90 International Journal of HEMATOLOGY Case Report 1. Introduction Nosocomial bacterial infections frequently complicate the late posttransplantation period after allogeneic bone marrow transplantation (BMT), especially in patients requiring pro- longed immunosuppressive treatment for chronic graft- versus-host disease (GVHD) [1-3]. Gram-positive encapsu- lated bacteria such as Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae play important roles in bacterial infections occurring during the late period following BMT [4-6]. We describe 2 cases where Streptococcus pneumoniae was the causative pathogen of purulent arthritis following allogeneic BMT. Both patients received grafts from unre- lated human lymphocyte antigen (HLA)-matched donors and suffered from chronic GVHD of the skin. Their skin dis- ease seriously delayed the recovery from arthritis, which caused deteriorating mobility of the affected joints for a Pneumococcal Arthritis Affects Performance Status in Patients With Chronic GVHD of the Skin Following Allogeneic Bone Marrow Transplantation Naoki Sakata, Masahiro Yasui, Keisei Kawa Department of Pediatrics, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan Received October 19, 2000; received in revised form February 9, 2001; accepted February 19, 200l Abstract We encountered 2 patients with pneumococcal arthritis following bone marrow transplantation (BMT). Both patients received grafts from unrelated human lymphocyte antigen(HLA)-matched donors and had suffered from chronic graft-versus- host disease (GVHD). One, a 10-year-old boy, suffered from Epstein-Barr virus–related lymphoproliferative disease (EB- LPD) and received oral 6-mercaptopurine and methotrexate to manage lymphadenopathy. Twenty-four months after BMT and 7 months after the onset of EB-LPD, pneumococcal arthritis occurred in both knee joints.The other patient, a 10-year-old girl, received multiagent immunosuppressive therapy for her chronic GVHD. At 51 months following BMT, pneumococcal arthritis occurred in her left knee joint. Chronic GVHD of the skin delayed the recovery from the arthritis in both patients. This complication is quite rare but can be very serious, in regard to the patient’s performance status following BMT.Although vaccination against pneumococcus or preventive antibiotics should be administered to high-risk patients, early diagnosis and treatment may be the best strategy for pneumococcal arthritis. Int J Hematol. 2001;74:90-94. ©2001 The Japanese Society of Hematology Key words: Pneumococcal arthritis; Chronic GVHD; BMT; Quality of life; Late complication Correspondence and reprint requests: Naoki Sakata, MD, Department of Pediatrics, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodo Izumi, Osaka 594-1101, Japan; 0725-56-1220; fax: 0725-56-5682 (e-mail: nsakata@mch.pref.osaka.jp). long time.Vaccination and preventive antibiotics do not pro- vide complete prophylaxis of this complication. Early diag- nosis and treatment, including rehabilitation, may be the best strategy for maintaining a good performance status. 2. Case Reports 2.1. Case 1 In July 1995, a 6-year-old boy was diagnosed with acute myelomonocytic leukemia (AMMoL) showing a typical chromosomal abnormality, inv(16)(p13;q22) (Figure 1A). The patient was treated with conventional chemotherapy (OCLSG N-91) and reached complete remission following induction chemotherapy consisting of cytarabine, dauno- mycin, and prednisolone (PRD). At onset, the cere- brospinal fluid (CSF) was intact, but leukemic cells were revealed in the CSF after completion of the second consol- idation chemotherapy consisting of cytarabine, dauno- mycin, and etoposide. We decided to treat the patient with allogeneic BMT because his cerebrospinal system relapse on therapy predicted poor prognosis. He received 12 Gy fractionated total-body irradiation (2 Gy  6) and melpha- lan (180 mg/m 2 ) as conditioning for allogeneic BMT from