Hematologist Allegedly Fails to Properly Manage Patient After Bone Marrow Transplant

Case Overview

This case involves a middle-aged female patient who underwent a flow cytometry test and bone marrow transplantation for severe anemia. During the transplant, the plaintiff experienced hypertension, severe headaches, and high blood pressure. She later experienced a seizure, confusion, and urinary incontinence. A CT scan was performed which was negative for any acute bleeding or other changes. Her blood pressure significantly improved after the transplant was completed. She experienced a second seizure and was then taken for another MRI. The MRI demonstrated a large brain hemorrhage. The plaintiff was taken to another hospital, where she underwent a craniotomy to treat the hemorrhage. The patient had already suffered extensive neurological damage and was unresponsive after the procedure was completed. She remained in the hospital where she slowly regained consciousness and movement but was left with permanent and severe brain damage. It is alleged that the management of the high blood pressure that occurred during or around the time of the bone marrow transplant was unacceptable.

Questions to the Hematology expert and their responses

Do you have experience pre/post treating patients who have undergone a progenitor cell marrow transplant?

Patients undergoing allogeneic stem cell transplantation are closely monitored before, during, and after receiving donor cells.

What monitoring of the patient should take place before, during and after progenitor cell marrow transplant?

They will have frequent vital signs checked, particularly when receiving conditioning agents or blood/marrow products. These patients are extremely immunocompromised and often have very low blood counts requiring frequent transfusions. Therefore, frequent vital signs are checked looking for signs of infection and hemodynamic instability. They are also at risk for acute graft versus host disease and end organ damage related to transplant.

What follow up should be ordered for patients displaying hypertension following this procedure?

Given the clear end organ damage (seizure, mental status changes, etc...), this would be considered an emergency requiring up to an ICU level of care to control the blood pressure. Treatment could include oral and IV agents and may require a constant drip of medication by IV to control the blood pressure. Patients with severe aplastic anemia often have critically low platelet counts which may have contributed to her risk of intracerebral hemorrhage in the setting of uncontrolled hypertension and seizure. The mental status changes and seizure would have prompted me to obtain a STAT CT scan and a follow up MRI if there were no conclusive findings. I would have assumed a diagnosis of hypertensive emergency and referred the patient for intensive care if simple interventions did not rapidly control her blood pressure or once he developed CNS findings as described above. An arterial line for continuous blood pressure monitoring would be needed in this case.

About the expert

This triple board certified Hematology expert received an M.D. and Ph.D at University of California, San Diego. He later went on to complete a Residency in Internal Medicine ar the Harvard affiliated Brigham and Women's Hospital. He is Fellowship trained in Hematology/Oncology. He has received numerous honors throughout his career, most notably the American Society of Hematology Junior Faculty Research Scholar Award and the Translational Research Training in Hematology Award for his contribution to the field of Hematology. A well-respected academic, this expert is freuently invited guest speaker both nationally and internationally and has taught medical students at Harvard and residents, fellows at Harvard affiliated hospitals. He is currently an Assistant Professor of Hematology/Oncology at a major university.

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Specialties:

Hematology