Rapid autologous marrow recovery and eradication of infectious mononucleosis despite severe immunosuppression following second transplantation for ...
Bone Marrow Transplantation, (1999) 23, 91–93 1999 Stockton Press All rights reserved 0268–3369/99 $12.00 http://www.stockton-press.co.uk/bmt
Case report Rapid autologous marrow recovery and eradication of infectious mononucleosis despite severe immunosuppression following second transplantation for aplastic anemia H-C Rossbach1, KM Hosler1, W Chamizo2, T Mueller2, NH Grana1, AG Lacson2 and JL Barbosa1 1
Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation and 2Pathology, All Children’s Hospital, University of South Florida College of Medicine, St Petersburg, FL, USA
Summary: A patient with aplastic anemia failed to respond to immunosuppressive therapy and first marrow transplantation (BMT). Recovery of autologous hematopoiesis was rapid following a second stem cell transplant with a non-myeloablative preparatory regimen. The autologous immune response to infectious mononucleosis (IM) 4 weeks post-transplant was normal despite recent and ongoing severe immunosuppression. Keywords: aplastic anemia; second bone marrow transplant; mixed chimerism; autologous marrow recovery; Epstein–Barr virus infection
Bone marrow transplantation (BMT) is considered the therapy of choice for younger patients with aplastic anemia (AA) and matched, related, donors.1 Initial immunosuppressive therapy (IS), and BMT only for those patients not responding has been suggested as a reasonable alternative treatment.2,3 This approach may be justified as graft rejection and failure are now rarely encountered even in multiply transfused patients with genotypically human leukocyte antigen (HLA)-identical donor transplants preceded by treatment with cyclophosphamide (CPM) and antithymocyte globulin (ATG).4 Autologous hematopoietic recovery following BMT occurs infrequently and, in general, not rapidly.5–7 In transplant patients, reactivation of the Epstein–Barr virus (EBV) frequently leads to atypical infection8–10 or lymphoproliferative disease.11 Particular risk factors include HLA disparity between donor and recipient; T cell depletion of the graft in vitro; and anti-T cell (eg anti-CD3) therapy in vivo for the prevention of graft rejection and/or GVHD. We report a patient who failed IS and experienced graft rejection and recurrent marrow hypoplasia after a first HLA-matched BMT. Rapid return of autologous hematopoiesis was noted within 4 weeks from a second (stem cell) Correspondence: Dr H-C Rossbach, 880 Sixth St So., St Petersburg, FL 33701, USA Received 31 March 1998; accepted 30 July 1998
transplant. Despite ongoing severe immunosuppression, his autologous immune response to reactivation of EBV, in the form of acute infectious mononucleosis (IM), led to rapid eradication of his infection.
Case report An 8-year-old boy presented to an outside institution with severe thrombocytopenia following a febrile upper respiratory tract infection. Idiopathic thrombocytopenic purpura was suspected and treatment begun with gamma globulins (IVIG) and steroids, without response. Upon transfer, a bone marrow aspirate showed profound hypocellularity. Cytogenetic analysis, chromosome breakage studies, and Ham and sucrose tests were normal. Serologic evidence of a recent parvo virus infection was evident. Pancytopenia ensued. IS with ATG and prednisone (15 and 2 mg/kg/day, respectively, in two 10-day courses, 1 month apart) and daily cyclosporin A (CsA) did not lead to improvement in hematopoiesis. Platelets and red cells were transfused on 18 and three occasions, respectively.
First marrow transplant Seven months following diagnosis, the patient underwent an HLA-matched BMT from his 1-year-older brother. The PR included CPM (50 mg/kg/day for 4 days) and ATG (30 mg/kg/day for 3 days). A total of 3.8 × 108 nucleated cells/kg after red cell depletion were infused. GVHD prophylaxis included CsA and methotrexate. The postBMT course was uneventful. Myeloid engraftment with an absolute neutrophil count (ANC) ⬎500 was evident by day 19; however, the patient did not become red cell and platelet transfusion independent. Neutropenia recurred and the marrow remained hypocellular. There was no evidence of persistent parvo virus infection. Donor/recipient analysis, using short tandem repeat sequences (STR), revealed 40 and 35% donor hematopoiesis 8 and 12 weeks post-BMT, respectively (Figure 1). Twice weekly treatment with GCSF was required to maintain an ANC above 1000.
Autologous marrow recovery and IM after 2nd transplant for AA H-C Rossbach et al
92
60
250
200
Platelet count (× 1000)
% donor hematopoiesis
50
40
30
20
150
100
50 10
0 0
–6 –3
0
2
4
14
19
7
14
26
Week Figure 1
0
21
28
35
Day Figure 2 Platelet counts in the second peri-transplant period.
Percentage of donor hematopoiesis.
Second stem cell transplant A second transplant was performed 4 months after the first. The PR was modeled after the Seattle protocol for patients with AA and graft rejection prior to second BMT, using IS with an anti-CD3 monoclonal antibody and high-dose steroids (HJ Deeg and J Sanders, personal communication). OKT3 (Ortho Biotech, Raritan, NJ, USA; 0.4 mg/kg/day) was infused from the day prior to transplant, with a slow taper, until day 23; methylprednisolone (20 mg/kg/day) from day −5, also tapered, until day 18. CsA therapy commenced on day 19. Two G-CSF-mobilized, peripheral blood stem cell apheresis products from the same donor, contained approximately 9 × 108 nucleated cells/kg each, with 4.2 × 106 CD34+ cells/kg measured in the first. Only two red cell but no platelet products (Figure 2) were transfused following the stem cell infusions. The marrow was cellular with active and progressive hematopoiesis 16 days post-transplant. Initially, a rising percentage of donor hematopoiesis was documented by STR analysis (30, 50 and 60% on days 13, 20 and 24, respectively, Figure 1); however, full chimerism was never achieved. Three weeks posttransplant, a pruritic, erythematous, maculo-papular rash with erythema of the ears, palms and soles of the hands and feet, suspected to be GVHD but with equivocal biopsy, responded quickly to steroids. One week later (day 28), following discharge and despite recent therapy with acyclovir, the patient presented with signs and symptoms of acute IM, including enlarged, beefy-red tonsils covered by white membranes; massive, bilateral cervical adenopathy; and Table 1
splenomegaly. Both donor and recipient (in the absence of IVIG therapy for 7 months) expressed serologic evidence of exposure to EBV prior to BMT; repeat EBV serology showed a marked increase in antibody titers to the viral capsid antigen (VCA-IgM, VCA-IgG) and early antigen-D but not to the nuclear antigen (EBNA) (Table 1). A lymph node biopsy revealed effacement of architecture and diffuse replacement by a polymorphous population of small, mature lymphocytes, immunoblasts and plasmacytoid cells. Special stains revealed a balanced population of T- and Blymphocytes with equal proportions of kappa- and lambdapositive B cells. Immunoperoxidase stains for EBV showed the immunoblasts intensely positive. Flow cytometric analysis disclosed predominance (57%) of a T-lymphocyte population of cytotoxic/suppressor subtype (CTL), expressing CD3, CD8 and HLA-DR, which was thought to be of donor origin. A population of natural killer cells (NK) (CD16+, 8%) was also noted. Surprisingly, STR analysis revealed greater than 95% cells to be of recipient origin. All symptomatology resolved within a week of (re)-initiation of therapy with IVIG and acyclovir. Interestingly, the patient continues to have an elevated anti-VCA-IgM titer 11 months post second transplant while the anti-EBNA titer, elevated pretransplant, remains negative. Further analysis of T and B cell function is currently ongoing. Repeat STR analysis of peripheral blood 3, 4 and 5 months post-transplant, respectively, showed a decreasing percentage of donor hematopoiesis with 27, 26 and 0% (Figure 1) while the marrow remains normocellular with trilineage hematopoiesis. The patient remains well with normal blood counts
Epstein–Barr virus serologic studies
Antibody
Donor
Pre-BMT
1 month
11 months
VCA IgG VCA IgM EBNA Ab Early Ag D
1.54 neg 392 51
1.49 neg 83 10
144 121 15 382
153 191 ⬍10 223
Reference pos. pos. pos. pos.
⬎0.99 ⬎0.99 ⬎56 ⬎120
Autologous marrow recovery and IM after 2nd transplant for AA H-C Rossbach et al
and no clinical evidence of EBV infection 11 months after the second transplant. Discussion Graft rejection and delayed graft failure are rarely seen in patients with AA with genotypically HLA-identical donors, in particular when either irradiation or ATG is added to CPM in the preparatory regimen. Graft rejection is associated with significant morbidity and mortality but successful engraftment following a second transplant has been observed.6 The patient reported here appeared to have experienced rapid engraftment following a second (PBSC) transplant and was thought to have GVHD of the skin. Nevertheless, concern remained about the durability of donor hematopoiesis, given that donor/recipient studies never revealed complete chimerism following either transplant. Few patients with stable, long-term, mixed chimerism after allogeneic BMT for AA have been reported. The risk of rejection is significantly increased in patients never achieving complete chimerism and only a very small number experience autologous marrow recovery.7 Additionally, the vigorous early immune response to reactivation of EBV/IM, which included the generation of anti-VCA-IgM antibodies and the massive CTL and NK cell infiltrates in the involved lymph node, all commonly seen in immunocompetent individuals,12 led to the assumption that donor hematopoiesis had been established successfully. We were surprised to find that the cellular immune response (based on our molecular analysis (STR) of the node infiltrate) and presumably the humoral response as well, was recipientderived, despite recent and ongoing severe immunosuppression. Even though pharmacologic antiviral therapy has been postulated to be effective in BMT patients with EBV infection,8,9 we believe that the generation of CTL, as invoked recently,10 may be a more important mechanism in the effective control of EBV reactivation. The discontinuation of OKT3 therapy would have been expected to facilitate the cytotoxic response. Chimerism studies of separate myeloid and lymphoid cell fractions were not performed. However, since more than 95% of the combined B, T and NK lymphocyte populations in the affected LN were of recipient origin only 4 weeks post transplant, it appears reasonable to assume that the transient donor engraftment was limited to the myeloid population and that the rash was not GVHD but quite possibly of viral etiology. It remains unclear why the VCA-IgM antibody titer continues to be elevated in the absence of any symptomatology 11 months post transplant while a convalescent increase in the EBNA antibody titer has not occurred. We speculate that the third immunosuppressive regimen (OKT3/steroids after prior failure of ATG/CsA and subsequent ATG/CPM) finally resulted in a selective inhibition of autoreactive, hematopo-
iesis-inhibiting T-lymphocyte clones and subsequent cure of his aplastic anemia. At the same time, interestingly, it impacted upon neither the eradication of the EBV infection nor alloreactive effector cells capable of recognition of minor HLA disparity between donor and recipient and, ultimately, graft rejection.
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