Feasibility of Allogeneic Hematopoietic Stem Cell Transplantation Following Recent Invasive Fungal Infections in Pediatric Patients

Abstract

A recent history of filamentous invasive fungal infection (IFI) often leads to postponement or contraindication of allogeneic hematopoietic stem cell transplantation (alloHSCT) in children. However, careful assessment is required to determine whether, and when, it is optimal for these patients to undergo transplantation—particularly those with urgent hematologic disease progression or in those with profound, prolonged neutropenia in whom immune reconstitution is required as part of IFI treatment. A retrospective cohort study included patients aged 0–18 years who underwent alloHSCT within 120 days of probable or proven IFI between Jan 2015 and Aug 2023. Medical records and 100-day post-transplant outcomes were reviewed. Ten patients (median age 8.5 years, range 3 months–16 years; 5 male) underwent alloHSCT <120 days after IFI (Table 1). Primary indications were acute lymphoblastic leukemia (n=4) and acute myeloid leukemia (n=4). IFI occurred a mean of 54.5 days pre-HSCT (SD=40.8). Median neutropenia duration before IFI was 22 days (SD=21.5). IFIs included aspergillosis, trichosporonosis, mucormycosis and fusariosis. Seven patients received combination antifungal therapy; three required surgery. All patients showed improvement in IFI manifestations before conditioning for allo-HSCT. Fever resolved in eight patients (mean 45 days pre-HSCT, SD=40), nine showed biomarker improvement, and seven had radiologic improvement. One patient with urgent HSCT need began conditioning 12 days after IFI diagnosis, when clinical improvement was documented, despite persistent fever and worsening imaging. No IFI-related deaths or relapses occurred within 100 days post-HSCT. Observing clinical improvement in IFI manifestations is important before alloHSCT, but complete clinical or radiologic resolution may not be achievable and does not appear essential. Recent IFI should not be considered a contraindication for urgent alloHSCT.