Resumo

We report a case of hemorrhagic cystitis after bone marrow transplant.

Dados do caso

Feminino 13 anos

Palavras chaves

Cistite, Transplante de Medula Óssea, Hematúria

Histórico Clínico

A 13-year-old girl on the 53rd day after bone marrow transplant (BMT) presented dysuria and fever. Broad-spectrum antibiotic therapy was initiated, however, there was no bacterial growth in blood or urine cultures. After 3 days, she started with macroscopic hematuria. Urine adenovirus screening was negative and polyomavirus screening was positive.

Achados Radiológicos

Bladder with reduced capacity and marked parietal thickening, especially of the anterior and superior walls.

Discussão

Hemorrhagic cystitis (HC) is considered a frequent complication of BMT, which can occur in up to 66% of these patients, especially those who underwent allogeneic transplantation [1-6]. HC is classified in early and late types according to the BMT date. Early type HC occurs up to 7-9 days [1,4] after the BMT and results from toxicity of the conditioning regimen [1,3,6]. Late type HC occurs between 2 weeks and 6 months after the BMT and may result from viral infection [1-6] or graft versus host disease [2]. Among the infectious causes, the main etiologies are BK palyomavirus (BKV - 80.8%), adenovirus (15.4%) JC virus (3.8%), cytomegalovirus and, rarely, simian virus SV40 [1-6]. The main cause of late HC is related to BKV [3]. Primary infection of BKV is believed to occur in early childhood and may cause a self-limiting respiratory tract disease [5,6]. The infection remains latent in immunocompetent hosts, however, when in a immunosuppression state, there may be a reactivation of viral replication which may progress to nephropathy or ureteral stenosis in kidney transplant recipients or HC in BMT recipients [3,5,6]. The diagnostic criteria for BKV-associated HC consist of: cystitis symptoms (dysuria, hypogastric pain), macroscopic hematuria and viruria greater than 7 log copies/mL [1]. Although not essential for the diagnosis, the main role of imaging is the characterization of urinary bladder hematoma that may indicate irrigation. Other imaging findings include: reduced bladder capacity, continuous or discontinuous bladder wall thickening (notable predominance in the anterior wall), which may be accompanied by hypervascularization on color Doppler or parietal enhancement and perivesical adipose tissue densification in computed tomography [3,5,6]. Most cases resolve in 3 to 5 weeks with supportive therapy and antiviral therapy with Cidofuvir is controversial, due to lack of evidence of its benefit [1].

Lista de Diferenciais

• Adenovirus associated hemorrhagic cystitis
• JC virus associated hemorrhagic cystitis
• Cytomegalovirus associated hemorrhagic cystitis
• Simian virus SV40 associated hemorrhagic cystitis
• Graft versus host disease

Diagnóstico

• Human polyomavirus BK-associated hemorrhagic cystitis

Aprendizado

Teaching Points: - Hemorrhagic cystitis is classified in early and late types; - Early type HC (< 1 week after BMT) results from toxicity of the conditioning regimen; - Late type HC (2 weeks to 6 months after BMT) results from viral infection or graft versus host disease; - Cystitis symptoms, macroscopic hematuria and viruria are the main findings of BKV-associated HC diagnosis; - The main role of imaging is to recognize intravesical clots.

Referências

• 1. Cesaro S, Dalianis T, Hanssen Rinaldo C, Koskenvuo M, Pegoraro A, Einsele H, et al. (2018) ECIL guidelines for the prevention, diagnosis and treatment of BK polyomavirus-associated haemorrhagic cystitis in haematopoietic stem cell transplant recipients. Journal of Antimicrobial Chemotherapy 73(1):12-21 (PMID: 29190347).
• 2. Campo LD, León NG, Palacios DC, Lagana C, Tagarro D. (2014) Abdominal complications following hematopoietic stem cell transplantation. Radiographics 34(2):396-412 (PMID: 24617687).
• 3. Hannick JH, Koyle MA. (2019) Canadian Urological Association Best Practice Report: Pediatric hemorrhagic cystitis. Canadian Urological Association Journal 13(11):E325 (PMID: 31763977).
• 4. Pérez-Huertas P, Cueto-Sola M, Escobar-Cava P, Fernández-Navarro JM, Borrell-García C, Albert-Marí A, et al. (2017) BK virus-associated hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation in the pediatric population. Journal of Pediatric Oncology Nursing 34(1):13-19 (PMID: 25653684).
• 5. Zaleska-Dorobisz U, Biel A, Sokołowska-Dąbek D, Olchowy C, Łasecki M. (2014) Ultrasonography in the diagnosis of hemorrhagic cystitis–a complication of bone marrow transplantation in pediatric oncology patients. Journal of ultrasonography 14(58):258 (PMID: 26675710).
• 6. Schulze M, Beck R, Igney A, Vogel M, Maksimovic O, Claussen CD, et al. (2008) Computed tomography findings of human polyomavirus BK (BKV)-associated cystitis in allogeneic hematopoietic stem cell transplant recipients. Acta Radiologica 49(10):1187-1194 (PMID: 18932047).

Imagens

Ultrasonography of the bladder in the transverse plane demonstrating reduced capacity and marked thickening and irregularity of the anterior wall.

Ultrasonography of the bladder in the midline longitudinal plane demonstrating reduced capacity and marked thickening and irregularity of the anterior and superior wall.

Vídeos

Artigo recebido em quarta-feira, 25 de março de 2020

Artigo aprovado em segunda-feira, 30 de março de 2020