Maja Rozenberg-Arska

Influence of Cytomegalovirus Seropositivity on Outcome after T Cell-Depleted Bone Marrow Transplantation: Contrasting Results between Recipients of Grafts from Related and Unrelated Donors

We analyzed the effect of cytomegalovirus (CMV) serostatus on overall survival (OS) and transplant-related mortality (TRM) in 253 consecutively treated patients receiving partially T cell-depleted (TCD) bone marrow from either matched related donors (MRDs; n=205) or matched unrelated donors (MUDs; n=48). Short-course, low-dose preemptive therapy with ganciclovir was provided as soon as a positive antigenemia assay result was obtained. Ganciclovir prophylaxis, which was identical to preemptive therapy, was given to patients with acute graft-versus-host disease (GVHD) grades II-IV who had to be treated with high-dose steroids. In recipients of transplants from MRDs, inferior OS and increased TRM were predicted by extensive chronic GVHD (P<.001). High-risk disease status and older age adversely influenced OS (P=.001) and TRM (P=.002), respectively; older age resulted in a trend toward decreased OS (P=.066). In recipients of transplants from MUDs, OS and TRM were strongly influenced by patient CMV seropositivity (P=.013 and.007, respectively). In conclusion, CMV seropositivity is not an adverse risk factor for OS and TRM in recipients of transplants from MRDs. However, in recipients of transplants from MUDs, patient CMV seropositivity strongly affects OS and TRM.

Prevention and treatment of epstein–barr virus‐associated lymphoproliferative disorders in recipients of bone marrow and solid organ transplants

van Gorp, J., Doornewaard, H., Verdonck, L.F., Klopping, C., Vos, P.F. & van den Tweel, J.G. (1994) Posttransplant T cell lymphoma. Cancer, 73, 3064–3072. Gottschalk, S., Ng, C.Y.C., Perez, M., Smith, C.A., Sample, C., Brenner, M.K., Heslop, H.E. & Rooney, C.M. (2001) An Epstein– Barr virus deletion mutant associated with fatal lymphoproliferative disease unresponsive to therapy with virus-specific CTLs. Blood, 97, 835–843. Gratama, J.W., Oosterveer, M.A.P., Zwaan, F.E., Lepoutre, J., Klein, G. & Ernberg, I. (1988) Eradication of Epstein–Barr virus by allogeneic bone marrow transplantation: implications for sites of viral latency. Proceedings of the National Academy of Science of the United States of America, 85, 8693–8696. Gratama, J.W., Lenette, E.T., Lonnqvist, M.A.P., Klein, G., Ringden, O. & Ernberg, I. (1992) Detection of multiple Epstein–Barr viral strains in allogeneic bone marrow transplantation. Journal of Medical Virology, 37, 39–47. Green, M., Kaufmann. M., Wilson, J. & Reyes, J. (1997) Comparison of intravenous ganciclovir followed by oral acyclovir with intravenous ganciclovir alone for prevention of cytomegalovirus and Epstein–Barr virus disease after liver transplantation in children. Clinical Infectious Diseases, 25, 1344–1349. Gross, T.G., Hinrichs, S.H., Davis, J.R., Mitchell, D., Bishop, M.R. & Wagner, J.E. (1998) Depletion of EBV-infected cells in donor marrow by counterflow elutriation. Experimental Hematology, 26, 395–399. Gross, T.G., Steinbuch, M., DeFor, T., Shapiro, R.S., McGlave, P., Ramsay, N.K.C., Wagner, J.E. & Filipovich, A.H. (1999) B cell lymphoproliferative disorders following hematopoietic stem cell transplantation: risk factors, treatment and outcome. Bone Marrow Transplantation, 23, 251–258. Gruhn, B., Meerbach, A., Egerer, R., Mentzel, H.J., Hafer, R., Ringelmann, F., Sauerm, M., Hermann, J. & Zintl, F. (1999) Successful treatment of Epstein–Barr virus-induced transverse myelitis with ganciclovir and cytomegalovirus hyperimmune globulin following unrelated bone marrow transplantation. Bone Marrow Transplantation, 24, 1355–1358. Gruhn, B., Meerbach, A., Hafer, R., Zell, R., Berndt, A., Kosmehl, H., Wutzler, P. & Zintl, F. (2001) Early diagnosis and pre-emptive therapy of Epstein–Barr virus-associated lymphoproliferative disease following hematopoietic stem cell transplantation. Blood, 98, S393a. Abstract. Gustafsson, A., Levitsky, V., Frisan, T., Dalianis, T., Ljungman, P., Ringden, O., Winiarski, J., Emberg, I. & Masucci, M.G. (2000) Epstein–Barr virus (EBV) load in bone marrow transplant recipients at risk to develop posttransplant lymphoproliferative disease: prophylactic infusion of EBV-specific cytotoxic T-cells. Blood, 95, 807–814. Hale, G. & Waldmann, H. (1998) Risks of developing Epstein–Barr virus-related lymphoproliferative disorders after T-cell-depleted marrow transplants. Blood, 91, 3079–3083. Hanel, M., Fiedler, F. & Thorns, C. (2001) Anti-CD20 monoclonal antibody (rituximab) and cidofovir as successful treatment of an EBV-associated lymphoma with CNS involvement. Onkologie, 24, 491–494. Haque, T. & Crawford, D.H. (1999) The role of adoptive immunotherapy in the prevention and treatment of lymphoproliferative disease following transplantation. British Journal of Haematology, 106, 309–316. Haque, T., Thomas, J.A., Falk, K.I., Parratt, R., Hunt, B.J., Yacoub, M. & Crawford, D.H. (1996) Transmission of donor Epstein–Barr virus (EBV) in transplanted organs causes lymphoproliferative disease in EBV-seronegative recipients. Journal of General Virology,

Natural occurring IgG and IgM antibodies to gram-negative bacteria and lipopolysaccharides in human sera

In sera of 28 non-infected elderly individuals, relationships between natural occurring antibody populations against O-antigen deficient lipopolysaccharides (J5LPS, ReLPS and Lipid A), a mixture of twelve O-antigen containing lipopolysaccharides (“mixed LPS”) and five different gram-negative bacterial strains, were assessed in a quantitative ELISA. Concomitant measurement of total IgG and IgM concentrations (in radial immunodiffusion assays—RIDA) allowed for the expression of IgG and IgM antibody concentrations per mg IgG.ml−1 and per mg IgM m−1 respectively. Statistically significant positive correlations were found between IgM antibody concentrations to all mentioned antigens for each possible combination (r≥0·381; P<0·05). The strongest correlation was found between IgM concentrations to ReLPS and Lipid A (r=0·852; P<0·001). IgG antibody concentrations to ReLPS correlated statistically significant with IgG antibody concentrations to Lipid A (r=0·692; P<0·001), to J5LPS (r=0·409; P<0·05) and to “mixed LPS” (r=0·409; P<0·05). Beside the statistically significant correlations of IgG antibody concentrations to “mixed LPS” with ReLPS and with Lipid A (r=0·528; P<0·001), IgG antibody concentrations to “mixed LPS” also correlated statistically significant with three gram-negative enterobacterial strains. These data indicate that the application of “mixed LPS” as a capture antigen for the selection of donor sera with a high IgG antibody concentration to this polyvalent antigen, eventually will yield a pooled serum which also contains relatively high IgG antibody concentrations to O-antigen deficient lipopolysaccharide preparations as well as enterobacterial strains.

Intensive cytoreductive therapy followed by autologous bone marrow transplantation for patients with hematologic malignancies or solid tumors

Fifty patients were studied. Twenty patients with non‐Hodgkins lymphomas (NHL) of high‐grade malignancy and 21 patients with acute leukemia (AL) were treated with high‐dose cyclophosphamide and total body irradiation, and three patients with Hodgkins disease (HD) and six patients with solid tumors were treated with high‐dose cyclophosphamide and VP16‐213. Those procedures were followed by autologous bone marrow transplantation (ABMT). All patients had received conventional chemo(radio)therapy before the ABMT procedure. Although remissions were obtained in patients with cytotoxic drug‐resistant diseases (lymphomas and solid tumors), none has become a long‐term survivor, as occurred also in patients with solid tumors in partial remission (PR). Two of five patients with NHL in PR at the time of ABMT have become long‐term disease‐free survivors (28+, 56+ months). Ten patients with NHL were treated in complete remission (CR) and seven are in unmaintained CR; four with long follow‐up (14+ to 59+ months). All patients with AL were treated in CR; two patients received ABMT in second CR, and both relapsed. Ten of nineteen patients in first CR relapsed; eight are alive in CR, five with long follow‐up. Four deaths were therapy‐related, all were patients in poor clinical condition. Intensive cytoreductive therapy followed by ABMT can produce prolonged disease‐free survival (and probably cure) in a fair number of patients with poor risk NHL in CR and PR and probably also in patients with acute myeloblastic leukemia in first CR. This procedure was not successful in achieving long‐term disease‐free survival in patients with refractory lymphomas or solid tumors.

The Influence of Flucloxacillin and Amoxicillin with Clavulanic Acid on the Aerobic Flora of the Alimentary Tract

SummaryIn a randomized study, 42 patients undergoing extensive maxillo-facial surgery (correction of the position of the mandible or maxilla by using autologous bone transplants) received prophylactically tenday courses of either flucloxacillin or amoxicillin with clavulanic acid. Patients were comparable with regard to age and type of surgery. During the prophylactic treatment the effect of antibiotics used on the microbial flora of the alimentary tract was studied. Patients receiving flucloxacillin showed increased numbers ofKlebsiella spp. isolated from the faeces (59% of the patients versus 19% of the patients receiving amoxicillin with clavulanic acid). Patients receiving amoxicillin with clavulanic acid showed higher colonization rates of oropharynx with Enterobacteriaceae than patients receiving flucloxacillin (ten patients versus five patients). 60% of those strains isolated from patients receiving amoxicillin with clavulanic acid were resistant to this combination, as compared to 20% of gramnegative bacilli isolated from patients receiving flucloxacillin. In 50% of patients receiving amoxicillin with clavulanic acid, colonization of the gut with yeast occurred, as compared to 18% of patients receiving flucloxacillin. Only one infection leading to a partial loss of the graft was seen in the group of patients receiving flucloxacillin.ZusammenfassungIm Rahmen einer randomisierten Studie erhielten 42 Patienten, bei denen umfangreiche maxillo-faziale chirurgische Eingriffe (Korrektur der Unter- oder Oberkiefer-Position unter Verwendung autologen Knochentransplantats) durchgeführt wurden, als Antibiotika-Prophylaxe entweder Flucloxacillin oder Amoxicillin plus Clavulansäure über zehn Tage. Die Patienten waren im Hinblick auf ihr Alter und die Art des chirurgischen Eingriffs vergleichbar. Während der Antibiotikaprophylaxe wurden Veränderungen der mikrobiellen Flora des Verdauungstraktes registriert. Patienten, die Flucloxacillin erhielten, wiesen im Stuhl vermehrtKlebsiella spp. auf (Nachweis bei 59% der Fälle im Gegensatz zu 19% der Fälle unter Amoxicillin plus Clavulansäure). Bei Patienten, die Amoxicillin plus Clavulansäure erhielten, wurde häufiger einer Kolonisation des Oropharynx mit Enterobacteriaceae nachgewiesen (zehn gegenüber fünf Patienten). Bei Patienten, die Amoxicillin plus Clavulansäure erhielten, waren 60% der Isolate gegen diese Kombination resistent; Isolate gramnegativer Stäbchenbakterien von mit Flucloxacillin behandelten Patienten waren hingegen nur zu 20% resistent. Bei 50% der Patienten, die eine Amoxicillin-Clavulansäure-Prophylaxe erhielten, kam es zu einer Kolonisation des Darmes mit Hefen, unter Flucloxacillin-Prophylaxe hingegen nur bei 18% der Patienten. In der mit Flucloxacillin behandelten Patientengruppe trat eine Infektion auf, die zum Teilverlust des Transplantates führte.

Successful treatment with chemotherapy and subsequent allogeneic bone marrow transplantation for myeloid blastic crisis of chronic myelogenous leukemia following advanced Hodgkin's disease

A 33‐year‐old man was treated with intensive chemotherapy for myeloid blastic crisis of chronic myelogenous leukemia (CML), which developed after radiotherapy and chemotherapy for Hodgkins disease. After achieving a second chronic phase, he underwent allogeneic bone marrow transplantation (BMT). Despite many complications, 1 year after BMT the disease was in complete remission and the patient was in excellent condition. The incidence of CML following treatment for Hodgkins disease is briefly discussed. This is the first report of prolonged complete remission for blastic crisis of CML, which developed after combined treatment for advanced Hodgkins disease.

Enhanced binding of murine monoclonal antibodies to lipopolysaccharide structures of Enterobacteriaceae after treatment with antibiotics

Abstract Four strains of E. coli , two encapsulated and two unencapsulated, were grown in the presence or absence of the β-lactam antibiotics aztreonam, ceftazidime and ceftriaxone, the fluoroquinolone ciprofloxacin, and the aminoglycoside netilmicin. Treatment of the unencapsulated strains with β-lactams and ciprofloxacin resulted in enhanced binding of murine Mabs (all:IgM) directed to rough lipopolysaccharide structures in ELISA. However, binding of these Mabs to antibiotic treated E. coli 07K1 (bearing a thin capsule) was only slightly increased, and was unchanged in E. coli 08K49 (surrounded by a thick capsule). Treatment of bacteria with netilmicin did not result in differences in binding of these monoclonal antibodies. These results show that the inner parts of the lipopolysaccharide become more accessible to antibodies when, especially unencapsulated, bacteria are grown in the presence of certain antibiotics.

Beta-lactam antibiotics enhance the binding of antibodies to outer membrane, non-LPS antigenic structures in Enterobacteriaceae

Abstract Eight clinical isolates of Enterobacteriaceae were grown in the presence or absence of a sub-inhibitory concentration of various β-lactam antibiotics. We studied the activity of rabbit antiserum directed to heat-killed Escherichia coli J5 against these bacteria. The J5-antiserum was used unabsorbed or after absorption with either viable E. coli J5 bacteria or with E. coli J5 LPS. Results with the absorbed sera were expressed as relative ELISA titers: the titer obtained with one of the absorbed sera was compared with the titer obtained with the unabsorbed serum against the same antigen. The titers obtained with unabsorbed serum to antibiotic-treated bacteria were at least four times higher than those of untreated bacteria. When the activity of antiserum absorbed with E. coli J5 bacteria was tested, none of the untreated bacteria showed a significant change in titer. However, 75% of the antibiotic-treated micro-organisms showed a decrease in relative titer of greater than 50%, and 50% of these antibiotic-treated bacteria showed a decrease in relative titer of greater than 75%. When the reactivity was tested with antiserum absorbed with E. coli J5 LPS, there was no decrease in titer with untreated or antibiotic-treated bacteria. The results indicate that the antibodies that are binding more efficiently to Enterobacteriaceae as a result of treatment with β-lactam antibiotics are probably primarily directed to non-LPS structures. We conclude, therefore, that the cell wall composition of Enterobacteriaceae is changed after growth in the presence of a sub-inhibitory concentration of various β-lactam antibiotics, resulting in an enhanced binding of antibodies directed to non-LPS epitopes of these bacteria.

Humoral immunity in human gram-negative septic shock. I. Potentially cross-protective anti-lipopolysaccharide antibodies

Abstract In sera of 17 adult patients with clinically and bacteriologically documented gram-negative septic shock, IgG and IgM antibody concentrations to various rough lipopolysaccharide (R-LPS) antigens (J5-LPS, Re-LPS, Lipid A), to a mixture of smooth (S-) LPS preparations and to the gram-negative bacterial strain that caused the septic shock, were measured in quantitative ELISA. Antibody concentrations were expressed as proportional to the total IgG (for IgG antibodies) or the total IgM concentration (for IgM antibodies) and compared with the antibody concentrations to the corresponding LPS and gram-negative bacterial antigens in sera of non-infected controls (n=28). It was shown that gram-negative septic shock was associated with decreased total IgG and IgM concentrations (46% and 52% respectively of the mean concentration in control sera, P

Humoral immunity in human Gram-negative septic shock II. Specific anti-bacterial immunity: opsonic activity and the effect of intravenous immunoglobulin G administration

Abstract In the serial sera of patients with clinically and bacteriologically documented Gram-negative septic shock (n = 17), the effect of intravenous immunoglobulin G (i.v. IgG) was investigated. Patients received one dose (200 mg per kg, max. 12g) of either a standard i.v.IgG preparation (IGIV, n = 8) or i.v.IgG from the plasma of volunteers immunized with E. coli J5 bacteria (J5-IGIV, n = 9). At study entry heat labile and heat stable serum opsonic activity was relatively poor in the majority of patients (65%). There were large variations in the serum IgM and IgG against the causative organisms. Total haemolytic complement concentrations were decreased in all patients (range 20 to 80%, mean 52% of the concentration in human pooled serum). Two and 24 hours after treatment with either J5-IGIV or IGIV, serum opsonic activity remained unchanged as did complement and IgM antibody concentrations. In contrast, after two hours the IgG antibody concentration against the infecting pathogen had increased significantly, from a mean value of 68 to a mean value of 88 percent units per ml, n = 17, 0·01