma, amyloidosis,
autoimmune disorders and other conditions [1]. Engraft-
ment syndrome is a potential complication of hematopoietic
stem cell transplantation (HSCT). The syndrome is a febrile
clinical condition that occurs in the early neutrophil
recovery phase after hematopoietic stem cell transplantation
[2]. It is characterized by noninfectious fever and various
clinical findings, such as skin rash mimicking acute graft-
versus-host disease, diarrhea, pulmonary infiltrates, weight
gain and neurological manifestations [3]. The pathogenesis
of engraftment syndrome is not clearly understood, but
involves the release of proinflammatory cytokines, includ-
ing tumor necrosis factor-alpha and interleukin-1 resulting
in increased capillary permeability [2, 3]. Engraftment
syndrome has been described after allogeneic and autolo-
gous HSCT [4]. It is likely associated with increased mor-
tality [2]. Corticosteroid is often effective therapy [2].
The incidence of engraftment syndrome varies from 7
to 59% depending on the definition used [4]. In 2003,
Maiolinon et al. [4] introduced new diagnostic criteria for
engraftment syndrome. These criteria are noninfectious
fever plus any of the following: skin rash, diarrhea or
pulmonary infiltrate [4]. The diarrhea is defined, in
engraftment syndrome, as noninfectious diarrhea manifest
as at least two episodes of liquid bowel movements per day
without documentation of infection by standard procedures
[4]. Based on this definition, the incidence of engraftment
syndrome in autologous HSCT is 20% [4].
To our knowledge, the endoscopic findings in patients
with colitis secondary to engraftment syndrome have never
been reported.
The Case
A 55-year-old Caucasian woman with a history of multiple
myeloma underwent autologous peripheral blood stem cell
transplant. On day 8 posttransplant, she developed fever
and diarrhea that turned bloody on day 14 posttransplant.
Infectious stool studies were negative. Colonoscopy was
done on day 20 posttransplant and showed inflammation in
the rectum, the sigmoid colon, the descending colon and in
the transverse colon. The inflammation was characterized
by congestion, erythema, granularity and aphthous ulcer-
ations. The inflammation was patchy in the rectum (Fig. 1),
linear in the descending colon (Fig. 2) and more diffuse in
the transverse colon (Fig. 3). The colitis was mild in the
rectum and severe in the transverse colon. For the sake of
patient’s safety, the scope was not advanced beyond the
transverse colon. Several biopsies were obtained with cold
forceps for histology and HSV and CMV PCR. The PCR
studies were negative. The biopsies from the colon showed
A. A. Alkhatib (&) Á K. K. Boynton
Department of Medicine, Division of Gastroenterology,
University of Utah, 30 North 1900 East, SOM4R118,
Salt Lake City, UT 84132, USA
e-mail: khatibamer@yahoo.com
A. M. Badheeb
Division of Hematology and Bone Marrow Transplant, H. Lee
Moffitt Cancer Center & Research Institute, Tampa, FL, USA
e-mail: badheeb@yahoo.com
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Dig Dis Sci (2010) 55:1500–1501
DOI 10.1007/s10620-009-0841-1

2. scattered epithelial apoptosis associated with crypt
abscesses and total necrosis of individual crypts. These
changes were consistent with acute graft-vs-host disease
grade 2–3. The patient was diagnosed with engraftment
syndrome and treated with prednisone. The patient’s diar-
rhea resolved.
References
1. Copelan EA. Hematopoietic stem-cell transplantation. N Engl J
Med. 2006;354(17):1813–1826. doi:10.1056/NEJMra052638.
2. Spitzer TR. Engraftment syndrome following hematopoietic stem
cell transplantation. Bone Marrow Transplant. 2001;27(9):893–898.
doi:10.1038/sj.bmt.1703015.
3. Cahill RA, Spitzer TR, Mazumder A. Marrow engraftment and
clinical manifestations of capillary leak syndrome. Bone Marrow
Transplant. 1996;18(1):177–184.
4. Maiolino A, et al. Engraftment syndrome following autologous
hematopoietic stem cell transplantation: definition of diagnostic
criteria. Bone Marrow Transplant. 2003;31(5):393–397. doi:
10.1038/sj.bmt.1703855.
Fig. 1 Endoscopic image of the rectum showing patchy colitis
Fig. 2 Endoscopic image of the descending colon showing linear
colitis
Fig. 3 Endoscopic image of the transverse colon showing diffuse
colitis
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