Fernando Campilho

Clinical effectiveness of hyperbaric oxygen therapy for BK-virus-associated hemorrhagic cystitis after allogeneic bone marrow transplantation.

Late-onset hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT) has been associated with BK virus (BKV). Antiviral drugs are of limited efficacy and the optimal treatment for HC has not yet been established. Hyperbaric oxygen (HBO) may benefit these patients. We, therefore, retrospectively evaluated the effectiveness of HBO therapy in 16 patients with HC after allogeneic HSCT. All 16 patients had macroscopic hematuria and BKV infection. Patients received 100% oxygen in a hyperbaric chamber at 2.1 atmospheres for 90 min, 5 days per week, with a median 13 treatments (range, 4–84). Fifteen patients (94%) showed complete resolution of hematuria. Median urinary DNA BKV titers declined after HBO (P<0.05). Patients started on HBO earlier after diagnosis of HC responded sooner (P<0.05). HBO was generally well tolerated and proved to be a reliable option for this difficult to manage condition.

Positive selection for CD34+ reduces the incidence and severity of veno-occlusive disease of the liver after HLA-identical sibling allogeneic peripheral blood stem cell transplantation

OBJECTIVE T-cell depletion (TCD), primarily developed to prevent graft-vs-host disease (GVHD), might reduce early liver dysfunction after allogeneic hematopoietic stem cell transplantation. However, no comparative studies have been performed to investigate this. We analyzed the influence of selection for CD34(+) cells on the incidence and severity of hepatic veno-occlusive disease (VOD). PATIENTS AND METHODS Five hundred and one patients who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) from HLA-identical siblings were included in the present study. Two hundred and ninety patients (59%) were grafted with CD34+ positively selected grafts and 211 (41%) with nonmanipulated grafts. Their mean age was 38 years (range 17-63). All patients had hematological malignancies and 96% were conditioned with combinations either of cyclophosphamide plus total-body irradiation or of cyclophosphamide plus busulphan. Most of the patients received GVHD prophylaxis with methotrexate (MTX) or cyclosporin A. RESULTS Fifty-two patients (10.4%) developed VOD. VOD was more frequent in patients receiving nonmanipulated grafts (16.1% vs 6.2%; p<0.0009), in those with a Karnofsky score less than 90 (17.5% vs 7.8%; p=0.001), and with the use of MTX for GVHD prophylaxis (14.8% vs 7%; p=0.005). In multivariate analyses, only CD34+ positive selection (p=0.0007) and Karnofsky score (p=0.004) emerged as independent risk factors for VOD. The same effect was observed in the subset of patients with severe VOD. CONCLUSION These findings show that CD34+ selection not only decreases the incidence of GVHD but also prevents VOD after HLA-identical sibling PBSCT.

Predictive Value of Immature Reticulocyte and Platelet Fractions in Hematopoietic Recovery of Allograft Patients

Hematopoietic progenitor cell transplantation is the treatment of choice for patients with malignant hematologic diseases. Neutrophil (NEUT) and platelet (PLT) counts are used to evaluate hematologic engraftment of transplanted patients. Recent-generation hematology analyzers offer an alternative way to evaluate immature peripheral blood (PB) cell fractions, which may also give an indication of hematopoietic recovery. The immature reticulocyte fraction (IRF) and immature platelet fraction (IPF) in PB samples may provide early indicators of transplant success. We evaluated the predictive value of IRF and IPF for the hematologic recovery of 46 adult patients undergoing allogeneic PB progenitor cell transplantation. We observed that IRF recovery anticipated by 4 days compared with NEUT recovery (11 vs 15 d) and IPF by 2 days compared with PLT (10 vs 12 d). The recovery was different for patients undergoing a nonmyeloablative regimen (NMA); we observed an early IRF recovery by 5 days compared with NEUT (10 vs 15 d) and a IPF compared with PLT recovery by 2 days (9 vs 11 d). We also observed significant correlations between NEUT and PLT recovery with recoveries of the new parameters IRF and IPF. We concluded that IRF and IPF predicted hematopoietic recovery. For allografted patients after NMA regimens, prediction was even more clinically relevant. These immature fractions open new perspectives for monitoring patient transfusion support through the posttransplantation recovery.

Mobilization and Collection of Peripheral Blood Stem Cells in Multiple Myeloma Patients Older Than 65 Years

Over the past 10 years, the incidence of multiple myeloma (MM) has been greater among individuals >65 years old than in younger age groups. This retrospective study of peripheral blood stem cell mobilization and harvesting examined patients of various age groups who were afflicted with this pathology. One group of 17 patients ≥65 years of age with MM (group A) were mobilized between 2002 and 2009 and compared with 33 consecutive patients of younger ages with the same diagnosis treated in 2008 and 2009 (group B). The 2 populations had a similar gender distribution; their median ages were 66 and 52 years, respectively. A successful mobilization was defined as a collection of ≥2.5 × 10(6) CD34+/kg body weight. The mobilization used filgrastim (16 μg/kg/d) with the beginning of the harvest on the fifth day. The median number of outpatient apheresis procedures per patient was 2 in group A and 1 in group B. There were no incidents or serious adverse reactions. Patients in group A collected 4.68 × 10(6) CD34+ cells/kg and for group B 3.30 × 10(6)/kg. The group A patients required a greater number of apheresis procedures to collect the appropriate graft. In conclusion, mobilization with growth factors and PHSP harvest by apheresis was safe with reasonable costs for subjects including those aged ≥65 years, resulting in an option for autologous transplantation.

Minimal change nephrotic syndrome after stem cell transplantation: a case report and literature review

Graft-versus-host disease is one of the most frequent complications occurring after haematopoietic stem cell transplantation. Recently, renal involvement has been described as a manifestation of chronic graft-versus-host disease. Immunosuppression seems to play a major role: clinical disease is triggered by its tapering and resolution is achieved with the resumption of the immunosuppressive therapy. Prognosis is apparently favourable, but long term follow up data are lacking.We report a case of a 53-year-old man who developed nephrotic syndrome 142 days after allogeneic stem cell transplantation for acute myeloid leukaemia. Onset of nephrotic syndrome occurred after reduction of immunosuppressants and was accompanied by manifestations of chronic graft-versus-host disease. Histological examination of the kidney was consistent with Minimal Change Disease. After treatment with prednisolone and mycophenolate mofetil he had complete remission of proteinuria and improvement of graft-versus-host disease. Eighteen months after transplantation the patient keeps haematological remission and normal renal function, without proteinuria.Since patients with chronic graft-versus-host disease might be considered at risk for development of nephrotic syndrome, careful monitoring of renal parameters, namely proteinuria, is advisable.

IL-10 overexpression predisposes to invasive aspergillosis by suppressing antifungal immunity

2. Abajian M, Mlynek A, Maurer M. Physical urticaria. Curr Allergy Asthma Rep 2012;12:281-7. 3. Kaplan AP, Garofalo J, Sigler R, Hauber T. Idiopathic cold urticaria: in vitro demonstration of histamine release upon challenge of skin biopsies. N Engl J Med 1981;305:1074-7. 4. Siebenhaar F, Weller K, Mlynek A, Magerl M, Altrichter S, Vieira Dos Santos R, et al. Acquired cold urticaria: clinical picture and update on diagnosis and treatment. Clin Exp Dermatol 2007;32:241-5. 5. Singleton R, Halverstam CP. Diagnosis and management of cold urticaria. Cutis 2016;97:59-62. 6. Boyce JA. Successful treatment of cold-induced urticaria/anaphylaxis with anti-IgE. J Allergy Clin Immunol 2006;117:1415-8. 7. Metz M, Ohanyan T, Church MK, Maurer M. Omalizumab is an effective and rapidly acting therapy in difficult-to-treat chronic urticaria: a retrospective clinical analysis. J Dermatol Sci 2014;73:57-62. 8. Casale TB, Bernstein JA, Maurer M, Saini SS, Trzaskoma B, Chen H, et al. Similar efficacy with omalizumab in chronic idiopathic/spontaneous urticaria despite different background therapy. J Allergy Clin Immunol Pract 2015;3: 743-50.e1. 9. Grabbe J. Pathomechanisms in physical urticaria. J Investig Dermatol Symp Proc 2001;6:135-6. 10. Newcomb RW, Nelson H. Dermographia mediated by immunoglobulin E. Am J Med 1973;54:174-80.

Visceral Leishmaniasis: A Differential Diagnosis to Remember after Bone Marrow Transplantation

Leishmania infection in immunocompromised hosts is reported in the literature, mostly concerning human immunodeficiency virus infected patients. It is not well characterized in the context of stem cell transplantation. We report a rare case clinical case of visceral leishmaniasis after allogeneic bone marrow transplantation. A 50-year-old Caucasian male was referred to allogeneic bone marrow transplantation with a high-risk acute lymphoblastic B leukemia in first complete remission. Allogeneic SCT was performed with peripheral blood stem cells from an unrelated Portuguese matched donor. In the following months, patient developed mild fluctuating cytopenias, mostly thrombocytopenia (between 60 and 80∗109/L). The only significant complaint was intermittent tiredness. The common causes for thrombocytopenia in this setting were excluded—no evidence of graft versus host disease, no signs of viral or bacterial infection, and no signs of relapsed disease/dysplastic changes. The bone marrow smear performed 12 months after transplantation revealed an unsuspected diagnosis: a massive bone marrow infiltration with amastigotes.

Rhizomucor and scedosporium infection post hematopoietic stem-cell transplant.

Hematopoietic stem-cell transplant recipients are at increased risk of developing invasive fungal infections. This is a major cause of morbidity and mortality. We report a case of a 17-year-old male patient diagnosed with severe idiopathic acquired aplastic anemia who developed fungal pneumonitis due to Rhizomucor sp. and rhinoencephalitis due to Scedosporium apiospermum 6 and 8 months after undergoing allogeneic hematopoietic stem-cell transplant from an HLA-matched unrelated donor. Discussion highlights risk factors for invasive fungal infections (i.e., mucormycosis and scedosporiosis), its clinical features, and the factors that must be taken into account to successfully treat them (early diagnosis, correction of predisposing factors, aggressive surgical debridement, and antifungal and adjunctive therapies).

Inadvertent transmission of occult CML through allo-SCT

Recurrence of original disease and secondary malignancy are both important causes of unsuccessful SCT. In both cases the malignant clone is host derived. On the other hand, donor cell leukemia is driven by the graft. This is very infrequent and only partially understood. A third and different scenario is the inadvertent transmission of occult leukemia from the donor. These cases are even more rare and raise major ethical considerations concerning the patient, the donor, the doctors and the BM registry systems. We have recently observed an atypical clinical case of inadvertent transmission of occult CML with allo-SCT. A 48-year-old male with no relevant medical past history was diagnosed with smoldering myeloma in 2004. First signs of progression were noted in September 2008 and at this time cytogenetic analysis revealed complex karyotype with: del13q14, three copies of 17 chromosomes, relative deletion of TP53 gene and a translocation involving 14q32. The first-line treatment was thalidomide plus dexamethasone, and after achieving a very good PR the patient was referred to high-dose melphalan conditioning regimen and auto-SCT. He maintained a very good PR for 2 years. At this point signs of aggressive progression led to second-line chemotherapy with bortezomib plus dexamethasone. The patient achieved a very good PR. Considering that this was a young patient with poor cytogenetic prognosis who had an HLAmatched sister, it was decided to proceed with the treatment with allogeneic peripheral SCT from the related donor. The donor was a healthy female with no relevant medical history. Donor routine workup analyses were unremarkable. A reduced-intensity conditioning regimen with fludarabine and BU was performed. CsA and mycophenolate mofetil were used as GVHD prophylaxis. There were no remarkable toxicities after this procedure. One month after transplant the patient had a very good PR, was a complete chimera and the 20 metaphases analyzed by conventional cytogenetics had a normal female karyotype (46,XX). Three months later the cytogenetic analysis revealed 16 metaphases with a complex female karyotype that included t(9;22). The complex karyotype was: 46,XX,del(1)(p36),der(9) t(1;9)(p36;q34),der(22)t(9;22)(q34;q11.2)add(9)(q34). With further genetic studies including chromosome painting (FISH WCP1, WCP9, WCP22, Metasystems, Altlussheim, Germany): 46,XX,del(1) (p36),der(9)t(1;9)(p36;q34),ins(22;?)(q11.2;?)[3].ish,der(1)t(1;9)(p36.1; q34)(wcp1+,wcp9+),der(9)t(1;9)(p36.2;q34)(wcp9+,ABL1+,wcp1+),der (22)(22pter→22q11.2::9q34→9q34::1p36.1→1p36.2::22q11.2→22 qter)(wcp22+,BCR+,ABL1+,wcp1+,wcp22+). FISH analysis revealed 7% of nucleus with del13q14 and 36% with BCR-ABL. Qualitative PCR analyses revealed the presence of BCR-ABL1 p210 (b2a2). The donor was contacted and agreed to submit herself to BCRABL screening even though she was asymptomatic and maintained unremarkable blood analysis. She had the same complex karyotype and the quantitative RT-PCR of BCR-ABL1 was 57.3% (normalized international BCR-ABL). She was diagnosed with molecular CML. Six months later the patient remained with normal blood count and cytogenetic analysis revealed 30 metaphases with a normal male karyotype, 25 complex female karyotype with t(9;22) and 4 with a normal female karyotype. FISH analysis was consistent with 9% of the nuclei showing del13q14. Quantitative analysis of BCR-ABL1 was 23.7% (normalized international BCR-ABL). The donor maintained a normal blood count and a detectable BCR-ABL1 translocation on cytogenetic analysis. It was discussed and decided among the patient, the donor and the medical team to start imatinib 400 mg/day in both siblings. Currently (24 months after transplantation and 19 months after imatinib), the patient and the donor have major molecular responses. Also, the patient is in CR from multiple myeloma. Amelogenin gene analysis for the assessment of chimerism was performed and the patient was a complete chimera. It is relevant to consider that a sclerodermic chronic GVHD was diagnosed 12 months after transplantation and is under treatment with CsA and corticotherapy, with gradual improvement. In conclusion, one should always be aware of the possibility of occult neoplasms in the donor, even though only rare reports are available in the literature. Striking ethical concerns arise in this setting as well as many questions about the best therapeutic choice for both patients and donors. It is also interesting to consider the actual donor workup and the eventual need for new reliable methods to prevent such events. As case reports appear in the literature one speculates whether the growing molecular knowledge of diseases will contribute to changing the donor’s workup in the future. Written informed consent was obtained from the patient for publication of this letter. A copy of the written consent is available upon request.

Genotypic resistance of cytomegalovirus to antivirals in hematopoietic stem cell transplant recipients from Portugal: A retrospective study

Abstract The aim of this study was to characterize Human Cytomegalovirus (HCMV) drug resistance mutations in UL97 and UL54 genes in allogeneic hematopoietic stem cell transplant (allo‐HSCT) recipients in Portugal. We have performed a retrospective study with 22 patients from a cohort of patients with different haematological malignancies submitted to allo‐HSCT between 2010 and 2014. Patients were selected according to clinical and laboratory data of HCMV infection and management. HCMV resistance mutations were characterized by sequencing of UL97 and UL54 genes. Sequence data were compared with: 1) HCMV genome reference strain AD169; and also 2) UL97 from Merlin strain (GenBank: AY446894.2), and UL54 from TB40/E strain (GenBank: ABV71585.1). Resistance mutations were identified in seven patients (32%): five harboured resistance mutations in UL97: A594V (n = 2), C592G (n = 1), L595W (n = 1), and C603W (n = 1); and two harboured resistance mutations in UL54: P522S and L957F, one in each patient. Several natural polymorphisms and unknown mutations were found in both UL97 and UL54, with the majority of the patients harbouring more than one unknown mutation in UL97 but only one in UL54. No simultaneous mutations were found. This is the first study in Portugal to characterize HCMV UL97 and UL54 sequences and to identify HCMV drug‐resistance mutations in allo‐HSCT patients. The UL97 resistance mutations found were amongst the most frequent resistant mutations, while UL54 L957F mutation was here reported for the first time in a clinical specimen. This information provides important information regarding HCMV strains and antiviral resistance in our population. HighlightsWe have analysed HCMV mutations in UL97 and UL54 in allogeneic HSCT patients.5 patients had UL97 resistance mutations (C592G, A594V, L595W and C603W).2 patients had UL54 mutations (P522S and L957F).We have reported several new unknown mutations and natural polymorphisms.We have first reported a case with the L957F UL54 mutation in clinical samples.