Tracheoesophageal fistula induced by aspergillus infection following bone marrow transplantation

A 10-year-old boy was referred to the BMT department for treatment of MDS (refractory anemia with excess 20% myeloblasts). The conditioning for BMT included total lymphoid irradiation (600 rad), VP16 (1,275 mg), cyclophosphamide ( 1,260 mg), melphalan (5 I mg) and total body irradiation (1,200 rad). On the day of transplant (day 0) the patient received BM (8.4 X lo* cells/kg body weight), T-cell depleted with monoclonal antibody (rat anti-human IgG antiCDw52) from his HLA matched sister. The course of BMT was completed by graft rejection on post-BMT day 5.5. A second BMT was performed with cells from the sister, but without T-cell depletion. Prior conditioning consisted of anti-thymocytic globulin for 3 days and one dose of cyclophosphamide (60 mg/kg body weight). Granulocyte macrophage colony stimulating factor (GMCSF) and Interleukin-3 (lL3) were given post-BMT to enhance engraftment. On day 2 after the second BMT, (57 days post first BMT) while receiving broad spectrum antibiotics (imipenem, vancomycin, amikacin) and amphotericin B (0.5 mg/kg; asphophlactic dose) the patient developed fever, neutropenia, cough, inspiratory wheezing and his abdomen was distended. A day later he was in acute respiratory distress with consolidation in the right upper lobe as determined by chest radiography. Flexible fiberoptic endoscopy detected an obstruction by white material in the opening of the left main bronchus (LMB). Histopathological examination of the material, obtained by suction through the bronchoscope, revealed typical aspergillosis hyphae. No bronchial or transbronchial biopsies were carried out. A second rigid bronchoscopy was performed