From the Guidelines
Fever after hematopoietic stem cell transplant (HSCT) or bone marrow transplant (BMT) is primarily caused by infections, with bacterial, viral, and fungal pathogens being the most common culprits, as well as graft-versus-host disease (GVHD), medication reactions, and engraftment syndrome. The causes of fever can be broken down into three phases: preengraftment, postengraftment, and late phase.
Preengraftment Phase
During the preengraftment phase, infections are the leading cause of fever, with oral, gastrointestinal, and skin flora being the primary sources of infection, including Candida species and Aspergillus species, as well as herpes simplex virus (HSV) reactivation 1.
Postengraftment Phase
In the postengraftment phase, impaired cell-mediated immunity increases the risk of infections, particularly from herpes viruses, such as CMV, which can cause pneumonia, hepatitis, and colitis, as well as Pneumocystis carinii and Aspergillus species 1.
Late Phase
The late phase is characterized by a higher risk of infections in allogeneic recipients with chronic GVHD, including CMV, varicella-zoster virus (VZV), EBV-related posttransplant lymphoproliferative disease, community-acquired respiratory viruses (CRV), and infections with encapsulated bacteria, such as Haemophilus influenzae and Streptococcus pneumoniae 1. Some key points to consider when evaluating fever in HSCT or BMT patients include:
- Infections are the most frequent cause of fever
- GVHD can cause fever, skin rash, gastrointestinal symptoms, or liver dysfunction
- Medication reactions can trigger fever
- Engraftment syndrome can cause fever, rash, and pulmonary symptoms
- Broad-spectrum antibiotics, antifungals, and viral prophylaxis may be necessary
- Blood cultures, chest imaging, and CMV PCR testing are essential diagnostic steps
- Early intervention is crucial to improve outcomes in immunosuppressed patients.