Fecal microbiota transplant after hematopoietic SCT: report of a successful case

Bone Marrow Transplantation (2015) 50, 145 © 2015 Macmillan Publishers Limited All rights reserved 0268-3369/15 www.nature.com/bmt

LETTER TO THE EDITOR

Fecal microbiota transplant after hematopoietic SCT: report of a successful case Bone Marrow Transplantation (2015) 50, 145; doi:10.1038/ bmt.2014.212; published online 29 September 2014 Fecal microbiota transplants1 are being commonly used for treating patients with Clostridium difficile infections. Patients who receive BM transplantation experience severe immune suppression not only because of the drugs used in the conditioning and immunosuppression therapies, but also because of the procedure itself. Owing to the concerns associated with microbiota transplant in this population of patients, very few case reports have been published so far.2 We recently treated a 60-year-old woman with Philadelphiapositive acute lymphoblastic leukemia (ALL). She received chemotherapy and achieved full remission. Four months after the initial diagnosis, an allogeneic transplantation from an unrelated donor was performed using fludarabine and BU in the conditioning regimen. She received the immunosuppressive agents, tacrolimus and MTX. Ten months after transplantation, she was admitted for treating pseudomembranous colitis, and was administered oral vancomycin, which had to be changed subsequently to metronidazole, owing to an allergic response. One month later, the woman underwent sinus endoscopic surgery. Twelve months after transplantation, an admission due to C. difficile infection was necessary, which was followed with a new course of oral metronidazole. Another admission at the intensive care unit was necessary, 13 months after transplantation, owing to diarrhea and shock. C. difficile was once again identified in the stool sample. A course of oral metronidazole and intrevenous (i.v.) meropenem was administered. She initially showed signs of clinical improvement. However, after 10 days of antibiotic treatment, she still had diarrhea and a persisting C. difficile infection. She was still using sirolimus as part of the immunosuppressive therapy, and had recently resumed treatment with dasatinib, a therapeutic used during the maintenance therapy for leukemia during 1 year. We decided to perform fecal microbiota transplantation, with material from two different donors, delivered by means of push enteroscopy, as previously described.3 There were no complications and the patient was discharged 2 days later. Two years after the hematopoietic SCT (HSCT) and 10 months after the microbiota transplantation, she has had no infections or diarrhea. During her last appointment, 1 month before we wrote this letter, she reported that her bowel habits showed significant improvements. The absence of any kind of infection after the procedure called for our attention. Recently, the bacterial diversity of the intestinal

tract was associated with the results of BM transplantation.4 Patients who maintained the diversity had much better outcomes. We believe that patients undergoing HSCT should be considered for fecal microbiota transplantation if they have an active C. difficile infection. The infection pattern before and after the procedure attracted our immediate attention. After the microbiota transplantation, antibiotics were not needed anymore. A recent study showed that probiotics played an important role in B-celldependent specific tolerance, in an animal model.5 Clearly, there is much more to explore and learn about the intestinal microbiota, and their implications for human health.

CONFLICT OF INTEREST The authors declare no conflict of interest.

CG de Castro Jr1, AJ Ganc2, RL Ganc3, MS Petrolli4 and N Hamerschlack5 1 Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil; 2 Endoscopy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil; 3 Gastroenterology and Endoscopy Departments, Hospital Israelita Albert Einstein, São Paulo, Brazil; 4 Santa Marcelina Hospital, São Paulo, Brazil and 5 Hematology and Bone Marrow Transplantation, Hospital Israelita Albert Einstein, São Paulo, Brazil E-mail: [email protected] or [email protected]

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