Gérard Tertian

Human parvovirus B19 infection in organ transplant recipients

We report a 61‐yr‐old kidney transplant recipient with human Parvovirus B19 (HPV B19) infection presenting as a severe pancytopenia 1 month after transplantation. Bone marrow aspiration revealed severe erythroid hypoplasia with giant and dystrophic proerythroblasts. Bone marrow cells were positive for HPV B19 DNA detected by polymerase chain reaction (PCR). Pancytopenia resolved shortly after administration of intravenous immunoglobulins. Nineteen cases of HPV B19 infection in organ transplant recipients have been so far reported in the literature. Immunocompromised patients should be considered at risk from developing symptomatic HPV B19 infections. In such patients, specific anti‐HPV B19 IgM and IgG antibodies may be absent or transient and therefore their negativity cannot rule out the diagnosis of HPV B19 infestation. Bone marrow smear morphological findings may suggest the diagnosis but testing for viral DNA by PCR is mandatory. Patients may spontaneously recover. However, since specific anti‐viral therapy is not currently available, intravenous immunoglobulin administration appears to be the more efficacious treatment.

Lenalidomide with or without erythropoietin in transfusion-dependent erythropoiesis-stimulating agent-refractory lower-risk MDS without 5q deletion

After failure of erythropoiesis-stimulating agents (ESAs), lenalidomide (LEN) yields red blood cell (RBC) transfusion independence (TI) in 20–30% of lower-risk non-del5q myelodysplastic syndrome (MDS). Several observations suggest an additive effect of ESA and LEN in this situation. We performed a randomized phase III study in 131 RBC transfusion-dependent (TD, median transfusion requirement six RBC units per 8 weeks) lower-risk ESA-refractory non-del5q MDS. Patients received LEN alone, 10 mg per day, 21 days per 4 weeks (L arm) or LEN (same schedule) + erythropoietin (EPO) beta, 60,000 U per week (LE arm). In an intent-to-treat (ITT) analysis, erythroid response (HI-E, IWG 2006 criteria) after four treatment cycles (primary end point) was 23.1% (95% CI 13.5–35.2) in the L arm and 39.4% (95% CI 27.6–52.2) in the LE arm (P=0.044), while RBC-TI was reached in 13.8 and 24.2% of the patients in the L and LE arms, respectively (P=0.13). Median response duration was 18.1 and 15.1 months in the L and LE arms, respectively (P=0.47). Side effects were moderate and similar in the two arms. Low baseline serum EPO level and a G polymorphism of CRBN gene predicted HI-E. Combining LEN and EPO significantly improves erythroid response over LEN alone in lower-risk non-del5q MDS patients with anemia resistant to ESA.

Regular automated erythrocytapheresis in sickle cell patients

Giardina, P.J. & Grady, R.W. (2010) Combined iron chelation therapy. Annals of the New York Academy of Sciences, 1202, 79–86. Jetsrisuparb, A., Komvilaisak, P., Wiangnon, S. & Jetsrisuparb, C. (2010) Retrospective study on the combination of desferrioxamine and deferasirox for treatment of iron-overloaded thalassemic patients: first evidence of more than 2 years. Journal of Pediatric Hematology Oncology, 32, 400–403. Otto-Duessel, M., Brewer, C., Gonzalez, I., Nick, H. & Wood, J.C. (2008) Safety and efficacy of combined chelation therapy with deferasirox and deferoxamine in a gerbil model of iron overload. Acta Haematologica, 120, 123–128. Roberts, D.J., Brunskill, S.J., Doree, C., Williams, S., Howard, J. & Hyde, C.J. (2007) Oral deferiprone for iron chelation in people with thalassaemia. Cochrane Database of Systematic Reviews, 18;(3): CD004839. Tanner, M.A., Galanello, R., Dessi, C., Smith, G.C., Westwood, M.A., Agus, A., Pibiri, M., Nair, S.V., Walker, J.M. & Pennell, D.J. (2008) Combined chelation therapy in thalassemia major for the treatment of severe myocardial siderosis with left ventricular dysfunction. Journal of Cardiovascular Magnetic Resonance, 10, 12. Voskaridou, E., Douskou, M., Terpos, E., Papassotiriou, I., Stamoulakatou, A., Ourailidis, A., Loutradi, A. & Loukopoulos, D. (2004) Magnetic resonance imaging in the evaluation of iron overload in patients with beta thalassaemia and sickle cell disease. British Journal of Haematology, 126, 736–742.

Leucémie lymphoïde chronique, léiomyoblastome, vascularite thrombosante et anticorps anticardiolipine : à propos d'un cas

Resume Les auteurs rapportent un cas complexe associant une leucemie lymphoide chronique, un leiomyoblastome digestif et une vascularite cutanee thrombosante avec anticorps anticardiolipine serique faisant discuter un nouveau mecanisme physiopathogenique des vascularites au cours des hemopathies.

Clinical Efficacy of Irradiation in CLL Patients: Predictive Value of in Vitro Radio-induced Apoptosis

In order to identify CLL patients for whom irradiation could be beneficial, we investigated the relationship between in vitro radio-induced apoptosis of leukemic cells and response to low-dose splenic or lymph node radiotherapy. Fourteen patients were included in the in vitro study. Leukemic cells were analyzed by Hoechst staining immediately after collection or 24 h of culture following in vitro irradiation of 0-10 Gy. The tumor response rate was 47% (one CR and six PR), with a mean duration of response of 3 months (range: 1-4). A high correlation between tumor response and in vitro tests was observed (p <0.01) and the positive predictive value of the in vitro tests for tumor and hematological responses was 100% at 5 Gy. These results suggest that the sensitivity of leukemic cells to irradiation should be first evaluated in an in vitro assay to spare refractory patients from the useless toxicity radiotherapy.

Un syndrome d'activation histio-monocytaire peut révéler une maladie lupique. À propos de trois observations

An hemophagocytic syndrome occured in 3 patients with active Lupus Erythematosus. None of them exhibited any evidence of infectious pathology. Steroid therapy was effective. Relapse was observed in 2 patients and again resolved under steroid therapy. Moderate levels of TNF were observed in the 3 patients. Lupus must be considered as a possible cause of hemophagocytic syndrome in the absence of underlying infection.

A Somatic Mosaicism in the G6PD Gene Inducing a Late Onset Chronic non Spherocytic Hemolytic Anemia

To the Editor: With more than 400 million people affected, G6PD deficiency is the most common human red cells enzyme defect. More than 140 mutations have been identified. Localized on chromosome Xq28, the G6PD gene encodes the first enzyme of the pentose phosphate pathway. The active form is a homodimer or a tetramer and is widely expressed in all cells. Because of the absence of mitochondria in red cells, this enzymatic pathway represents the sole way to produce NADPH in erythrocytes and to preserve a constant stock of reduced glutathione, the major source of reducing power against oxidative stress. G6PD deficiency typically leads to an acute intravascular hemolysis occurring when red cells are exposed to an increased oxidative stress such as infection, drugs, or the classical fava bean (Vicia faba) intake. However, in rare patients, very low enzymatic level induces the class I G6PD deficiency according to the WHO classification, ie, a chronic non-spherocytic hemolytic anemia. These cases are sporadic and correspond to de novo germinal mutations occurring recurrently in “hot spots,” mostly in the exon 10 of the G6PD gene, implicated in the dimer formation and the stability of the active enzyme. These sporadic mutations correspond to single amino-acid substitutions or in frame deletions, but no null mutation has been reported yet, probably because such mutation would be lethal; indeed, a minimal residual G6PD activity is essential during embryogenesis. We report here the case of 65 years old Caucasian man referred in 1993 for hemolytic anemia. No personal or familial history of anemia was reported. Nine and five years before, the hemoglobin (Hb) level and the mean corpuscular volume (MCV) were normal. At diagnosis, the anemia was moderate (Hb 119 g/L), macrocytic (MCV 104 fL), and regenerative (reticulocyte count: 550 G/L) with hemolytic features. Platelets and leucocytes counts were normal. No spleen enlargement was noted. With a follow-up of 17 years, we noticed a progressive worsening of the anemia, requiring 8-16 packed red cell transfusions per year. Concomitantly, macrocytosis increased up to 144 fL despite acid folic intake. Several bone marrow examinations ruled out any dysplastic changes and repeated cytogenetics analyses showed no emerging clone. He died at the age of 82 from heart failure. At diagnosis, the first screening tests were negative for various acquired or constitutional causes of hemolysis, including immune hemolytic anemia, paroxystic nocturnal hemoglobinuria (PNH), membrane red cells disorders, or hemoglobinopathies. Finally, dosage of G6PD activity in red cells displayed repeatedly very low levels from 0.6 to 1.5 UI/g of Hb (normal range 5.3-7.9). Sequencing the G6PD gene from peripheral blood revealed the presence of a single nucleotide substitution at the junction between exon and intron 10 (Figure 1A, upper). This substitution (G to A) led to the abolition of a splicing donor site, resulting in a shorter protein with aberrant C-terminus. While occurring at the germline level, it is known that severe mutations in the G6PD gene can lead to two distinct situations: in the worst case, the residual level is not sufficient for a normal embryogenesis and such mutation would be lethal since G6PD activity, as a source of reducing power against oxidative stress, is essential during embryogenesis. In the best case (ie, a sufficient level of activity in nonhematopoietic cells), such mutation would induce a chronic anemia from birth that should remain steady. Given the surprisingly late onset of anemia and the further dramatic worsening of hematological parameters over follow-up in our patient, we therefore hypothesized that the mutation occurred somatically in hematopoietic cells. We sequenced the G6PD gene in skin fibroblasts and could not detect the mutation (Figure 1A, lower). Since the mutation abolished a BAN I restriction site, we confirmed this observation using RLFP after PCR amplification of the exon 10–intron 10 junction (Figure 1B). Enzyme activities were then measured in both cell types and were found normal in skin fibroblasts, but nearly undetectable in all the blood cells we tested, including red cells and leukocytes (Figure 1C). Our report is the first description of a somatic mosaicism involving the G6PD gene in the hematopoietic cells. One explanation could be that the mutation was a mark of a clonal hematopoiesis in a context of an underlying myelodysplastic syndrome (MDS). Indeed, acquired mutations in genes implicated in red cell physiology, including red cell membrane skeleton, hemoglobin synthesis, or structure, have been long recognized in MDS. However, little is known about red cell enzymes activities in MDS and no mutation in the corresponding genes, restricted to the hematopoietic lineages and leading to acquired alterations in their function or expression has been reported yet. In this view, we checked whether any mark of MDS was detectable in our patient. Sequential bone marrow aspirations and cytogenetics studies failed to detect any dysplastic changes or clonal evolution during the follow-up. High-throughput genomic studies have recently revealed existence of clonal hematopoiesis of indeterminate potential (CHIP) in apparently healthy persons. CHIP is defined by the presence of

O-010 Prognostic factors of response to azacitidine (AZA) in low-risk MDS resistant to erythroid stimulating agents (ESA). The GFM Azaepo 08 study

Conclusions: Our data demonstrate that HSCs are disease-initiating cells in MDS. While MDS HSCs exhibit relatively few functional differences from their normal counterparts, committed myeloid progenitors in low-risk MDS exhibit numerous alterations including loss of GMPs, upregulation of CRT, and increased phagocytosis by macrophages, with increased expression of CD47 and decreased phagocytosis associated with disease progression. These findings are consistent with a model in which committed progenitors in MDS undergo molecular alterations that promote programmed cell removal, thereby resulting in the cytopenias that characterize MDS, but this mechanism does not appear to be critical for disease maintenance by HSCs.

Angéïte thrombosante dans le cadre d'un syndrome des antiphospholipides: une nouvelle cause de vascularite au cours des hémopathies

Abstract We describe an originally case of thrombotic vasculitis during chronic lymphocytic leukemia, caused by the presence of anti-phospholipid antibodies.

ANTI-IL-2 Receptor Antibody Treatment for Lymphoproliferative Disease: Transient Response in A Case of Ki-1+ Anaplastic Large Cell Lymphoma

Most cases of Ki-1 + anaplastic large cell lymphomas (ALCL) express the CD25 antigen, and we have recently shown that IL-2 producing cells can also be detected in these lymphomas. The latter cells may thus constitute targets for anti-CD25 Mab treatment. In one patient with a chemoresistant disseminated Ki-1 + ALCL such a therapeutic approach was undertaken. We report the dramatic antitumoral effect of anti-CD25 Mab obtained in this patient. This confirms the observation, previously reported in adult T cell leukemia, showing that this therapeutic regimen is also efficient in CD25 + solid tumors.