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.