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Allogeneic haemopoietic stem cell transplantation (SCT) is the only curative option for severe bone marrow (BM) failure in patients with Fanconi anaemia (FA). We have developed a non total body irradiation (TBI) conditioning protocol consisting of fludarabine (120-150 mg/m(2)), low dose of cyclophosphamide (40 mg/kg) and antilymphocyte globulin (45 mg/kg). Graft-versus-host disease (GVHD) prophylaxis was with cyclosporin alone for sibling allografts but also included Campath-1 H (days 1-5 post SCT) for the unrelated allografts. We have performed two sibling and two unrelated BM transplants with a follow-up of 11-51 months. All patients experienced minimal toxicity and were discharged from hospital 28-32 days post SCT. Neutrophil and platelet engraftment occurred from days 11 to 19 and 15 to 34, respectively. All patients achieved stable full donor haemopoiesis with normalisation of the peripheral blood count despite one of them having myelodysplasia (MDS) with 8% blasts prior to the SCT. The only site of acute GVHD was in the skin (grade I-II) and only one patient progressed to limited chronic GVHD. This protocol is associated with reduced toxicity and prompt engraftment in FA patients with AA and/or MDS undergoing SCT using sibling or unrelated donors.

Late death after unrelated-BMT for dyskeratosis congenita following conditioning with alemtuzumab, fludarabine and melphalan

A 14-year-old girl from the UK underwent volunteer unrelated donor bone marrow transplant (VUD BMT) for accelerated phase chronic myeloid leukaemia. On day +40 she became febrile, and peripheral blood smears demonstrated a 1% Plasmodium vivax parasitaemia. Although she had never been outside the UK, her male donor had documented Plasmodium vivax infection during a vacation in Papua New Guinea. Following appropriate treatment, he had been asymptomatic for 11 months before marrow harvesting. This is the first case report of malarial transmission by VUD BMT, and illustrates the potential problem of recrudescence of latent, dormant forms of Plasmodium vivax infection following transplantation into an immuno-compromised recipient. Even after appropriate therapy, malarial infection should be included in the differential diagnosis for all post-transplant febrile episodes.