Anna Amelia Colombo

Persistent Symptomless Human Metapneumovirus Infection in Hematopoietic Stem Cell Transplant Recipients

Sequential nasopharyngeal aspirates from patients without respiratory symptoms undergoing hematopoietic stem cell transplantation (HSCT) were tested for genomic RNA of human metapneumovirus (hMPV). Persistent hMPV infection was documented in most of them and confirmed by virus isolation. hMPV infection etiology was also evaluated during the same period in samples from pediatric patients with acute respiratory diseases (ARDs). Sequence analysis of hMPV in HSCT recipients documented infection by hMPV genotype A and strong interhost similarity; this pattern differs from that observed in pediatric patients with ARDs. The data indicate that HSCT recipients may frequently develop symptomless hMPV infection.

A sequence of immuno‐chemotherapy with Rituximab, mobilization of in vivo purged stem cells, high‐dose chemotherapy and autotransplant is an effective and non‐toxic treatment for advanced follicular and mantle cell lymphoma

Summary. Options for relapsed/refractory indolent lymphoma include chemotherapy, immunotherapy and high‐dose therapy with autologous support. The best combination of these approaches, however, is not defined. We treated 10 patients with relapsed/refractory follicular (n = 7) or mantle cell lymphoma (n = 3) using chemotherapy, immunotherapy, high‐dose therapy and autotransplant in a sequence of four phases, each designed to play a specific role in tumour eradication. After the debulking with VACOP‐B (doxorubicin, cyclophosphamide, etoposide, vincristine, prednisone, bleomycin) (phase 1), 9/10 patients responded but none achieved a molecular response. After the immuno‐chemotherapy phase, which combined Rituximab with vincristine and cyclophosphamide, seven patients were in complete response (CR) and three in good partial response (PR), and all those with a molecular marker of disease showed a disappearance of the signal from marrow and blood. Phase 3, which coupled high‐dose cytarabine with Rituximab, was effective in mobilizing an adequate number of progenitor cells that were polymerase chain reaction negative in all informative cases. Phase 4 consisted of high‐dose therapy with autologous support followed by two doses of Rituximab. Autograft was performed in nine patients. The haematopoietic recovery was as expected. This sequence of chemotherapy, immuno‐chemotherapy, stem cell mobilization with in vivo purging and autotransplant, organized in four blocks of treatment, was simple to administer and devoid of toxic effects. It permits rapid attainment of clinical and molecular response and enables the harvest of lymphoma‐free peripheral blood progenitor cells even in heavily pretreated patients with relapsed or refractory disease.

Nephrotic syndrome after allogeneic hematopoietic stem cell transplantation as a late complication of chronic graft-versus-host disease.

Background. This study aims to determine the incidence and outcome of nephrotic syndrome in patients who underwent allogeneic stem cell transplantation in a single center. Methods. Records of 279 adult patients with hematological diseases who underwent allogeneic hematopoietic stem cell transplantation were analyzed to evaluate the incidence and outcome of nephrotic syndrome. The diagnosis of chronic graft-versus-host disease was based on clinical evidence with histological confirmation whenever possible. Results. Of the 279 patients, 105 with a minimum follow-up of 100 days developed chronic graft-versus-host disease: six of these had nephrotic syndrome. The cumulative incidence of nephrotic syndrome was 8% at day +1681. Patients grafted with peripheral blood stem cells had a higher probability of developing nephrotic syndrome than did those grafted with bone marrow: 24% and 3%, respectively. The pathological diagnosis was membranous glomerulonephritis in four patients, and minimal change disease in one; the diagnosis could not be histologically confirmed in the sixth patient. All patients had extensive chronic graft-versus-host disease and were receiving treatment with cyclosporine A and steroids (four patients). Response to immunosuppressive therapy with cyclosporine A and steroids was achieved in all patients at a median time of 12 weeks after transplantation. Conclusion. Patients with chronic graft-versus-host disease may be considered to be at risk of nephrotic syndrome: careful monitoring of renal function is advisable, particularly in patients receiving allogeneic peripheral stem cell grafts.

Reconstitution of Human Cytomegalovirus–Specific CD4+ T Cells is Critical for Control of Virus Reactivation in Hematopoietic Stem Cell Transplant Recipients but Does Not Prevent Organ Infection

The relative contribution of human cytomegalovirus (HMCV)-specific CD4(+) and CD8(+) T cells to the control of HCMV infection in hematopoietic stem cell transplant (HSCT) recipients is still controversial. HCMV reactivation and HCMV-specific CD4(+) and CD8(+) T cell reconstitution were monitored for 1 year in 63 HCMV-seropositive patients receiving HSCT. HCMV reactivation was detected in all but 2 patients. In 20 of 63 (31.7%) patients (group 1) HCMV infection resolved spontaneously, whereas 32 of 63 (50.8%) patients (group 2) controlled the infection after a single short-course of pre-emptive therapy and the remaining 9 (14.3%) patients (group 3) suffered from relapsing episodes of HCMV infection, requiring multiple courses of antiviral therapy. The kinetics and magnitude of HCMV-specific CD8(+) T cell reconstitution were comparable among the 3 groups, but HCMV-specific CD4(+) T cells were lower in number in patients requiring antiviral treatment. HCMV-seronegative donors, as well as unrelated donors (receiving antithymocyte globulin) and acute graft-versus-host disease (GVHD) were associated with both delayed HCMV-specific CD4(+) T cell reconstitution and severity of infection. Conversely, these risk factors had no impact on HCMV-specific CD8(+) T cells. Eight patients with previous GVHD suffered from HCMV gastrointestinal disease, although in the presence of HCMV-specific CD4(+) and CD8(+) systemic immunity and undetectable HCMV DNA in blood. Reconstitution of systemic HCMV-specific CD4(+) T cell immunity is required for control of HCMV reactivation in adult HSCT recipients, but it may not be sufficient to prevent late-onset organ localization in patients with GVHD. HCMV-specific CD8(+) T cells contribute to control of HCMV infection, but only after HCMV-specific CD4(+) T cell reconstitution.

N-acetylcysteine in the treatment of steroid-resistant acute graft-versus-host-disease: preliminary results. Gruppo Italiano Trapianto di Midollo Osseo (GITMO).

BACKGROUND Acute graft-versus-host disease (GVHD) results from reactivity of donor immunocompetent cells versus host tissues. Its pathogenesis involves co-stimulatory molecules, cytokines, free radicals, and oxidative stress products. N-Acetylcysteine (NAC) is an antioxidant that inhibits the B7-1/CD28 expression in vitro, and it may contrabalance the effects of free radicals and oxidative stress; it has been tested in eight patients with steroid-resistant acute GVHD. METHODS NAC was given at the dose of 150 mg/kg bolus intravenously, followed by 50 mg/kg intravenous continuous infusion over 3 weeks or less up, to clinical GVHD resolution. In four patients, flow cytometric analysis of co-stimulatory molecules was performed on peripheral mononuclear cells before and after NAC therapy. RESULTS We achieved prompt response in six patients: four had complete response, two partial response. Two patients died of acute GVHD, and four of intercurrent disease. We noticed significant decrease in CD80, CD25, and CD8+ cells after NAC therapy. CONCLUSION NAC therapy is feasible; it may give response in steroid-resistant acute GVHD. More extensive studies are needed to confirm these data.

Differential outcome of neurological HCMV infection in two hematopoietic stem cell transplant recipients

BackgroundHuman cytomegalovirus (HCMV) infection of the central nervous system (CNS) is a rare but life threatening condition which may follow hematopoietic stem cell transplantation. Diagnosis, monitoring and treatment approaches rely on anecdotal reports.Case presentationsThe different outcomes of HCMV CNS disease in an adult and a pediatric T-cell depleted hematopoietic stem cell transplant (HSCT) recipient are reported. In the first case, HCMV encephalitis emerged in the context of simultaneous impairment of the T- and B-cell immunity. Antiviral treatment only reduced viral load in peripheral blood and the patient died. In the second case, an HCMV radiculopathy was observed and antiviral treatment was adjusted on the basis of intrathecal drug level. In addition, donor HCMV-specific cytotoxic T lymphocytes (CTLs) were infused. Viral load in the CNS decreased and the patient recovered from the acute event. In neither case were drug-resistant HCMV variants observed in blood or CNS samples.ConclusionsT-cell depleted HSCT appears a predisposing condition for CNS HCMV infection since never observed in other HSCT recipients at our center in the last 15 years. Intensive diagnostic approaches and timely aggressive combination treatments might improve clinical outcome in these patients.

Cytomegalovirus and Epstein-Barr Virus DNA Kinetics in Whole Blood and Plasma of Allogeneic Hematopoietic Stem Cell Transplantation Recipients

Currently, no consensus has been reached on the optimal blood compartment to be used for surveillance of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) DNAemia. Although several comparative studies have been performed correlating CMV and EBV DNA loads in whole blood (WB) versus plasma, to our knowledge, no studies to date have analyzed the kinetics of both viruses in the 2 blood compartments. In this retrospective noninterventional multicenter cohort study, the kinetics of CMV and EBV DNA in 121 hematopoietic stem cell transplantation (HSCT) recipients were investigated by analyzing in parallel 569 and 351 paired samples from 80 and 58 sequential episodes of CMV and EBV DNAemia, respectively. Unlike previous studies, this study used a single automated molecular method that was CE-marked and Food and Drug Administration-approved for use in quantifying CMV and EBV DNA in both plasma and WB. Furthermore, the complete viral replication kinetics of all episodes (including both the ascending and the descending phases of the active infection) was examined in each patient. The previously observed overall correlation between CMV DNA levels in WB and plasma was confirmed (Spearmans ρ = .85; P < .001). However, although WB and plasma CMV DNAemia reached peak levels simultaneously, in the ascending phase, the median CMV DNA levels in plasma were approximately 1 log10 lower than WB. Furthermore, in patients who received preemptive therapy, CMV DNA showed a delayed decrease in plasma compared with WB. A lower correlation between EBV DNA levels in plasma versus WB was found (Spearmans ρ = .61; P < .001). EBV DNA kinetics was not consistent in the 2 blood compartments, mostly due to the lower positivity in plasma. Indeed, in 19% of episodes, EBV DNA was negative at the time of the EBV DNA peak in WB. Our results suggest a preferential use of WB for surveillance of CMV and EBV infection in HSCT recipients.

Neurological Complications Involving the Central Nervous System After Allogeneic Hematopoietic Stem Cell Transplantation During a Period of Evolution in Transplant Modalities: A Cohort Analysis.

Background Neurological complications (NC) after hematopoietic stem cell transplantation (HSCT) are rare events. The evolution of transplant procedures has resulted in improved survival and has allowed elderly patients or those with comorbidity to receive an HSCT. The risk of NC in these patients has still not been well defined. Therefore, we carried out an observational study to estimate the occurrence and identify the risks associated with NC. Methods The study cohort included 452 adult-allogeneic HSCT recipients, transplanted from 1997 to 2012. The median follow up was 1.3 year (0-15.7). A myeloablative regimen was used in 307 patients. Two hundred patients were grafted from matched unrelated donor (MUD), of these, 129 (64.5%) received an in vivo T-cell depletion. Results Out of 452 patients, 30 (6.6%) developed NC. Infections were the most frequent causes of NC (30%). Overall survival decreased in patients developing NC (P < 0.001). Univariate survival regression on the cumulative incidence of NC identified period of transplant, linear trend between 4-year periods (1997-2012) (P < 0.001), MUD (P < 0.001), and recipients age (P = 0.034) as significant risk factors. In multivariate analysis, period of transplant (P < 0.001) and MUD (P = 0.004) remained significant independent risk factors. Matched unrelated donor recipients showed a 3.8-fold elevated risk of developing NC. Conclusions Analysis highlights a temporal trend of incidence of NC that progressively increased over time and confirms a strong association between donor type and risk of NC. Our observations suggest that, although relatively uncommon, NC after allo-HSCT, may become more frequent due to the improved overall survival in recent years.

Long-term control of extensive refractory chronic graft versus host disease in a multiple myeloma relapsing after allogeneic transplant. A case report

Multiple myeloma (MM) is an incurable hematological malignancy. Allogeneic stem cell transplantation (ASCT) represents a possible curative option for a subset of young and fit patients having a HLA-identical sibling. The long-term impact of ASCT is still hampered by significant early and long-term morbidity and mortality mainly due to graft versus host disease (GvHD). Some degree of chronic GVHD (cGvHD) was reported in about half of patients after allotransplant independently by their hematological disease. Chronic GvHD management still relies on corticosteroid administration, with 10% of patients who need continuous immunosuppression for an indefinite period [1]. Notably 50–60% of patients developing cGvHD requires secondary immunosuppressive agent other than steroids in the light of worsening manifestation of cGvHD as well as for emergent steroid related toxicity [2,3]. Pre-clinical data [4–6] had prompted evidences of the crucial role of Bortezomib mediated NF-kB inhibition for immune regulation, opening the way for its successful use in steroid refractory cGvHD developing in myeloma patients relapsing after allotransplant [7–10]. In these reports Bortezomib was administered twice-weekly at conventional doses for a median of 6–8 cycles then stopped. There are limited data regarding the feasibility of long-term administration of low-dose Bortezomib with the aim of obtaining persistent inhibition of cGVHD while preserving anti-myeloma effect. A young woman, with a previous history in 2001 of solitary plasmacytoma at lumbar tract treated with radiotherapy, progressed to light chain symptomatic myeloma in 2005, when she was 31 years old, with appearance of diffuse bone lesions. She received four Bortezomib plus dexamethasone (BD) cycles as induction followed by a tandem auto-allo transplant from an HLA identical sibling. Conditioning regimen consisted of myeloablative conventional doses of busulfan plus melphalan followed by standard acute GvHD (aGvHD) prophylaxis with calcineurin inhibitors plus methotrexate, obtaining a full donor chimerism and a very good partial remission (VGPR) according to IMWG criteria [11]. No significant sign of aGvHD was documented except for mild anorexia and nausea completely resolved at 30 days after transplant. Three months after transplant, she was diagnosed with chronic severe GvHD according to NHI global score [12]. Affected sites included skin (score1⁄4 3), mouth (score1⁄4 2) and fasciae (score1⁄4 3) with the consequent need of primary systemic treatment with prednisone 1mg/kg obtaining only slight initial improvement of cGVHD. In September 2007, seven months after transplant, there was a progressive worsening of GvHD manifestations with extension of skin and fasciae involvement (extensive skin depigmentation and papulo-squamous lesions involving more than 70% of body surface area, progressive joints contractures significantly limiting ADL); secondary systemic therapy with mycophenolate was started and maintained until January 2010 when there was a further significant spread of skin involvement (diffuse keratosis with extensive hypo-depigmentation and dermal sclerosis). Extracorporeal photopheresis (ECP) was started in addition to the ongoing mycophenolate, obtaining a stabilization of sclerosis and slight improvement of keratosis. Partial remission with full donor chimerism was maintained until September 2010, when isolated new lytic bone lesion occurred (dorsal tract vertebral collapse, treated with kyphoplasty followed by local radiation). Soon after (December 2010), cGvHD skin and joint involvement worsened, with a consequent need for additional immunosuppression with four weekly doses of Rituximab followed by continuous low dose Thalidomide; IMiDs-based therapy was effective either for management of cGvHD symptoms as well as for myeloma control, with mild toxicity (grade 2 peripheral neuropathy). Overt myeloma progression, with diffuse bone involvement and serum and urine monoclonal component reappearance, was documented in December 2013, eight year after allotransplant. In the same there was a worsening of cGvHD characterized by severe joint stiffness (score 3) and cutaneous deep sclerosis involving

Late post-transplant recurrence of Chronic Myeloid Leukaemia after immuno-chemotherapy for secondary Non-Hodgkin's Lymphoma

We read with great interest the paper published by Norkin et al. 1]. They described six cases of very late recurrences of leukaemia nd discussed the possible mechanisms by which late relapses ccur. Two of reported cases concern patients who relapsed 13 and 7 years, respectively, after allogeneic peripheral stem cell translantation for Chronic Myeloid Leukaemia (CML) performed in the re-Imatinib era and in the corresponding “Comments” section the uthors hypothesize that relapses were likely due to loss of immune urveillance. However, specific reasons for immune system failure ere not identified in their cases. We would like to report on a late molecular relapse in a CML atient who received Rituximab-based immuno-chemotherapy for secondary post-transplant Non-Hodgkin’s Lymphoma (NHL). A 7-year-old male was diagnosed with chronic phase CML in 1989 nd proceeded with allogeneic bone marrow transplant from his ully HLA matched brother in May 1990. Myeloablative condiioning regimen consisted of TBI and Cyclophosphamide. T-cell epletion of the graft was not performed. Cyclosporine was used s prophylaxis against Graft Versus Host Disease (GVHD). Eleven ays after transplant the patient developed a grade 2 acute GVHD, reated by standard steroid therapy. Chronic GVHD did not occur nd 100 days after transplant immunosuppressive treatment was apered. The patient obtained a complete molecular response (undeectable BCR-ABL transcript by RQ-PCR; assay sensitivity threshold × 10−5), and yearly testing showed persistent negativity for BCRBL transcript. The patient was well until April 2004, when a diffuse arge B-cell NHL stage III EBV-unrelated was diagnosed. Six courses f Rituximab + CHOP were administered allowing achievement of complete clinical remission. Thereafter, the patient was strictly onitored for both CML and NHL recurrence. In November 2008 18 years after transplantation) RQ-PCR for BCR-ABL mRNA resulted ositive at a very low level, while FISH and cytogenetic analyis were negative for Ph chromosome. BCR-ABL transcript load ncreased slowly over time and in October 2009 it reached the level f 0.19% according to International Scale [2]. Bone marrow was orphologically normal and the patient was still in complete cytoenetic response. At that time, Imatinib treatment was started at 00 mg daily. After 12 months of Imatinib therapy, BCR-Abl mRNA s undetectable. No lymphoma relapse has been observed so far. he donor was serially monitored for BCR-ABL rearrangement in eripheral blood and results were negative. Microsatellites analysis as not performed. Very late recurrences (beyond 10 years) are rare in CML pts given ransplantation in first chronic phase [3], although the true incience could be underestimated as relapses occurring at molecular evel only are not considered. Recently, a patient-specific PCR strat[