• Yu-Rong Huang, Cai-Qin Xie, Jie-Feng Tong, Xiao-Hong Zhang, Yang Xu, and Xiang-Gui Yuan.
• Department of Hematology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
• Medicine (Baltimore). 2020 Apr 1; 99 (14): e19807.

RationaleVery severe aplastic anemia (vSAA) with active infections is always fatal. Adequate infection control before hematopoietic stem cell transplantation is recommended.Patient ConcernsA 38-year-old woman with vSAA suffered from acute perforated appendicitis and invasive pulmonary fungal infection, and she failed to respond to intense antimicrobial therapies.DiagnosisShe was diagnosed with refractory vSAA with stubborn acute perforated appendicitis and invasive pulmonary fungal infection.InterventionsWe successfully completed an emergent reduced intensity conditioning-matched unrelated donor (MUD)-peripheral blood stem cell transplantation (PBSCT) as a salvage therapy in the presence of active infections. The conditioning regimens consisted of reduced cyclophosphamide 30 mg/kg/day from day-5 to day-3, fludarabine 30 mg/m/day from day-5 to day-3 and porcine-antilymphocyte immunoglobulin 15 mg/kg/day from day-4 to day-2 without total body irradiation. Cyclosporin A, mycophenolate mofetil and short-term methotrexate were administered as graft-versus-host disease (GVHD) prophylaxis. Neutrophils and platelets were engrafted on day+15 and day+21. Appendiceal abscess and severe pneumonia developed after neutrophil engraftment, which were successfully managed with intense antimicrobial therapy and surgical intervention.OutcomesOnly limited cutaneous chronic GVHD was observed 5 months after transplantation. The patient still lives in a good quality of life 2 years after transplantation.LessonsActive infections may be no longer a contraindication to hematopoietic stem cell transplantation for some patients with vSAA.

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