Transfusion Associated Graft versus Host Disease

Case 1: A five-year-old girl, a case of acute lymphoblastic leukemia (L1) presented with fever and lethargy a fortnight after receiving the late intensification chemotherapy consist-ing of vincristine, daunorubicin, cytarabine, etoposide, thioguanine and oral dexamethasone over a period of five days (UK ALL X protocol)(8). She had been in a sustained first remission for nearly 18 weeks. Examination revealed a febrile child with no localizing features. Investigations revealed a hemoglobin (Hb) of 95 g/L, a while blood cell (WBC) count of 0.04 109/L and a platelet count of 8 × 109/L. The very severe leuco-penia precluded a differential count. The serum biochemistry, including liver and renal function tests, was within normal limits. In accordance with the protocol for febrile neutropenia, she was started on intravenous cefotaxime and amikacin. A packet red-cell transfusion was administered on day 3 of admission for anemia (Hb level of 69 g/L). The blood culture grew Escherchia coli and Streptococcus pneumoniae that were sensitive to the antimicrobials being administered. Fever subsided on day 4 of admission. The child appeared to be recovering till day 9, when she had high-grade fever. It was followed by an erythematous maculopapular rash, which was first noticed on the trunk and spread to involve the palms and soles, with periungual and auricular erythema. Simultaneously, she had loose stools and was detected to be icteric. Repeat investigations revealed a Hb of 82 g/L, a WBC count of From the Division of Pediatric Hematology-Oncology, Advanced Pediatric Center and Department of Histopathology*, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012 India.