ABSTRACT TITLE

LEFLUNOMIDE AND ARTESUNATE COMBINATION THERAPY AS A PREEMPTIVE STRATEGY FOR CMV

INFECTION POST HAPLOIDENTICAL STEM CELL TRANSPLANT

PRESENTING AUTHOR: DR SANGEETHA K PARTHIBAN

GUIDED BY: DR NAVIN KHATTRY

INSTITUTE DETAILS: TATA MEMORIAL HOSPITAL BANGALORE MUMBAI

EMAIL ID: parthibansangeetha12@gmail.com

CELL NUMBER:9819042349

ABSTRACT

BACKGROUND: Prolonged immunosuppressive therapy prior to allogeneic hematopoietic stem cell

transplant (HSCT) delays the immune reconstitution rendering increased susceptibility of patients to
CMV reactivation and disease . This increases theand subsequent risk of transplant related mortality
which in recent years has decreased muchconsiderably due to the use of pre emptive therapy for
CMV reactivation. Ganciclovir has been the preferred drug The standard drug used both in pre
emptive andand therapeutic setting is as wellganciclovir. Patients who are resistant to Gganciclovir
may respond to Ffoscarnet or Ccidofovir. However , these drugs are associated with increased
toxicities, costs and issues ofare not no n availableility (ie cidofovir and foscarnet ) in India.
Leflunamide and Aartesunate have shown activity against CMV both in vitro and in vivo. These 2
drugs apart from being are easily available in India, are not associated with major toxicities such as
renal or hematopoietic and are inexpensive. They may be best used in situations where low white
blood cell aand platelet count precludes the use of Gganciclovir. We report a case of patient with
AML who underwent haploidentical transplant and was treated successfully with a combination of
Lleflunomide and Aartesunate . To the best of our knowledge , this is first such report in literature.

CASE REPORT : A 31 year old male diagnosed with FLT3 ITD Positive AML successfully underwent
haploidentical allogenic stem cell transplant with Fludarabine, Treosulfan and TBI as conditioning
regimen on 29.12.15. He received Cyclosporine, MMF and post transplant cyclophosphamide as
GVHD prophylaxis

On D+31 Post transplant his CMV titres were 857 copies . He was started on Oral leflunomide at
100mg OD for 3 days followed by 20mg OD. Ganciclovir was avoided considering his low counts. As
the CMV copies continued to raise ., His On D+49 the titres beingwere 4.9 log4. , He was started on
Injectable Artesunate on D+49 at 3.5mg/kg in two divided doses. He tolerated the drugs well except
nausea and dizziness , hence the dose of Aartesunate was reduced to OD. On D+56, his His CMV
titres reduced by 1 log and by 4 log on D+65. CMV titres were less than 150 on D+70. He received
Injectable Artesunate for a total of 30 days and Oral Leflunomide for 44 days showing . Hence
Leflunomide and Artesunate in combination proved to be beneficial in the treatment of CMV
reactivation in our patient. Hence we would like to conclude that the combination therapy could be a
promising and a safe alternative in treating CMV infections post transplant patients.

RESULTS