A 10-year-old boy developed severe dyspnea and respiratory failure during a hospitalization for an allogeneic unrelated bone marrow transplantation for acute myeloid leukemia. He had first presented 23 weeks earlier with acute myeloid leukemia and had not responded to the initial induction chemotherapy. Next, he was successfully treated with another regimen of remission-induction chemotherapy without complications. He received an allogeneic unrelated bone marrow transplant after a conditioning regimen of cyclophosphamide (Endoxan; AstaMedica BV; Diemen, the Netherlands) therapy, total body irradiation, and low-dose antithymocyte globulin. Both donor and recipient were seronegative for cytomegalovirus. Immediately after transplantation, the patient received therapy with cyclosporine A, short-course methotrexate, and total bowel decontamination. During this time, he was nursed in a protective environment. Seven days after undergoing the bone marrow transplantation, he developed a fever. A blood culture revealed a coagulase-negative Staphylococcus infection for which he was treated with IV antibiotics (ceftazidime and teicoplanin). Six days later (13 days after the bone marrow transplantation), a chest radiograph showed bilateral pulmonary infiltrates (Fig 1).
Physical Examination
The results of the physical examination conducted 13 days after the bone marrow transplantation were as follows: BP, 117/52 mm Hg; pulse rate, 164 beats/min; body temperature, 39.5[degrees]C; and breathing frequency, 40 breaths/min. The jugular veins were not distended. A chest examination revealed crackles on the right ventral side, but on the left side no abnormalities were heard. Heart sounds were normal, and no murmurs were discerned. The palms of the hands showed a flaky appearance. The remainder of the physical examination revealed no abnormalities.
Laboratory Findings
The laboratory findings obtained 13 days after the bone marrow transplantation were as follows: total WBC count, < 0.1 X [10.sup.3] cells/[micro]L; hemoglobin, 5.8 mmol/L; hematocrit, 26.3%; platelet count, 7 X [10.sup.3] cells/[micro]L; prothrombin time, 17.7 s; fibrinogen, 6.5 g/L; urea, 4.2 mmol/L; creatinine, 56 mmol/L; total bilirubin, 34 [micro]mol/L; conjugated bilirubin, 20 [micro]mol/L; lactate dehydrogenase, 334 IU/L; [gamma]-glutamyltransferase, 48 IU/L; alkaline phosphatase, 88 IU/L; aspartate aminotransferase, 22 IU/L; alanine aminotransferase, 10 IU/L; total protein, 40 g/L; magnesium, 0.54 mmol/L; and serum lactate, 1.8 mmol/L.
Hospital Course
Because the fever persisted, a fungal infection was suspected, and IV liposomal amphotericin B (3 mg/kg/d) was added to the patient's treatment. Next, his blood showed rapid donor myelopoietic engraftment, and his condition stabilized. Twelve days later (at 25 days after transplantation), he developed dyspnea, which rapidly progressed to complete respiratory failure for which he was mechanically ventilated with a respiratory rate of 30 breaths/min, a positive end-expiration pressure of 8 mm Hg, a maximal inspiratory pressure of 40 mm Hg, and an inspiratory oxygen fraction of 100%. His arterial blood gas levels while receiving mechanical ventilation were as follows: pH, 7.32; P[O.sub.2], 68.3 mm Hg; PC[O.sub.2], 64.5 mm Hg; bicarbonate, 32 mmol/L; base excess, 5 mmol/L; and oxygen saturation, 92%.
The chest radiograph immediately after intubation showed bilateral diffuse airspace consolidations, with a suggestion of a cavitary lesion in the left upper lobe (Fig 2). The patient's condition was stabilized by treatment with mechanical ventilation...