Zhengqin Tian,1,* Qihang Man,1,* Yixin Yang,1,* Xiaomei Zhang,2,* Hexian Guan,1 Wenjing Gu,2 Ying Wang,1 Dandan Song,2 Rongmu Luo,1,2 Jingbo Wang1 

1Department of Hematology, Aerospace Center Hospital, Beijing, People’s Republic of China; 2Department of Hematology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Rongmu Luo; Jingbo Wang, Email luorongmu@163.com; wangjingbo721@126.com

Abstract: Engraftment syndrome (ES) is an early complication of hematopoietic stem cell transplantation (HSCT) characterized by fever and additional clinical manifestations including rash, diarrhea, lung infiltrates, weight gain, and neurological symptoms. Steroid-resistant ES following HSCT significantly affects the efficacy of transplantation and may even result in patient mortality. As ES essentially represents a cytokine storm induced by engrafted donor cells with interferon-gamma (IFN-γ) playing a central role, we hypothesized that emapalumab (an anti-IFN-γ monoclonal antibody) may be an effective approach to treat steroid-resistant ES. Here, we present a case report of a 14-year-old female patient who received a second haploidentical HSCT due to a relapse of acute myeloid leukemia. Nine days after the transplantation, the patient developed a fever and exhibited a poor response to antimicrobials (ceftazidime/avibactam). A few days later, the patient presented with a new-onset rash, weight gain, and impaired liver function, leading to a diagnosis of ES. Initial immunosuppressive (tacrolimus and mycophenolate mofetil) treatment failed to control the disease. On day 16 post-transplantation, the patient received two infusions of 50 mg of emapalumab. Following the initiation of emapalumab treatment, the patient’s fever returned to normal and ES was effectively controlled. This case report demonstrated that emapalumab had a possible efficacy for steroid-resistant ES and provided a novel therapeutic strategy to treat this clinical complication.

Keywords: haploidentical hematopoietic stem cell transplantation, engraftment syndrome, emapalumab, acute myeloid leukemia