Acute heart failure after allogeneic blood stem cell transplantation due to massive myocardial infiltration by cytotoxic T cells of donor origin

A 17-year-old male with AML FAB M4 relapsed 4 months after myeloablative co nditioning and peripheral blood stem cell transplantation (PBSCT) from an H LA-identical unrelated donor. A second PBSC harvest was infused 2 days afte r completion of cytoreductive therapy with mitoxantrone 7 mg/m(2)/day i,v, for 3 days (total dose 21 mg/m(2)), fludarabine 30 mg/m(2)/day i,v, for 6 d ays (total dose 180 mg/m(2)) and Ara-C 125 mg/m(2)/day i,v, for 5 dags (tot al dose 625 mg/m2), Neutrophil recovery occurred on day +10 and was associa ted with GVHD grade III of the skin which was treated with cyclosporin A (C sA) and prednisone, Because of fever of unknown origin and progressive fati gue combined with hypotension on day +15 after second PBSCT, echocardiograp hy was performed which revealed a dramatic decrease in systolic function co mpared to the status pre-transplant. On the same day acute heart failure wi th consecutive ventricular fibrillation occurred, Although resuscitation wa s performed immediately the patient died. The autopsy revealed massive infi ltration by donor CD8-positive lymphocytes with concomitant extensive damag e of the heart tissue. Acute myocarditis of viral origin was excluded by in situ hybridization and nested PCR techniques, In this patient, myocardial involvement by acute GVHD seems to have triggered a fatal arrhythmia and he art failure.