Magdalena Kurenko-Deptuch

Chronic Granulomatous Disease: The European Experience

CGD is an immunodeficiency caused by deletions or mutations in genes that encode subunits of the leukocyte NADPH oxidase complex. Normally, assembly of the NADPH oxidase complex in phagosomes of certain phagocytic cells leads to a “respiratory burst”, essential for the clearance of phagocytosed micro-organisms. CGD patients lack this mechanism, which leads to life-threatening infections and granuloma formation. However, a clear picture of the clinical course of CGD is hampered by its low prevalence (∼1∶250,000). Therefore, extensive clinical data from 429 European patients were collected and analyzed. Of these patients 351 were males and 78 were females. X-linked (XL) CGD (gp91phox deficient) accounted for 67% of the cases, autosomal recessive (AR) inheritance for 33%. AR-CGD was diagnosed later in life, and the mean survival time was significantly better in AR patients (49.6 years) than in XL CGD (37.8 years), suggesting a milder disease course in AR patients. The disease manifested itself most frequently in the lungs (66% of patients), skin (53%), lymph nodes (50%), gastrointestinal tract (48%) and liver (32%). The most frequently cultured micro-organisms per episode were Staphylococcus aureus (30%), Aspergillus spp. (26%), and Salmonella spp. (16%). Surprisingly, Pseudomonas spp. (2%) and Burkholderia cepacia (<1%) were found only sporadically. Lesions induced by inoculation with BCG occurred in 8% of the patients. Only 71% of the patients received antibiotic maintenance therapy, and 53% antifungal prophylaxis. 33% were treated with γ-interferon. 24 patients (6%) had received a stem cell transplantation. The most prominent reason of death was pneumonia and pulmonary abscess (18/84 cases), septicemia (16/84) and brain abscess (4/84). These data provide further insight in the clinical course of CGD in Europe and hopefully can help to increase awareness and optimize the treatment of these patients.

Disseminated bacillus Calmette-Guérin infection and immunodeficiency.

To the Editor: Disseminated bacillus Calmette-Guerin (BCG) infection has been noted in patients with primary immunodeficiency. Incidence rates have ranged from 0.06 to 1.56 cases per million vaccinated, and mortality rates have remained at ≈60% (1–7). Of 946 patients with primary immunodeficiency, including 29 with severe combined immunodeficiencies, diagnosed from 1980 through 2006 at the Children’s Memorial Health Institute in Warsaw, adverse events after BCG vaccination were observed in 16 (8,9). All 16 were children who had been vaccinated at birth with BCG, Brazilian strain (BioMed, Lublin, Poland). Four patients with severe combined immunodeficiency showed adverse reactions to BCG. Patient M.K. had mild inflammation at the site of the BCG injection and was successfully treated with rifampin. The patient subsequently received a bone marrow transplant, and 2 months later poor appetite, failure to thrive, and subfebrile condition were noted. Disseminated skin changes (with pus formation in the subcutaneous layer), osteomyelitis, and multiple lesions in the liver were found. A skin biopsy showed tuberculoma formations, which were PCR-positive for Mycobacterium tuberculosis complex (Amplified Mycobacterium Tuberculosis Direct [MTD] Test, Gen-Probe, Inc., San Diego, CA, USA) but had negative culture results. Complete recovery, including full immunologic reconstitution, was reached after 12 months of treatment with triple antituberculosis (TB) therapy (rifampin, isoniazid, and ciprofloxacin). Patient M.C., a 6-month-old boy, was admitted to an intensive care unit because of respiratory insufficiency. An unhealed BCG vaccination site was noted. Bronchopulmonary lavage samples were tested for M. bovis; positive PCR and culture results led to the diagnosis of disseminated BCG infection. Despite intensive anti-TB therapy, the child died of multiple organ failure. Autopsy showed typical granuloma formations and a hypoplastic thymus, typical for severe combined immunodeficiency. Male patients S.D. and C.G. were admitted to intensive care units at 6 and 8 months of age, respectively, with lymphadenopathy and multiple organ insufficiency. Each boy died of multiple organ failure; postmortem examination found granuloma formation and a hypoplastic thymus in each (8). Eight patients with severe combined immunodeficiency had local adverse events after vaccination with BCG. Inflammation <1 cm in diameter at the vaccination site was observed for all 8. For all except 1, dual anti-TB therapy (rifampin, isoniazid) or monotherapy was successful. For 1 of these patients, anti-TB treatment was stopped 3 months after bone marrow transplant, but increasing inflammation and lymphadenitis appeared 1 month later, with positive PCR and negative culture results for Mycobacterium spp. After 12 months of triple anti-TB therapy, this patient fully recovered. In 2-month-old female patient, W.M., who had interferon-γ–receptor deficiency, axillary lymphadenopathy with normal healing of the vaccination site was noted 7 weeks after BCG vaccination. Tuberculous lymphadenitis was diagnosed by histopathologic methods. Despite dual anti-TB therapy and streptomycin administration, the girl died. At autopsy, multiple tuberculous granulomas were found (5). In 4-month-old female patient M.K., who had interleukin-2–receptor deficiency, axillary lymphadenopathy with positive results from Mycobacterium typing was noted. Dual anti-TB therapy for 12 months produced good results. In 7-month-old female patient B.B., axillary lymphadenopathy was noted. Mycobacteria PCR-positive for the M. tuberculosis complex were found in the purulent secretion. Despite dual anti-TB therapy, the patient experienced 2 episodes of relapse. After another 2 years of anti-TB therapy, disseminated BCG infection, with pulmonary consequences, developed. In patient R.C., a 6-month-old boy, osteomyelitis was diagnosed, and delayed healing of the BCG vaccination scar was noted. Investigation of his immunologic status showed no abnormalities. However, because granulomatous inflammation was present in a bone biopsy sample and staining for BCG produced a positive result, triple anti-TB therapy was provided for 12 months, with good results. The literature describes >200 cases of disseminated BCG infection in patients with primary immunodeficiency (1–7). The diagnostic difficulties described for 8 of our patients with primary immunodeficiency have been noted by others (1–6,8–10). In only 2 cases was the Mycobacterium species successfully isolated and identified as M. tuberculosis complex, and in 1 case it was the M. bovis BCG strain. We propose novel criteria for the diagnosis of disseminated BCG infection in persons with primary immunodeficiency (Table). These criteria have recently been submitted to the European Society for Immunodeficiencies. Table Suggested diagnostic criteria for disseminated bacillus Calmette-Guerin (BCG) infection in persons with primary immunodeficiency* We believe that patients with severe combined immunodeficiency and any form of mild local changes at the BCG injection site should be given anti-TB therapy, which should be continued until complete immunologic reconstitution occurs after bone marrow transplant. Disseminated BCG infection with regional lymph node involvement needs at least triple anti-TB therapy followed by long-term prophylaxis. Disseminated BCG infection needs anti-TB therapy, including ≥4 anti-TB drugs, until the patient fully recovers.

Successful treatment of refractory autoimmune thrombocytopenia with rituximab and cyclosporin A in a patient with chronic granulomatous disease.

Dear Editor, Although immunodeficiency and autoimmunity seem to be on the opposite sides of the immune response in many cases, they are associated to each other [1]. We present the first case of female with coexistence of chronic granulomatous disease (CGD) and refractory autoimmune thrombocytopenia (ITP), successfully treated with rituximab and cyclosporin A (CyA). The patient was diagnosed with CGD in 1999 at the age of 14. Thrombocytopenia with platelets (PLT) 9×10/l was first observed in June 2002, and the patient was given prednisone as the initial treatment. The response was good but thrombocytopenia (PLT<20×10/l) relapsed when the dosage of prednisone was tapered below 20 mg/day. In March 2003 the patient received high doses IVIg but during that treatment, aggravation of the haemorrhagic diathesis with epistaxis, menorrhea and secondary anaemia (Hb 8.2 g/dl) was observed. Due to severe diathesis, methylprednisolone 1,000 mg i.v. for 7 days was introduced. The platelet count increased to 340×10/l within few days, and all symptoms of bleeding retreated completely. The patient was discharged from hospital on 60 mg oral prednisone with the recommendation of reducing the dose. She was also given oral contraception. In January 2004 the patient was admitted to our Department because of epistaxis, presence of petechiae on both lips, upper palate and lower extremities. The patient’s complete blood count revealed Hb 11.2 g/dl, red blood cells 4.03×10/l, white blood cells 9.07×10/l and PLT count 3×10/l. The patient received puls of dexamethasone 40 mg i.v. for 4 days [2]. The maximum elevation of platelet count to 77×10/l was achieved, but no consent for splenectomy obtained. After 3 weeks, thrombocytopenia PLT 3×10/l relapsed, but the next dexamethasone course was not effective. The patient was then qualified for rituximab treatment whichwas administered inMay 2004 four times on aweekly basis at 375 mg/m [3, 4]. During that period, platelet and blood transfusions were required. Platelet transfusions were not effective in increasing platelet level, but there was a significant clinical response in terms of diminishing bleeding symptoms. There was also a short episode of fever with good reaction to antibiotic therapy, but neither clinical, radiological nor laboratory signs of infectionwere observed. Twoweeks after the last dose of rituximab, shewas admitted to the hospital suffering from partial blindness due to both eyes retinal haemorrhage, haematuria and profound anaemia (Hb 6.5 g/dl) caused by extensive epistaxis and menorrhea with platelet count of 2×10/l. After RBC and PLT transfusions, therapy with cyclosporinA (2.5mg/kg of bodyweight per day) was introduced [5]. The patient was discharged from the hospital after 10 days completely recovered from blindness with the platelet count of 7×10/l, but 3 days later she was presented with strong headache, nausea and general weakness. CT scan of head showed no signs of cerebral bleeding. The cyclosporin level was within therapeutic ranges, and no renal or hepatic damage was observed. Two months after the last dose of rituximab and 1.5 months after cyclosporin A was introduced, the patient required no blood transfusions and was in stabile medical state without haemorrhagic diathesis symptoms. For the next 2 months, her PLT count varied between 11 and 29×10/l with no signs of bleeding and significant clinical improvement. The dosage of CyAwas reduced to 1 mg/kg per day and continued at that level with only slight changes since it was enough to maintain a therapeutic serum level between 200 and 400 ng/ml. Renal and hepatic functions as well as blood cells counts were checked every 4 weeks. In January 2005, 7 months after CyAwas started, the platelet count was 84×10/l, while in March 2005 it reached J. Treliński . K. Chojnowski . M. Kasznicki . T. Robak (*) Department of Haematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland e-mail: robaktad@csk.umed.lodz.pl Tel.: +48-42-6895191 Fax: +48-42-6895192

Treosulfan-based conditioning regimen in a second matched unrelated peripheral blood stem cell transplantation for a pediatric patient with CGD and invasive aspergillosis, who experienced initial graft failure after RIC.

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency caused by a defect of phagocyte NADPH-oxidase and characterized by severe, recurrent bacterial and fungal infections. Invasive aspergillosis (IA) is the leading cause of mortality in patients with CGD. We report the case of a 3-year-old boy with CGD, who developed IA despite antifungal prophylaxis. His treatment consisted of a 10-month-long multi-drug antifungal therapy, together with surgery, but these did not cause any substantial clinical improvement. BMT in high-risk patients with CGD remains a challenge due to both, higher risk of graft rejection and inflammatory flare in the course of immune recovery. Our patient rejected the first matched unrelated donor (MUD) allograft after RIC regimen recommended by the EBMT Inborn Errors Working Party for high-risk patients. After treosulfan-based conditioning and second MUD peripheral blood stem cell transplantation both, full reconstitution of the granulocytic series and complete recovery from IA, were achieved.

Vaccination-related Mycobacterium bovis BCG infection.

To the Editor: The high prevalence of tuberculosis (TB) underlines the important role of BCG (bacillus Calmette-Guerin) immunization. The vaccine, however, is not free from complications, which could be local or disseminated. Disseminated BCG infection as a result of TB vaccination is a rare complication with an incidence of 0.06 to 1.56 cases per million vaccinations; it occurs exclusively in patients with immune deficits. However, in these cases, the prognosis is unfavorable; up to 70% of patients die, despite intensive antituberculous treatment (1–4). A 4-month-old-girl exhibited enlargement of left axillary lymph nodes during a 1.5-month period. She was the second child of healthy parents, with no family history of genetic disorders or TB. She was vaccinated according to the regimen compulsory in Poland: the first dose of BCG and anti–hepatitis B virus (HBV) vaccination on the first day of life, followed by vaccination against diphtheria, tetanus, pertussis, poliomyelitis, and the second dose of anti-HBV after 6 weeks. BCG vaccination was performed intradermally in the upper part of left arm by administration of 0.1 mL Brazilian Moreau strain (Biomed, Lublin, Poland). On hospital admission, the patient was in reasonably good condition but pale, with grossly enlarged, adjacent left axillary lymph nodes and hepatosplenomegaly. Laboratory tests showed anemia, thrombocytopenia, elevated transaminase activity, a high C-reactive protein level, and high level of immunoglobulin M (IgM) class anti-cytomegalovirus (CMV) reactive antibodies. Based on clinical manifestations and biochemical and serologic signs, CMV infection was suspected. The patient was administered a 14-day regimen of ganciclovir (10 mg/kg/day); results of liver function tests and blood count normalized, and hepatosplenomegaly decreased. However, the lymph nodes continued to enlarge, and diagnostic excision and bone marrow aspiration were performed to exclude a neoplastic process. A histopathologic image of the excised lymph nodes showed caseating granulomas, and tuberculous lymphadenitis was suggested (Figure). Figure Digitally processed hematoxylin-eosin staining of the excised lymph nodes, showing caseating, tuberculosislike granulomas (original magnification ×100). At that time, a diagnosis of disseminated BCG infection as a complication of TB vaccination in a presumed immunocompromised patient was proposed. This idea was based on suggestive lymph node pathology, which showed caseating granulomas, a history of TB vaccination, and the exclusion of other pathologic changes. Flow cytometry measurements showed abnormally low expression of the α chain of the interferon (IFN)-γ receptor on peripheral blood lymphocytes. Only 20% lymphocytes expressed CD 119 (IFN-γ receptor outer subunit R1). Three-drug anti-tuberculous therapy (with rifampin, isoniazid, and streptomycin) was introduced despite chest and bone radiographs that were negative for infection, no abnormalities found on funduscopy, and negative results of Ziehl-Neelsen staining of lymph node tissue. Despite this therapy, the childs condition worsened; she exhibited a high temperature, hemolysis, and progressive neutropenia, thrombocytopenia, cholestasis, and renal failure. Uncontrolled sepsis developed, and she died. At postmortem examination, the diagnosis of disseminated BGC infection was made on the basis of multiple TB-like granulomas in the lungs, lymph nodes, meninges, liver, spleen, and kidneys. However, direct microbiologic confirmation of BCG infection was lacking because cultures were negative and Ziehl-Neelsen and periodic acid–Schiff staining did not show acid-fast bacilli, other bacteria, or fungi in these specimens. This case represents a rare complication of antituberculous vaccination, that is a progressive, disseminated BCG infection in a patient with deficiency of IFN-γ receptor. Concomitant CMV infection was diagnosed by positive IgM antibody response. Transient response to the ganciclovir treatment made the final diagnosis of BCG infection more difficult and probably postponed implementation of the anti-TB therapy. Until now ≈100 cases have been reported in the literature, most of them in infants and young children. These patients also had clear predisposition to other severe infections with intracellular microorganisms such as atypical mycobacteria, Salmonella spp., Listeria monocytogenes, and Leishmania spp (1–5). The INF-γ receptor is present on many cell types; however, its deficiency on macrophages may be responsible for the inhibition of phagocytosis and intracellular killing and the observed deficit of an antimycobacterial immunity. Among children with a clinical syndrome of IFN- γ–receptor deficiency, a clear genetic defect was identified in ≈20%. In our patient, the diagnosis was made by detection by flow cytometry of abnormally low expression of the α chain of the IFN-γ receptor on peripheral blood lymphocytes. This method appears to have high diagnostic value, given the fact that genetic methods are not always available and are expensive and often insensitive. The prognosis in patients with BCG infection secondary to IFN-γ–receptor deficiency is unfavorable. A few cases of successful treatment with allogenic bone marrow transplantation have been reported with long-term improvement of general condition and stable receipt of the graft as shown by molecular analysis of peripheral leukocytes (4,6–8). However, as specific and efficient therapy for this condition has not been as yet proposed, supportive measures with early diagnosis and institution of anti-TB and antimicrobial drug treatment appear to be important in managing this rare immune deficiency. The level of IFN-γ-receptor expression in populations known to be susceptible to TB, and its potential role in this phenomenon, appears to be a promising area of study.