Arshad Iqbal initially presented with complaints of intermittent low grade fever and headache in Nov 2020 to local PAF hospital from where he was ref to PNS Shifa. Bone marrow examination in Dec 2020 showed AML M1 with 90% blasts SSB positive. He was then transferred to CMH Rwp. Immunophenotyping for acute leukemia was also consistent with.

He was started on D3A7 induction therapy followed by BME at AFIP in Jan 2021 which showed hematological remission with 2% blasts. He further received 3x HIDAC for consolidation at CMH Oncology ward Rwp. BME in May 2021 at AFBMTC was consistent with CR and immunophenotyping in May 2021 did not identify any CD34 positive blasts. Post 2x HIDAC Arshad developed fungal chest infection. He received oral Voriconazole for one month.

He was referred to AFBMTC for Allogenic transplant and workup for HLA matching was started. No fully HLA matched sibling donor could be identified but he was found to be haplo matched with younger brother Amir Iqbal.

Arshad was transplanted on 22/6/2021 with Flu¹⁵⁰, Bu^{9.6 IV}, Mel¹⁴⁰, ATG⁵ with PTCy¹⁰⁰ used as conditioning therapy. Neutrophil engraftment was achieved on Day +15. Arshad experienced a difficult post-transplant period with problems like febrile neutropenia, Mucositis grade II/III, Acute Gut GVHD, Hypertension, Skin problems, CMV reactivation, TA-TMA, Azotemia and Electrolyte disturbances. Arshad started developing anemia, thrombocytopenia with worsening Creatinine clearance, hyperbilirubinemia and high LDH on 19/7/21. Blood film examination for schistocytes revealed 5-6/HPF. TA-TMA was suspected and Sandimmune was stopped. Patient continued to deteriorate clinically and biochemically despite stopping CSA. It was decided to started plasma exchange for TA-TMA on 27/7/21. Patient had hypotensive episode during first session of plasma exchange. He responded well to IV fluid challenge. He had total 3 session of PLEX over a period of 3 days. He started improving clinically as well as biochemically. Parameters improved prior to discharge.