Results
The patient was a 17-year-old boy who underwent HSCT from matched sibling donor with peripheral blood stem cells in Behcet Uz Children’s Hospital, Turkey on August 18, 2020 for chronic myeloid leukemia. The conditioning regimen was busulfan plus cyclophosphamide; single agent cyclosporine was introduced for GVHD prophylaxis. No notable event like acute GVHD, sepsis, veno-occlusive disease or infection during early HSCT period was recognized. He had neutrophil engraftment on day +17 and platelet engraftment on day +23. Bone marrow aspirations (first and second months after HSCT) showed cytological and molecular remission and complete donor chimerism. As he had no GVHD, cyclosporine was tapered and stopped at day +65. Until day +93, he had no complaints during clinical visits and he had complete donor chimerism. At day +94, his mother showed fever, anosmia, chest pain and shortness of breath. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was positive on nasopharyngeal swab specimen. His mother hospitalized with pneumonia and shortness of breath. The patient was quarantined at home without any symptoms regarding COVID-19. Three days after this event, the patient started to suffer from large amount of watery diarrhea - three to five times a day with no blood - and abdominal pain, nausea, vomiting, and anorexia. One day later, the patient presented a maculopapular rash initially involving the nape of the neck, ears, shoulders, the palms of the hands, and the soles of the feet. It was pruritic. When he was admitted to the hospital, he had maculopapular rash <25 percent of body area, large amount of watery diarrhea, abdominal pain, nausea, vomiting, and anorexia but he had no fever or respiratory signs. The. radiological imaging revealed no finding related to COVID infection but RT-PCR testing for SARS-CoV-2 was positive on nasopharyngeal swab specimens.. No other viral reactivation or infection (cytomegalovirus, Epstein-Barr virus, adenovirus), as well as pathogens in the gaita specimen was detected. At that time, the patient was still on preventive anti-infectious treatment by sulfamethoxazole-trimethoprime, fluconazole, and acyclovir. But a period of one month had passed since cyclosporine was stopped. Complete blood count showed 3.5 × 109/L white blood cells including 2.2 × 109/L neutrophils, and lymphopenia (0.43 × 109/L), hemoglobin 9.6 g/dl, and platelets 103 × 109/L. Blood chemistry showed electrolyte imbalances and elevated kidney function tests. But liver function tests and bilirubines were in normal limits. He had metabolic acidosis in blood gas. Emprically metronidasole for diarrhea and favipravir for COVID-19 were started. The patient received intravenous immunoglobulin for immune deficiency secondary to HSCT. After two days, the rash spread to involve the whole integument, eventually become confluent one day after. He had still large amount of watery diarrhea with 10 to 15 times a day, abdominal pain, nausea, vomiting, and anorexia but no fever or respiratory signs. Cyclosporine IV and steroid 2 mg/kg was started because of the cutaneous and digestive GVHD grade III. Endoscopic evaluation of gastrointestinal tract could not be done because of the diagnosis of COVID. At day 5 after starting steroid and cyclosporine, the clinic picture was improved. At day 7, he had rash 25 to 50 percent of body area, diarrhea less watery with 5 to 10 times a day. He had no anorexia, food intolerance, nausea, and vomiting. We added non-absorbable budesonide and mycophenolate mophetil PO to the treatment. At day 14, he had rash <25 percent of body area, diarrhea less watery with 2 to 4 times a day. His COVID-19 PCR test was still positive. In the following period, we tapered the steroid dose. At day 29, his COVID-19 PCR test was negative in the wo samples taken 24 hours apart after the initial positive test. IgG antibody was still negative on day 35 after the initial COVID-19 PCR positivity.