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BMTCN PRACTICE QUESTIONS WITH COMPLETE SOLUTIONS.
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- Oxford University (OX)
BMTCN PRACTICE QUESTIONS WITH COMPLETE SOLUTIONS.
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BMTCN CHAPTER 5: GRAFT-VERSUS-HOST DISEASE WITH 100% CORRECT
ANSWERS
T.R. is a 28-year-old woman with acute myeloid leukemia in her second complete remission who
is admitted for a matched unrelated allogeneic stem cell transplantation. Her conditioning
regimen is as follows:
Myeloablation (busulfan/cyclophosphamide) and immunosuppression with tacrolimus and
methotrexate (5 mg/m2 on days +1, +3, +6, and +11).
She did not receive methotrexate on day +11 because of severe mucositis. Her transplant course
was complicated by mucositis, neutropenic fever, and Clostri - answer D. A and C
The patient's immunosuppressive drugs need to be at a therapeutic level. Try to use as little
additional immunosuppression as is necessary to control GVHD so as to maintain allo- effect of
the transplant against any residual leukemia. Often, grade 1 or 2 skin GVHD responds to topical
steroids.
T.R.'s tacrolimus level is therapeutic at 11. One week later, at the scheduled clinic visit, her rash
has decreased to grade 1. T.R. reports "watery diarrhea" five times per day. She is admitted to
the hospital for further evaluation and treatment. How should the patient be managed?
(1) Continue PO medications.
(2) Add antidiarrheal agents.
(3) Rule out infectious etiology of diarrhea.
(4) Change medications from PO to IV.
(5) Request gastrointestinal (GI) consult.
(6) Obtain accurate meas - answer C. 2,3,4,5,6
Infectious etiology must always be ruled out (e.g., Clostridium difficile [C. difficile], rotavirus).
Medications should be changed from PO to IV to ensure absorption. GI consult to follow and
, assess need for colonoscopy. GI GVHD grading is based on volume of stool, so an accurate
assessment of amount of diarrhea is important. Once C. difficile is ruled out, antidiarrheal
agents may be started.
T.R.'s tacrolimus level remains therapeutic at 11. The volume of diarrhea in 24 hours is 1,000 ml.
Infectious etiology workup is negative. Colonoscopy was obtained, and the report describes
erythema and ulcerations. Cytomegalovirus (CMV) and other viral strains are negative. The
formal interpretation of biopsy shows consistency with GVHD. T.R. is therefore diagnosed with
stage 2 acute GVHD. How should the patient be managed?
A. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
B. A - answer A. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
One week later, T.R.'s volume of diarrhea has increased to 3,000 ml per day. How should the
patient be treated?
A. Increase steroids.
B. Add infliximab or ATG and attempt to taper steroids.
C. Continue same treatment and wait.
D. Start clear liquids PO to replace GI fluid loss. - answer B. Add infliximab or ATG and attempt to
taper steroids.
No preferred second-line therapy with acute GVHD currently exists. It often is physician or
institution preference. Any of the drugs in B are acceptable. No data show that increasing
steroids above 2 mg/kg per day is effective.
What is the standard regimen of immunosuppression for myeloablative transplant?
A. Steroids
B. Tacrolimus and cyclosporine
C. Steroids and tacrolimus
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