Objective:To investigate the early diagnosis,treatment and prevention of pneumocystotis pneumonia (PCP) after allogeneic hematopoietic stem cell transplantation (allo-HSCT).Method:The clinical data of 9 cases who developed PCP after allo-HSCT were discussed including clinical symptoms,signs,the β-D-glucan levels,blood gase,CT scan imaging,and results of bronchoscopy and alveolar douche examination.Result:The data showed that the time of onset of symptoms ranged from 80 to 316 d after allo-HSCT. The common clinical presentations were fever,cough,progressive exertional dyspnea and hypoxia. The β-D-glucan levels were higher than in normal controls. The most common abnormal chest CT findings included bilateral diffuse interstitial infiltrations,patchy shadows and frosted glass like change. All of the 9 cases were given trimethoprim-sulfamethoxazole (SMZ/TMP,SMZCO) for 3 weeks. Of them,6 cases with severe hypoxia were treated with corticosteroids concomitantly. All of them recovered.Conclusion:Most PCP occurred at 3 to 12 months after allo-HSCT. Diagnosis of PCP should be considered whenever the patients have fever,dyspnea,hypoxia and high level β-D-glucan,especially when the chest CT findings revealed interstitial infiltration and frosted glass like change. The therapy with SMZCO should start immediatedly,which is effective in the prevention and treatment of PCP.
Objective To explore the effects of Basiliximab (Simulect) on reducing the incidence of severe acute GVHD in haploidentical bone marrow transplantation (BMT). Methods Nine patients with leukemia received haplotype Allo-BMT from HLA two or three loci mismatched related donor. Most patients were classified as high risk category. The donors of patients were administrated with G-CSF 250 μg/day for 7 doses prior to marrow harvest. In addition to combination of CsA, MTX, ATG and Mycophenolate mofetil for GVHD prophylaxis, Simulect was administered to prevent severe GVHD. A total 40 mg Simulect was given in two doses of 20 mg each by 30 min intravenous infusion on 2 h before transplantation and day 4 after transplantation.Results All patients were engrafted. 100 % donors hematopoietic cells after transplantation was determined by cytogenetic evidence analysis. None developed the Ⅱ-Ⅳ acute GVHD. Eight patients could be evaluated for chronic GVHD. All experienced chronic GVHD confined to the skin. The median follow-up duration was 14 months (range 12～20 months). One patient died from CMV infection on 3 months and one patient died from disease relapse on 14 months. The remaining 7 patients were survived in disease free situation.Conclusion The use of Simulect in haploidentical bone marrow transplantation is effective on preventing acute severe GVHD and improving disease-free survival.
Objective To investigate the effects of Basiliximab on alloreactive T lymphocytes precursors, hematopoietic progenitor cells by ex vivo assay and prophylaxis of graft-versus-host disease (GVHD) in mismatched bone marrow transplantation.Methods Two groups were set up: (1) Basiliximab group including 72 leukemia patients subject to haploidentical bone marrow transplantation (BMT) with Basiliximab for prophylaxis of GVHD without ex vivo T-cell depletion. (2) Control group having 15 patients receiving the same regimen before Nov. 2000, without Basiliximab for GVHD prophylaxis. Limiting-dilution method was used to determine the effect of Basiliximab on reactivity of cytotoxic T lymphocyte precursors (CTLP). In the semi-solid hematopoietic culture system, the effect of Basiliximab on the colony proliferation of CFU-GM, BFU-E and CFU-Meg was measured. Results In Basiliximab group, 72 patients established trilineage with full donor hematopoietic reconstitution. Engraftment rate showed no statistical difference between the two groups. The incidence of grade Ⅱ-Ⅳ GVHD was 12.5 % (9 cases) in Basiliximab group and 33.3 % (5 cases) in control group respectively (P0.05). The extensive chronic GVHD had no statistical difference between two groups. Immune reconstitution was achieved in 18 months, blood CD3, CD8, CD19 and CD56 cells were returned to normal levels in 12 months, and CD4 cells became normal in 18 months after transplantation. The median follow-up duration was 22 months and there were 42 patients with disease-free survival. Kaplan-Meler life curve revealed the 2-year disease-free survival rate was 58.3 %. There was no statistically significant difference in the disease-free survival and rate of relapse between the two groups. The experiment with donor mononuclear cells of bone marrow showed Basiliximab significantly reduced the number and frequency of CTLP by 10-fold to 100-fold, but had no effect on the colony proliferation of normal hematopoietic cells of CFU-GM, BFU-E and CFU-MK.Conclusion Basiliximab can selectively eliminate and reduce the number of allorective T cells, which results in reduction of severity GVHD.
Extracellular high mobility group box 1 (HMGB1) is a novel cytokine that takes part in the processes of in: ammation, tissue damage and regeneration. Mesenchymal stem cells (MSCs) are adult stem cells characterized by their inherently suppressive activities on inflammative and allo-immune reactions. In the present study, we have addressed whether HMGB1 could affect the biological properties of human bone marrow MSCs. Transwell experiments showed that HMGB1 induced MSC migration and this effect could not be hampered by a blocking antibody against the receptor for advanced glycation end products (RAGE). MSCs exposed to HMGB1 were negative for CD31, CD45, CD80, and HLA-DR, and displayed equal levels of CD73, CD166, and HLA-ABC compared with their counterparts, but HMGB1 profoundly suppressed MSC proliferation in a dose-dependent manner as evaluated by carboxyfluorescein diacetate succinmidyl ester dye dilution assay. Furthermore, HMGB1 triggered the differentiation of MSCs into osteoblasts as identified by histochemical staining, traditional RT-PCR and real-time RT-PCR analysis on mRNA expression of lineage-specific molecular markers. The differentiation-inductive activity could neither be inhibited by RAGE neutralizing antibody. Moreover, HMGB1-treated MSCs displayed unchanged suppressive activity on in vitro lymphocyte cell proliferation elicited by ConA. Collectively, the data suggest that MSCs are a target of HMGB1.
Abstract The clinical applications of human leukocyte antigen (HLA) haploidentical hematopoietic stem cells transplantation (haplo-HSCT) have offered most of the young severe aplastic anemia (SAA) patients an opportunity to accept curative therapy at the early stage of bone marrow lesions. However, the outcome of juvenile SAA patients received haplo-HSCT remain to be improved due to high incidence of graft failure and graft vs host disease (GVHD). Mesenchymal stem cells (MSCs) have been characterized by their hematopoiesis-supporting and immunomodulatory properties. In the current study, we designed a combination of haplo-HSCT with allogenic MSC for treatment of SAA in pediatric and adolescent patients and evaluated its effects. Juvenile patients (<18 years) with SAA (n = 103) were given HLA-haploidentical HSC combined with allogenic MSC after a conditioning regimen consisting of busulfan, cyclophosphamide, fludarabine, and antithymocyte globulin and an intensive GVHD prophylaxis, including cyclosporine, short-term methotrexate, mycophenolate mofetil, and basiliximab. Neutrophil engraftment was achieved in 102 of 103 patients in a median time of 14.3 days (range 9-25 days). The median time of platelet engraftment was 25.42 days (range 8-93 days). The cumulative incidence of II-IV acute GVHD at day +100 was 26.32% ± 0.19% and III-IV acute GVHD was 6.79% ± 0.06% at day +100, respectively. The cumulative incidence of chronic GVHD was 25.56% ± 0.26%. The overall survival was 87.15% ± 3.3% at a median follow-up of 40 (1.3-98) months. Our data suggest that cotransplantation of HLA-haploidentical HSC and allogenic mesenchymal stem cell may provide an effective and safe treatment for children and adolescents with SAA who lack matched donors.
The use of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) has increased steadily since its introduction by Powles et al. [1Guinan E.C. Boussiotis V.A. Neuberg D. et al.Transplantation of anergic histoincompatible bone marrow allografts.N Engl J Med. 1999; 340: 1704-1714Crossref PubMed Scopus (377) Google Scholar]. Although successful hematopoietic engraftment and control of acute graft-versus-host disease (aGVHD) through transplantation of mega-dose granulocyte colony-stimulating factor (G-CSF)–primed bone marrow grafts have been reported, immune reconstruction in recipients is usually delayed [2Wang H.X. Yan H.M. Duan L.N. et al.Haploidentical hematopoietic stem cell transplantation in children hematologic malignancies with G-CSF–mobilized marrow grafts without T cell depletion: a single-center report of 45 cases.Pediatr Hematol Oncol. 2008; (Accepted)PubMed Google Scholar, 3Ji S.Q. Chen H.R. Wang H.X. et al.Comparison of outcome of allogeneic bone marrow transplantation with and without granulocyte colony-stimulating factor (lenograstim) donor marrow priming in patients with chronic myelogenous leukemia.Biol Blood Marrow Transplant. 2002; 8: 261-267Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 4Ji S.Q. Chen H.R. Wang H.X. et al.G-CSF–primed haploidentical marrow transplantation without ex vivo T cell depletion: an excellent alternative for high-risk leukemia.Bone Marrow Transplant. 2002; 30: 861-866Crossref PubMed Scopus (53) Google Scholar, 5Ji S.Q. Chen H.R. Yan H.M. et al.Anti-CD25 monoclonal antibody (basiliximab) for prevention of graft-versus-host disease after haploidentical bone marrow transplantation for hematological malignancies.Bone Marrow Transplant. 2005; 36: 349-354Crossref PubMed Scopus (47) Google Scholar]. This might result from the use of an intensive conditioning regimen and a combination of several immunosuppressive agents in haplo-HSCT, resulting in a high rate of infections after transplantation. Among these infections, cytomegalovirus (CMV) is a major cause of morbidity and mortality. Prophylactic ganciclovir, either alone [6Yanada M. Yamamoto K. Emi N. et al.Cytomegalovirus antigenemia and outcome of patients treated with pre-emptive ganciclovir: retrospective analysis of 241 consecutive patients undergoing allogeneic hematopoietic stem cell transplantation.Bone Marrow Transplant. 2003; 32: 801-807Crossref PubMed Scopus (50) Google Scholar] or in combination with foscarnet [7Bacigalupo A. Bregante S. Tedone E. et al.Combined foscarnet-ganciclovir treatment for cytomegalovirus infections after hemopoietic stem cell transplantation (HSCT).Transplantation. 1996; 62: 376-380Crossref PubMed Scopus (60) Google Scholar], has been empirically used to prevent the development of systemic CMV infections. This approach is limited by the risk of treatment-associated neutropenia and/or renal toxicity, however. We report a preemptive therapy protocol designed to control CMV viremia after haplo-HSCT. This study comprised 54 patients who underwent haplo-HSCT according to protocols described previously [2Wang H.X. Yan H.M. Duan L.N. et al.Haploidentical hematopoietic stem cell transplantation in children hematologic malignancies with G-CSF–mobilized marrow grafts without T cell depletion: a single-center report of 45 cases.Pediatr Hematol Oncol. 2008; (Accepted)PubMed Google Scholar, 4Ji S.Q. Chen H.R. Wang H.X. et al.G-CSF–primed haploidentical marrow transplantation without ex vivo T cell depletion: an excellent alternative for high-risk leukemia.Bone Marrow Transplant. 2002; 30: 861-866Crossref PubMed Scopus (53) Google Scholar, 5Ji S.Q. Chen H.R. Yan H.M. et al.Anti-CD25 monoclonal antibody (basiliximab) for prevention of graft-versus-host disease after haploidentical bone marrow transplantation for hematological malignancies.Bone Marrow Transplant. 2005; 36: 349-354Crossref PubMed Scopus (47) Google Scholar]. All of the patients and donors were negative for CMV-PP65 antigenemia detected with the CMV Brite reagent kit (Biotest Diagnostics, Denville, NJ). Once hematopoietic engraftment was achieved, peripheral blood samples were collected, and CMV pp65–positive cells were measured up to day 100 posttransplantation. For CMV infection prophylaxis, ganciclovir 10 mg/kg/day was administered starting on day 9 pretransplantation, followed by acyclovir 500 mg twice daily from day 1 to day 30 posttransplantation, then tapered to 600 mg/day orally for up to 6 months after transplantation. If CMV pp65–positive cells were detected, then foscarnet treatment was started at a dose of 60 mg/kg/day, with appropriate hydration maintained with 1000 mL saline solution/m2 of body surface area. During foscarnet treatment, peripheral blood cell count, creatinine levels, and electrolyte concentrations were monitored. CMV antigenemia occurred in 16 patients between day 30 and day 93 (median, 54 days) after transplantation. Among these 16 patients, 8 patients had fever, and 1 patient had fever with nausea, vomiting, and diarrhea and was diagnosed with CMV colitis. All 16 patients tested negative for CMV pp65 within 7 to 21 days (median, 12 days) after initiation of low-dose foscarnet therapy. In a 6- to 24-month follow-up, 1 patient tested positive for CMV pp65 again 12 months after transplantation. After treatment with gancyclovir, this patient was CMV pp65–negative. The patient with CMV colitis was treated with foscarnet 120 mg/kg/day for 2 weeks, after which the symptoms were controlled and the patient tested negative for CMV pp65. During foscarnet treatment, 5 patients reported nausea and loss of appetite and 2 patients exhibited slight symptoms of urethral stimulation. No patient exhibited obvious changes in levels of electrolytes, creatinine, leukocytes, or platelets in peripheral blood. No patient developed irreversible renal or marrow failure. Based on our findings, we recommend foscarnet as the first-line antiviral drug to prevent CMV infection in patients undergoing haplo-HSCT, which is associated with a higher rate of CMV viremia compared with HLA-identical HSCT. Low-dose foscarnet provides effective preemptive therapy for CMV antigenemia with acceptable toxicity. Financial disclosure: This work was partially supported by Beijing Medical Development Grants 2007-2033 and 2006-2042.
Hormographiella aspergillata is a rare and emerging cause of invasive mould infections in patients with haematological malignancies, with a mortality rate of approximately 70%. Here, we present the first reported case of suspected disseminated H. aspergillata infection in China. The patient experienced a second relapse of acute myeloid leukaemia and developed neutropenia, fever, discrepant blood pressure between limbs, and cutaneous lesions limited to the left upper extremity. Since lung tissue biopsy was not feasible, metagenomic next-generation sequencing (mNGS) and panfungal polymerase chain reaction (PCR) analysis of bronchoalveolar lavage fluid and blood samples were performed, which indicated probable H. aspergillata pulmonary infection. Histopathology of cutaneous lesions revealed numerous fungal hyphae within dermal blood vessels. mNGS of a skin biopsy sample identified H. aspergillata sequences, and the fungi was subsequently recovered from fungal culture, proving cutaneous H. aspergillata infection. Despite combined antifungal therapy, the patient died owing to disease progression. Additionally, 22 previously reported cases of invasive H. aspergillata infection were reviewed in patients with haematological malignancies. Thus, mNGS is a powerful diagnostic tool for the early and effective detection of invasive H. aspergillata infections, with the advantage of sequencing all potential pathogens, and providing results within 24 h.
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