Relapsed aplastic anemia occurs in approximately 30% of patients treated with ATG and cyclosporine.5 One variable that affects rates of relapse is the taper schedule for cyclosporine, with relapse rates much higher in patients who undergo a rapid taper schedule. Many relapses can be treated effectively with reinstitution of immunosuppression. If a patient fails to respond to immunosuppressive therapy, bone marrow transplantation must be considered. Another important consideration in this case is secondary MDS. Up to 20% of patients with aplastic anemia treated with immunosuppression will develop secondary clonal hematopoietic diseases, including MDS, acute leukemia, and paroxysmal nocturnal hemoglobinuria. Repeating the bone marrow biopsy to rule out a secondary clonal disorder is appropriate in this case. A bone marrow biopsy would also rule out both progressive MDS and CLL, which are considerations in this case but are less likely overall.
- Recurrent aplastic anemia.
5. Frickhofen N, Heimpel H, Kaltwasser JP, Schrezenmeier H. Antithymocyte globulin with or without cyclosporin A: 11-year follow-up of a randomized trial comparing treatments of aplastic anemia. Blood 2003;101:1236–42
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