Biomedical subjects
Publications and source records attributed to R Or.
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Gastrointestinal complications are described frequently after preparation of patients for bone marrow transplantation (BMT). Two patients who underwent BMT developed complications due to gastrointestinal bezoars. One patient developed intestinal obstruction, which necessitated emergency surgery, and the other patient had a gastric bezoar, which caused vomiting. The diagnosis and treatment of this rare complication after BMT are described.
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Two patients undergoing bone marrow transplantation developed severe gastrointestinal symptoms, one during the peri-transplantation period and the other several months post-transplantation and following documented intestinal graft-versus-host disease. After detection of Giardia lamblia trophozoites in a stool specimen from one patient and a duodenal aspirate from the other, treatment with metronidazole was administered and all symptoms resolved. Giardiasis should be considered in transplant patients with diarrhea. Negative stool examinations do not rule out this possibility, and consideration should be given to examining a sample of small intestinal contents for Giardia trophozoites.
We described two patients with severe thrombocytopenia and bleeding tendency related to treatment with glibenclamide (short-acting sulfonylurea). To the best of our knowledge, thrombocytopenic purpura associated with this medication has been reported only twice previously. We suggest that platelet count should be carried out early after initiating glibenclamide treatment and every 3 months thereafter.
A 37-year-old male patient with advanced refractory plasma cell myeloma underwent T-cell depleted bone marrow transplantation (BMT) after 7 years of active disease previously treated with combination chemotherapy and irradiation. After the BMT there was marked clinical improvement and the patient is currently in good clinical condition two years after the BMT was performed. However, residual myeloma cells are still seen in the marrow and stable levels of paraprotein are still present in the serum. No GVHD was encountered after BMT. The problems of BMT in myeloma are discussed with a review of the current pertinent literature.
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The present report summarizes our experience in applying a new approach in bone marrow transplantation for the treatment of beta-thalassemia major. Ex-vivo pretransplant T-lymphocyte depletion with CAMPATH-1 was used for prevention of acute and chronic graft versus host disease and total lymphoid irradiation was added for the conditioning regimen for abrogation of potential rejection of T-cell depleted marrow allografts. Ten patients with homozygous beta-thalassemia major were 9-48 months of age (median 18.5 months) and received HLA-identical allogeneic T-cell depleted marrow after treatment with total lymphoid irradiation, busulfan and cyclophosphamide. Seven patients are alive and free of disease, 3-46 months post-transplantation. The actuarial probability of survival and of disease-free survival at two years was 70%. Three patients died: one of intracranial hemorrhage post-transplantation, one from busulfan interstitial pneumonitis, and one who rejected the first graft and developed fatal chronic graft versus host disease after a second transplant. Seven patients are alive and well with follow-up of 3-45 months, with no signs of acute or chronic GVHD. We conclude that T-cell depleted bone marrow transplantation is indicated for homozygous transfusion dependent young patients with beta-thalassemia who are minimally transfused, particularly in areas where optimal conventional therapy is not feasible.
An immunocompromised patient, 6 weeks after bone marrow transplantation, developed extensive skin infection due to Trichophyton rubrum. Because she could not tolerate ketoconazole and was hypersensitive to griseofulvin, she received itraconazole with complete recovery within 30 days. This case demonstrates that itraconazole may be effective treatment for dermatophytosis, even in immunocompromised hosts, and that there is no cross-reactivity between ketoconazole and itraconazole.
The incidence of interstitial pneumonitis (IP) was reviewed in 80 consecutive patients who received allogeneic T lymphocyte-depleted bone marrow transplantation (BMT) for malignant and non-malignant diseases. Pretransplant conditioning used in malignant disorders included total lymphoid irradiation (TLI) 150 cGy x 4, total body irradiation (TBI) 200 cGy x 6, and cyclophosphamide (CY) 120 mg/kg. In non-malignant diseases conditioning included no TBI, but adjusted doses of TLI in addition to CY (severe aplastic anemia) or CY and busulfan (severe beta-thalassemia major). In the malignant group only one patient developed graft-versus-host disease (GVHD) grade I; IP developed in 12 out of 61 patients (19.7%) and IP-associated fatality occurred in five patients (8.2%). Cytomegalovirus (CMV) was associated with only two of the five fatal IP. In the non-malignant group there was no GVHD; one patient out of 19 (5.2%) had IP, which was fatal and not associated with CMV. These data indicate that fatal IP may appear in the absence of GVHD. The relatively low incidence of IP-related mortality in recipients of allogeneic T lymphocyte-depleted BMT suggests that although prevention of GVHD and elimination of drugs used for GVHD prevention may reduce the incidence of fatal pulmonary complications, other approaches have to be investigated for complete prevention of IP which still represents a major complication in patients with malignant hematologic disorders treated by allogeneic BMT.
Host T lymphocytes which escape the effects of chemoradiotherapy may proliferate and lead to graft rejection, particularly in recipients of T cell-depleted bone marrow (BM) allografts. We studied the efficacy of several conditioning regimens including a new immunosuppressive regimen--total lymphoid irradiation (TLI) plus conventional chemotherapy and total body irradiation (TBI)--in abrogating residual host T lymphocytes as assessed by their ability to grow in vitro. A total of 38 patients were evaluated, 29 with hematologic malignancies, six with severe aplastic anemia (AA) and three with beta-thalassemia major (TM), of whom 32 were transplanted with HLA-identical T cell-depleted allogeneic BM from sibling donors. The median observation period was 15 months (range 3-21) posttransplant. Peripheral blood mononuclear cells (PBMC) taken from each patient on the day of transplant were cultured with interleukin 2 (IL-2) + phytohemagglutinin + irradiated donors' PBMC. Survival of cells for less than 2 weeks in vitro without proliferation was observed in 20 of 29 cases with malignancies and was considered negative. In this group only two leukemia (L) patients rejected the graft. Limited cell growth (less than or equal to 3 weeks) was seen in four L patients, two of whom showed early graft failure. Vigorous T cell growth (greater than 5 weeks, 62-96% CD4+ cells) was noted in eight cases (two L, four AA, two TM; none received TBI). In this group, sustained engraftment was observed in 7/7 patients who were treated with cyclosporin A (CSA) post grafting. Overall, we could demonstrate no clear correlation between graft failure and cell growth in vitro. The proliferating cells exhibited considerable cytotoxic activity in vitro against several tumor cell lines and were susceptible to pharmacological doses of CSA. The low incidence of continuous T cell proliferation in vitro in PBMC of L patients suggests that a combination of TLI, TBI and cyclophosphamide (CY) is highly effective in abrogating the host T cells and subsequent graft rejection. Since a rather small number of patients was included in this study, further studies are needed to determine the possible value of the in vitro T cell proliferation assay as a means for predicting graft failure.
Homogeneous populations of human mast cells were differentiated and grown by culturing bone marrow cells in the presence of conditioned medium derived from lectin-stimulated human peripheral blood mononuclear cells. The cells obtained were similar in ultrastructure, proteoglycan type and lipid products generated upon calcium ionophore A23187, and immunological activation to the murine E-mast cells (E-MC) differentiated in culture containing IL-3. Fluorescence analysis revealed that the human E-MC expressed IgE-Fc receptors which retained bound IgE through several washes. These cells did not express cell-surface lymphoid determinants (T11, T4, T8 and B4) and myeloid determinants 'My'. However, 40% of these cells expressed monocytic surface determinants, such as M-1. The amount of histamine that was found per 10(6) cells was 525 +/- 106 ng (mean +/- SE, n = 4). These cultured mast cells possessed granular chondroitin sulphate E proteoglycan of about 180,000 MW. Following activation with either calcium ionophore A23187 or anti-hIgE challenge, these mast cells released their preformed mediators and generated mainly leukotriene C4 leukotriene B4, and platelet-activating factor. In conclusion, according to all of these criteria, these human cultured mast cells show many similarities to the murine cultured E-mast cells, and therefore could be considered as the culture analogue of the human intestinal E-mast cells identified recently.
The occurrence of HSV infection and the effect of prophylaxis with oral acyclovir were evaluated prospectively in 34 consecutive patients undergoing bone marrow transplantation (BMT). All allogeneic BMT procedures involved T-lymphocyte depletion for prevention of graft-vs.-host disease (GVHD). Five HSV-seronegative patients did not receive acyclovir, and they did not develop HSV infection. Oral acyclovir was administered to 15 HSV-seropositive BMT recipients; 14 untreated HSV-seropositive BMT recipients served as a control group. The adult dose of acyclovir was 400 mg three times a day on Days -6 to +14 and 200 mg three times a day on Days +15 to +90. Children received 500 mg/m2 per day divided into three equal doses on Days -6 to +14 and 250 mg/m2 per day again divided into three on Days +15 to +90. In the group on prophylaxis, only one developed HSV infection during the time prior to engraftment. In the reference group, 12 of 14 (85.7%) developed oral HSV infection within 0 to 16 days (median 11 days) after the transplantation. Time for engraftment (duration of neutropenia) was shorter in patients receiving acyclovir. After engraftment, HSV infection was not observed during administration or following discontinuation of acyclovir on Day 90, but occurred in three patients in whom acyclovir was discontinued on Days 25, 35 and 40 after BMT. In the untreated group, two patients had recurrence of HSV infection on Days 40 to 60, and one had two infectious episodes. GVHD occurred in only two recipients, neither of whom had HSV infection. We conclude that the incidence of HSV infection during the period until engraftment in recipients of T-lymphocyte-depleted BMT is high, similar to that reported by others in recipients of whole BMT. Relatively low-dose oral acyclovir administered for 90 days can effectively prevent HSV infections in previously HSV-seropositive BMT recipients and may also shorten the period until engraftment.
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Serum ferritin levels were monitored in nine patients with acute lymphoblastic leukemia (ALL), nine patients with acute nonlymphoblastic leukemia (ANLL), four patients with chronic myelogenous leukemia (CML), three patients with non-Hodgkin's lymphoma (NHL), and three patients with severe aplastic anemia (SAA) undergoing bone marrow transplantation (BMT) for hematologic malignancies or aplastic anemia. Serum ferritin analysis was performed before and after BMT at monthly intervals and/or according to the clinical condition of the patient. Serum ferritin increased considerably during the first 3 months following BMT and then decreased in patients with an uncomplicated course. Ferritin levels in the serum of patients who had undergone BMT decreased gradually when complete remission was achieved, but increased with any clinical complication. Thus, elevation of serum ferritin concentration was predictable for clinical complications and for relapse. Patients with acute leukemia with serum ferritin levels above 400 micrograms/l at time of BMT had a risk of relapse within 1 year, triple that patients with lower ferritin levels. All patients who underwent BMT to treat severe aplastic anemia have completely recovered. Accordingly, following an initial increase after BMT, serum ferritin levels returned to normal and remained so in line with the patients' good clinical condition. The findings indicate that serum ferritin yields useful information in the clinical evaluation of patients undergoing BMT.
A 45-year-old male developed myasthenia gravis 8 years ago. He received prednisone for 3 years, and resumed complete clinical remission. Five years later, he was admitted with obstruction of the superior vena cava. Invasive thymoma was diagnosed by chest X-ray and an open lung biopsy. Radiation followed by combination chemotherapy with cyclophosphamide, vincristine, and prednisone induced a complete remission. The patient remained disease-free for more than 20 months after the first admission to our department. To the best of our knowledge, superior vena cava syndrome as the presenting symptom of thymoma has never been reported previously.