ADENOVIRUS

Symptoms and Treatmentsof Hematopoietic Progenitor Cell Transplantation

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What is adenovirus?• Adenoviruses are a group of viruses that typically cause respiratory illness such as the common cold, conjunctivitis (an

infection in the eye), croup, bronchitis, or pneumonia.• Adenovirus infection affects approximately 5% of all stem cell transplant patients.• The virus may occur 1 month posttransplant.• Adenovirus lives in bodily fluids and can be spread by coughing, sneezing, or being in contact with someone who has

diarrhea. • Infection can be mild to severe and life threatening.

What are the risk factors associated with adenovirus? • Conditioning regimen (chemotherapy and/or radiation given to the patient before his or her transplant)• Donor type

– Autologous transplant (patient receives his or her own stem cells) – Allogeneic transplant (patient receives stem cells from a related or unrelated donor)

• Graft versus host disease (GvHD) – Acute GvHD: donor lymphocytes may attack the cells in the body – Immunosupressive medications lower the body’s ability to fight infection.

• Viral load – Increased amount of the virus in the body may correlate with increased diarrhea or respiratory symptoms in stem cell transplant patients.

How is adenovirus diagnosed?If the patient is having diarrhea or respiratory symptoms, the following tests may be ordered:

• Viral polymerase chain reaction (PCR): viral load in the blood, urine, or stool that can quantify the amount of virus present• Viral culture from blood, urine, tissue, saliva, nasal discharge, or stool• Chest X ray that can show an infection in the lungs.

The following are the most common symptoms of adenovirus infection. However, each child may experience symptoms differently. Symptoms may include:

• Fever• Diarrhea• Respiratory symptoms: sore throat, tracheitis, bronchitis• Pneumonia: fever, cough, fatigue, difficulty breathing deeply, feeling out of breath• Conjunctivitis: infection of the eye (redness, discharge from the eye)• Hemorrhagic cystitis: bleeding of the bladder• Hepatitis: inflammation of the liver caused by the virus

What are the treatment options for adenovirus?• Cidofovir: antiviral medication that can be given through an intravenous (IV) line• Ribavirin: antiviral treatment that can be taken by mouth or inhaled• Intravenous immunoglobulin (IVIG): given through an IV to provide antibodies to help fight off infection• Virus-specific T cells• Increased fluid intake: keeping your child well hydrated by encouraging fluids by mouth is important. If necessary, an IV

may be started to give your child fluids and essential electrolytes.

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• Bronchodilator medications to open your child’s airways often are administered in an aerosol mist by a mask or through an inhaler.

• Supplemental oxygen through a mask, nasal prongs, or an oxygen tent • Mechanical ventilation: a child who becomes very ill with adenovirus may require mechanical ventilation or a respirator to

assist with breathing for a period of time.• Your medical team will determine the best treatment plan for your child.

Prevention of Adenovirus• A strict regimen of hand washing is important to prevent the spread of adenoviruses to infants, children, and adults. If

your child is in the hospital, healthcare workers may wear special isolation apparel, such as gowns and gloves, when they enter your child’s room.

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Symptoms and Treatmentsof Hematopoietic Progenitor Cell Transplantation

What is autoimmune hemolytic anemia (AIHA)?• AIHA is an uncommon disorder that destroys red blood cells (RBC) resulting in a decreased hemoglobin and RBC level.• RBC destruction (hemolysis) occurs when your body makes antibodies that attack your own RBCs instead of identifying

foreign objects such as bacteria and viruses.• The degree of RBC destruction depends on the type of antibody causing the problem.• Secondary AIHA can occur after stem cell transplant.• AIHA is classified as warm AIHA, cold AIHA, mixed-type, or drug-induced AIHA.

What are the risk factors associated with AIHA?• Malignancy (Hodgkin disease, leukemia, myelodysplasia)• Immunodeficiency disorders• Lymphoproliferative disorders• Autoimmune disorders, the next leading cause of warm AIHA• Infections, the next leading cause of cold AIHA

How is AIHA diagnosed?If a patient has low hemoglobin or a sudden drop in hemoglobin, the following tests may be ordered:

• Complete blood count (CBC)/retic count: measures RBC activity• Direct antiglobulin test (indirect Coomb’s test): detects antibodies against RBCs that are present in the blood• Haptoglobin: measures how fast RBCs are destroyed. When RBCs die, they release hemoglobin. Haptoglobin attaches to

this released hemoglobin, which is also called free or plasma hemoglobin. Free hemoglobin is not contained within RBCs. The level of free hemoglobin is usually very low, but it rises when RBCs are dying.

• Plasma hemoglobin: plasma normally does not contain free hemoglobin. If the plasma hemoglobin level is high, this indicates breakdown of RBCs.

• Urinalysis: looks for RBCs in the urine• Viral studies: measure the amount of a specific virus in blood and urine• Liver function tests• Lactate dehydrogenase• Bone marrow aspirate or biopsy

The following are the most common symptoms of AIHA. However, each child may experience symptoms differently. Symptoms may include:

• Dark urine• Weakness or fatigue• Shortness of breath• Dizziness• Pale skin color• Jaundice, yellow skin color• Heart murmur• Increased heart rate• Enlarged liver or spleen

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What are the treatment options for AIHA?• Medicines

– Steroids: effect may be seen in several weeks – Rituximab: an infusion given through an IV to stimulate the immune system – Intravenous immune globulin (IVIG): an infusion given through an IV to stimulate the immune system

• Blood transfusions, given when anemia is severe• Plasmapheresis or plasma exchange: blood is taken out of the body through a catheter, and a cell separator removes

plasma from the blood. The blood cells are returned to the patient. The goal is to remove the antibodies that are attacking the RBCs.

• Splenectomy• Your medical team will determine the best treatment plan for your child.

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Symptoms and Treatmentsof Hematopoietic Progenitor Cell Transplantation

What is BK virus?• Named for the initials of the first infected patient• Infects up to 90% of the world’s population • Can cause hemorrhagic cystitis, a life-threatening bleeding and swelling in the bladder • Does not cause symptoms in patients with healthy immune systems

What are the risk factors associated with BK virus? • Conditioning regimen: chemotherapy and/or radiation given to the patient before his or her transplant• Donor type

– Autologous transplant (patient receives his or her own stem cells) has a low occurrence of BK virus – Allogeneic transplant (patient receives stem cells from a related or unrelated donor) has increased incidence of BK virus

• Graft versus host disease (GvHD) – In acute GvHD, donor lymphocytes may attack the cells in the body. – Immunosupressive medications lower the body’s ability to fight infection.

• Viral load – Increased amount of the virus in the blood or urine shows a link with increased bleeding from the bladder in stem cell transplant patients.

How is BK virus diagnosed?If the patient has blood in their urine or pain during urination, the following tests may be ordered:

• Urinalysis: looks for blood in the urine• Urine culture: looks for bacterial infection in the urine• Viral polymerase chain reaction (PCR): measures the viral load in the blood and urine to quantify the amount of virus

present• Viral culture: looks for viral infection in the urine

The following are the most common symptoms of BK virus infection. However, each child may experience symptoms differently. Symptoms may include:

• Blood in the urine ranging from blood that you cannot see, to red-colored urine, to blood clots in the urine• Cystitis: inflammation of the bladder causing painful urination• Narrowing of the ureter, muscular tubes that carry urine from the kidneys to the bladder• Kidney failure• Nephropathy: damage to the kidneys• Respiratory illness

What are the treatment options for BK virus? • Ciprofloxacin: an antibiotic that may decrease the virus in the blood• Cidofovir: an antiviral medication that can be given through an IV or placed into the bladder• Hydration: Intravenous (IV) fluids given to help flush out the bladder• Pain and antispasm medications: for bladder spasms or blood in the urine• Manual or continuous bladder irrigation may be needed if a blood clot obstructs the bladder. A catheter is placed in the

urinary tract, and the bladder is flushed using fluids to help break up any clots.• Leflunomide: an immunosuppressive medication that has antiviral properties• Intravenous immune globulin (IVIG): infusion that provides temporary antibodies to help fight infections• Your medical team will determine the best treatment plan for your child.

BK VIRUS

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