Abstract In a post-transplant patient, a multitude of confounding variables can make common problems less straightforward. Herein, we present a case of severe anemia in a lung transplant recipient. A 72-year-old male with past medical history of single lung transplant (CMV donor-positive/recipient-positive) for interstitial lung was found to have significant anemia about 10 months post-transplant. He was admitted with hemoglobin down to 5.6 and received a blood transfusion of 2 units packed red cells. He was started on darbepoetin alfa and was discharged with plans for outpatient bone marrow biopsy. Follow-up bloodwork in clinic about 1 week later again found a hemoglobin of 6.8 and patient was re-admitted for blood transfusion and further work-up. He was experiencing symptoms of dyspnea on exertion and activity intolerance. In-hospital evaluation revealed normal iron studies; elevated lactate dehydrogenase and low haptoglobin, though Coomb’s test negative; negative fecal occult blood; peripheral blood smear with an increase in schistocytes; and bone marrow biopsy showed normocellular marrow with robust hematopoiesis. Through collaboration with hematology, it was determined that anemia was likely medication-induced. At time of admission, patient’s medication list included triple immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone; maribavir for CMV viremia (started 2 months prior); dapsone for PJP prophylaxis; azithromycin; darbepoetin alfa; amongst other less relevant medications. Maribavir was elucidated as the most likely culprit given the timing of medication initiation and hemoglobin drop. The medication was discontinued, after which hemoglobin and hematocrit recovered. Many of the medications on this patient’s home regimen had the potential for bone marrow suppression, and though maribavir is not typically associated with significant myelosuppression, it does have a reported incidence of anemia of about 10%. The relation chronologically of onset of anemia and initiation of maribavir made it the most likely culprit, and recovery of .hematocrit after discontinuation of the medication further confirmed this suspicion. In a patient with multiple risk factors for myelosuppression, it is important to thoroughly investigate all possible causes and to take a careful approach to elucidate the etiology in order to provide the best management for a patient. This abstract is funded by: None
Robertson et al. (Fri,) studied this question.