Roberto L. Silva

Phialemonium curvatum infection after bone marrow transplantation

We report a case of cutaneous infection caused by Phialemonium curvatum GAMS et COOKE, 1983, after bone marrow transplantation. The genus Phialemonium was created by GAMS & MCGINNIS in 1983 including three new species: Ph. obovatum, Ph. curvatum and Ph. dimorphosporum, and represents an intermediate genus between Acremonium and Phialophora. Nowadays, the genus Phialemonium is considered to be a pheoid fungus which may cause the eventual lesions observed in pheo- and hyalohyphomycosis. Species of this genus have been described as opportunistic agents in humans and animals, mainly as a result of immunosuppression. In the present case, the patient had multiple myeloma and received an allogenic bone marrow transplant from his HLA-compatible brother. Two months after transplantation, he developed purplish and painful nodular lesions on the right ankle. Some of these lesions drained spontaneously and apparently hyaline mycelial filaments were observed, whose culture was initially identified as Acremonium sp. Subsequent studies showed that the fungus was Phialemonium curvatum. The infection was treated with amphotericin B, followed by ketoconazole. The patient was submitted to surgical debridement followed by two skin grafts to repair the bloody area. The duration of the treatment was 4 months and secondary prophylaxis with ketoconazole alone was maintained for one additional month. No recurrence was observed after discontinuation of treatment. The authors comment on the pathogenicity of the genus Phialemonium.

Scedosporium apiospermum SINUSITIS AFTER BONE MARROW TRANSPLANTATION: REPORT OF A CASE

A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patients follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. Itraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.

O transplante de medula óssea na leucemia mielóide aguda: análise de 80 pacientes transplantados no complexo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

The patients records of eighty consecutive patients with acute myeloid leukemia (AML) submitted to allogeneic (allo BMT) and autologous (auto BMT) bone marrow transplantation (BMT) between 1989 and 2001 were assessed. Forty percent were alive in the end of the study; 37.9% of allogeneic patients and 45.4% of autologous. Factors such as gender, the French-American-British AML classification, induction treatment, number of infused cells and the conditioning regiment did not have any impact in survival. Patients with AML from M1 to M4, and who were consolidated with high doses of arabinoside had better a survival rate (p=0.0148). Patients in their first complete remission also had better survival both with allogeneic and autologous BMT, with respective survival rates of 52.6% and 69.2%. Acute graft-versus-host disease (GvHD) had an impact when it was compared the absence, grade I/II with III/IV giving a p-value of 0.0285. Infection was the most frequent cause of death in allogeneic BMT. In autologous BMT relapse was the principal cause of death. Toxicity related to the procedure occurred in 38.9% of patients who died in allogeneic BMT and 16.7% in autologous BMT. In univariant Cox analyses for prognostic factors, the disease status and acute GvHD were significant, but this significance was lost in the multiple variant analyses (p-value = 0.069).

Transplante autólogo de células-tronco hematopoiéticas sem uso de hemocomponentes

Abstract Hematopoietic stem cell transplantation (HSCT) is standardtherapy for the treatment of some hematological neoplasms andsupport with blood transfusions is considered essential for thisprocedure. Herein we describe the case of a Jeovah´s witness whohad Hodgkins lymphoma in third partial remission and wassubmitted to high-dose chemotherapy using a classic conditioningregimen (carmustine, etoposide, cytarabine, melphalan) with pos-terior infusion of autologous peripheral blood stem cells withoutthe use of blood transfusions. The patient had the usual degree ofhematological toxicity and was treated with clinical supportmeasures, such as the use of erythropoietin, IL-11 and anti-fibrinolytics, with the goal of minimizing the risk of bleeding andserious anemia. The HSTC coursed without major complications.This report shows that the autologous peripheral blood stem celltransplantation without the use of blood and platelet transfusionsis feasible in special situations, where patients clearly expresstheir wishes and where there is a favorable clinical condition withrigorous medical care provided by specialists. Rev. bras. hematol.hemoter. 2006;

Human Leukocyte Antigen–Haploidentical Transplantation for Relapsed/Refractory Hodgkin Lymphoma: A Multicenter Analysis

Reduced-intensity-conditioned allogeneic stem cell transplantation (SCT) remains a potentially curative approach for patients with relapsed/refractory Hodgkin lymphoma (HL) after an autologous stem cell transplantation. In the absence of an HLA-identical donor, haploidentical SCT (haplo-SCT) with post-transplantation cyclophosphamide (PT-Cy) has been evaluated with favorable preliminary results. We evaluated 24 patients who underwent haplo-SCT for relapsed/refractory HL. The conditioning regimen consisted of cyclophosphamide, fludarabine, and total body irradiation. Graft-versus-host disease (GVHD) prophylaxis consisted of a calcineurin inhibitor, mycophenolate mofetil, and PT-Cy (50 mg/kg/day for 2 days) for all patients. After a median follow-up of 2 years, the cumulative incidence (CI) of nonrelapse mortality was 26% and the CI of grades II to IV acute GVHD and chronic GVHD were 17% and 24%, respectively. Estimation of progression-free and overall survival at 2 years were 54% and 66%%, respectively. Haplo-SCT is a valuable option for relapsed/refractory HL patients after a failed autologous SCT, with favorable survival and relatively low risk of GVHD.

Allogeneic bone marrow transplantation in patients with severe aplastic anemia younger than 12 years old, conditioned with cyclophosphamide and total body irradiation

ResumoO transplante de medula ossea e o tratamento deescolha para criancas com anemia aplastica grave, quepossuem um doador com antigeno leucocitario huma-no compativel. O grande problema com relacao a estaterapeutica eram as elevadas taxas de rejeicao naque-les pacientes que recebiam o condicionamento classi-co so com ciclofosfamida, principalmente entre ospolitransfundidos no pre-transplante de medula ossea.Com objetivo de reduzir os indices de rejeicao, opta-mos por associar a irradiacao corporal total com300cGyaciclofosfamida,nadosede50mg/kg/diaintra-venosa,porquatrodiasnascriancascomidadeinferiora 12 anos, portadoras de anemia aplastica grave, noperiodo de janeiro de 1991 a dezembro de 2001. Dos13pacientesavaliadosnesteestudo,osresultadosobti-dos foram os seguintes: taxa de sobrevida livre de do-enca de 92,3% em 120 meses; sobrevida global de84,6% em 140 meses; toxicidade imediata aceitavelrelacionada ao tratamento e diminuicao no crescimen-to de quatro criancas, que, no entanto, entraram no es-tudo ja com deficit pre-transplante de medula ossea,impossibilitando a correlacao da persistencia da baixaestatura com o regime de condicionamento. Reducaodosniveissericosdohormoniodecrescimentoinsulinasimile-1,enormalidadedosniveissericosdohormoniodecrescimentoeproteinaligadoradehormoniodecres-cimentoinsulinasimiletipo3namaioriadoscasosava-liados.Aavaliacaodoshormoniostireoidianostambemfoi realizada, nao sendo observada nenhuma alteracaonos niveis sericos destes pacientes. Em relacao a avali-acao oftalmologica nao se observou catarata em ne-nhum caso. Avaliou-setambemodesenvolvimentose-xual, o qual mostrounormalidadedoscaracteressexu-aissecundarioseniveishormonais.Naohouverejeicaonos pacientes estudados.AbstractBone marrow transplantation is the treatment ofchoice for children with severe aplastic anemia whohaveadonorcompatibleinhumanleukocyteantigensystem. The great problem of this therapy is the highrejection rate in patients who received the classicconditioning only with cyclophosphamide, mainly inthe polytransfused patients, in the pre-transplant.Aiming to reduce the rejection rates, we chose theassociation of total body irradiation with 300 cGy tocyclophosphamide50mg/kg/day,intravenous,forfourdaysinchildrenyoungerthan12yearsold,withsevereaplasticanemia,fromJanuary1991toDecember2001.Of the thirteen patients enrolled in this study thefindings were: Disease-free survival rate of 92.3% in120 months; global survival rate of 84.6% in 140