Treatment
The patient underwent 5 courses of chemotherapy (CTX) according to the ”VCD” scheme. Based on the results of control restaging, the patient was found to have stabilized the underlying disease according to the IMWG (International Myeloma Working Group) criteria (plasma cell infiltration remained up to 22%) (7). It was decided to conduct 2 courses of chemotherapy according to the ”TCD” scheme (Thalidomide + Cyclophosphamide + Dexamethasone).
Then the patient underwent 2 courses of chemotherapy according to the DR-PACE scheme (Dexamethasone / lenalidomide / cisplatin / doxorubicin / cyclophosphamide / etoposide) (8,9). However, despite the intensive courses, the patient, according to the cytological study of the bone marrow, retained plasma cell infiltration up to 28%. Due to the lack of effect on the ongoing therapy, the question of choosing a treatment method was discussed. We feared that other courses of chemotherapy could accumulate toxicity, thereby increasing the risk of failed hematopoietic stem cell (HSC) mobilization and bone marrow failure. Considering these factors, the patient decided to undergo Auto-SCT (autologous hematopoietic stem cell transplantation).
The patient underwent mobilization of peripheral HSCs. ”Etoposide 375mg/m2 +G-CSF” was prepared in the amount of CD34 +=9.23mln / kg, which is sufficient for Auto-SCT. The patient was discharged for the recovery period. In June 2020, the patient was admitted to the Department of Oncohematology and Bone Marrow Transplantation for Auto-SCT (BMT). At the time of receipt, she had no active complaints. On July 2, 20, high-dose chemotherapy (MEL 200 mg/m2) was implemented, followed by transplantation of autologous hematopoietic stem cells in the amount of 5.58 million/kg. At +17D, the patient developed complications such as febrile neutropenia and probable invasive pulmonary aspergillosis; antifungal therapy with voriconazole and antibacterial therapy with piperacillin-tazobactam were prescribed. At +25D, bone marrow non-engraftment was recorded (0.5 thousand/μl). The general condition deteriorates sharply, acute respiratory failure develops, respiratory rate (RR) up to 36 per minute, saturation (SpO2), against the background of oxygen insufflation of 10 liters per minute - 90-91%), persistent fever, unproductive cough. On computed tomography of the lungs, subtotal infiltration from both sides is noted (involvement of the lung parenchyma on both sides is about 60%). On day 28 after transplantation, SARS-CoV-2 RNA from a nasopharyngeal smear was detected by PCR. The treatment was supplemented with anticoagulant therapy with heparin, glucocorticosteroid therapy (GCS) with dexamethasone 12 mg per day, as well as NIV (non-invasive ventilation of the lungs) in CPAP mode with FiO2 = 65%, a change in body position was performed, on the stomach - prone position. When assessing blood parameters, deep cytopenia was noted (due to the absence of bone marrow engraftment), which significantly worsened the course of the disease.
In dynamics, against the background of the ongoing complex therapy, the patient’s condition improved, in the form of a decrease in signs of respiratory failure, restoration of blood counts. Control computed tomography of the chest organs showed positive dynamics, a decrease in the size of infiltration in the lungs, the volume of lung lesions was 40% (Figure 1), recovery of blood parameters (neutrophilic engraftment was noted) (Table 1). However, despite the clinical improvement, the patient, according to PCR data for COVID-19 from a nasopharyngeal smear, from 08.12.2020 and 08.26.2020, SARS-CoV-2 RNA remained. And 09.02.2020 (+62D), according to PCR-RNA SARS-CoV-2 from a nasopharyngeal smear, the infection was not detected. In this regard, at +64D after Auto-BMT, the patient was discharged from the hospital with improvement, with a relief of signs of coronavirus infection.