Engraftment Failure or Aplastic Anemia: A Case Report

Secondary engraftment failure is defined as neutrophils increase to ≥ 0.5 x 10 ⁹/L and subsequently decrease to a lower level until additional treatment to obtain engraftment is given. We report a case of a 64 year old female with multiple myeloma and secondary engraftment failure after high dose chemotherapy with autologous hematopoietic stem cell transplantation (AHSCT) on day +64.  The patient presented with severe pancytopenia and a bone marrow biopsy and aspirates revealed a hypocellular marrow without increased plasma cells. An extensive infectious disease work up was negative for bacterial, fungal or viral source including cytomegalovirus, HHV 6, parovirus, BK virus, and adenovirus. The patient received stem cell boost on day +98 and failed to engraft. A repeat bone marrow biopsy performed on Day +127 revealed less than 10% cellularity with no signs of hematopoiesis and no plasma cells. Therefore, the patient met the criteria for severe aplastic anemia (AA). The patient was initiated on eltrombopaq after one week treatment of steroid and cyclosporine with minimal improvement in neutrophil counts.  Although uncommon, the case study examines the rare occurrence of AA in the post-transplant population. The case report highlights that secondary engraftment failure and AA are uncommon complications of AHSCT and can be life threatening. Careful clinical evaluation and pathology review are necessary to determine the cause of graft failure in the autologous transplant setting in order to provide the appropriate medical and supportive care.