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Yamamoto K, Najima Y, Iizuka H, Harada Y, Sadato D, Kanai A, Matsui H, Inamoto K, Mukae J, Shingai N, Toya T, Igarashi A, Shimizu H, Kobayashi T, Kakihana K, Sakamaki H, Ohashi K, Harada H, Doki N. Successful Cord Blood Transplantation for Idiopathic CD4+ Lymphocytopenia. Acta Haematol 2021; 144:698-705. [PMID: 34062545 DOI: 10.1159/000516347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/04/2021] [Indexed: 11/19/2022]
Abstract
Idiopathic CD4+ lymphocytopenia (ICL) is the depletion of CD4+ lymphocytes to <300 cells/mm3 without human immunodeficiency virus infection or other causes of lymphocytopenia. ICL causes fatal infections; its etiology remains unclear and it lacks consensus regarding therapeutic options. We report the first patient with ICL who had a successful clinical course following a cord blood transplant (CBT). A 45-year-old woman was diagnosed with ICL and underwent partial hepatectomy for an abscess caused by the Mycobacterium avium complex. No specific gene alterations were detected through next generation sequencing-based evaluation. Following a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, busulfan, and 4 Gy total body irradiation, a single-unit CBT was performed. Neutrophils were engrafted on day +14. CD4+ lymphocyte counts increased to over 300 cells/mm3 on day +436. After 75 months, she was alive without any sequelae. CBT with an RIC regimen could be a curable treatment option for ICL.
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Affiliation(s)
- Keita Yamamoto
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroko Iizuka
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuka Harada
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Daichi Sadato
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Akinori Kanai
- Department of Molecular Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Hirotaka Matsui
- Department of Molecular Laboratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kyoko Inamoto
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Junichi Mukae
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuhiko Kakihana
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hironori Harada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
- Laboratory of Oncology, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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2
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Lucijanic M, Jaksic O. Progressive multifocal leukoencephalopathy during rituximab maintenance after rituximab and bendamustine treatment for relapsed follicular lymphoma. Ann Hematol 2020; 99:2191-2192. [PMID: 32556456 DOI: 10.1007/s00277-020-04143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Marko Lucijanic
- Hematology Department, University hospital Dubrava, Av. Gojka Suska 6, 10000, Zagreb, Croatia
| | - Ozren Jaksic
- Hematology Department, University hospital Dubrava, Av. Gojka Suska 6, 10000, Zagreb, Croatia. .,School of Medicine, University of Zagreb, Zagreb, Croatia.
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3
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Lee SW, Choi D, Heo M, Shin EC, Park SH, Kim SJ, Oh YK, Lee BH, Yang SH, Sung YC, Lee H. hIL-7-hyFc, A Long-Acting IL-7, Increased Absolute Lymphocyte Count in Healthy Subjects. Clin Transl Sci 2020; 13:1161-1169. [PMID: 32339447 PMCID: PMC7719369 DOI: 10.1111/cts.12800] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022] Open
Abstract
A low lymphocyte count puts immune-compromised patients at risk of mortality. hIL-7-hyFc is a homodimeric interleukin-7 (IL-7), a potent T-cell amplifier, fused to the hybridizing IgD/IgG4 immunoglobulin domain. We performed a randomized, double-blind, placebo-controlled, dose-escalation, phase I study to assess the pharmacokinetic, pharmacodynamic, safety, tolerability, and immunogenicity profiles of hIL-7-hyFc administered s.c. and i.m. to healthy volunteers. Thirty subjects randomly received hIL-7-hyFc or its matching placebo in an 8:2 ratio at 20, 60 μg/kg s.c., or 60 μg/kg i.m. The hIL-7-hyFc was slowly absorbed and its terminal half-life was 63.26 hours after i.m. administration. The hIL-7-hyFc increased absolute lymphocyte count, mostly in T-cells, which peaked 3 weeks after administration and then lasted for several additional weeks. The hIL-7-hyFc was well-tolerated after a single s.c. and i.m. administration. Injection site reaction was the most common treatment-emergent adverse event, which resolved spontaneously without treatment. The hIL-7-hyFc can be developed into a beneficial treatment option for patients with compromised T-cell immunity. This trial was registered at www.clinicaltrials.gov as #NCT02860715.
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Affiliation(s)
- Sang Won Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Clinical Pharmacology and Therapeutics, Hanyang University Seoul Hospital, Seoul, Korea
| | | | - MinKyu Heo
- Genexine, Inc., Seongnam-si, Gyeonggi-do, Korea
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea.,Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Su-Hyung Park
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea.,Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - So Jeong Kim
- Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | | | | | | | | | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
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4
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Vijayakumar S, Viswanathan S, Aghoram R. Idiopathic CD4 Lymphocytopenia: Current Insights. Immunotargets Ther 2020; 9:79-93. [PMID: 32548074 PMCID: PMC7239889 DOI: 10.2147/itt.s214139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia is a condition characterized by low CD4 counts. It is rare and most of the information about this illness comes from case reports. Presentation is usually in the 4th decade of life with opportunistic infections, autoimmune disease or neoplasia. The pathophysiology of this condition is not well understood. Management revolves around treatment of the presenting condition and close follow-up of these patients. This review presents a narrative summary of the current literature on idiopathic CD4 lymphocytopenia.
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Affiliation(s)
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
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5
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Berno T, Riva M, Fedrigo M, Naso A, Anglani M, Briani C, Adami F. Immunomodulatory drugs in plasma cell diseases: everything has its price. Leuk Lymphoma 2019; 61:206-208. [PMID: 31502492 DOI: 10.1080/10428194.2019.1657574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tamara Berno
- Department of Medicine, Hematology and Clinical Immunology Unit, University of Padova School of Medicine and Surgery, Padova, Italy
| | - Marcello Riva
- Department of Medicine, Hematology and Clinical Immunology Unit, University of Padova School of Medicine and Surgery, Padova, Italy
| | - Marny Fedrigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiovascular Pathology and Pathological Anatomy Unit, University of Padova School of Medicine and Surgery, Padova, Italy
| | - Agostino Naso
- Department of Medicine, Nephrology Unit, Azienda Ospedaliera di Padova, Padova, Italy
| | - Mariagiulia Anglani
- Department of Neuroscience, Neuroradiology Unit, Padova University Hospital, Padova, Italy
| | - Chiara Briani
- Department of Neuroscience, Neurology Unit, University of Padova School of Medicine and Surgery, Padova, Italy
| | - Fausto Adami
- Department of Medicine, Hematology and Clinical Immunology Unit, University of Padova School of Medicine and Surgery, Padova, Italy
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6
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T cell deficiencies as a common risk factor for drug associated progressive multifocal leukoencephalopathy. Immunobiology 2018; 223:508-517. [PMID: 29472141 DOI: 10.1016/j.imbio.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/19/2018] [Accepted: 01/21/2018] [Indexed: 01/07/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a disease of the central nervous system caused by neuropathogenic prototypes of ubiquitous community-acquired JC virus (JCV). The disease became of particular concern following its association with certain therapies that modulate immune system function without heavy immunosuppression. Due to lack of prophylactic/treatment options and poor outcomes, which often include severe disability or death, PML is a considerable concern for development of new drugs that interfere with immune system functions. In this review of clinical and research findings, we discuss the evidence that deficiencies in CD4+ T helper cells, cytotoxic CD8+ T cells, and interferon gamma are of crucial importance for development of PML under a variety of circumstances, including those associated with use of various drugs, regardless of differences in their mechanisms of action. These deficiencies apparently enable transformation of the harmless JCV archetype into neuropathogenic prototypes, but the site(s), and the mechanisms, of this transformation are yet to be elucidated. Here we discuss the evidence for brain as one of the sites of this transformation, and propose a model of PML pathogenesis that emphasizes the central role of T cell deficiencies in the two life cycles of the JCV, one non-pathogenic and one neuropathogenic. Finally, we conclude that the development of clinical grade T cell functional tests and more consistent use of already available laboratory tests for T cell subset analysis would greatly aid the effort to more accurately predict and assess the magnitude of PML risk for concerned therapeutic interventions.
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7
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Vögelin M, Biedermann L, Frei P, Vavricka SR, Scharl S, Zeitz J, Sulz MC, Fried M, Rogler G, Scharl M. The Impact of Azathioprine-Associated Lymphopenia on the Onset of Opportunistic Infections in Patients with Inflammatory Bowel Disease. PLoS One 2016; 11:e0155218. [PMID: 27214202 PMCID: PMC4877071 DOI: 10.1371/journal.pone.0155218] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/26/2016] [Indexed: 12/18/2022] Open
Abstract
Background Thiopurines are known to cause lymphopenia (<1,500 lymphocytes/μl). As severe lymphopenia (<500C/μl) is associated with opportunistic infections, we investigated severity of thiopurine-related lymphopenia and development of opportunistic infections in our tertiary referral centre. Methods We retrospectively screened medical records of 1,070 IBD patients and identified 100 individuals that developed a total of 161 episodes of lymphopenia during thiopurine treatment between 2002 and 2014. Occurrence of opportunistic infections was documented. A control group consisted of IBD patients receiving thiopurines but without developing lymphopenia. Results Of a total of 161 episodes of lymphopenia, 23% were severe (<500C/μl). In this subgroup, thiopurine dosing was modified in 64% (dosage reduction: 32%, medication discontinued: 32%). We identified 9 cases (5.5%) of opportunistic infections, of which only two occurred during severe lymphopenia. One opportunistic infection (4.5%) was identified in the control group. No association was found between opportunistic infections and severity of lymphopenia. All patients who suffered from opportunistic infections were receiving additional immunosuppressive medication. Conclusion Our patients treated with thiopurines rarely developed severe lymphopenia and opportunistic infections did not occur more often than in the control group. A careful monitoring of lymphocytes and prophylactic adjustment of thiopurine therapy might contribute to this low incidence.
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Affiliation(s)
- Marius Vögelin
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pascal Frei
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephan R. Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Sylvie Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael C. Sulz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Michael Fried
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- * E-mail:
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8
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Berghoff M, Schänzer A, Hildebrandt GC, Dassinger B, Klappstein G, Kaps M, Gizewski ER, Acker T, Grams A. Development of progressive multifocal leukoencephalopathy in a patient with non-Hodgkin lymphoma 13 years after treatment with cladribine. Leuk Lymphoma 2012; 54:1340-2. [PMID: 23098217 DOI: 10.3109/10428194.2012.740669] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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9
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Zhang M, Li F, Rasper M, Saad AG, Kesari S. Prolonged stability of progressive multifocal leukoencephalopathy in a patient with chronic lymphocytic leukemia. J Clin Oncol 2010; 28:e503-6. [PMID: 20585084 DOI: 10.1200/jco.2009.26.8078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Meng Zhang
- Daping Hospital, Third Military Medical University, Chongqing, China
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10
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Chihara D, Takeoka T, Shirase T, Kishimoto W, Arimoto-Miyamoto K, Tsuji M, Ohno T. Progressive multifocal leukoencephalopathy in myelodysplastic syndrome involving pure red cell aplasia. Intern Med 2010; 49:2347-52. [PMID: 21048373 DOI: 10.2169/internalmedicine.49.4081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare and fatal demyelinating disease of the central nervous system caused by JC polyomavirus (JCV) reactivation in an immunocompromised host. We describe a case of PML in a 76-year-old woman with myelodysplastic syndrome, who had been treated with azathioprine for a pure red cell aplasia-like condition. PML was diagnosed based on the neurologic symptoms, the magnetic resonance imaging patterns and the detection of JCV DNA in the cerebrospinal fluid. She died ten months after the diagnosis. An autopsy confirmed the diagnosis, and JCV DNA was detected in the cerebrum. Azathioprine might have triggered PML.
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Affiliation(s)
- Dai Chihara
- Division of Hematology and Immunology, Department of Internal Medicine, Ohtsu Red Cross Hospital, Ohtsu
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11
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Kiewe P, Seyfert S, Körper S, Rieger K, Thiel E, Knauf W. Progressive Multifocal Leukoencephalopathy with Detection of JC Virus in a Patient with Chronic Lymphocytic Leukemia Parallel to Onset of Fludarabine Therapy. Leuk Lymphoma 2009; 44:1815-8. [PMID: 14692540 DOI: 10.1080/1042819031000116625] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Along with the establishment of more intense chemotherapeutic regimens including fludarabine for the treatment of indolent lymphoproliferative diseases like chronic lymphocytic leukemia (CLL), an increasing amount of cases with progressive multifocal leukoencephalopathy (PML) due to JC virus have been observed. We report a patient with CLL who developed PML parallel to the onset of fludarabine therapy. Spinal fluid was tested positive for JC virus. Despite virostatic treatment with cidofovir, neurologic symptoms were progressive and the disease ultimately fatal. The present case suggests that immunosuppression caused by chronic lymphoproliferative malignancies alone may be a factor in the development of PML. Chemotherapy with fludarabine may act as an additional trigger. The question remains whether serologic screening for JC virus in patients with chronic lymphoproliferative disease undergoing intense chemotherapy might be valuable once sufficient antiviral treatment has been established.
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Affiliation(s)
- Philipp Kiewe
- Department of Hematology, Oncology and Transfusion Medicine, Benjamin Franklin University Hospital, Free University of Berlin, Berlin, Germany
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12
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Oshima K, Tsuchiya K, Niizato K, Akiyama H, Arai T, Nagashima K. Clinicopathological study of early progressive multifocal leukoencephalopathy incidentally found in a schizophrenia patient. Neuropathology 2009; 29:684-8. [PMID: 19170897 DOI: 10.1111/j.1440-1789.2008.00992.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 58-year-old Japanese man developed psychomotor excitement and hallucinatory paranoia at age 53, which gradually developed to residual schizophrenia. He was administered various common tranquilizers until death. Myelodysplastic syndrome was noted 10 months before death. A routine autopsy was performed. The brain weighed 1365 g, and macroscopic observation revealed no remarkable findings. However, microscopic examination disclosed cells with enlarged and basophilic nuclei, and unusual astrocytes in the demyelinated foci, especially at the corticomedullary junctions in the temporal and occipital lobes. On the other hand, the white matter was relatively intact. Immunohistochemical analysis using anti-JC virus protein, VP-1 antibody, demonstrated JC virus-infected cells in not only abnormal glial cells and neurons but also normal-looking cells, which are suggestive of progressive multifocal leukoencephalopathy (PML). Immunostaining for GFAP revealed severe gliosis and some scattered abnormal enlarged nuclear cells in the lesions. Some clusters of CD8-positive lymphocytes were seen, which kill infected cells. PML could be considered a short-term disease preceding death, as "incidental PML" in this case. This is a rare autopsy case of early PML occurring in a schizophrenia patient with PML.
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Affiliation(s)
- Kenichi Oshima
- Department of Psychiatry, Tokyoo Metropolitan Matsuzawa Hospital, Tokyo, Japan.
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13
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Kesari S, Akar S, Saad A, Drappatz J, Koralnik IJ, DeAngelo DJ. Progressive multifocal leukoencephalopathy in a patient with relapsed acute myelogenous leukemia. J Clin Oncol 2008; 26:3804-7. [PMID: 18669471 DOI: 10.1200/jco.2008.17.3047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Santosh Kesari
- Department of Neurology, Dana-Farber/Brigham and Women's Cancer Center, Center for Neuro-Oncology, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW A severe decrease of CD4 T cells predisposes humans to opportunistic infections. In adults, HIV is certainly the most common cause of CD4 lymphocytopenia, but other causes, such as infections, autoimmune diseases, immunosuppressive therapy, lymphoma and idiopathic forms need to be considered. This review summarizes the current knowledge of the poorly understood syndrome of idiopathic CD4 lymphocytopenia. RECENT FINDINGS Little research has tried to systematically dissect this probably heterogeneic syndrome after its initial description in 1992. Numerous cases presenting with opportunistic infections have been reported. Disturbed differentiation of stem cell precursors may contribute to CD4 lymphocytopenia. Because infections and lymphoma may also cause CD4 lymphocytopenia, the distinction between cause and effect may evolve only during follow-up. SUMMARY The manifestation of opportunistic infections calls for the evaluation of the immune system for CD4 lymphocytopenia. The differential diagnosis of this condition in adults comprises primarily HIV infection and less often other diseases or drugs. Idiopathic CD4 lymphocytopenia is very rare. The clinical significance of low CD4 cell counts in HIV negative patients still awaits its systematic analysis. Prophylaxis of opportunistic infections is oriented at the recommendations of HIV-infected individuals and causal treatment remains experimental.
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Affiliation(s)
- Ulrich A Walker
- Division of Rheumatology and Clinical Immunology, Freiburg University Hospital, Freiburg, Germany
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Woodard P, Helton K, McDaniel H, Khan RB, Thompson S, Hale G, Benaim E, Kasow K, Leung W, Horwitz E, Srivastava DK, Tong X, Yusuf U, Cunningham JM, Handgretinger R. Encephalopathy in pediatric patients after allogeneic hematopoietic stem cell transplantation is associated with a poor prognosis. Bone Marrow Transplant 2005; 33:1151-7. [PMID: 15077130 PMCID: PMC7091772 DOI: 10.1038/sj.bmt.1704480] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Encephalopathy is a poorly characterized complication of hematopoietic stem cell transplantation (HSCT). No comprehensive report of encephalopathy exists for children, and the literature contains only a few for adults. We analyzed a large cohort of 405 pediatric patients who underwent allogeneic HSCT during a 10-year period and identified 26 patients (6.4%) who experienced encephalopathy. Identifiable causes of encephalopathy included infection (n=5), single or multiorgan failure (n=4), medication-related complications (n=3), nonconvulsive seizures (n=4), acute disseminated encephalomyelitis (n=2), thrombotic thrombocytopenic purpura (n=2), and stroke (n=1). We were unable to identify the etiology of encephalopathy in five (19%) patients. The prognosis for pediatric patients with encephalopathy was poor: only four (15%) experienced complete neurologic recovery, and 10 (38%) patients experienced partial recovery with residual neurologic deficits. Nine (35%) patients with complete or partial recovery survive long term. A total of 17 patients died; one died of progressive encephalopathy, and 16 died of either relapse of primary disease or toxicity. MRI, CSF analysis including molecular testing for infectious pathogens, and brain biopsy were helpful in obtaining a diagnosis in most of our patients. However, a standardized approach to accurate and timely diagnosis and treatment is needed to improve outcome in these patients.
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Affiliation(s)
- P Woodard
- Division of Stem Cell Transplantation, Department of Hematology-Oncology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
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