P. S. R. K. Sastry

Pulmonary microsporidial infection in a patient with CML undergoing allogeneic marrow transplant

Very few cases of human microsporidial infection have been reported. The advent of AIDS has changed this. There is increasing recognition that microsporidia are important opportunistic pathogens. However, the number of cases reported in the non-HIV population is small. We report here a case of microsporidial infection in a female patient with chronic myeloid leukemia undergoing allogeneic bone marrow transplantation. There was also an associated fungal infection. The diagnosis could be reached only after postmortem and was confirmed by electron micrography. We suggest that transplant patients are another group of patients who are susceptible to this group of opportunistic pathogens.

Trial of amifostine in autologous stem cell transplant

We read with interest the recent publication of a prospective randomized trial of amifostine cytoprotection in myeloma patients receiving high-dose melphalan by the Australian Leukemia and Lymphoma Group. A few other studies have also shown similar cytoprotective benefit. However, our limited nonrandomized, retrospective experience suggests lack of beneficial effect of amifostine in autologous stem cell transplantation (ASCT). The study group (Group A) consisted of seven patients with myeloma and two with Hodgkin’s disease who received melphalan 200mg/m or BEAM (standard doses with melphalan 140mg/m), respectively, between May 2002 and May 2004. The median age was 44 years (range, 20–54 years). The control group (Group B) consisted of nine patients (seven myeloma and two Hodgkin’s disease) aged 41 years (range, 21–59 years). There were six male and three female subjects in Group A, and seven male and two female subjects in Group B. All patients had received prior chemotherapy, while three patients had also received prior radiation. Pre-transplant glomerular filtration rate (GFR) was low in seven patients in group A and five patients in group B. Pulmonary function tests were abnormal in two and one patient in groups A and B, respectively. Blood biochemistry and cardiac function were normal in all patients. The median serum albumin and serum creatinine levels in study population were 3.5 g/dl and 0.7mg/dl, while that in control group were 4.0 g/dl and 0.8mg/dl, respectively. The median CD34þ cell dose in study arm was 2.6 10 /kg and 2.2 10 /kg in the control arm. Group A patients received amifostine at the dose of 910mg/m as a short i.v. infusion over 15min, half an hour prior to melphalan. Hematological and nonhematological toxicity, engraftment kinetics, need for supportive care including blood products, duration of growth factors, antibiotics, opioid analgesics and parenteral nutrition, and the duration of hospitalization was studied. Toxicity was graded according to the NCI toxicity grading. Amifostine infusion-related adverse events were seen in 44% of patients (bradycardia1⁄4one, drop in blood pressure1⁄4 one, vomiting1⁄4 two), none of which required discontinuation of the drug. In contrast to the recent publication, we did not find any reduction in the severity and/or duration of mucositis nor a benefit in other parameters studied with amifostine (Tables 1 and 2). In fact, hospital stay was significantly increased in the amifostine arm (P1⁄4 0.04) with a resultant increase in cost. It is difficult to explain the discrepancy between our findings and those from other studies. Despite the small sample size of our patients, we feel that caution is warranted before concluding that amifostine is beneficial in ASCT patients.

Serum Tumor Necrosis Factor for Monitoring Response of Hepatic Veno-occlusive Disease to Pentoxiphyllin-A Case Report

Hepatic veno-occlusive disease (VOD) is the second most common cause of death after autologous bone marrow transplantation (ABMT). A patient with multiple myeloma undergoing ABMT developed classic features of hepatic VOD. He responded to treatment with pentoxiphyllin. Serum tumor necrosis factor (TNF) levels showed remarkable correlation with the severity of VOD and response to therapy.