Rosa Branca

Clinical effectiveness of hyperbaric oxygen therapy for BK-virus-associated hemorrhagic cystitis after allogeneic bone marrow transplantation.

Late-onset hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT) has been associated with BK virus (BKV). Antiviral drugs are of limited efficacy and the optimal treatment for HC has not yet been established. Hyperbaric oxygen (HBO) may benefit these patients. We, therefore, retrospectively evaluated the effectiveness of HBO therapy in 16 patients with HC after allogeneic HSCT. All 16 patients had macroscopic hematuria and BKV infection. Patients received 100% oxygen in a hyperbaric chamber at 2.1 atmospheres for 90 min, 5 days per week, with a median 13 treatments (range, 4–84). Fifteen patients (94%) showed complete resolution of hematuria. Median urinary DNA BKV titers declined after HBO (P<0.05). Patients started on HBO earlier after diagnosis of HC responded sooner (P<0.05). HBO was generally well tolerated and proved to be a reliable option for this difficult to manage condition.

IL-10 overexpression predisposes to invasive aspergillosis by suppressing antifungal immunity

2. Abajian M, Mlynek A, Maurer M. Physical urticaria. Curr Allergy Asthma Rep 2012;12:281-7. 3. Kaplan AP, Garofalo J, Sigler R, Hauber T. Idiopathic cold urticaria: in vitro demonstration of histamine release upon challenge of skin biopsies. N Engl J Med 1981;305:1074-7. 4. Siebenhaar F, Weller K, Mlynek A, Magerl M, Altrichter S, Vieira Dos Santos R, et al. Acquired cold urticaria: clinical picture and update on diagnosis and treatment. Clin Exp Dermatol 2007;32:241-5. 5. Singleton R, Halverstam CP. Diagnosis and management of cold urticaria. Cutis 2016;97:59-62. 6. Boyce JA. Successful treatment of cold-induced urticaria/anaphylaxis with anti-IgE. J Allergy Clin Immunol 2006;117:1415-8. 7. Metz M, Ohanyan T, Church MK, Maurer M. Omalizumab is an effective and rapidly acting therapy in difficult-to-treat chronic urticaria: a retrospective clinical analysis. J Dermatol Sci 2014;73:57-62. 8. Casale TB, Bernstein JA, Maurer M, Saini SS, Trzaskoma B, Chen H, et al. Similar efficacy with omalizumab in chronic idiopathic/spontaneous urticaria despite different background therapy. J Allergy Clin Immunol Pract 2015;3: 743-50.e1. 9. Grabbe J. Pathomechanisms in physical urticaria. J Investig Dermatol Symp Proc 2001;6:135-6. 10. Newcomb RW, Nelson H. Dermographia mediated by immunoglobulin E. Am J Med 1973;54:174-80.

Visceral Leishmaniasis: A Differential Diagnosis to Remember after Bone Marrow Transplantation

Leishmania infection in immunocompromised hosts is reported in the literature, mostly concerning human immunodeficiency virus infected patients. It is not well characterized in the context of stem cell transplantation. We report a rare case clinical case of visceral leishmaniasis after allogeneic bone marrow transplantation. A 50-year-old Caucasian male was referred to allogeneic bone marrow transplantation with a high-risk acute lymphoblastic B leukemia in first complete remission. Allogeneic SCT was performed with peripheral blood stem cells from an unrelated Portuguese matched donor. In the following months, patient developed mild fluctuating cytopenias, mostly thrombocytopenia (between 60 and 80∗109/L). The only significant complaint was intermittent tiredness. The common causes for thrombocytopenia in this setting were excluded—no evidence of graft versus host disease, no signs of viral or bacterial infection, and no signs of relapsed disease/dysplastic changes. The bone marrow smear performed 12 months after transplantation revealed an unsuspected diagnosis: a massive bone marrow infiltration with amastigotes.

Rhizomucor and scedosporium infection post hematopoietic stem-cell transplant.

Hematopoietic stem-cell transplant recipients are at increased risk of developing invasive fungal infections. This is a major cause of morbidity and mortality. We report a case of a 17-year-old male patient diagnosed with severe idiopathic acquired aplastic anemia who developed fungal pneumonitis due to Rhizomucor sp. and rhinoencephalitis due to Scedosporium apiospermum 6 and 8 months after undergoing allogeneic hematopoietic stem-cell transplant from an HLA-matched unrelated donor. Discussion highlights risk factors for invasive fungal infections (i.e., mucormycosis and scedosporiosis), its clinical features, and the factors that must be taken into account to successfully treat them (early diagnosis, correction of predisposing factors, aggressive surgical debridement, and antifungal and adjunctive therapies).

Inadvertent transmission of occult CML through allo-SCT

Recurrence of original disease and secondary malignancy are both important causes of unsuccessful SCT. In both cases the malignant clone is host derived. On the other hand, donor cell leukemia is driven by the graft. This is very infrequent and only partially understood. A third and different scenario is the inadvertent transmission of occult leukemia from the donor. These cases are even more rare and raise major ethical considerations concerning the patient, the donor, the doctors and the BM registry systems. We have recently observed an atypical clinical case of inadvertent transmission of occult CML with allo-SCT. A 48-year-old male with no relevant medical past history was diagnosed with smoldering myeloma in 2004. First signs of progression were noted in September 2008 and at this time cytogenetic analysis revealed complex karyotype with: del13q14, three copies of 17 chromosomes, relative deletion of TP53 gene and a translocation involving 14q32. The first-line treatment was thalidomide plus dexamethasone, and after achieving a very good PR the patient was referred to high-dose melphalan conditioning regimen and auto-SCT. He maintained a very good PR for 2 years. At this point signs of aggressive progression led to second-line chemotherapy with bortezomib plus dexamethasone. The patient achieved a very good PR. Considering that this was a young patient with poor cytogenetic prognosis who had an HLAmatched sister, it was decided to proceed with the treatment with allogeneic peripheral SCT from the related donor. The donor was a healthy female with no relevant medical history. Donor routine workup analyses were unremarkable. A reduced-intensity conditioning regimen with fludarabine and BU was performed. CsA and mycophenolate mofetil were used as GVHD prophylaxis. There were no remarkable toxicities after this procedure. One month after transplant the patient had a very good PR, was a complete chimera and the 20 metaphases analyzed by conventional cytogenetics had a normal female karyotype (46,XX). Three months later the cytogenetic analysis revealed 16 metaphases with a complex female karyotype that included t(9;22). The complex karyotype was: 46,XX,del(1)(p36),der(9) t(1;9)(p36;q34),der(22)t(9;22)(q34;q11.2)add(9)(q34). With further genetic studies including chromosome painting (FISH WCP1, WCP9, WCP22, Metasystems, Altlussheim, Germany): 46,XX,del(1) (p36),der(9)t(1;9)(p36;q34),ins(22;?)(q11.2;?)[3].ish,der(1)t(1;9)(p36.1; q34)(wcp1+,wcp9+),der(9)t(1;9)(p36.2;q34)(wcp9+,ABL1+,wcp1+),der (22)(22pter→22q11.2::9q34→9q34::1p36.1→1p36.2::22q11.2→22 qter)(wcp22+,BCR+,ABL1+,wcp1+,wcp22+). FISH analysis revealed 7% of nucleus with del13q14 and 36% with BCR-ABL. Qualitative PCR analyses revealed the presence of BCR-ABL1 p210 (b2a2). The donor was contacted and agreed to submit herself to BCRABL screening even though she was asymptomatic and maintained unremarkable blood analysis. She had the same complex karyotype and the quantitative RT-PCR of BCR-ABL1 was 57.3% (normalized international BCR-ABL). She was diagnosed with molecular CML. Six months later the patient remained with normal blood count and cytogenetic analysis revealed 30 metaphases with a normal male karyotype, 25 complex female karyotype with t(9;22) and 4 with a normal female karyotype. FISH analysis was consistent with 9% of the nuclei showing del13q14. Quantitative analysis of BCR-ABL1 was 23.7% (normalized international BCR-ABL). The donor maintained a normal blood count and a detectable BCR-ABL1 translocation on cytogenetic analysis. It was discussed and decided among the patient, the donor and the medical team to start imatinib 400 mg/day in both siblings. Currently (24 months after transplantation and 19 months after imatinib), the patient and the donor have major molecular responses. Also, the patient is in CR from multiple myeloma. Amelogenin gene analysis for the assessment of chimerism was performed and the patient was a complete chimera. It is relevant to consider that a sclerodermic chronic GVHD was diagnosed 12 months after transplantation and is under treatment with CsA and corticotherapy, with gradual improvement. In conclusion, one should always be aware of the possibility of occult neoplasms in the donor, even though only rare reports are available in the literature. Striking ethical concerns arise in this setting as well as many questions about the best therapeutic choice for both patients and donors. It is also interesting to consider the actual donor workup and the eventual need for new reliable methods to prevent such events. As case reports appear in the literature one speculates whether the growing molecular knowledge of diseases will contribute to changing the donor’s workup in the future. Written informed consent was obtained from the patient for publication of this letter. A copy of the written consent is available upon request.

Genotypic resistance of cytomegalovirus to antivirals in hematopoietic stem cell transplant recipients from Portugal: A retrospective study

Abstract The aim of this study was to characterize Human Cytomegalovirus (HCMV) drug resistance mutations in UL97 and UL54 genes in allogeneic hematopoietic stem cell transplant (allo‐HSCT) recipients in Portugal. We have performed a retrospective study with 22 patients from a cohort of patients with different haematological malignancies submitted to allo‐HSCT between 2010 and 2014. Patients were selected according to clinical and laboratory data of HCMV infection and management. HCMV resistance mutations were characterized by sequencing of UL97 and UL54 genes. Sequence data were compared with: 1) HCMV genome reference strain AD169; and also 2) UL97 from Merlin strain (GenBank: AY446894.2), and UL54 from TB40/E strain (GenBank: ABV71585.1). Resistance mutations were identified in seven patients (32%): five harboured resistance mutations in UL97: A594V (n = 2), C592G (n = 1), L595W (n = 1), and C603W (n = 1); and two harboured resistance mutations in UL54: P522S and L957F, one in each patient. Several natural polymorphisms and unknown mutations were found in both UL97 and UL54, with the majority of the patients harbouring more than one unknown mutation in UL97 but only one in UL54. No simultaneous mutations were found. This is the first study in Portugal to characterize HCMV UL97 and UL54 sequences and to identify HCMV drug‐resistance mutations in allo‐HSCT patients. The UL97 resistance mutations found were amongst the most frequent resistant mutations, while UL54 L957F mutation was here reported for the first time in a clinical specimen. This information provides important information regarding HCMV strains and antiviral resistance in our population. HighlightsWe have analysed HCMV mutations in UL97 and UL54 in allogeneic HSCT patients.5 patients had UL97 resistance mutations (C592G, A594V, L595W and C603W).2 patients had UL54 mutations (P522S and L957F).We have reported several new unknown mutations and natural polymorphisms.We have first reported a case with the L957F UL54 mutation in clinical samples.

Outcomes of allogeneic stem cell transplantation among patients with acute myeloid leukemia presenting active disease: Experience of a single European Comprehensive Cancer Center.

Introduction: Allogeneic hematopoietic stem cell transplantation (ASCT) representes a potentially curative approach for patients with relapsed or refractory acute myeloid leukemia (AML). We report the outcome of relapsed/refractory AML patients treated with ASCT. Method: A retrospective cohort from 1994 to 2013 that included 61 patients with diagnosis of relapsed/refractory AML. Outcomes of interest were transplant-related mortality (TRM), incidence of acute and chronic graft-versus-host disease (GVHD), relapse incidence, progression-free survival (PFS) and overall survival (OS). Statistical significance was set at p<0.05. Results: The median age was 61 years (range 1 to 65). The cumulative incidence of 90 days, 1 year, and 3 years TRM were 60%, 26.7%, and 13.3%, respectively (p<0.001). The incidence of relapse was 21.7% at 1 year, 13% at 3 years, and 8.7% at 5 years. Median OS was estimated to be 8 months (95CI 3.266-12.734) and median PFS, 3 months (95CI 1.835-4.165). Conclusion: In our cohort, TRM in first years after ASCT remains considerable, but ASCT in this setting seems to be a good choice for AML patients with active disease. However, novel approaches are needed to reduce TRM and relapse in this set of patients.

Twenty Years of Autologous Stem Cell Transplantation in Diffuse Large B-Cell Lymphoma: A Single Portuguese Center Experience

INTRODUCTION Diffuse large B-cell lymphoma can be cured in 60% - 70% of patients. Autologous stem cell transplantation is the standard treatment for relapsed disease. This high-intensity treatment after first complete remission in patients with high International Prognostic Index remains controversial and was performed in our department during some years. MATERIAL AND METHODS Retrospective study, review of clinical records. RESULTS This study evaluates the outcome of 113 patients transplanted between 1992 and 2012. Considering status before transplantation patients were divided in groups: a) first complete remission after 1 line of chemotherapy (n = 64); b) first complete remission after ≥ two chemotherapy lines (n = 15); c) second complete remission (n = 15); d) more advanced diseased (n = 19). Chemotherapy used in first line therapy was mainly R-CHOP (n = 71) and CHOP (n = 28). The median follow-up of patients still alive was 34 months (1 - 221). At five years, overall survival was 73% (± 5) and disease free survival was 75% (± 5). CONCLUSION Conventional chemotherapy followed by autologous stem cell transplant is a safe and efficient option for selected patients. In our series 70% high-risk patients were free from disease with this strategy.