Syngeneic peripheral blood stem cell transplantation with immunosuppression for hepatitis-associated severe aplastic anemia / Hepatite bagli siddetli aplastik anemi icin immunosupresyonla singeneik periferik kan kok hucre transplantasyonu.
Subject: Aplastic anemia (Care and treatment)
Hematopoietic stem cells (Transplantation)
Bone marrow (Transplantation)
Immunotherapy
Stem cells
Authors: Savic, Aleksandar
Balint, Bela
Urosevic, Ivana
Rajic, Nebojsa Todorovic, Milena
Percic, Ivanka
Popovic, Stevan
Pub Date: 12/01/2010
Publication: Name: Turkish Journal of Hematology Publisher: Aves Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Aves Yayincilik ISSN: 1300-7777
Issue: Date: Dec, 2010 Source Volume: 27 Source Issue: 4
Accession Number: 305562399
Full Text: Abstract

Hepatitis-associated aplastic anemia occurs in up to 10% of all aplastic anemia cases. Syngeneic bone marrow transplantation is rare in patients with severe aplastic anemia and usually requires pre-transplant conditioning to provide engraftment. We report on a 29-year-old male patient with hepatitis-associated severe aplastic anemia who had a series of severe infectious conditions before transplantation, including tracheal inflammation. Life-threatening bleeding, which developed after bronchoscopy, was successfully treated with activated recombinant factor VII and platelet transfusions. Syngeneic peripheral blood stem cell transplantation using immunosuppressive treatment with antithymocyte globulin and cyclosporin A without high-dose pre-transplant conditioning was performed, followed by complete hematologic and hepatic recovery. (Turk J Hematol 2010; 27: 294-8)

Key words: Aplastic anemia, hepatitis, peripheral blood stem cell transplantation, trachea, infection, bleeding

Received: September 27, 2009

Accepted: Juanuary 25, 2010

Ozet

Hepatite bagli aplastik anemi, tum aplastik anemi olgularinin %10'undan daha az bir oranda meydana gelir. Siddetli aplastik anemili hastalarda singeneik kemik iligi transplantasyonu nadir olup, genellikle hibritlesmeyi saglamak icin nakil oncesi sartlandirma gerektirmektedir. Transplantasyondan once, trakea enflamasyonu da dahil olmak uzere siddetli enfeksiyonlar geciren hepatite bagh siddetli aplastik anemili 29 yasinda erkek bir hastaya iliskin bir rapor sunulmustur. Bronkoskopiyi takiben gelisen yasami tehdit eden kanama, aktive edilmis rekombinant faktor VII ye platelet transfuzyonlanyla basarili sekilde tedavi edilmistir. Yuksek doz nakil oncesi sartlandirma olmaksizin, antitimosit globulin ve sikiosporin A ile immunosupresif tedavi yontemiyle singeneik periferikkan kok hucre transpiantasyonu gercekletirilmi ve ardindan tam hematolojik ve hepatik iyileme gozlenmitirl (Turk J Hernatol 2010; 27.294-8)

Anahtar kelimeler: Aplasti Anemi, hepatit, periferik kan kok hucre transpiantasyonu, trake, enfeksiyon, kanama

Geli tarihi: 27 Eylul 2009

Kabul tarihi: 25 Ocak 2010

Introduction

Hepatitis-associated aplastic anemia is a well-described disease that occurs in 2 to 5% of aplastic anemia cases in the West, and in 4 to 10% in the Far East (1). Hepatitis of the hepatitis-associated aplastic anemia does not appear to be caused by any of the known hepatitis viruses (1), (2). Syngeneic bone marrow transplantation in patients with severe aplastic anemia (SAA) is rare, and usually requires pre-transplant conditioning to provide engraftment (3), (4).

We report a patient with hepatitis-associated SAA who was successfully treated with syngeneic peripheral blood stem cell (PBSC) transplantation after a series of infectious and bleeding complications. To our best knowledge, this is only the second published case of syngeneic PBSC transplantation in hepatitis-associated SAA (5). The patient gave informed consent for review of his medical records and publication of this case.

Case Report

A 29-year-old male patient presented with fatigue, fever and skin and mucosal bleeding at the end of January 2008. He has a twin brother.

Initial laboratory findings showed severe pancytopenia and elevation of bilirubin and liver enzymes (Table 1, Day -116). Acquired idiopathic SAA was diagnosed following bone marrow biopsy, which indicated less than 10% cellularity. A series of tests were performed including hepatitis C virus (HCV), HBV, human immunodeficiency virus (HIV), anti-nuclear antibody (ANA), and Ham and Hartman test, which were all negative. Cytogenetics evaluation was normal. The patient was completely dependent on platelet and packed red blood cell (RBC) transfusions in order to control the bleeding and anemia.

There was a severe deterioration in the patient's liver condition, with development of jaundice and an increase in blood liver enzyme concentrations, at the beginning of March 2008 (Table 1, Day -77). In mid-March, the patient received mycophenolate mofetil 750 mg twice daily, together with 5 [micro]g/kg/d of recombinant human granulocyte colony-stimulating factor (G-CSF) and 1 mg/kg/day of methyl-prednisolone. The patient developed diabetes mellitus, which required regular short-acting insulin treatment and necessitated discontinuation of corti-costeroid treatment. Combined mycophenolate mofetil and G-CSF treatment caused elevation of granulocytes to 1.3 x [10.sup.9]/L in the second half of April, but showed no improvement in the platelet count (Table 1, Day -30). The improvement in RBC was the result of RBC transfusions. From the beginning of the disease until the end of April, the patient suffered two episodes of enterococcal sepsis and pneumonia and four febrile episodes.

HLA typing was performed after repeated attempts. His twin brother was HLA identical (PCR-SSP A*01-, B*08 B*35, DRB1*03-). We decided to perform syngeneic PBSC transplantation using anti-thymocyte globulin (ATG) and cyclosporin A as an immunosuppressive regimen without high-dose chemotherapy conditioning.

The transplantation procedure was postponed because the patient developed fever, hemoptysis and a sensation of a foreign body in his throat at the initial day of the planned conditioning regimen in April. Inspiratory stridor was auscultated over the trachea. Indirect laryngoscopy showed no signs of a laryngeal disease. A computed tomography (CT) scan showed a thickening of the anterior wall of the trachea, with internal air pockets, mucosal erosion and intraluminal soft tissue formations (Figure 1 a).The patient received liposomal amphotericin and antibiotics. A bronchoscopy was performed with a support of platelet transfusions and fresh frozen plasma, because of slightly prolonged prothrombin time. This caused extensive bleeding from the trachea, which was life-threatening given the concurrent development of alveolar hemorrhage and global respiratory insufficiency (Figure 1b). The patient received one dose of recombinant factor (rF) Vita 90 [micro]g/kg and platelet transfusion, after which the bleeding was markedly reduced. A week later, the fever stopped and the respiratory insufficiency was eliminated, but the patient still suffered from hemoptysis. A decision was made to start the transplantation procedure. Mycophenolate mofetil and G-CSF were discontinued before transplantation. The patient was still severely pancytopenic before transplantation, and exhibited hepatitis with some signs of improvement (Table 1, Day -4).

[FIGURE 1 OMITTED]

G-CSF was given as 10 [micro]g/kg/day to mobilize the donor's PBSCs. A large volume apheresis specimen was obtained using peripheral vein access with a Cobe-Spectra cell separator on Day 5 of mobilization. The cell harvest, with a total of 7.8 x [10.sup.8]/kg of MNC, 4.37 x [10.sup.8]/kg of CD3+, 11.7 x [10.sup.6]/kg of CD34+, and 12.9 x [10.sup.6]/kg of CD133+ cells, was infused on Day 0, following immunosuppression, as follows: 8.5 mg/kg/day of ATG (Fresenius) for 4 days (from Day -4 to -1) and 5 mg/kg/day of cyclosporin A intravenous (i.v.) in two equal doses for 7 days (from Day -1 to Day 6), followed by a switch to oral cyclosporin A. Mycophenolate mofetil was added on Day +14 as 1 g twice daily due to persistent thrombocytopenia and anemia. The patient received G-CSF as 5 [micro]g/kg after PBSC infusion until white blood cell (WBC) recovery. He also received standard prophylactic antibacterial, antifungal and antiviral treatments.The transplant took place without any febrile episodes or other complications. Neutrophil engraftment was rapid. The granulocytes were over 1.0 x [10.sup.9]//L on Day +8 (Table 1). The final RBC transfusion was on Day +16, and the final platelet transfusion on Day +27. The platelet number reached 100 x [10.sup.9]//L on Day +48 (Table 1), whereas RBC reached 100 g/L on Day +79. The patient was discharged from the hospital on Day +34. A follow-up CT scan of the trachea showed resolution of the lesions, with minor scarring. A complete resolution of the patient's liver disease was established. Diabetes mellitus was well controlled through diet. A follow-up bone marrow biopsy showed normal findings.Mycophenolate mofetil was discontinued, while cyciosporin A was gradually tapered. The patient is well and without signs of rejection 15 months after transplantation.

Discussion

In summary, this case demonstrates concomitant hepatitis of unknown origin and SAA. The patient has a twin brother, but the transplantation was delayed for several reasons, such as severe hepatitis, unusual life-threatening tracheal complications, most likely of infectious origin, and due to repeated, unsuccessful HLA testing.

Inflammation of the tracheal wall is rarely reported in aplastic anemia, and it is usually caused by aspergillosis (6), (7). The situation was further complicated by life-threatening bleeding provoked by bronchoscopy, which was successfully treated by rFVIIa and platelet transfusions. This complication has not been previously reported in aplastic anemia. Successful off-label use of rVIIa has been reported for bleeding in cases of liver disease and in severely injured trauma patients (8), (9). It has been used rarely for bleeding complications in aplastic anemia (10).

Ultimately, we conducted a successful syngeneic transplantation using immunosuppressive treatment without high-dose pre-transplant conditioning, which is rarely reported in hepatitis-associated SAA (4). Conditioning regimens with cyclophosphamide (+ or -) ATG, or with fludarabine, cyclophosphamide (+ or -) ATG, are widely used in allogeneic settings with high rates of sustained engraftment and survival (11), (12). In the settings of syngeneic transplantation in aplastic anemia, application of cyclophosphamide in the conditioning regimen provides sustained engraftment, but increases early mortality (3). Syngeneic transplantation without conditioning is followed by a high rate of graft failure without the adverse effects on overall survival (3). The concept of syngeneic transplantation without conditioning or with ATG conditioning alone, as in our case, is therefore feasible (4), (13). Hepatitis usually precedes aplastic anemia (1), (2). In this case, hepatitis was present at the time of diagnosis and it severely deteriorated during the course of SAA. We believe that the immunosuppressive treatment may have had an important role both for the hematologic condition and for liver improvement (14). The liver improvement was rapid and complete following ATG and cyclosporin A treatment applied during the transplantation procedure In all likelihood, both SAA and hepatitis were probably caused by immune reactions (1), (2), (14), (15). In light of other studies that have explored the role of stem cells in liver injury, it is even possible that the stem cell transplantation may have contributed, to some extent, to the resolution of the patient's liver disease (16). Although hematopoietic stem cell transplantation with high-dose conditioning is generally a safe and successful treatment procedure in hepatitis-associated aplastic anemia (1), (2), (17), there is a risk of liver disease deterioration (18) .

This case confirms that rFVIIa, combined with platelet transfusion, may be effective in controlling tracheal bleeding in rare situations of tracheal infection in hepatitis-associated SAA. It also demonstrates the possibility of rapid liver disease resolution and sustained engraftment after syngeneic PBSC transplantation using immunosuppressive treatment without high-dose pre-transplant conditioning in hepatitis-associated SAA.

Conflict of Interest

No author of this paper has a conflict of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included in this manuscript.

Address for Correspondence: M.D. Aleksandar Savic, Hajduk Veljkova 1-3 21000 Novi Sad, Serbia Phone: +381 21 484 3963 E-mail: asavic@uns.ac.rs

References

(1.) Brown KE, Tisdale J, Barrett AJ, Dunbar CE, Young NS.Hepatitis-associated aplastic anemia. N Engl J Med 1997;336:1059-64.

(2.) Safadi R, Or R, Ilan Y, Naparstek E, Nagler A, Klein A, Ketzinel-Gilaad M, Ergunay K, Danon D, Shouval D, Galun E. Lack of known hepatitis virus in hepatitis-associated aplastic anemia and outcome after bone marrow transplant. Bone Marrow Transplant 2001;27:183-90.

(3.) Hinterberger W, Rowlings PA, Hinterberger-Fischer M, Gibson J, Jacobsen N, Klein J, Kolb HJ, Stevens D, Horowitz MM, Gale RP Results of transplanting bone marrow from genetically identical twins into patients with aplastic anemia. Ann Intern Med

(4.) Hwang WL, Yang Y, Chen GR, Tsai CS, Jour JH.Syngeneic peripheral blood stem cell transplantation with brief immunosuppression for severe aplastic anemia. Bone Marrow Transplant 2000;25:337-9.

(5.) Niki T, Nakao S, Ueda M, Tsuchiya H, Nakatsumi T, Shiobara S, Mod T, Matsuei K, Matsuda T, Tachibana Y.Incomplete marrow recovery associated with hepatitis after syngeneic bone marrow transplantation for aplastic anaemia: successful treatment with second marrow transplantation without preconditioning. Br J Haematol 1990;75:285-6.

(6.) Drury AE, Allan RA, Underhill H, Ball S, Joseph AE.Calcification in invasive tracheal aspergillosis demonstrated on ultrasound: a new finding. Br J Radiol 2001;74:955-8.

(7.) Vail CM, Chiles C. Invasive pulmonary aspergillosis: radiologic evidence of tracheal involvement. Radiology 1987;165:745-6.

(8.) Ramsey G. Treating coagulopathy in liver disease with plasma transfusions or recombinant factor Vila: an evidence-based review. Best Pract Res Clin Haematol 2006;19:113-26.

(9.) Boffard KD, Riou B, Warren B, Choong PI, Rizoli S, Rossaint R, Axelsen M, Kluger Y; NovoSeven Trauma Study Group. Recombinant factor Vila as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma 2005;59:8-15.

(10.) Blatt J, Gold SH, Wiley JM, Monahan PE, Cooper HC, Harvey D. Off-label use of recombinant factor Vila in patients following bone marrow transplantation. Bone Marrow Transplant 2001;28:405-7.

(11.) Storb R, Blume KG, O'Donnell MR, Chauncey T, Forman SJ, Deeg HJ, Hu WW, Appelbaum FR, Doney K, Flowers ME, Sanders J, Leisenring W. Cyclophosphamide and antithymocyte globulin to condition patients with aplastic anemia for allogeneic marrow transplantations: the experience in four centers. Biol Blood Marrow Transplant 2001;7:39-44.

(12.) Srinivasan R, Takahashi Y, McCoy JP, Espinoza-Delgado I, Dorrance C, Igarashi T, Lundqvist A, Barrett AJ, Young NS, Geller N, Childs RW. Overcoming graft rejection in heavily transfused and allo-immunised patients with bone marrow failure syndromes using fludarabine-based haematopoietic cell transplantation. Br J Haematol 2006;133:305-14.

(13.) Anderlini P, Riggs SA, Koerbling M, Champlin R.Syngeneic blood stem cell transplantation for infectious mononucleosis-related aplastic anaemia. Br J Haematol 1999;106:159-61.

(14.) Osugi Y, Yagasaki H, Sako M, Kosaka Y, Taga T, Ito T, Yamamoto M, Ohara A, Sato T, Mimaya J, Tsukimoto I, Kojima S. Antithymocyte globulin and cyclosporine for treatment of 44 children with hepatitis associated aplastic anemia. Haematologica 2007;92:1687-90.

(15.) Young NS, Maciejewski J. The pathophysiology of acquired aplastic anemia. N Engl J Med 1997;336: 1365-72.

(16.) Dalakas E, Newsome PN, Harrison DJ, Plevris JN. Hematopoietic stem cell trafficking in liver injury.FASEB J 2005;19:1225-31.

(17.) Locasciulli A, Bacigalupo A, Oneto R, Bruno B, Marsh J, Tichelli A, Socie G, Passweget J. Hepatitis-associated aplastic anaemia: epidemiology and treatment results obtained in Europe. A Report of the EBMT Aplastic Anemia Working Party. Blood 2010;149:890-5.

(18.) Van Dam J, Farraye FA, Gale RP, Zeldis JB. Fulminant hepatic failure following bone marrow transplantation for hepatitis-associated aplastic anemia. Bone Marrow Transplant 1990;5:57-60.

Aleksandar Savic (1), Bela Balint (2), Ivana Urosevic (1), Nebojsa Rajic (1), Milena Todorovic (3), Ivanka Percic (1), Stevan Popovic(1),

(1) Clinic of Hematology, Clinical Center of Vojvodina, Novi Sad, Serbia

(2) Institute of Transfusiology, Military Medical Academy, Belgrade, Serbia

(3) Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia

doi:10.5152/tjh.2010.52
Table 1. Laboratory findings for blood and liver function

Parameters *      Day #
                   -116    -77    -30     -4     +8   +48  +250

WBC                 0.2  0.345   3.15   1.83    4.2  6.09  6.81
[x[10.sup.9/]L]

Neutrophils       0.069  0.107    1.3  0.354   1.57  2.43  2.66
[x[10.sup.9/]L]

Hb [g/L]             46   80.4   79.9   90.6   78.9   102   117

Hct [1/1]          0.13  0.215  0.218  0.237  0.222  0.27  0.32

Pit                15.6   19.2   11.9   23.9     13   106   176
[x[10.sup.9/]L]

Rtc [%]             0.3      -    0.3    0.3    0.2   4.2  1.68

AST [U/L]            67    835    460    283     32    40    22

ALT [U/L]           197   1835   1360   1099     27    49    13

Gamma-GT [U/L]       95    166    449    285     34    35    13

Total bilirubin      25    157     51     56     18    26    17
[[mu]mol/L]

Direct bilirubin    7.2   68.4   39.9   14.3    4.9   6.7   3.9
[[mu]mol/L]

upper normal values: AST 37 U/L, ALT 40 U/L, gamma-GT 55 U/L, Total
bilirubin 21 [micro]mol/L, direct bilirubin 4.2 [micro]mol/L # - before
transplantation, + after transplantation
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.