Persistent nausea and anorexia after marrow transplantation: a prospective study of 78 patients.

BACKGROUND: Persistent nausea, vomiting, anorexia, and poor oral intake are common after hematopoietic cell transplantation. In the past, herpesvirus infections and acute intestinal graft-versus-host disease (GVHD) were the most common causes. METHODS: We studied 76 patients with 78 episodes of these symptoms to discern the causes. Diagnoses were based on histology of skin and intestinal biopsy specimens, viral cultures, and responses to therapy. RESULTS: The mean day of study entry was day 57+/-31.3 posttransplant. Acute GVHD was the most common cause of symptoms, affecting 63 patients (81%) as the sole cause of symptoms and an additional 4 patients (5%) who had other concurrent causes. Patients with GVHD had marrow donors who were unrelated or HLA-mismatched in 27/63 cases. Gastric edema, erythema, and apoptotic epithelial cells were the most useful findings for the diagnosis of GVHD. Prednisone therapy (1-2 mg/kg/day) was effective in 58 of 63 patients (92%). Infection by herpes simplex virus, cytomegalovirus, or Candida was found in six patients, three of whom had concurrent GVHD. Other causes of symptoms were medications (one patients), parenteral nutrition (one patient), and sagittal sinus thrombosis (one patient). CONCLUSIONS: Acute GVHD is now the dominant cause of persistent nausea and anorexia in marrow transplant patients who are beyond day 20 posttransplant. The diagnosis can be made clinically in most cases and confirmed by endoscopic biopsy of gastric mucosa. Infections, medications, and rare cases of central nervous system disease are much less common.

Ganciclovir for the treatment of cytomegalovirus gastroenteritis in bone marrow transplant patients. A randomized, placebo-controlled trial.

STUDY OBJECTIVE: To determine the efficacy of ganciclovir for the treatment of cytomegalovirus enteritis after bone marrow transplant. DESIGN: A randomized, double-blind, placebo-controlled trial. SETTING: Inpatient units of a cancer center. PATIENTS: Consecutive patients with biopsy-documented cytomegalovirus infection of the gastrointestinal tract. Cytomegalovirus was identified by culture or by immunohistologic or standard histologic analysis. INTERVENTIONS: Ganciclovir, 2.5 mg/kg body weight every 8 hours for 14 days, or placebo, with dosage adjusted for decreases in renal function. Therapy was discontinued if the neutrophil count or creatinine clearance fell below preset criteria. MEASUREMENTS AND MAIN RESULTS: Virus cultures of throat, urine, and blood specimens were done before, 3 times weekly during, and weekly for 3 weeks after therapy. Endoscopy was repeated after treatment. Patients were examined, and blood counts, electrolytes, and renal and hepatic function were monitored during therapy. Ganciclovir recipients had cessation of oropharyngeal (P = 0.001) and urinary (P = 0.004) cytomegalovirus excretion and negative cultures of repeat esophageal specimens (P = 0.002) more often than placebo recipients. No difference existed in either clinical symptoms or endoscopic appearance between the groups after treatment. Cytomegalovirus pneumonia occurred in four patients who received ganciclovir and in six who received placebo. One ganciclovir recipient and four placebo recipients were withdrawn from treatment because of neutropenia, but there was no overall difference in the proportional decrease in leukocyte counts between groups. CONCLUSIONS: Although ganciclovir suppressed cytomegalovirus replication, 2 weeks of treatment was not associated with clinical or endoscopic improvement when compared with supportive care.