Higher risk with allogenic transplant
Stroke
Median time of presentation 28 days post-transplant
Usually hemorrhagic due to thrombocytopenia
Can also be ischemic due infection, thrombosis, endocarditis
Infection
Aspergillus (main cause), CMV, HSV, Toxoplasma, Candida, Cryptococcus, bacterial meningitis
Metabolic encephalopathy
Causes include hypoxemia, electrolyte abnormalities, metabolic acidosis, sepsis, hepatic failure, medications (sedatives and analgesics), thiamine deficiency
Median time of presentation 28 days post-transplant
Usually hemorrhagic due to thrombocytopenia
Can also be ischemic due infection, thrombosis, endocarditis
Aspergillus (main cause), CMV, HSV, Toxoplasma, Candida, Cryptococcus, bacterial meningitis
Causes include hypoxemia, electrolyte abnormalities, metabolic acidosis, sepsis, hepatic failure, medications (sedatives and analgesics), thiamine deficiency
Pulmonary edema
Risk factors: low EF, veno-oclussive disease, severe sepsis, anemia, high-dose chemo
Pericardial effusion, pericardial tamponade
Rare, associated with cyclophosphamide toxicity, infection, chronic GVHD, renal failure
Risk factors: low EF, veno-oclussive disease, severe sepsis, anemia, high-dose chemo
Rare, associated with cyclophosphamide toxicity, infection, chronic GVHD, renal failure
Engraftment syndrome
Due to rapid return of neutrophils
Features: fever, rash, pulmonary edema, weight gain, liver and renal dysfunction, and/or encephalopathy
Diffuse alveolar hemorrhage
Bronchiolitis obliterans with or without organizing pneumonia
Due to rapid return of neutrophils
Features: fever, rash, pulmonary edema, weight gain, liver and renal dysfunction, and/or encephalopathy
Intestinal GVHD
abdominal pain, nausea/vomiting, diarrhea, GI bleeding +/- peritonitis, hepatitis, rash
Pseudo-obstruction
Veno-occlusive disease of liver
common
usually first 21 days after transplant
high dose chemo→endothelial damage of central hepatic venules→ thrombosis
RUQ pain, jaundice, weight gain
GI bleed
Chemo, GVHD, or CMV/adenovirus → diffuse mucosal bleeding, ulcers, or necrosis
abdominal pain, nausea/vomiting, diarrhea, GI bleeding +/- peritonitis, hepatitis, rash
common
usually first 21 days after transplant
high dose chemo→endothelial damage of central hepatic venules→ thrombosis
RUQ pain, jaundice, weight gain
Chemo, GVHD, or CMV/adenovirus → diffuse mucosal bleeding, ulcers, or necrosis
Tumor lysis syndrome
Hemorrhagic cystitis, veno-occlusive disease
Hemolytic uremic syndrome
Acute (<100 days post-transplant) or chronic
rash, mucositis, diarrhea, fever, +/- hepatitis, polyneuropathy, polymyositis, GI bleed, pancreatitis
See also neutropenic fever and Immunocompromised antibiotics
Viral
CMV: pneumonitis most fatal, can also cause CNS infection, retinitis, hepatitis, pancreatitis, esophagitis, colitis
RSV
Adenovirus
HHV-6: pneumonitis, bone marrow suppression, enteritis, encephalitis
HSV: pneumonia, hepatitis, rash, encephalitis, DIC
Bacterial
increased risk due to neutropenia, mucositis, skin fragility, GI problems, indwelling lines
Pseudomonas, klebsiella
MRSA, strep viridans, enterococcus
C. diff
Pneumonia, endocarditis, UTI, colitis, meningitis, etc.
Fungal
Aspergillus: pulmonary, hepatic, endocarditis, CNS infection (main cause of CNS infection)
Candida: pneumonia, hepatic, CNS infection, endophthalmitis, esophagitis
Pneumocystis: pneumonia
Cryptococcus: CNS, pneumonia
Toxoplasmosis: CNS infection, pneumonia
Causative organisms by time after transplant:
early (<30 days): bacteria, candida, aspergillus, HHV, RSV
mid (30-100 days): CMV, PCP, adenovirus, HSV, aspergillus
late (>100 days): CMV
CMV: pneumonitis most fatal, can also cause CNS infection, retinitis, hepatitis, pancreatitis, esophagitis, colitis
RSV
Adenovirus
HHV-6: pneumonitis, bone marrow suppression, enteritis, encephalitis
HSV: pneumonia, hepatitis, rash, encephalitis, DIC
increased risk due to neutropenia, mucositis, skin fragility, GI problems, indwelling lines
Pseudomonas, klebsiella
MRSA, strep viridans, enterococcus
C. diff
Pneumonia, endocarditis, UTI, colitis, meningitis, etc.
Aspergillus: pulmonary, hepatic, endocarditis, CNS infection (main cause of CNS infection)
Candida: pneumonia, hepatic, CNS infection, endophthalmitis, esophagitis
Pneumocystis: pneumonia
Cryptococcus: CNS, pneumonia
early (<30 days): bacteria, candida, aspergillus, HHV, RSV
mid (30-100 days): CMV, PCP, adenovirus, HSV, aspergillus
late (>100 days): CMV
Prednisone
Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension, ulcers
Tacrolimus, cyclosporine
Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout, cardiotoxicity
Mycophenolate mofetil, methotrexate
Cytopenias, GI distress
Azathioprine
Cytopenias, pancreatitis, hepatitis
Also consider toxicities related to other medications, including prophylactic or broad spectrum antibiotics
Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension, ulcers
Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout, cardiotoxicity
Cytopenias, GI distress
Cytopenias, pancreatitis, hepatitis
Stem cell transplant complications
Higher risk with allogenic transplant
Transplant complications
Stroke
Oncologic therapy related adverse events
Median time of presentation 28 days post-transplant
Lung transplant complications
Usually hemorrhagic due to thrombocytopenia