Aya Nishida

Clinical features of secondary pulmonary alveolar proteinosis: pre-mortem cases in Japan

To the Editors: Pulmonary alveolar proteinosis (PAP) is a rare syndrome that predominantly affects the lungs, and is characterised by the accumulation of surfactant lipids and proteins in the alveoli and terminal airways 1. In 1999, we published findings that high levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) neutralising autoantibodies were detected specifically in patients with idiopathic PAP 2. Recently, as a result of the excellent sensitivity and specificity of GM-CSF autoantibody assays in identifying this form of PAP 3, it has been proposed that the nomenclature for this condition should be changed to “autoimmune PAP” rather than “idiopathic PAP” 4. Secondary or hereditary PAP is not associated with GM-CSF autoantibodies but develops as a consequence of a separate underlying disorder or genetic background 5. Recently, we demonstrated that the characteristic high-resolution computed tomography (HRCT) findings in secondary PAP are distinct from those in autoimmune PAP 6. However, physicians may not suspect secondary PAP, even when encountering unexplained pulmonary opacities on chest radiograph or computed tomography in patients with pre-existing haematological or infectious diseases, since there is little information available on the clinical features. Here, we outline the clinical features of adult-onset secondary PAP based on our database of 40 pre-mortem cases in which serum GM-CSF autoantibodies were negative, and compare them with other cases in the literature. A total of 404 patients with pre-mortem cytologically or pathologically proven PAP were registered in our study group between 1999 and 2009. We obtained consent from all treating physicians for each identified case according to the guidelines for epidemiological studies from the Ministry of Health, Labour and Welfare 7, and all clinical data were de-identified. 360 (89%) cases were positive for serum GM-CSF autoantibody. The clinical features of 223 of the cases were previously published as …

Secondary pulmonary alveolar proteinosis complicating myelodysplastic syndrome results in worsening of prognosis: a retrospective cohort study in Japan

BackgroundSecondary pulmonary alveolar proteinosis (sPAP) is a very rare lung disorder comprising approximately 10% of cases of acquired PAP. Hematological disorders are the most common underlying conditions of sPAP, of which 74% of cases demonstrate myelodysplastic syndrome (MDS). However, the impact of sPAP on the prognosis of underlying MDS remains unknown. The purpose of this study was to evaluate whether development of sPAP worsens the prognosis of MDS.MethodsThirty-one cases of sPAP and underlying MDS were retrospectively classified into mild and severe cases consisting of very low-/low-risk groups and intermediate-/high-/very high-risk groups at the time of diagnosis of MDS, according to the prognostic scoring system based on the World Health Organization classification. Next, we compared the characteristics, disease duration, cumulative survival, and prognostic factors of the groups.ResultsIn contrast to previous reports on the prognosis of MDS, we found that the cumulative survival probability for mild MDS patients was similar to that in severe MDS patients. This is likely due to the poor prognosis of patients with mild MDS, whose 2-year survival rate was 46.2%. Notably, 75% and 62.5% of patients who died developed fatal infectious diseases and exacerbation of PAP, respectively, suggesting that the progression of PAP per se and/or PAP-associated infection contributed to poor prognosis. The use of corticosteroid therapy and a diffusing capacity of the lung for carbon monoxide of less than 44% were predictive of poor prognosis.ConclusionDevelopment of sPAP during the course of MDS may be an important adverse risk factor in prognosis of patients with mild MDS.

Rapid T‐cell chimerism switch and memory T‐cell expansion are associated with pre‐engraftment immune reaction early after cord blood transplantation

Cord blood (CB) contains immature immune cells and is thought to be less active in inducing allogeneic immune reaction than other sources of stem cells. However, a high incidence of immune-mediated complications has been reported, such as pre-engraftment immune reaction (PIR) and haemophagocytic syndrome (HPS) early after cord blood transplantation (CBT) (Kishi et al, 2005; Narimatsu et al, 2007; Frangoul et al, 2009; Takagi et al, 2009; Patel et al, 2010). In addition, we reported that human leucocyte antigen (HLA) disparity in the graft-versus-host (GVH) direction adversely affected engraftment kinetics when single calcineurin inhibitors were used for GVH disease (GVHD) prophylaxis (Matsuno et al, 2009). These observations suggested that the GVH reaction plays a critical role in engraftment. Here, we report the engraftment kinetics of donor-derived T cells using a multicolour flow cytometry-based method (HLAFlow method) (Watanabe et al, 2008) and also describe the results of naı̈ve/memory T-cell phenotype analyses early after CBT. Between November 2009 and September 2010, 73 adult patients underwent single-unit CBT at Toranomon hospital. This study reports 41 patients who were eligible for chimerism analysis using the HLA-Flow method and survived more than 14 d after CBT. Characteristics of the patients and CB are summarized in Table SI. All patients provided written informed consent, and the study was conducted in accordance with institutional review board requirements. Peripheral blood was collected at 1, 2, 3, 4, and 8 weeks after CBT. Anti-HLA monoclonal antibodies in combination with lineage-specific antibodies were used to analyse the lineagespecific chimerism as previously reported (Watanabe et al, 2008). Anti-HLA antibodies specific for donor and recipient HLA in all patients are summarized in Table SII. At 2, 4, and 8 weeks after CBT, T-cell subsets were analysed using the following monoclonal antibodies: peridinin-chlorophyllprotein – cyanin 5 5 (PerCP-Cy5 5)-CD8, phycoerythrin – cyanin 7 (PE-Cy7)-CCR7, allophycocyanin (APC)-CD4, APC-Cy7-CD3 (BD Pharmingen, San Jose, CA, USA), and Pacific Blue-CD45RA (CALTAG, Carlsbad, CA, USA). Absolute numbers of CD4 T cells (CD3CD4), CD8 T cells (CD3CD8), and naı̈ve (CD45RACCR7) and memory (CD45RA CCR7 ) T cells were calculated by multiplying the peripheral lymphocyte counts by the percentage of positive cells. PIR was characterized by non-infectious high-grade fever (>38 5°C) coexisting with skin eruption, diarrhoea, jaundice and/or body weight gain greater than 5% of baseline, developing 6 or more days before engraftment (Kishi et al, 2005; Uchida et al, 2011). Cumulative incidence of neutrophil engraftment, PIR, and GVHD were calculated using Gray’s method. Intergroup comparisons were performed using the Mann–Whitney U-test. We analysed lineage-specific chimerism for 32, 40, 40, 34, and 34 patients at a median of 8 (range, 7–11; week 1), 15 (14–20; week 2), 22 (21–25; week 3), 29 (28–36; week 4), and 57 (56–62; week 8) days post-transplant, respectively. Fig 1A shows representative results for CD4 T-cell chimerism. CD4 and CD8 T-cell chimerism results in all patients are shown in Fig 1B. Of 41 enrolled patients, 37 achieved neutrophil engraftment at a median of 19 d (range, 13–38 d). Thirty-nine patients achieved donor-dominant T-cell chimerism (>90%) by 3 weeks after CBT, whereas the remaining two patients, with recipient-dominant T-cell chimerism (>90%) at every point tested, developed graft failure because of early relapse (day 14 post-transplant) and rejection, respectively. Among the 39 patients who achieved donor-dominant T-cell chimerism, two died before engraftment due to non-relapse causes on day 28 (infection) and day 25 (diffuse alveolar haemorrhage), respectively. Among those with donor-dominant chimerism, 24 (63%) of 38 evaluable patients developed PIR at a median of 8 (6–11) days after CBT. Patients who achieved donor-dominant T-cell chimerism (>90%) at 1 week had a higher incidence of PIR compared to those who did not (P = 0 017, Fig 1C). In a representative patient at 2 weeks after CBT, rapid conversion from naı̈ve to memory phenotype was observed in both CD4 and CD8 T cells (Fig 2A). Fig 2B shows the relative proportion of naı̈ve CD4 and CD8 T cells at 2, 4, and 8 weeks after CBT in 37 evaluable patients who achieved donor-dominant T-cell chimerism. Patients who developed PIR had significantly more lymphocytes, CD4 T cells, CD8 T cells, CD4 memory T cells, and CD8 memory T cells at 2 weeks after CBT compared with those without PIR (Fig 2C and data not shown). Our data confirmed that a majority of patients achieved donor-dominant T-cell chimerism around 2 weeks after CBT. We also found that early recipient-type T-cell chimerism was closely associated with graft rejection. A remarkable finding was that a rapid recipient-to donor-dominant switch

Cunninghamella bertholletiae pneumonia showing a reversed halo sign on chest computed tomography scan following cord blood transplantation

This is the first reported case of a patient who developed fungal pneumonia caused by Cunninghamella bertholletiae (= C. elegans) following cord blood transplantation and who showed a reversed halo sign on a chest computed tomography scan (CT). In addition, the pathological findings related to the reversed halo sign are described in detail for the first time. The patient died due to respiratory failure and at autopsy, a consolidation corresponding to the reversed halo sign noted on CT was found histologically to be composed of a central infarct with some retained air spaces surrounded by a peripheral ring-like hemorrhagic band. Pulmonary vasculatures were occluded by thrombi containing numerous Zygomycetes hyphae within the central infarct and less frequently along the surrounding hemorrhagic band. A reversed halo sign may be an early marker to initiate preemptive therapy against Zygomycetes including C. bertholletiae.

A Novel Reduced-Toxicity Myeloablative Conditioning Regimen Using Full-Dose Busulfan, Fludarabine, and Melphalan for Single Cord Blood Transplantation Provides Durable Engraftment and Remission in Nonremission Myeloid Malignancies

A pilot study of a novel, reduced-toxicity, myeloablative conditioning regimen using intravenous busulfan 12.8 mg/kg, fludarabine 180 mg/m(2), and melphalan 80 mg/m(2) for single cord blood transplantation (CBT) was conducted at our institution. Fifty-one patients with myeloid malignancies not in remission were included in this study. Their median age was 59 years (range, 19 to 70 years), with a median hematopoietic cell transplantation-specific comorbidity index score of 3. With a median observation period of 39.6 months (range, 24.3 to 90.8 months) among the survivors, overall survival and progression-free survival at 2 years were both 54.9%. Forty-six of 51 achieved neutrophil engraftment at a median of 19.5 days (range, 13 to 38 days) after transplantation, with a cumulative incidence of 90.2%. No patient developed graft rejection in this study. All patients who achieved engraftment showed hematological complete remission with complete donor chimerism. Eleven patients relapsed at a median of 4.9 months (range, .5 to 26.7 months). Cumulative incidences of nonrelapse mortality (NRM) at 100 days and 2 years were 11.8% and 25.5%, respectively. In conclusion, the present results show that the novel conditioning regimen for single CBT provided durable engraftment and remission with acceptable NRM leading to excellent survival, even for a relatively older population with myeloid malignancies not in remission.

Clinical and Microbiological Characteristics of Breakthrough Candidemia in Allogeneic Hematopoietic Stem Cell Transplant Recipients in a Japanese Hospital

ABSTRACT Few data on breakthrough candidemia (BC), defined as candidemia that develops on administration of antifungal agents (AFAs), in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients are available. The medical and microbiological records of recipients of an allo-HSCT obtained between December 2008 and December 2014 were reviewed. Of 768 allo-HSCT cases, 26 developed BC. Among the 26 causative strains, 22 strains were stored and identified by sequencing. The following species were isolated: Candida parapsilosis (9 strains), C. glabrata (4 strains), C. guilliermondii (3 strains), and other Candida species (6 strains). The AFAs being used when BC developed were micafungin (17 cases), liposomal amphotericin B (5 cases), itraconazole (2 cases), and voriconazole (2 cases). All 17 cases who developed BC during micafungin administration were administered 150 mg/day of micafungin. The susceptibilities of the causative Candida species to the administered AFAs when breakthrough occurred ranged from susceptible to resistant. Especially, 85% of the Candida species that caused BC during micafungin administration were susceptible to micafungin. Additionally, 75% of the strains were wild type for susceptibility to the administered AFAs when breakthrough occurred. Systemic steroid administration and a longer severe neutropenic phase (≥5 days) were independent risk factors for BC (P = 0.016 and P = 0.015, respectively). BC developed in allo-HSCT recipients even when they received a sufficient dose of AFA, including micafungin, to which the causative Candida species were susceptible and/or had wild-type susceptibility in vitro. Systemic steroid administration and a longer severe neutropenic phase were host-based factors associated with BC.

Identification of the BRAF V600E mutation in Japanese patients with hairy cell leukemia and related diseases using a quenching probe method

Hairy cell leukemia (HCL) is a rare B-cell lymphoid malignancy that is difficult to distinguish from other morphological variants. The frequency of HCL has not been determined accurately in Japan. Recent studies revealed that the BRAF V600E mutation is the causal genetic event in HCL. We assessed the BRAF mutation in Japanese patients with HCL and related diseases using the quenching probe (QP) method, a single-nucleotide polymorphism detection system, and evaluated the incidence rate of HCL among Japanese patients with chronic lymphocytic leukemia, and related diseases. We identified 18 cases (33.3%) harboring the BRAF mutation among 54 patients diagnosed with, or suspected of having HCL. Of BRAF V600E-positive patients, 7 were only detected using the QP method, not by direct sequencing, whereas 11 were positive using both tests. In a larger cohort of Japanese patients diagnosed with chronic lymphoid leukemia or related diseases, the frequency of HCL was 4%. Patients with the BRAF V600E mutation had a significantly higher frequency of neutropenia, thrombocytopenia, and elevated soluble interleukin-2 receptor and common B-cell surface markers than patients without the mutation. Our results confirm that BRAF V600E-positive HCL is a relatively rare disorder in the Japanese leukemia patient population.

Oral beclomethasone dipropionate as an initial treatment for stages 1-2 gastrointestinal tract acute graft-versus-host disease following unrelated cord blood transplantation.

Dear Editor, Oral beclomethasone dipropionate (BDP) is a topically active corticosteroid with low systemic bioavailability [1, 2]. Several studies demonstrated that BDP as monotherapy or in combination with systemic corticosteroid is safe and effective for treatment of gastrointestinal tract acute graft-versus-host disease (GI-aGVHD) following allogeneic hematopoietic stem cell transplantation (HSCT) [3–5]. However, there have been not much data available regarding this issue in unrelated cord transplantation (UCBT). In this study, the efficacy of BDP monotherapy as an initial treatment for stages 1– 2 GI-aGVHD following single UCBT was evaluated. Patients who had stage 3 or 4 skin GVHD, any stages of liver GVHD, or active GI infections were excluded. BDP was administered orally as one enteric-coated cellulose capsule for the delayed-release formulation and an aqueous suspension for the immediate-release formulation every 6 h for a total daily dose of 8 mg [3, 6]. Thirty-five patients were included in this study from January 2006 through April 2009. The patients’ characteristics are summarized in Table 1. Twenty-six of the 35 patients (74.2 %) responded to BDP treatment. Initial response was achieved at a median of 4 days (range, 2– 5 days) of BDP treatment. Among those who responded to BDP treatment, two patients developed GVHD involving skin (>50 % body surface area) during BDP treatment and required systemic corticosteroids. Two patients had recurrence of GI symptoms after withdrawal of BDP, which recovered with re-administration of the drug. Three patients progressed, and six had no improvement. These non-responders received systemic corticosteroids at a dose of 0.5–2 mg/kg/day. Of the nine patients who received systemic corticosteroids for treatment of GI-aGVHD, five responded, and the remaining four did not. There were no significant differences in response rates including GVHD-affected sites in the GI tract (upper or lower) or the stage of GI-aGVHD (stage 1 vs. stage 2). Twelve (34.2 %) developed ≥1 new infectious episode, and one developed symptomatic adrenal insufficiency during BDP treatment. Treatment* Naoyuki Uchida nuchida@toranomon.gr.jp