Gabriella Girelli

Multispecific T cell response and negative HCV RNA tests during acute HCV infection are early prognostic factors of spontaneous clearance

Background/Aims: Hepatitis C virus (HCV) infection results in a high frequency of chronic disease. The aim of this study was to identify early prognostic markers of disease resolution by performing a comprehensive analysis of viral and host factors during the natural course of acute HCV infection. Methods: The clinical course of acute hepatitis C was determined in 34 consecutive patients. Epidemiological and virological parameters, as well as cell mediated immunity (CMI) and distribution of human leukocyte antigens (HLA) alleles were analysed. Results: Ten out of 34 patients experienced self-limiting infection, with most resolving patients showing fast kinetics of viral clearance: at least one negative HCV RNA test during this phase predicted a favourable outcome. Among other clinical epidemiological parameters measured, the self-limiting course was significantly associated with higher median peak bilirubin levels at the onset of disease, and with the female sex, but only the latter parameter was independently associated after multivariate analysis. No significant differences between self-limiting or chronic course were observed for the distribution of DRB1 and DQB1 alleles. HCV specific T cell response was more frequently detected during acute HCV infection, than in patients with chronic HCV disease. A significantly broader T cell response was found in patients with self-limiting infection than in those with chronic evolving acute hepatitis C. Conclusion: The results suggest that host related factors, in particular sex and CMI, play a crucial role in the spontaneous clearance of this virus. Most importantly, a negative HCV RNA test and broad CMI within the first month after onset of the symptoms represent very efficacious predictors of viral clearance and could thus be used as criteria in selecting candidates for early antiviral treatment.

An estimate of the current risk of transmitting blood‐borne infections through blood transfusion in Italy

Summary. We conducted a retrospective cohort study to estimate the incidence of major blood‐borne agents among Italian blood donors and calculated the risk of infection among blood recipients using the ‘incidence/window period model’. The study was conducted among 46 180 blood donors enrolled in six blood centres between 1994 and 1999. During follow‐up, seven new infections were confirmed: three donors seroconverted for anti‐human immunodeficiency virus (HIV); two for anti‐hepatitis C virus (HCV); and two showed hepatitis B surface antigen (HBsAg) reactivity; no cases of syphilis were observed. The incidence rates per 100 000 person/years were: 4·06 (95% CI: 0·82–11·85) for HIV; 2·41 (95% CI: 0·29–8·70) for HCV; and 2·70 (95% CI: 0·32–9·77) for HBsAg; the incidence for total hepatitis B virus (HBV) infection was 9·77 per 100 000 person/years (95% CI: 1·16–35·36). The estimated risk of an infectious blood unit not being detected was: 2·45 (95% CI: 0·13–12·33) per 1 million units for HIV; 4·35 (95% CI: 0·30–22·39) for HCV; and 15·78 (95% CI: 1·16–84·23) for HBV. Overall, an estimated 22·58 per 1 million units are infected. In Italy, the risk of transfusion‐transmitted infections is low and is similar to that in other western countries. The introduction of new more sensitive screening tests could reduce the residual risk of transfusion‐transmitted infection by 40–80%.

Intra-Erythrocyte Infusion of Dexamethasone Reduces Neurological Symptoms in Ataxia Teleangiectasia Patients: Results of a Phase 2 Trial

BackgroundAtaxia Teleangiectasia [AT] is a rare neurodegenerative disease characterized by early onset ataxia, oculocutaneous teleangiectasias, immunodeficiency, recurrent infections, radiosensitivity and proneness to cancer. No therapies are available for this devastating disease. Recent observational studies in few patients showed beneficial effects of short term treatment with betamethasone. To avoid the characteristic side effects of long-term administration of steroids we developed a method for encapsulation of dexamethasone sodium phosphate (DSP) into autologous erythrocytes (EryDex) allowing slow release of dexamethasone for up to one month after dosing. Aims of the study were: the assessment of the effect of EryDex in improving neurological symptoms and adaptive behaviour of AT patients; the safety and tolerability of the therapy.MethodsTwenty two patients (F:M = 1; mean age 11.2 ± 3.5) with a confirmed diagnosis of AT and a preserved or partially supported gait were enrolled for the study. The subjects underwent for six months a monthly infusion of EryDex. Ataxia was assessed by the International Cooperative Ataxia Rating Scale (ICARS) and the adaptive behavior by Vineland Adaptive Behavior Scales (VABS). Clinical evaluations were performed at baseline and 1, 3, and 6 months.ResultsAn improvement in ICARS (reduction of the score) was detected in the intention-to-treat (ITT) population (n = 22; p = 0.02) as well as in patients completing the study (per protocol PP) (n = 18; p = 0.01), with a mean reduction of 4 points (ITT) or 5.2 points (PP). When compared to baseline, a significant improvement were also found in VABS (increase of the score) (p < 0.0001, ITT, RMANOVA), with statistically significant increases at 3 and 6 months (p < 0.0001). A large inter-patient variability in the incorporation of DSP into erythrocytes was observed, with an evident positive effect of higher infusion dose on ICARS score decline. Moreover a more marked improvement was found in less neurologically impaired patients. Finally, a 19 month-extension study involving a subgroup of patients suggested that Erydex treatment can possibly delay the natural progression of the disease.EryDex was well tolerated; the most frequent side effects were common AT pathologies.ConclusionsEryDex treatment led to a significant improvement in neurological symptoms, without association with the typical steroid side effects.Trial registrationCurrent Controlled Trial2010-022315-19SpA

Severe autoimmune hemolytic anemia in a patient with chronic lymphocytic leukemia responsive to fludarabine-based treatment

Fludarabine is an analogue of adenosine monophosphate which is relatively resistant to deamination by adenosinedeaminase and selectively inhibits DNA synthesis [5]. Recent clinical investigations indicate that the drug has significant single-agent activity against various lymphoid malignancies, particularly chronic lymphocytic leukemia (CLL) and indolent non-Hodgkins lymphomas. In two separate trials of previously treated patients with CLL, this agent was found to induce response rates (complete + partial remission) of 32~ and 48%, respectively [3, 4]. In previously untreated patients the overall response rate may be as high as 80%, with approximately one third of the patients achieving complete remission [5]. Major toxicity on the currently used low-dose schedules consists of transient myelosuppression and infection. Recently, Bastion et al. reported on the occurrence of severe autoimmune hemolytic anemia (AIHA) in two patients with advanced CLL undergoing treatment with fludarabine [1]. We describe here an additional patient with advanced CLL whose fludarabine-based therapeutic program was complicated by severe AIHA. V.T., a 47-year-old man, was diagnosed at our institution as having B-CLL, Rai stage 0, in October 1989. In January 1991, because of progressive lymphocytosis (84000/ram 3) and splenomegaly (10 cm below the costal margin), the patient was started on daily chlorambucil and prednisone. Four months later, despite a reduction in the number of circulating lymphocytes (20 700/mm3), a significant spleen enlargement was still present and the patient was enrolled on a more aggressive chemotherapy program consisting of monthly courses of fludarabine (25 mg/sqm/day for 5 days) and prednisone (40 mg/sqm/ day for 5 days). Before the start of this regimen hemo-

Influence of Orally Administered Antibiotics on anti-T Agglutinin of Normal Subjects and of Cirrhotic Patients

Abstract. Anti‐T agglutinin was studied in normal healthy subjects and in cirrhotic patients before and after oral administration of antibiotics depressing intestinal microbial flora. After antibiotic treatment anti‐T levels were significantly reduced. These observations show that bacterial antigens of intestinal origin are likely to be responsible for anti‐T production and that there must be common determinants between them and T antigen of red blood cells. It is not sure whether the previously reported increase of anti‐T levels in liver cirrhosis is in favour of the hypothesis that hypergammaglobulinaemia in this condition is due to failure of diseased liver to trap gut‐derived antigens.

Clinical effectiveness of platelets in additive solution treated with two commercial pathogen-reduction technologies

Two noninferiority, randomized, controlled trials were conducted in parallel comparing the safety and efficacy of platelets treated with Intercept or Mirasol pathogen‐reduction technologies versus standard platelets.

Mycoplasma Pneumoniae Infection Complicated by Paroxysmal Cold Hemoglobinuria with Anti-P Specificity of Biphasic Hemolysin

SummaryA 7-year-old boy with Mycoplasma Pneumoniae infection complicated by transitory paroxysmal cold haemoglobinuria (PCH) is described. The Donath-Landsteinerantibody exhibited anti-P specificity; hemolytic activity was partially inhibited against papainized erythrocytes at 0° C incubation temperature and increased from 8° C upwards. The association of Mycoplasma pneumoniae infection with PCH has been described 4 times only and in one instance where specificity was stated it was anti-I.ZusammenfassungBei einem 7jährigen Jungen trat im Anschluß an eine Pneumonie durch Mykoplasma pneumoniae eine akute passagere Kältehämoglobinurie auf. Der Donath-LandsteinerAntikörper zeigte Anti-P-Spezifität. Die hämolytische Aktivität gegen papainisierte Erythrozyten wurde bei einer Inkubationstemperatur von 0° C teilweise gehemmt und stieg bei Inkubationstemperaturen von über 8° C an. Das Auftreten einer passageren Kältehämoglobinurie im Anschluß an eine Infektion mit M. pneumoniae wurde bisher nur viermal beschrieben; nur in einem Fall wurde die Spezifität angegeben, dabei handelte es sich um Anti-I.

Dexamethasone targeted directly to macrophages induces macrophage niches that promote erythroid expansion

Cultures of human CD34pos cells stimulated with erythroid growth factors plus dexamethasone, a model for stress erythropoiesis, generate numerous erythroid cells plus a few macrophages (approx. 3%; 3:1 positive and negative for CD169). Interactions occurring between erythroblasts and macrophages in these cultures and the biological effects associated with these interactions were documented by live phase-contrast videomicroscopy. Macrophages expressed high motility interacting with hundreds/thousands of erythroblasts per hour. CD169pos macrophages established multiple rapid ‘loose’ interactions with proerythroblasts leading to formation of transient erythroblastic island-like structures. By contrast, CD169neg macrophages established ‘tight’ interactions with mature erythroblasts and phagocytosed these cells. ‘Loose’ interactions of CD169pos macrophages were associated with proerythroblast cytokinesis (the M phase of the cell cycle) suggesting that these interactions may promote proerythroblast duplication. This hypothesis was tested by experiments that showed that as few as 103 macrophages significantly increased levels of 3-(4,5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide incorporation frequency in S/G2/M and cytokinesis expressed by proerythroblasts over 24 h of culture. These effects were observed also when macrophages were co-cultured with dexamethasone directly conjugated to a macrophage-specific CD163 antibody. In conclusion, in addition to promoting proerythroblast proliferation directly, dexamethasone stimulates expansion of these cells indirectly by stimulating maturation and cytokinesis supporting activity of macrophages.

Activity of the BH3 mimetic ABT-737 on polycythemia vera erythroid precursor cells

An increased expression of antiapoptotic molecules is often found in malignant cells, where it contributes to their clonal expansion by conferring an improved survival ability. We found that erythroid precurors derived from patients with polycythemia vera (PV) with medium and high JAK2V617F mutation rates often express elevated levels of the antiapoptotic molecules Bcl-2 and Bcl-X(L) (5 of 12 patients with 3 to 7 times Bcl-2 and 3 of 12 patients with 4 to 7 times Bcl-X(L) than average normal controls) and are more resistant to myelosuppressive drugs than normal erythroblasts. ABT-737, a small-molecule inhibitor of Bcl-2, Bcl-X(L), and Bcl-W, induced apoptosis preferentially in JAK2V617F-high PV erythroid precursors as compared with JAK2V617F-low or normal erythroblasts. ABT-737 inhibited also the proliferation of PV erythroblasts and interfered with the formation of endogenous erythroid colonies by PV hematopoietic progenitors. Altogether, these results suggest that small-molecule inhibitors of Bcl-2/Bcl-X(L) may be used in the treatment of patients with PV with high JAK2V617F allele burden.

Hemolysis in patients with antibody deficiencies on immunoglobulin replacement treatment

Immunoglobulin (Ig)G replacement with intravenous or subcutaneous immunoglobulins is a lifelong substitutive therapy in patients with primary antibody deficiencies (PADs). Hemolysis after immunoglobulin therapy was described in patients receiving high immunoglobulin dosages. The issue of hemolysis after immunoglobulin administration at replacement doses has been considered of little clinical significance.