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.