Page 1637 - Hematology_ Basic Principles and Practice ( PDFDrive )

1458 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

monitoring tests (e.g., pp65 antigenemia or PCR) for 10 to 20 weeks. checked before and monitored after HSCT. High hepatitis B viral
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No special measures are needed during neutropenia because a detect- load (>10 copies/mL) is the most important risk factor for reactiva-
able circulating white count usually is necessary for reactivation of tion in patients positive for surface antigen undergoing HSCT.
CMV. If the patient is CMV seronegative before transplantation but High-circulating hepatitis B viral load in the intended recipient is an
the donor is seropositive, the same monitoring algorithm used for the indication for lamivudine. There is no evident correlation between
CMV-seropositive patient is needed. hepatitis C genotype and type or severity of liver disease after
If the donor and recipient are CMV seronegative before transplan- transplantation.
tation, infection through blood products is possible; therefore exclusive
use of CMV-seronegative blood products or other means of prevent-
ing CMV seroconversion, such as leukocyte depletion by filtration, Human Immunodeficiency Virus
are recommended. CMV monitoring should be followed weekly, but
the duration of this testing can be shortened by 50%, to 6 to 10 weeks, A positive donor HIV test for a recipient candidate not known to
because late infection in seronegative recipients is uncommon. be seropositive is a contraindication for donation. If the screening
test for HIV is positive, a Western blot study should be completed
Varicella, Human Herpes Virus Type 6, and to confirm the result because of the potential for false-positive
testing.
Epstein-Barr Virus
A history of chickenpox is an adequate surrogate for performing the Syphilis
VZV antibody test. As an alternative to ordering varicella serology
on every patient, the test could be ordered in patients with no history If the indirect screening test for syphilis returns positive and is con-
of varicella infection or vaccination. firmed by a direct test, high-dose penicillin treatment should be given
Acyclovir used to prevent reactivation of HSV during neutropenia for 10 days after transplantation.
will also prevent occurrence of clinical VZV infection in most trans-
plantation recipients. Later after transplantation, when acyclovir
prophylaxis may have been discontinued, VZV reactivations usually Toxoplasma
are recognized by their characteristic dermatomal distribution, and
treated using acyclovir or valacyclovir. Historically, 15% of patients who undergo transplantation in the
Serology for HHV-6 is not tested before transplantation because United States are seropositive for Toxoplasma, but this percentage may
more than 95% of adults are seropositive for the virus. The trans- be higher for European centers. The risk for reactivation among
plantation recipient receiving minimal herpesvirus antiviral therapy seropositive patients is 2%, for an overall incidence of less than 1%
during the transplantation procedure is at risk for reactivation of of HSCT recipients. It is suspected that low-dose sulfa-based regi-
HHV-6. Whether the CMV-seronegative or HSV-seronegative mens, such as those used to prevent Pneumocystis pneumonia, may
recipient with a CMV-seronegative donor who ordinarily would be effective in preventing Toxoplasma.
receive no antiviral prophylaxis is at highest risk is not known.
Additionally, the consequences of asymptomatic and untreated
HHV-6 reactivation are not known. Review of Commonsense Measures to
The vast majority of adult patients undergoing transplantation Prevent Infection
and their donors are EBV seropositive. EBV reactivation is in the
differential diagnosis of any new mass, such as enlarged nodes or lung Commonsense measures that should be discussed before transplanta-
nodules after transplantation (Chapter 52). Now that sensitive tion or aggressive nontransplantation chemotherapy include attention
quantitative EBV viral load tests and effective treatments, such as to diet, travel, crowds, and pets. Additionally, a history of family or
rituximab, are available, investigators are monitoring high-risk recipi- social exposure to tuberculosis should be used to guide whether or
ents with quantitative viral load studies. 30 not a Mantoux test is applied before therapy.
Diet should be reviewed for herbal supplements or restricted
foods. Patients may not recognize that most supplements will
Hepatitis B and C have to be discontinued after HSCT. Ground meat products need
to be thoroughly cooked so that bacteria, distributed onto meat
Hepatitis B (core antibody, surface antibody, and surface antigen) and in the grinding process, are killed. Any fruits or vegetables that
hepatitis C serologies are tested in donor and recipient before trans- cannot be peeled should be washed. Salad bars are associated with
plantation. Hepatic dysfunction from either hepatitis B or C after occasional transmission of infections. Food products or supplements
HSCT can lead to life-threatening liver complications, including that inherently contain infectious organisms should be avoided,
venoocclusive disease and acute hepatic necrosis. Short-term compli- including undercooked eggs. Blue cheeses have molds spiked into
cations are usually due to hepatitis B, whereas the long-term compli- the cheese wheel as they are curing and should be avoided. Soft
cation of cirrhosis is due to hepatitis C. The risk for hepatitis in the cheeses carry the potential risk for Listeria infection. Yogurt contains
recipient can be reduced by antiviral therapy for recipients and Lactobacillus that, rather than causing gut problems, has been found
donors who have detectable viral loads and by transfer of immunity to cause infection in other sites, including the lungs after aspiration
from donor to recipient. A hepatitis-infected individual can be used events.
as a donor if no alternative donor is available or if the intended There are no particular travel restrictions, but strategies to mini-
recipient already is seropositive. mize transmission of infectious diseases have been summarized. Some
The risk for transmission is small when the hepatitis B–seropositive social situations, such as sitting in a crowded movie theater or class-
donor has an undetectable viral load; however, careful follow-up of room, increase the risk for acquiring a viral illness. Turning away from
recipients is recommended. A surface antigen-positive hepatitis B individuals who are coughing or sneezing may be helpful in prevent-
donor with a high viral load should be treated with lamivudine or ing the transmission of infections. Patients need instruction to
another agent to reduce the circulating viral load before transplanta- remember to complete the cycle of infection prevention by washing
tion. High-circulating hepatitis C viral load in the seropositive donor their hands as soon as possible after being close to such an individual.
for a seronegative recipient is an indication for antiviral therapy of Given outbreaks of noroviruses (Norwalk-like viruses) on cruise ships
the donor before HSCT. and other types of outbreaks (e.g., Staphylococcus) commonly
If the potential recipient has serologic evidence of infection with associated with the close living quarters during this type of travel,
hepatitis B or C before transplantation, viral load levels should be cruise ships should be avoided.