darkhorse
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You are asked to consult for hyperbilirubinemia in a 32-year-old female on the bone marrow
transplant service. Fifteen days ago she had an allogeneic bone marrow transplant for poor-risk
acute myeloid leukemia. She received busulfan and high-dose cyclophosphamide as a
preparative regimen. At 13 days after transplantation she started to develop icterus. Total
bilirubin started to rise. She also developed abdominal swelling and peripheral edema. The
patient's medications include valacyclovir, cefepime, and liposomal amphotericin. On
examination she has scleral icterus. The abdomen is distended. There are bowel sounds. There
is mild right upper quadrant tenderness. Ascites is present. She has 2+ pedal edema. She is
neutropenic and transfusion-dependent for red blood cells and platelets. Direct bilirubin is 7
mg/dL. Aspartate aminotransferase (AST) is 98 U/L, and alanine aminotransferase (ALT) is 86
U/L. Alkaline phosphatase is 50 U/L. Right upper quadrant ultrasound shows hepatomegaly.
Sonographic Murphy's sign is negative. What is the most likely diagnosis?
A. Leukemic infiltration of the liver
B. Graft-versus-host disease
C. Medication side effect
D. Venooclusive disease
E. Acalculous cholecystitis
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| nbus06
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BBB?
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| neuroblastoma
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Graft-versus-host disease occurs after BM &LIVER TRANSPLANTS--
Donor T cells recognise host tissue as FOREIGN and activate host CD4,CD8cells.
clinical findings--bile duct necrosis--(jaundice),bloody dirrhea,Dermatatis
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| me007
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D.
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| cool doctor
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D
budd-chiari
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| darkhorse
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D
Transplant preparative regimens cause a spectrum of acute toxicities. Nausea and vomiting are
common. Regimens that include high-dose cyclophosphamide may result in hemorrhagic
cystitis. Oral mucositis and alopecia are ubiquitous. Infectious complications are common in the
early transplant period, and broad-spectrum antibiotics must be inititated at the first sign of
fever regardless of the presence of positive cultures. Approximately 10% of these patients
develop venoocculsive disease of the liver. This is related to direct cytotoxic injury to
hepatic-venular and sinusoidal endothelium, with the subsequent development of a
hypercoagulable state. These symptoms may occur at any time during the first month after
transplantation, with a peak incidence around day 16. Clinical symptoms and signs include
tender hepatomegaly, ascites, jaundice, and fluid retention. Mortality is high, with progressive
hepatic failure culminating in a terminal hepatorenal syndrome. There are no proven therapies.
The absence of leukocytes makes leukemic infiltration and graft-versus-host disease less likely.
Medications may certainly produce liver disease, but the picture fits better with venoocclusive
disease. The absence of gallbladder wall thickening or sonographic Murphy's sign does not
support the diagnosis of acalculous cholecystitis.
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