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BMTCN EXAM QUESTIONS AND ANSWERS
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BMTCN EXAM QUESTIONS AND ANSWERS
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BMTCN EXAM QUESTIONS AND ANSWERST.R. is a 28-year-old woman with acute myeloid leukemia in her second complete
remission who is admitted for a matched unrelated allogeneic stem cell transplantation.
Her conditioning regimen is as follows:
Myeloablation (busulfan/cyclophosphamide) and immunosuppression with tacrolimus
and methotrexate (5 mg/m2 on days +1, +3, +6, and +11).
She did not receive methotrexate on day +11 because of severe mucositis. Her
transplant course was complicated by mucositis, neutropenic fever, and Clostridium
difficile diarrhea. T.R. had no symptoms of graft-versus-host disease (GVHD) during the
hospital course. Her blood counts recovered, and she was discharged to home. Day
+30 bone marrow showed 100% donor. A clinic visit on day +50 revealed a new
maculopapular rash covering 40% of T.R.'s body. She is staged as grade 2. The skin
biopsy is consistent with GVHD. What is the initial management?
A. Check tacrolimus level.
B. S - Answers- D. A and C
The patient's immunosuppressive drugs need to be at a therapeutic level. Try to use as
little additional immunosuppression as is necessary to control GVHD so as to maintain
allo- effect of the transplant against any residual leukemia. Often, grade 1 or 2 skin
GVHD responds to topical steroids.
T.R.'s tacrolimus level is therapeutic at 11. One week later, at the scheduled clinic visit,
her rash has decreased to grade 1. T.R. reports "watery diarrhea" five times per day.
She is admitted to the hospital for further evaluation and treatment. How should the
patient be managed?
(1) Continue PO medications.
(2) Add antidiarrheal agents.
(3) Rule out infectious etiology of diarrhea.
(4) Change medications from PO to IV.
(5) Request gastrointestinal (GI) consult.
(6) Obtain accurate measurement of stool volume.
A. 1,2,5
B. 1,3,6
C. 2,3,4,5,6
D. 2,3,4,5 - Answers- C. 2,3,4,5,6
Infectious etiology must always be ruled out (e.g., Clostridium difficile [C. difficile],
rotavirus). Medications should be changed from PO to IV to ensure absorption. GI
consult to follow and assess need for colonoscopy. GI GVHD grading is based on
volume of stool, so an accurate assessment of amount of diarrhea is important. Once C.
difficile is ruled out, antidiarrheal agents may be started.
, T.R.'s tacrolimus level remains therapeutic at 11. The volume of diarrhea in 24 hours is
1,000 ml. Infectious etiology workup is negative. Colonoscopy was obtained, and the
report describes erythema and ulcerations. Cytomegalovirus (CMV) and other viral
strains are negative. The formal interpretation of biopsy shows consistency with GVHD.
T.R. is therefore diagnosed with stage 2 acute GVHD. How should the patient be
managed?
A. Add systemic steroids (methylprednisolone 1-2 mg/kg per day).
B. Add mycophenolate.
C. Treat with infliximab.
D. Treat with antithymocyte globulin (ATG).
E. Add cyclosporine. - Answers- A. Add systemic steroids (methylprednisolone 1-2
mg/kg per day).
One week later, T.R.'s volume of diarrhea has increased to 3,000 ml per day. How
should the patient be treated?
A. Increase steroids.
B. Add infliximab or ATG and attempt to taper steroids.
C. Continue same treatment and wait.
D. Start clear liquids PO to replace GI fluid loss. - Answers- B. Add infliximab or ATG
and attempt to taper steroids.
No preferred second-line therapy with acute GVHD currently exists. It often is physician
or institution preference. Any of the drugs in B are acceptable. No data show that
increasing steroids above 2 mg/kg per day is effective.
What is the standard regimen of immunosuppression for myeloablative transplant?
A. Steroids
B. Tacrolimus and cyclosporine
C. Steroids and tacrolimus
D. Tacrolimus and methotrexate - Answers- D. Tacrolimus and methotrexate
C.W. presents to clinic on day 30 after allogeneic transplant (matched unrelated donor)
with a rash on her arms and chest. Using the Rule of Nines, what stage is the patient?
A. Stage 0
B. Stage 1
C. Stage 2
D. Stage 1-2 - Answers- D. Stage 1-2
The Rule of Nines determines that her chest
is 9% and her bilateral arms are 9% anteriorly and 9% posteriorly. It would need to be
known whether the patient's front or back of arms are involved. If only C.W.'s anterior
arms are involved, the total surface area is 18%. If both front and back of arms are
involved, the total surface area is 36%.
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