[Wife of Diver Down]

Hello all,

I finally have my own log in. My husband age 58 high risk MDS with complex cytogenetics was admitted on 2/14 for conditioning (happy valentines day) He had myeloablative conditioning with Fludarabine/Busulfan/ATG MUD 10/10 donor on 2/21 and is now D +33. There was a lot of debate about proceeding with transplant initially as he was not in remission and had a blast count of 14%.] Because of his poor cytogenetics and his good performance status they thought it best to proceed directly to transplant rather than proceeding with 7+3 induction and compromise his performance status.

On 2/21 he received the stem cells from a 10/10 donor. That evening he had a fever over 105.3 requiring ice baths. (Torture he calls it) No infection was found but of course he was on antibiotics pending negative cultures. It was thought to be related to ATG. He received steroids for 2 d and fever resolved. He ultimately recovered from that. His Nadir ANC was never less than 200 but was started on Neupogen on D2 which is standard for this center. On D +11 he engrafted and developed recurrent fever and rash ? engraftment syndrome vs acute GVHD. His total white count 3.4 Hgb 9.8 (good for him unsupported) platelets 150K He was discharged and then 1 d later had low grade fevers followed by rash >50 % of his body no blisters no diahrrea no LFT abnormalities. They decided to treat topically and hold on steroids but when fevers persisted after 5 d steroids were started at 2 mg/kg/d and Posaconozole and Pentamadine for prophylaxis was started Fevers resolved within hours and he has remained afebrile with improvement of rash. On Monday his Prednisone was tapered to 1.5 mg/kg but on Monday was found to have increased ALT/AST- 220/85 with normal Bili. They thought Posoconozole may be responsible so they held that 2 d ago, Also all his counts have declined and he required 2 U PRBC yesterday for Hgb of 7.5
Today LFT further increased with ALT/AST 341/130 Alk phos 150 and T Bili 1.4;
Further decline in Plat 44K ; WBC had declined but is stable for the last 2 d WBC 2.4

I am very worried about acute GVH;
Could this be the cause of the low counts as well?
Remarkably he feels better today than he has for the past week
Any input appreciated.