Severe Cellulitis Caused by Stenotrophomonas Maltophilia in a 48-Year-Old Male with Severe Aplastic Anemia During Hematopoietic Stem Cell Transplantation: A Case Report

Severe Cellulitis Caused by Stenotrophomonas Maltophilia in a 48-Year-Old Male with Severe Aplastic Anemia During Hematopoietic Stem Cell Transplantation: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Severe Cellulitis Caused by Stenotrophomonas Maltophilia in a 48-Year-Old Male with Severe Aplastic Anemia During Hematopoietic Stem Cell Transplantation: A Case Report Qian Guo, Juan Jiang, Yaping Jiang, Yu Zhang, Xiang Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4885479/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Cellulitis, a potentially severe bacterial skin infection, is typified by pain, fever, and erythema, posing diagnostic and therapeutic challenges. Hematopoietic stem cell transplantation (HSCT) is a critical treatment for severe aplastic anemia but temporarily impairs immune function, increasing the risk of opportunistic infections, including cellulitis. Case Presentation: This case report details a 48-year-old male with severe aplastic anemia who developed cellulitis caused by Stenotrophomonas maltophilia during HSCT. The infection occurred in his right arm and was admitted to Zhejiang Provincial Hospital of Traditional Chinese Medicine in March 2024. The patient's compromised immunity post-HSCT made managing the infection particularly complex. Conclusion: Despite the critical nature of the infection, the patient was effectively treated through a multidisciplinary approach and was discharged after 128 days. His recovery underscores the significance of early diagnosis and tailored treatment in immunocompromised patients, emphasizing the role of coordinated medical care in achieving favorable outcomes post-HSCT. aplastic anemia hematopoietic stem cell transplantation cellulitis erysipelas Stenotrophomonas maltophilia case report Figures Figure 1 Figure 2 Background Aplastic anemia (AA) is a life-threatening bone marrow failure disorder characterized by pancytopenia and a hypocellular bone marrow with excessive fat. AA has a progressive nature, and due to its gradual disease course and/or treatment-related complications, it carries a significant risk of morbidity and mortality [ 1 , 2 ] . Without definitive treatment, the mortality rate of severe AA (SAA) approaches 70% within two years [ 3 ] . Hematopoietic stem cell transplantation (HSCT) is a lifesaving therapy for AA patients [ 4 ] . However, due to various factors such as human leukocyte antigen (HLA) compatibility, donor and recipient gender and age, and conditioning regimens, 30–80% of patients may develop graft-versus-host disease (GVHD) post-transplant [ 5 , 6 ] . GVHD is a complication that can affect multiple organ systems, including the skin, liver, lungs, and gastrointestinal tract, with the skin being the most commonly affected organ. The severity of skin symptoms often reflects the overall severity of GVHD and serves as a critical monitoring indicator for treatment decisions [ 7 ] . Cellulitis is an acute, diffuse, suppurative inflammation involving the dermis and subcutaneous tissues, typically associated with wounds, ulcers, or other skin breaches. The affected areas usually present with expanding erythema, fever, tenderness, and swelling [ 8 ] . There is currently no gold standard diagnostic technique for cellulitis; diagnosis relies on clinical presentation and evaluation [ 9 ] . When cellulitis is accompanied by tissue necrosis, secondary necrotizing vasculitis may occur, leading to increased medical costs [ 10 ] . This case report presents a 48-year-old male SAA patient who developed a skin infection prior to HSCT and subsequently progressed to severe cellulitis post-transplant. Case presentation The patient, a 48-year-old male, was admitted with jaundice and dark urine for over half a month, and pancytopenia for 5 days without an obvious cause. Blood tests, bone marrow examinations, and multiple bone marrow aspirations showed hematopoietic suppression, with pathological findings of decreased nucleated cells and an increased lymphocyte ratio (87.5%), leading to a diagnosis of severe aplastic anemia (detailed hematologic and biochemical indices are shown in Fig. 1 ). A haploidentical hematopoietic stem cell transplantation (HSCT) was planned as the treatment strategy. On the 14th day of hospitalization, the patient developed redness, swelling, heat, and pain in his right arm. The condition worsened, with the skin turning black, ulcerating, and discharging pus. The wound area expanded from 0.5cm x 0.5cm to 4.5cm x 3.5cm x 0.4cm, with the largest area being 9.2cm x 5.5cm x 0.5cm (Fig. 2 ). Skin treatments included wet compresses, intramuscular tramadol 100mg (when NRS score was 5–7), irrigation and dressing changes, and gauze packing. Empirical anti-infective therapy initially included biapenem, meropenem, omadacycline, voriconazole, polymyxin B, ceftazidime-avibactam, and vancomycin while awaiting blood culture results. Blood cultures indicated a Gram-negative bacterial infection, and pathogen gene testing confirmed Stenotrophomonas maltophilia (SMA) positivity. Following a consultation with a microbiology expert, the treatment was adjusted: meropenem was discontinued, and aztreonam was added to cover metallo-beta-lactamase-producing Gram-negative bacteria, along with an increased dose of ceftazidime-avibactam. On the 32nd day of hospitalization, the patient entered the transplant ward for preconditioning and HSCT. Post-debridement blood cultures were negative, and the patient underwent two vacuum-assisted closure (VAC) procedures. After successful drainage and stabilization of blood counts, a skin graft was performed. Following the graft, the patient was readmitted and treated with lipid hydrocolloid dressings, wound cleansing solutions, foam dressings, and recombinant human epidermal growth factor gel for postoperative wound care. The patient's right arm skin healed well, and blood counts remained stable post-HSCT. Discussion and conclusions Severe aplastic anemia (SAA) is a life-threatening hematologic disorder characterized by pancytopenia and a hypocellular bone marrow. This condition arises from the destruction or severe deficiency of hematopoietic stem cells, resulting in a marked decrease in red blood cells, white blood cells, and platelets [ 11 ] . Patients with SAA are highly susceptible to infections, bleeding, and anemia-related symptoms such as fatigue and pallor. The etiology of SAA can include autoimmune destruction of bone marrow, exposure to toxic chemicals, certain medications, and viral infections. Treatment options primarily involve immunosuppressive therapy to curb the autoimmune attack or hematopoietic stem cell transplantation (HSCT) to restore bone marrow function [ 12 ] . Cellulitis is primarily caused by Gram-positive bacteria, with β-hemolytic streptococci being the most common pathogen [ 13 ] . Stenotrophomonas maltophilia (SMA) is a ubiquitous aerobic Gram-negative bacterium that has emerged as a global opportunistic human pathogen. It typically does not infect healthy hosts but exhibits high morbidity and mortality rates among individuals with severe immunocompromise and debilitation [ 14 , 15 ] . In patients with hematologic malignancies, SMA infection poses a severe and often fatal complication due to profound and prolonged neutropenia and the extensive use of broad-spectrum antibiotics. These infections are characterized by high morbidity and mortality rates [ 14 ] . However, cellulitis caused by Gram-negative bacteria like SMA is uncommon, even among immunocompromised patients [ 16 ] . The innovation and significance of this case report lie in highlighting a rare and severe infection in a patient with severe aplastic anemia (SAA) undergoing hematopoietic stem cell transplantation (HSCT). The identification of Stenotrophomonas maltophilia as the causative agent of cellulitis in this immunocompromised patient underscores the importance of considering atypical and multidrug-resistant pathogens in similar clinical scenarios. This case emphasizes the need for heightened vigilance and tailored antimicrobial strategies in managing infections in SAA patients during HSCT. By documenting this unusual infection, we contribute valuable insights into the complexities of infectious complications in severely immunocompromised patients, aiding in early recognition, prompt intervention, and improved outcomes. The report also serves as a critical reminder of the potential for rare pathogens to cause significant morbidity in HSCT recipients, advocating for comprehensive infection control measures and interdisciplinary collaboration in patient care. Declarations Author contributions QianGuo and XiangZhang managed the case and prepared and revised the manuscript. JuanJiang and YapingJiang assisted with the preparation and revision of the manuscript. YuZhang assisted with data analysis and revision of the manuscript. All co-authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work. All co-authors take full responsibility for the integrity of the report and the final manuscript. Funding Not applicable. Data Availability All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate the Ethics Committee of the First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine waived this case report’s ethical approval and consent requirement due to the study’s retrospective nature. This study was carried out in accordance with the guidelines of the Declaration of Helsinki. Consent for publication Written informed consent was obtained from the patient and his wife to publish this case report and accompanying images. A copy of the written consent is available for review by the editor of this journal. Competing interests The authors declare no competing interests References Bacigalupo A. How I treat acquired aplastic anemia. Blood. 2017;12911:1428–36. Alter BP. Diagnosis, genetics, and management of inherited bone marrow failure syndromes. Hematol Am Soc Hematol Educ Program. 2007:29–39. Tichelli A, Latour RPD, Passweg J, Knol-Bout C, Socié G, Marsh G, et al. Long-term outcome of a randomized controlled study in patients with newly diagnosed severe aplastic anemia treated with antithymocyte globulin and cyclosporine, with or without granulocyte colony-stimulating factor: a Severe Aplastic Anemia Working Party Trial from the European Group of Blood and Marrow Transplantation. Haematologica. 2020;1055:1223–31. Renaghan AD, Jaimes EA, Malyszko J, Perazlla M, Sprangers B, Rosner MH. Acute Kidney Injury and CKD Associated with Hematopoietic Stem Cell Transplantation. Clin J Am Soc Nephrol.2020;15;2: 289 – 97. Strobl J, Pandey RV, Krausgruber T, Kleissl L, Reininger B, Herac M, et al. Anti-apoptotic molecule BCL2 is a therapeutic target in steroid-refractory graft-versus-host disease. J Invest Dermatol. 2020;14011:2188–98. Flowers MED, Inamoto Y, Carpenter P, Lee SJ, Kiem HP, Petersdorf EW, et al. Comparative analysis of risk factors for acute graft-versus-host disease and for chronic graft-versus-host disease according to National. Institutes Health consensus criteria Blood. 2011;11711:3214–9. Strong Rodrigues K, Oliveira-Ribeiro C, De Abreu Fiuza Gomes S, Knobler R. Cutaneous Graft-Versus-Host Disease: Diagnosis and Treatment. Am J Clin Dermatol. 2018;191:33–50. Swartz MN. Clinical practice. Cellulitis N Engl J Med. 2004;350;9: 904 – 12. Raff AB, Kroshinsky D, Cellulitis. Rev JAMA. 2016;316:03: 325–37. Boettler MA, Kaffenberger BH, Chung CG, Cellulitis. A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis. Am J Clin Dermatol. 2022;23;2: 153 – 65. Young NS, Calado RT, Scheinberg P. Current concepts in the pathophysiology and treatment of aplastic anemia. Blood. 2006;1088:2509–19. Georges GE, Doney K, Storb R. Severe aplastic anemia: allogeneic bone marrow transplantation as first-line treatment. Blood Adv. 2018;215:2020–28. Bystritsky RJ, Cellulitis. Infect Dis Clin North Am. 2021;351:49–60. Micozzi A, Venditti M, Monaco M, Friedrich A, Taglietti F, Stantilli S, et al. Bacteremia due to Stenotrophomonas maltophilia in patients with hematologic malignancies. Clin Infect Dis. 2000;31:3: 705–11. An SQ, Berg G. Stenotrophomonas maltophilia. Trends Microbiol.2018;26;7: 637 – 38. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64;2: 148 – 55. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4885479","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":340379435,"identity":"312792e5-c260-48fd-8cee-b7187a8f6fea","order_by":0,"name":"Qian Guo","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Guo","suffix":""},{"id":340379436,"identity":"9c09645d-f1a9-42d8-af4c-44da365f5a5e","order_by":1,"name":"Juan Jiang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Jiang","suffix":""},{"id":340379437,"identity":"18908776-3ca7-4779-bd9a-eae365b5f526","order_by":2,"name":"Yaping Jiang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Yaping","middleName":"","lastName":"Jiang","suffix":""},{"id":340379438,"identity":"8d3026f7-eee5-41b1-814e-93c1cc4af1cd","order_by":3,"name":"Yu Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine)","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhang","suffix":""},{"id":340379440,"identity":"461b4e57-d994-4241-8df9-810f97a3ef2a","order_by":4,"name":"Xiang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIie2QsYoCMRCGswzEZrxYGtaHGBEUcdHiXmThQBsLK7G7QB7g2vUtrrKObGGnD2CjzdURRCyuMLuCndFSMF8xMPB/DP8wFgi8IlAMSr5/ym2SoBDqGWUyjOZlkIYNmZlnTtk8+i2DlCekUn+YVvC3P1IOZGC/s7RBYiayh/F9RWreaTVoxKXhrWZGW+yAAjlf3FcEsHZcpx5+GOQxOqWrDIeqR+FQOTkF6uyqrJFM6lcEYFta+qTaVTGPFalxGrvfpq5U0eULZbbU3i60WS3k+T9JRUW7j836AyH00h48SgFgOW97pPz5InJ+GAkEAoG35gIf3UeM/hHY+AAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine)","correspondingAuthor":true,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-08-09 08:22:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4885479/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4885479/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66124081,"identity":"ee4951db-79ee-4a6b-86ec-77910736147e","added_by":"auto","created_at":"2024-10-08 02:33:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73616,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBlood biochemical indicators of the course of the disease\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4885479/v1/c64db6301905d57315451d1d.png"},{"id":66124080,"identity":"70cb5330-6fa1-4ff9-8492-3cf427d95733","added_by":"auto","created_at":"2024-10-08 02:33:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1073015,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBreakdown of skin trauma\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure210.png","url":"https://assets-eu.researchsquare.com/files/rs-4885479/v1/8cfd8faceed9ccd6f83ef5a3.png"},{"id":74518838,"identity":"f1e8b106-e2cc-4a13-a912-850e77ec720d","added_by":"auto","created_at":"2025-01-23 05:33:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2005455,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4885479/v1/84bfffe4-4860-41fd-940f-8d5bd9c1ddd3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Severe Cellulitis Caused by Stenotrophomonas Maltophilia in a 48-Year-Old Male with Severe Aplastic Anemia During Hematopoietic Stem Cell Transplantation: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eAplastic anemia (AA) is a life-threatening bone marrow failure disorder characterized by pancytopenia and a hypocellular bone marrow with excessive fat. AA has a progressive nature, and due to its gradual disease course and/or treatment-related complications, it carries a significant risk of morbidity and mortality\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Without definitive treatment, the mortality rate of severe AA (SAA) approaches 70% within two years\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Hematopoietic stem cell transplantation (HSCT) is a lifesaving therapy for AA patients\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, due to various factors such as human leukocyte antigen (HLA) compatibility, donor and recipient gender and age, and conditioning regimens, 30\u0026ndash;80% of patients may develop graft-versus-host disease (GVHD) post-transplant\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. GVHD is a complication that can affect multiple organ systems, including the skin, liver, lungs, and gastrointestinal tract, with the skin being the most commonly affected organ. The severity of skin symptoms often reflects the overall severity of GVHD and serves as a critical monitoring indicator for treatment decisions\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Cellulitis is an acute, diffuse, suppurative inflammation involving the dermis and subcutaneous tissues, typically associated with wounds, ulcers, or other skin breaches. The affected areas usually present with expanding erythema, fever, tenderness, and swelling\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. There is currently no gold standard diagnostic technique for cellulitis; diagnosis relies on clinical presentation and evaluation\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. When cellulitis is accompanied by tissue necrosis, secondary necrotizing vasculitis may occur, leading to increased medical costs\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. This case report presents a 48-year-old male SAA patient who developed a skin infection prior to HSCT and subsequently progressed to severe cellulitis post-transplant.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 48-year-old male, was admitted with jaundice and dark urine for over half a month, and pancytopenia for 5 days without an obvious cause. Blood tests, bone marrow examinations, and multiple bone marrow aspirations showed hematopoietic suppression, with pathological findings of decreased nucleated cells and an increased lymphocyte ratio (87.5%), leading to a diagnosis of severe aplastic anemia (detailed hematologic and biochemical indices are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A haploidentical hematopoietic stem cell transplantation (HSCT) was planned as the treatment strategy.\u003c/p\u003e \u003cp\u003eOn the 14th day of hospitalization, the patient developed redness, swelling, heat, and pain in his right arm. The condition worsened, with the skin turning black, ulcerating, and discharging pus. The wound area expanded from 0.5cm x 0.5cm to 4.5cm x 3.5cm x 0.4cm, with the largest area being 9.2cm x 5.5cm x 0.5cm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Skin treatments included wet compresses, intramuscular tramadol 100mg (when NRS score was 5\u0026ndash;7), irrigation and dressing changes, and gauze packing. Empirical anti-infective therapy initially included biapenem, meropenem, omadacycline, voriconazole, polymyxin B, ceftazidime-avibactam, and vancomycin while awaiting blood culture results. Blood cultures indicated a Gram-negative bacterial infection, and pathogen gene testing confirmed Stenotrophomonas maltophilia (SMA) positivity. Following a consultation with a microbiology expert, the treatment was adjusted: meropenem was discontinued, and aztreonam was added to cover metallo-beta-lactamase-producing Gram-negative bacteria, along with an increased dose of ceftazidime-avibactam.\u003c/p\u003e \u003cp\u003eOn the 32nd day of hospitalization, the patient entered the transplant ward for preconditioning and HSCT. Post-debridement blood cultures were negative, and the patient underwent two vacuum-assisted closure (VAC) procedures. After successful drainage and stabilization of blood counts, a skin graft was performed. Following the graft, the patient was readmitted and treated with lipid hydrocolloid dressings, wound cleansing solutions, foam dressings, and recombinant human epidermal growth factor gel for postoperative wound care. The patient's right arm skin healed well, and blood counts remained stable post-HSCT.\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003eSevere aplastic anemia (SAA) is a life-threatening hematologic disorder characterized by pancytopenia and a hypocellular bone marrow. This condition arises from the destruction or severe deficiency of hematopoietic stem cells, resulting in a marked decrease in red blood cells, white blood cells, and platelets\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Patients with SAA are highly susceptible to infections, bleeding, and anemia-related symptoms such as fatigue and pallor. The etiology of SAA can include autoimmune destruction of bone marrow, exposure to toxic chemicals, certain medications, and viral infections. Treatment options primarily involve immunosuppressive therapy to curb the autoimmune attack or hematopoietic stem cell transplantation (HSCT) to restore bone marrow function\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCellulitis is primarily caused by Gram-positive bacteria, with β-hemolytic streptococci being the most common pathogen\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Stenotrophomonas maltophilia (SMA) is a ubiquitous aerobic Gram-negative bacterium that has emerged as a global opportunistic human pathogen. It typically does not infect healthy hosts but exhibits high morbidity and mortality rates among individuals with severe immunocompromise and debilitation\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. In patients with hematologic malignancies, SMA infection poses a severe and often fatal complication due to profound and prolonged neutropenia and the extensive use of broad-spectrum antibiotics. These infections are characterized by high morbidity and mortality rates\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. However, cellulitis caused by Gram-negative bacteria like SMA is uncommon, even among immunocompromised patients\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe innovation and significance of this case report lie in highlighting a rare and severe infection in a patient with severe aplastic anemia (SAA) undergoing hematopoietic stem cell transplantation (HSCT). The identification of Stenotrophomonas maltophilia as the causative agent of cellulitis in this immunocompromised patient underscores the importance of considering atypical and multidrug-resistant pathogens in similar clinical scenarios. This case emphasizes the need for heightened vigilance and tailored antimicrobial strategies in managing infections in SAA patients during HSCT. By documenting this unusual infection, we contribute valuable insights into the complexities of infectious complications in severely immunocompromised patients, aiding in early recognition, prompt intervention, and improved outcomes. The report also serves as a critical reminder of the potential for rare pathogens to cause significant morbidity in HSCT recipients, advocating for comprehensive infection control measures and interdisciplinary collaboration in patient care.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQianGuo and XiangZhang managed the case and prepared and revised the manuscript. JuanJiang and YapingJiang assisted with the preparation and revision of the manuscript. YuZhang assisted with data analysis and revision of the manuscript. All co-authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work. All co-authors take full responsibility for the integrity of the report and the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ethe Ethics Committee of the First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine waived this case report\u0026rsquo;s ethical approval and consent requirement due to the study\u0026rsquo;s retrospective nature. This study was carried out in accordance with the guidelines of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient and his wife to publish this case report and accompanying images. A copy of the written consent is available for review by the editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBacigalupo A. How I treat acquired aplastic anemia. Blood. 2017;12911:1428\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlter BP. Diagnosis, genetics, and management of inherited bone marrow failure syndromes. Hematol Am Soc Hematol Educ Program. 2007:29\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTichelli A, Latour RPD, Passweg J, Knol-Bout C, Soci\u0026eacute; G, Marsh G, et al. Long-term outcome of a randomized controlled study in patients with newly diagnosed severe aplastic anemia treated with antithymocyte globulin and cyclosporine, with or without granulocyte colony-stimulating factor: a Severe Aplastic Anemia Working Party Trial from the European Group of Blood and Marrow Transplantation. Haematologica. 2020;1055:1223\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenaghan AD, Jaimes EA, Malyszko J, Perazlla M, Sprangers B, Rosner MH. Acute Kidney Injury and CKD Associated with Hematopoietic Stem Cell Transplantation. Clin J Am Soc Nephrol.2020;15;2: 289\u0026thinsp;\u0026ndash;\u0026thinsp;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrobl J, Pandey RV, Krausgruber T, Kleissl L, Reininger B, Herac M, et al. Anti-apoptotic molecule BCL2 is a therapeutic target in steroid-refractory graft-versus-host disease. J Invest Dermatol. 2020;14011:2188\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlowers MED, Inamoto Y, Carpenter P, Lee SJ, Kiem HP, Petersdorf EW, et al. Comparative analysis of risk factors for acute graft-versus-host disease and for chronic graft-versus-host disease according to National. Institutes Health consensus criteria Blood. 2011;11711:3214\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrong Rodrigues K, Oliveira-Ribeiro C, De Abreu Fiuza Gomes S, Knobler R. Cutaneous Graft-Versus-Host Disease: Diagnosis and Treatment. Am J Clin Dermatol. 2018;191:33\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwartz MN. Clinical practice. Cellulitis N Engl J Med. 2004;350;9: 904\u0026thinsp;\u0026ndash;\u0026thinsp;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaff AB, Kroshinsky D, Cellulitis. Rev JAMA. 2016;316:03: 325\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoettler MA, Kaffenberger BH, Chung CG, Cellulitis. A Review of Current Practice Guidelines and Differentiation from Pseudocellulitis. Am J Clin Dermatol. 2022;23;2: 153\u0026thinsp;\u0026ndash;\u0026thinsp;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung NS, Calado RT, Scheinberg P. Current concepts in the pathophysiology and treatment of aplastic anemia. Blood. 2006;1088:2509\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorges GE, Doney K, Storb R. Severe aplastic anemia: allogeneic bone marrow transplantation as first-line treatment. Blood Adv. 2018;215:2020\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBystritsky RJ, Cellulitis. Infect Dis Clin North Am. 2021;351:49\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicozzi A, Venditti M, Monaco M, Friedrich A, Taglietti F, Stantilli S, et al. Bacteremia due to Stenotrophomonas maltophilia in patients with hematologic malignancies. Clin Infect Dis. 2000;31:3: 705\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn SQ, Berg G. Stenotrophomonas maltophilia. Trends Microbiol.2018;26;7: 637\u0026thinsp;\u0026ndash;\u0026thinsp;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64;2: 148\u0026thinsp;\u0026ndash;\u0026thinsp;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aplastic anemia, hematopoietic stem cell transplantation, cellulitis, erysipelas, Stenotrophomonas maltophilia, case report","lastPublishedDoi":"10.21203/rs.3.rs-4885479/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4885479/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Cellulitis, a potentially severe bacterial skin infection, is typified by pain, fever, and erythema, posing diagnostic and therapeutic challenges. Hematopoietic stem cell transplantation (HSCT) is a critical treatment for severe aplastic anemia but temporarily impairs immune function, increasing the risk of opportunistic infections, including cellulitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e This case report details a 48-year-old male with severe aplastic anemia who developed cellulitis caused by Stenotrophomonas maltophilia during HSCT. The infection occurred in his right arm and was admitted to Zhejiang Provincial Hospital of Traditional Chinese Medicine in March 2024. The patient's compromised immunity post-HSCT made managing the infection particularly complex.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Despite the critical nature of the infection, the patient was effectively treated through a multidisciplinary approach and was discharged after 128 days. His recovery underscores the significance of early diagnosis and tailored treatment in immunocompromised patients, emphasizing the role of coordinated medical care in achieving favorable outcomes post-HSCT.\u003c/p\u003e","manuscriptTitle":"Severe Cellulitis Caused by Stenotrophomonas Maltophilia in a 48-Year-Old Male with Severe Aplastic Anemia During Hematopoietic Stem Cell Transplantation: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-08 02:33:42","doi":"10.21203/rs.3.rs-4885479/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"afcb0a9c-e6eb-4e7c-b039-dfd84ba847da","owner":[],"postedDate":"October 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-23T05:23:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-08 02:33:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4885479","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4885479","identity":"rs-4885479","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}