DIFFUSE ALVEOLAR HEMORRHAGE AFTER ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE IN THE SETTING OF CONCURRENT INFECTION

@article{anastacio2026diffuse,
  title = {{DIFFUSE ALVEOLAR HEMORRHAGE AFTER ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE IN THE SETTING OF CONCURRENT INFECTION}},
  author = {Lucas De Barros ANASTACIO and Cassia Caetano de Oliveira MIRANDA and Anderson Martins PEREIRA and Wellington Morais de Azevedo Lucas ANASTACIO},
  journal = {Hematology, Transfusion and Cell Therapy},
  year = {2026},
  month = oct,
  doi = {10.1016/j.htct.2026.106855},
  url = {https://doi.org/10.1016/j.htct.2026.106855},
  note = {CC BY},
}

TY  - JOUR
TI  - DIFFUSE ALVEOLAR HEMORRHAGE AFTER ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE IN THE SETTING OF CONCURRENT INFECTION
AU  - Lucas De Barros ANASTACIO
AU  - Cassia Caetano de Oliveira MIRANDA
AU  - Anderson Martins PEREIRA
AU  - Wellington Morais de Azevedo Lucas ANASTACIO
PY  - 2026
DA  - 2026/10/23
JO  - Hematology, Transfusion and Cell Therapy
DO  - 10.1016/j.htct.2026.106855
UR  - https://doi.org/10.1016/j.htct.2026.106855
AB  - Introduction: Diffuse alveolar hemorrhage (DAH) is a severe pulmonary complication after hematopoietic stem cell transplantation (HSCT) associated with high mortality. Its pathophysiology is multifactorial and involves endothelial injury, inflammation, infection, and hemostatic abnormalities. The overlap with infection-associated alveolar hemorrhage represents a major diagnostic and therapeutic challenge. Case report: A 61-year-old woman with Philadelphia chromosome-negative B-cell precursor acute lymphoblastic leukemia harboring a TP53 mutation with high variant allele frequency was treated with mini-Hyper-CVAD and blinatumomab and subsequently underwent haploidentical allogeneic HSCT (5.65 × 10⁶ CD34+/kg) after conditioning with fludarabine, melphalan, and total body irradiation. During the post-transplant period, Stenotrophomonas spp. infection was identified, and targeted antimicrobial therapy with levofloxacin and trimethoprim-sulfamethoxazole was initiated. On day +8 after HCT, while initially clinically stable, she developed severe fatigue after ambulation, followed by an abrupt decrease in consciousness, gasping, and cardiac arrest in the setting of severe hypoxemia. During resuscitation, profuse bleeding from the oral cavity and airway was observed. Following resuscitation, she was transferred to the intensive care unit, where she remained critically ill with refractory hypoxemia despite invasive mechanical ventilation. Serial chest radiographs showed persistent diffuse bilateral pulmonary opacities consistent with severe alveolar hemorrhage, accompanied by ongoing bloody secretions through the endotracheal tube. Despite intensive supportive care, respiratory failure remained refractory, and the patient died on day +12 after HCT. Discussion: This case illustrates the diagnostic complexity of DAH after HCT, particularly in the presence of concurrent infection. The early post-transplant onset following Flu/Mel/TBI conditioning provides a relevant context of recent conditioning-related tissue and endothelial injury; however, the identification of Stenotrophomonas spp. precluded attribution of the pulmonary hemorrhage exclusively to a noninfectious inflammatory-endothelial syndrome and raised the possibility of infection-associated alveolar hemorrhage. In critically unstable patients, bronchoscopy and bronchoalveolar lavage may not be feasible, requiring integration of clinical, radiological, microbiological, and hemostatic findings. Management is equally challenging. Corticosteroids have traditionally been used for post-HCT DAH, although supporting evidence remains limited, while intensifying immunosuppression in the presence of active infection may be detrimental. Respiratory and hemodynamic support, targeted antimicrobial therapy, and correction of hemostatic abnormalities are therefore essential components of management. Conclusion: Alveolar hemorrhage after HCT is a life-threatening complication with complex management. Concurrent infection, conditioning-related endothelial injury, and hemostatic abnormalities may coexist, complicating etiologic classification and therapeutic decisions. This case highlights the fulminant course of severe early post-HCT alveolar hemorrhage and the challenge of balancing immunomodulatory treatment with infection control. Early recognition and multidisciplinary management remain essential, although prognosis is particularly poor after progression to refractory hypoxemic respiratory failure.
SN  - 2531-1379
SN  - 2531-1387
ER  -