A case of engraftment syndrome in the medical intensive care unit

Engraftment syndrome (ES) is an increasingly diagnosed complication after hematopoietic cell transplantation (HCT). Clinical presentation most commonly includes, but is not limited to fever, diarrhea, and skin rash developing at the time of absolute neutrophil count (ANC) recovery. Due to the broad and pleiotropic clinical presentation, ES can be a challenging diagnosis. Furthermore, despite many reports about the presentation of ES, the syndrome is still not completely understood. While most presentations of ES are mild and can either resolve spontaneously or with a brief course of systemic corticosteroids, mortality rates ranging from 8%-18% have been described. We present a case of ES in a critical care setting. A male patient who had an allogeneic HCT and developed fevers, diffuse skin rash, acute kidney injury and hypoxemic respiratory failure after his absolute neutrophilic count started recovering from nadir. He was subsequently transferred to the medical intensive care unit (MICU) for further management, where he was initially managed with mechanical ventilation, vasopressors and antibiotics. An extensive workup that included bronchoscopy with bronchoalveolar lavage was performed and failed to show an infectious etiology. Due to concern for ES, patient was started on steroids and his clinical status dramatically improved. The patient was eventually extubated and transferred back to the floor in stable condition. It is important for internists and critical care physicians in the MICU to be aware of post-HCT complications and be cognizant of the clinical signs of ES to better understand the syndrome and its management.