8/9/2019 A Case of Dengue Feverinduced Severe Aplastic Anemia Salvaged by Allogeneic Bone Marrow Transplant 2329 691…

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8/9/2019 A Case of Dengue Feverinduced Severe Aplastic Anemia Salvaged by Allogeneic Bone Marrow Transplant 2329 691…

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Citation: Khoj L, Baksh R, Aslam M, Kelta M, Albeirouti B, et al. (2013) A Case of Dengue Fever-Induced Severe Aplastic Anemia Salvaged by

 Allogeneic Bone Marrow Transplant. J Leuk 1: 120. doi:10.4172/2329-6917.1000120

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Volume 1 • Issue 3 • 1000120J Leuk

ISSN: 2329-6917 JLU, an open access journal

the literature in patients aged 8 and 11 years [2,3] both patients werediagnosed with AA ollowing a dengue virus inection, and both weresuccessully treated with chemotherapy alone. In the first case, BM

was planned but could not be done because an HLA-matched donorwas not available [2]. However, to our knowledge, the present case isthe first ever case where allogeneic BM was perormed or dengueever–induced SAA. Te patient tolerated the transplant well, with nomajor complications or graf-versus-host disease. Tere are only a ewreported cases o AA due to dengue ever in the literature. Albuquerqueet al. reported similar cases rom Latin America, and Ramzan et al.reported a case rom India [2,3]. In  both articles, the diagnosis o AAwas confirmed by IgG and IGM; however, none o the patients receiveda BM. Hemorrhagic episodes in patients with aplastic anemia occurusually secondary to thrombocytopenia and require requent supportwith platelet concentrates and other blood products. Inection withdengue virus (particularly dengue sero type-2 o South Asian genotype)is associated with dengue hemorrhagic ever. Dengue inection urther

worsens the disease process in patients with aplastic anaemia due touncontrolled hemorrhagic diathesis and major organ ailure, whichmay prove atal in these already immunocompromised patients, i nottreated appropriately [4].

In our case, the patient presented with bleeding due tothrombocytopenia. Upon investigation, the patient was ound to bepancytopenic, the dengue virus serology was positive or both IgGand IgM, and the bone marrow biopsy showed SAA. Other causeso AA, such as PNH and myelodysplastic syndrome, were excludedrom consideration. Hence, a diagnosis o dengue ever–induced AAwas made. Te deects could be the result o an autoimmune responsemediated by cytotoxic lymphocytes (CD8), which are detectablein the blood and bone marrow o AA patients. As is known in many

autoimmune diseases, an acute viral illness can trigger this autoimmuneresponse.

Most acquired AA is the result o an immune-mediated destructiono hematopoietic stem cells that causes pancytopenia and aplastic bonemarrow. Te severe orm o aplastic anemia is a lie-threatening bonemarrow ailure disorder that, i untreated, is associated with a veryhigh mortality rate. An immune response dominated by oligoclonalexpanded cytotoxic cells targets hematopoietic stem and progenitorcells, inducing their cell death via apoptosis and hematopoietic ailure[5]. Again, this can be triggered by a dengue virus inection.

Other viruses causing SAA, including parvovirus B19 andhepatitis, also share the same immunologic pathogenesis outlinedabove. wo hypotheses can be made concerning the pathogenesis oparvovirus B19–induced AA. Te first hypothesis involves the directeffect o parvovirus B19, suggesting that all 3 precursor cell linesin the bone marrow might become the target cells [6]. Te secondhypothesis is based on immunologic mediation. In virus-associatedhemophagocytic syndrome with an acute parvovirus B19 inection,raised levels o cytokines such as intereron γ would impair regulationo the phagocytic system, resulting in pancytopenia and/or decreased

hematopoiesis [7]. In hepatitis, activation o circulating cytotoxic cells increases, with the cells tending to accumulate in the liver, andthereore there is a large amount o cell infiltration rom the liver

parenchyma [8]. Recovery o autologous hematopoiesis in patientswhose stem cell transplant engrafment ailed and responsivenessto immunosuppressive therapies support the hypothesis that theimmunologic pathophysiology underlying an immune responsetriggered by acquired AA leads to bone marrow ailure [5].

Te other mechanism in which a dengue virus inection causesaplastic anemia is the replication o the virus in the hematopoietic cells,which directly damages these hematopoietic cells peripherally or in thebone marrow [9]. Tis supports the association between dengue everand AA as reported in our case.

Conclusion

Allogeneic BM is the transplant method o choice or SAA

in younger patients,  and it was achieved successully in our case.Te transplant was done ollowing a priming regimen withcyclophosphamide and antithymocyte Globulin and was made easiblebecause o a well-established collaboration and good organizationbetween different health institutions. In addition, finding an HLA-matched donor in our country is not challenging because most patientshave a large number o siblings. Regarding the serious associationbetween dengue ever and SAA, the importance o eradicating the Aedesaegypti mosquito, which is the main carrier o dengue ever, cannotbe overemphasized. Efforts should be placed to decrease morbidityand mortality related to dengue virus, and this could be establishedby proper sanitation and by having an effective vaccine and specificantiviral treatment.

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Citation: Khoj L, Baksh R, Aslam M, Kelta M, Albeirouti B, et al. (2013) A Case

of Dengue Fever-Induced Severe Aplastic Anemia Salvaged by Allogeneic

Bone Marrow Transplant. J Leuk 1: 120. doi:10.4172/2329-6917.1000120

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