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Answer 6
  1. Recurrent aplastic anemia. 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.

    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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