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5 Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self-harm in adolescents: self report survey in schools in England. BMJ 2002;325:1207–11. 6 Suris JC, Michaud PA, Viner R. The adolescent with a chronic condition. Part I: Developmental isssues. Arch Dis Child 2004;8:938–42.
3 Cassidy JT, Petty RE. Textbook of pediatric rheumatology, 4th ed. Philadelphia: Saunders, 2001. 4 Farrington ML, Haas JE, Nazar-Stewart V, Mellins E. Eosinophilic fasciitis in children frequently progresses to scleroderma-like cutaneous fibrosis. J Rheumatol 1993;20:128–32.
Relapse of autoimmune diseases after autologous T cell depleted stem cell transplantation may be triggered by T cells recently emigrated from the thymus I Ko¨tter*, T Daikeler*, H Einsele, S Koch, L Lochmann, L Kanz, J Lo¨ffler ............................................................................................................................... Ann Rheum Dis 2005;64:1787–1789. doi: 10.1136/ard.2004.032870
H
igh dose immunosuppressive therapy with subsequent autologous stem cell transplantation (ASCT) has proved effective for treatment resistant autoimmune diseases.1 However, in a number of patients, relapses of autoimmune disease after initial improvement or even remission occur. Until recently, it was impossible to differentiate recent thymic emigrants from residual or peripherally expanded T cells. Douek and coworkers2 and later our group3 described a method for detection of T cell receptor excision circles, stable DNA episomes which are formed during T cell receptor rearrangement in the thymus which are not replicated during mitosis, but are diluted during cell divisions.4 This study aimed at investigating whether these flares are associated with de novo T cell development. Peripheral blood mononuclear cells were collected from six patients, mean age 32.5 years, range 24–42 (four with systemic sclerosis (SSc), one with Wegener’s granulomatosis (WG), one with mutilating psoriatic arthritis (PsA)), after high dose immunosuppression with cyclophosphamide 50 mg/kg body weight plus anti-thymocyte globulin 20 mg/ kg on days 1–4, with subsequent retransfusion of 4.26106 (median) CD34+ selected (by CliniMacs device) cells/kg body weight. Blood collection was performed at week 2 and then, at bimonthly intervals, genomic DNA was extracted using the QIAmp DNA Blood Mini Kit. DNA was stored at 280˚C until analysis. T cell receptor rearrangement excision circles
(TRECs) were measured by real time polymerase chain reaction using the light cycler (Roche Diagnostics Corporation, Idaho, USA). The study was approved by the local ethics committee and patients’ informed consent obtained. All patients improved considerably (all patients with SSc) or went into remission (PsA, WG) after ASCT. In all patients, previous immunosuppressive therapy was discontinued, except in the patient with WG, who still received ciclosporin A for her kidney transplant. Two patients relapsed after 7, and 19 months, respectively (one SSc, one PsA). CD3+/CD4+ T cells were recovered after 6–14 months (median 12), and CD3+/CD8+ T cells a maximum of 3 months after ASCT in all patients. Autoantibodies disappeared in four of five patients after a median of 6 months and their recurrence or disappearance later did not correlate with relapse or remission. TRECs could not be detected in the patients shortly after ASCT (week 2), but recurred 9–26 months (median 16 months) after ASCT. In the two patients who experienced relapses, TRECs became detectable at the time when the first symptoms of relapse were noticed (SSc, patient No 3: relapse after 7 months, TRECs after 9 months; PsA, patient no 4: relapse after 19, TRECs after 21 months— the blood collection did not always coincide exactly with the diagnosis of relapse, which explains the 2 months’ difference between diagnosis and first detection of TRECs) (fig 1, table 1). Figure 1 First detection of TRECs and relation to diagnosis of relapse.
TREC detection Patient 1, WG Patient 2, SSc Relapse
Patient 3, SSc
Relapse
Patient 4, PsA Patient 5, SSc Patient 6, SSc 0
3
6
9
12
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18
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Letters 1788
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ND, not done; NA, not available, neg: negative. Week 0, week before conditioning; week 2, 2 weeks after peripheral blood stem cell transplantation (retransfusion of autologous stem cells).
ND ND 86105 ND NA NA ND ND 16105 ND ND ND ND ND ND ND ND ND ND None None 46104 ND ND ND None ND None None None 26104 None 1.46105 ND None None None None None None None None None ND None None None None ND ND ND ND ND ND ND ND ND ND ND ND TREC 1 2 3 4 5 6
Neg ANA 1/1000 ANA 1/500 SCl-70+ SCl-70 SCl-70 (not quantified) 6
ND ND ND None None 66104
ND None ND None 66104 ND
ND 66104 ND ND ND ND
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NA Neg ANA 1/500 Neg
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Week 138 Week 122
Neg ND
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ANA 1/300, Nucleoli 1/180, SCl-70+ Unspecific ANA 1/1500, SCl-70+
Week 60 Week 48 Week 36 Week 24 Week 16
ANA 1/500, Nucleoli 1/120 ANA 1/500 SCl-70 (not quantified) 5
Week 2 Week 0 Patient No
Continued Table 1
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1789
Week 204
Letters
Normally, immune reconstitution and TREC recurrence is considerably quicker in ASCT than in allogeneic SCT.5 TREC recurrence in the allogeneic setting is known to be delayed by clinical events such as graft versus host disease,6 whereas in ASCT CD34+ selection of the graft was associated with increased thymic output (‘‘rebound phenomenon’’).2 In the present study, T cell ontogenesis was delayed even in comparison with allogeneic SCT for haematological diseases (TREC recurrence: 6 months6). Premature immunosenescence may be one of the reasons for this delay in T cell ontogenesis after ASCT in autoimmune diseases.7 8 De novo T cell ontogenesis in the thymus may be a critical event inducing relapses of the autoimmune disease, which may not be caused by peripheral expansion of memory T cells which survived the conditioning treatment, but by newly developed T cells of thymic origin. Vice versa, as in four patients TRECs recurred without relapse of the autoimmune disease, one might also argue that the occurrence of TRECs is not causally associated with relapse. Further studies of the immune reconstitution, correlating the recurrence of TRECs with T cell subsets, T cell receptor diversity, and autoantibody production in patients with autoimmune diseases after ASCT will improve our understanding of the pathogenesis of these diseases and help in the development of new therapeutic concepts. .....................
Authors’ affiliations I Ko¨tter, T Daikeler, H Einsele, S Koch, L Lochmann, L Kanz, J Lo¨ffler, Tu¨bingen University, Hospital, Department of Internal Medicine II, Otfried-Mu¨ller-Str 10, D-72076 Tu¨bingen, Germany *The first and second authors contributed equally to this work. Correspondence to: Dr I Ko ¨ tter,
[email protected] Accepted 15 May 2005
REFERENCES 1 Tyndall A, Matucci-Cerinic M. Haematopoietic stem cell transplantation for the treatment of systemic sclerosis and other autoimmune disorders. Expert Opin Biol Ther 2003;3:1041–9. 2 Douek DC, Vescio RA, Betts MR, Brenchley JM, Hill BJ, Zhang L, et al. Assessment of thymic output in adults after haematopoietic stem-cell transplantation and prediction of T-cell reconstitution. Lancet 2000;355:1875–81. 3 Loeffler J, Bauer R, Hebart H, Douek DC, Rauser G, Bader P, et al. Quantification of T-cell receptor excision circle DNA using fluorescence resonance energy transfer and the LightCycler system. J Immunol Methods 2002;271:167–75. 4 Hazenberg MD, Verschuren MC, Hamann D, Miedema F, van Dongen JJ. T cell receptor excision circles as markers for recent thymic emigrants: basic aspects, technical approach, and guidelines for interpretation. J Mol Med 2001;79:631–40. 5 Peggs KS, Mackinnon S. Immune reconstitution following haematopoietic stem cell transplantation. Br J Haematol 2004;124:407–20. 6 Hazenberg MD, Otto SA, de Pauw ES, Roelofs H, Fibbe WE, Hamann D, et al. T-cell receptor excision circle and T-cell dynamics after allogeneic stem cell transplantation are related to clinical events. Blood 2002;99:3449–53. 7 Weyand CM, Fulbright JW, Goronzy JJ. Immunosenescence, autoimmunity, and rheumatoid arthritis. Exp Gerontol 2003;38:833–41. 8 Koetz K, Bryl E, Spickschen K, O’Fallon WM, Goronzy JJ, Weyand CM. T cell homeostasis in patients with rheumatoid arthritis. Proc Natl Acad Sci USA 2000;97:9203–8.
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