Bacterial
Bacterial infections are not often caused by bacteria living on the patient. When the WBC drops, your child is less able to fight infections.

• Signs/Symptoms: Localized redness, pus, tenderness and/or pain, fever, cough, difficulty urinating. Severe infections may present with a high fever, drop in blood pressure, change in heart or respiratory rate.
• Diagnosis: Blood cultures for any new fevers and every 24 hours if fevers continue. Urine cultures, chest x-ray, culture of pus may also be required.
• Treatment: IV antibiotics (ceftazidime plus others as indicated) and tylenol.

Viral
Adenovirus:
A group of viruses originally isolated from adenoidal tissue but can infect a wide range of organs. Adenovirus is spread by contact with infected feces, urine or respiratory droplets. As with all viral infections, the patient may have been infected prior to transplant.

• Signs/Symptoms: Adenovirus causes inflammation and necrosis of the cells it infects. In the normal healthy individual, the usual manifestation is a mild respiratory infection. In the bone marrow transplant patient, there is usually inflammation of the infected organ.
• Diagnosis: Adenovirus may be cultured from various bodily fluids or from biopsies of suspected organs. It is most often found in the urine, stool or nasal wash.
• Treatment: There are a few treatment options available. Immune globulin may be given daily instead of weekly. Ribavirin may be given IV. Good hand washing and proper use of gowns and gloves will help keep the virus from spreading. Patients may be required to remain in their rooms to prevent the spread of the infection.

Cytomegalovirus (CMV):
A common virus present in at least 50% of the general population. It is often present in the patient before transplant, and once chemotherapy is given and the immune system is destroyed, this virus can be "reactivated" and cause serious problems. It can be spread by contact with infected urine, tears, saliva, feces, or blood. The virus cannot live on inanimate surfaces.

• Signs/Symptoms: These depend on the body system infected. In the lungs, CMV may present as pneumonia. In the eyes, it may cause retinitis. Some patients may not show any signs of infection other than a positive culture.
• Diagnosis: Bodily fluids such as blood, urine and nasal secretions may be cultured for CMV. An eye exam will detect CMV retinitis and is done yearly after bone marrow transplant or earlier if necessary. Bronchoscopy is often able to detect CMV in the lung.
• Treatment: Anti-virals such as ganciclovir, foscarnet and CytoGam. Hand washing and proper use of gowns and gloves will help prevent the spread of CMV.

Epstein-Barr Virus (EBV):
A common virus with most adults having been exposed to and infected by it. Younger children are less likely to have been infected by EBV. It is the virus associated with infectious mononucleosis. EBV attacks the B-lymphocytes and uses them for viral replication. A person with a normal immune system is able to mount a response to the infection, thus the virus may remain dormant in the body. In the transplant patient, this virus can be very serious and like CMV, it can be "reactivated". It can cause EBV-lymphoproliferative disorder which is more like a cancer than an infection.

• Signs/Symptoms: Fevers, swelling of tonsils or lymph nodes, liver enlargement, confusion. The virus may spread and infect organs throughout the body. Some patients may test positive for the virus, yet remain asymptomatic.
• Diagnosis: Biopsy of swollen lymph nodes, looking for the presence of infected B-lymphocytes. Reactive lymphocytes in the peripheral blood may also be found. Special molecular tests are necessary to confirm this disease and may take one week to get the results back.
• Treatment: Reduction/discontinuation of immune suppression (steroids). Giving T-lymphocytes from the donor to the patient is often curative and is done most often. Higher doses of ganciclovir, alpha-interferon and daily immune globulin may be given. Surgical resection of the tumors and radiation to localized areas are rarely indicated.

Fungal
Aspergillus:
Commonly found in the environment, aspergillus is a fungus that is usually harmless to the normal population, but can be deadly to the immunocompromised patient. Prevention is easier than treatment. Intranasal and IV amphotericin-B and fluconazole are used prophylactically to prevent fungal infections. Sometimes exposure occurs prior to transplant but causes no problems until after the ablative therapy has decreased the patients ability to fight infection. The special hepafilters in the BMT unit are designed to filter the air clean and prevent aspergillus from being acquired during the early time period following the transplant.

• Signs/Symptoms: Depends upon the organs involved. Pulmonary aspergillosis may present with fever, cough or sinusitis. CNS involvement may present with changes in behaviors or physical status. Disseminated infection may appear as nodules on the skin.
• Diagnosis: Aspergillus usually has a nodular appearance on x-rays of the chest or head. Biopsy of the suspected lesion is often necessary and helps confirm the disease.
• Treatment: Daily administration of IV amphotericin-B and oral itraconazole are the medicines used to treat this infection. Surgical resection may be required depending on the location and number of the nodules.

Candida:
Candida is a fungus normally found in the human body. In the immuno-suppressed patient, candida can flourish. This organism is relatively easy to control with good oral hygiene and compliance with taking mouth cares (clotrimazole or nystatin).

• Signs/Symptoms: White patches in the mouth and/or white/gray coating on the tongue. In infants and toddlers, it can also present as a red rash in the diaper area.
• Diagnosis: The above mentioned changes are accurate indicators of a candida overgrowth. For disseminated candida in the bloodstream, blood cultures provide a positive diagnosis.
• Treatment: All patients must abide by a vigorous oral care routine including either clotrimazole or nystatin, both of which are anti-fungal agents. Lotrimin cream is used for the diaper rash. If candida arises despite the preventive measures being used, or is found in the blood or other organs, IV amphotericin or fluconazole may be required.

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