1
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Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GM, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International Recommendations for Screening and Preventative Practices for Long-Term Survivors of Transplantation and Cellular Therapy: A 2023 Update. Transplant Cell Ther 2024; 30:349-385. [PMID: 38413247 DOI: 10.1016/j.jtct.2023.12.001] [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: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the number of HCTs performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pretransplantation, peritransplantation, and post-transplantation exposures and other underlying risk factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and then updated in 2012. An international group of experts was convened to review the contemporary literature and update the recommendations while considering the changing practices of HCT and cellular therapy. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed, but cGVHD management is not covered in detail. These guidelines emphasize the special needs of patients with distinct underlying HCT indications or comorbidities (eg, hemoglobinopathies, older adults) but do not replace more detailed group-, disease-, or condition-specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Neel S Bhatt
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, Massachusetts
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, Arizona
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, California
| | | | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Gregory Mt Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, St Vincent's Clinical School Sydney, University of New South Wales, School of Medicine Sydney, University of Notre Dame Australia, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, PathWest Laboratory Medicine WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Department of Public Health and Primary Care, ACCENT VV, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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2
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Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GMT, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: a 2023 update. Bone Marrow Transplant 2024:10.1038/s41409-023-02190-2. [PMID: 38413823 DOI: 10.1038/s41409-023-02190-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the volume of HCT performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long-term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pre-, peri- and post-transplant exposures and other underlying risk-factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and updated in 2012. To review contemporary literature and update the recommendations while considering the changing practice of HCT and cellular therapy, an international group of experts was again convened. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed but cGVHD management is not covered in detail. These guidelines emphasize special needs of patients with distinct underlying HCT indications or comorbidities (e.g., hemoglobinopathies, older adults) but do not replace more detailed group, disease, or condition specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
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Affiliation(s)
- Seth J Rotz
- Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, MA, USA
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
| | - Peggy Burkhard
- National Bone Marrow Transplant Link, Southfield, MI, USA
| | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, NSW, Australia
- St Vincent's Clinical School Sydney, University of New South Wales, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, WA, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, WA, Australia
- PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, UK
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Susan K Stewart
- Blood & Marrow Transplant Information Network, Highland Park, IL, 60035, USA
| | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, TN, USA
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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3
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Wolff L, Clottu A, Mamez AC, Ribi C, Grandoni F. Myositis manifesting as respiratory insufficiency with anti-RNA polymerase III antibodies: an unusual presentation of graft-versus-host disease. Leuk Lymphoma 2023; 64:1588-1591. [PMID: 37287207 DOI: 10.1080/10428194.2023.2220452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Louis Wolff
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Aurélie Clottu
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Anne-Claire Mamez
- Division of Hematology, Geneva University Hospitals, Geneva, Switzerland
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Francesco Grandoni
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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4
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Futamura M, Ozaki Y, Makino H, Tsujimoto S, Shigesaka M, Tanaka A, Shimamoto K, Son Y, Ito T, Nomura S. Anti-MDA-5 Antibody-positive Dermatomyositis after Allogeneic Bone Marrow Transplantation for Acute Transformation of Chronic Myelogenous Leukemia. Intern Med 2023; 62:1081-1087. [PMID: 36070956 PMCID: PMC10125815 DOI: 10.2169/internalmedicine.9529-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Anti-melanoma differentiation-associated gene 5 (MDA-5) antibody-positive dermatomyositis is a disease with a poor prognosis associated with rapid progressive interstitial pneumonia. Autoimmune diseases have occasionally been reported to occur after hematopoietic stem cell transplantation (HSCT). We experienced a case of anti-MDA-5 antibody-positive dermatomyositis after HSCT. In this case, a sufficient dose of cyclophosphamide could not be administered due to an impaired bone marrow function. We discuss the complications of autoimmune diseases after HSCT.
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Affiliation(s)
- Mariko Futamura
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Yoshio Ozaki
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Hidehiko Makino
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- Department of Rheumatology, Osaka Medical and Pharmaceutical University Hospital, Japan
| | - Saki Tsujimoto
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Minoru Shigesaka
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Akihiro Tanaka
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Keiko Shimamoto
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Yonsu Son
- Department of Rheumatology and Clinical Immunology, Kansai Medical University Hospital, Japan
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Japan
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5
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Kvinge AD, Kvammen T, Miletic H, Bindoff LA, Reikvam H. Musculoskeletal Chronic Graft versus Host Disease-A Rare Complication to Allogeneic Hematopoietic Stem Cell Transplant: A Case-Based Report and Review of the Literature. Curr Oncol 2022; 29:8415-8430. [PMID: 36354723 PMCID: PMC9689675 DOI: 10.3390/curroncol29110663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Musculoskeletal graft versus host disease (GVHD) is a rare manifestation of chronic GVHD (cGVHD) following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Left untreated, the disease can cause extensive damage to muscle tissue and joints. We describe a 62-year-old male with musculoskeletal GVHD and generalized muscle pain and stiffness. In addition, we performed a systemic literature review based on published cases of musculoskeletal GVHD between 1983 and 2019. We identified 85 cases, 62% male and 38% female with an age of 4-69 years and median age of 39 years at diagnosis. The majority of patients (72%) also had manifestations of cGVHD in at least one other organ system, most frequently the skin (52%), followed by oropharyngeal mucosa (37%), and pulmonary and gastrointestinal tract (GI tract) (21%). We conclude that, while musculoskeletal cGVHD is a rare complication of allo-HSCT, it remains a serious and debilitating risk that must be considered in patients with muscle pain, muscle weakness, joint stiffness, and tissue inflammation. Early intervention is critical for the patient's prognosis.
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Affiliation(s)
| | - Tobias Kvammen
- Institute of Clinical Science, Faculty of Medicine, University of Bergen, N-5021 Bergen, Norway
| | - Hrvoje Miletic
- Department of Pathology, Haukeland University Hospital, N-5021 Bergen, Norway
- Department of Biomedicine, University of Bergen, N-5009 Bergen, Norway
| | - Laurence Albert Bindoff
- Department of Neurology, Haukeland University Hospital, N-5021 Bergen, Norway
- Institute of Medical Science, Faculty of Medicine, University of Bergen, N-5021 Bergen, Norway
| | - Håkon Reikvam
- Institute of Clinical Science, Faculty of Medicine, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
- Correspondence: ; Tel.: +55-97-5000; Fax: +55-97-2950
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Roy C, Lai EJ, Lee AHA, Schutz P, Maguire J, Toze CL, Nevill TJ, Abou Mourad YR. Granulomatous Myositis as a Manifestation of Chronic Graft-Versus-Host Disease: A Case Series and Review of the Literature. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e459-e462. [PMID: 35074288 DOI: 10.1016/j.clml.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Claudie Roy
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, Vancouver, Canada.
| | - Emily J Lai
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia Division of Community Internal Medicine, Royal Columbian Hospital, New Westminster, Canada
| | - Abigail Hyun Ae Lee
- Department of Medicine, University of British Columbia Division of Community Internal Medicine, Royal Columbian Hospital, New Westminster, Canada
| | - Peter Schutz
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - John Maguire
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Cynthia L Toze
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Thomas J Nevill
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Yasser R Abou Mourad
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, Vancouver, Canada
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Shiota T, Eura N, Hasegawa A, Kiriyama T, Sugie K. Pathological features of inflammatory myopathy as a manifestation of chronic graft-versus-host disease after allogeneic bone marrow transplantation. Neuropathology 2022; 42:309-314. [PMID: 35508303 DOI: 10.1111/neup.12816] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/26/2022] [Accepted: 04/02/2022] [Indexed: 11/28/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is the most important complication resulting in the death of bone marrow transplantation (BMT) survivors. It is also a relatively rare cause of inflammatory myopathy (IM). We report the case of a 46-year-old woman who developed severe cGVHD-related IM after BMT for myelodysplastic syndrome. She presented with severe muscle pain and weakness with cGVHD-related symptoms in other organs. Myopathological analysis showed moderate cell infiltration with remarkable necrotic and regenerative fibers. Sarcoplasm and capillaries expressed C5b9 and myxovirus resistance protein 1. Non-necrotic fibers in perifascicular regions expressed MHC-II. Steroid therapy did not sufficiently control cGVHD-related IM, and the patient was concurrently treated with an immunosuppressant. Our findings show that IM is a key manifestation of cGVHD and that the expression of interferon-inducible proteins in muscle pathology is useful for identifying cGVHD-related IM.
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Affiliation(s)
- Tomo Shiota
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Nobuyuki Eura
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Atsushi Hasegawa
- Department of Hematology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Takao Kiriyama
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Japan
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8
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Yan M, Su F, Cheng F, Shi J, Zheng W, Luo Y, Wang J, Lu H, Zhou H, Huang H, Tan Y. Chronic graft-versus-host disease-related polymyositis and myocarditis: A case report and review of the literature. Transpl Immunol 2022; 72:101598. [DOI: 10.1016/j.trim.2022.101598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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Shahzad M, Chaudhary SG, Basit A, Thellman C, Rodriguez L, Abhyankar SH, McGuirk JP, Mushtaq MU. Chronic graft-versus-host disease presenting as acute polymyositis: A case series and systematic review. Transpl Immunol 2021; 70:101520. [PMID: 34952168 DOI: 10.1016/j.trim.2021.101520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/24/2022]
Abstract
Chronic graft-versus-host disease (cGvHD) remains a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Commonly targeted organs are skin, eyes, mouth, gastrointestinal tract, and liver. Muscular involvement and presentation as acute polymyositis (APM) remain a rare manifestation of cGvHD. We present a case series of three patients who presented with APM as a sole presentation of cGvHD and were treated successfully with corticosteroids and ruxolitinib. We also conducted a systematic review including 72 patients to summarize current literature regarding APM associated with cGvHD after allo-HSCT. The estimated incidence of cGvHD-associated APM is up to 3.4%, with a median time to onset of 1.6 years post-allo-HSCT. Most cases (85%) presented with myalgia and progressive bilateral proximal muscle weakness with elevated creatine kinase and/or aldolase. Over half of the patients had a prior history of acute GvHD. Isolated APM presenting without other clinical manifestations of cGvHD was rare. Biopsy of affected muscles usually shows characteristic myonecrosis, which remains the gold standard for diagnosis. Most cases respond to systemic steroids and immunosuppressive therapy. However, refractory cases remain challenging to treat and can cause significant morbidity and mortality. Ruxolitinib appears to be an effective therapy in this setting.
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Affiliation(s)
- Moazzam Shahzad
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Sibgha Gull Chaudhary
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Abdul Basit
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Connor Thellman
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Liza Rodriguez
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Sunil H Abhyankar
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Joseph P McGuirk
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Muhammad Umair Mushtaq
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States.
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10
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Limaye S, Limaye V. Clinical Characteristics of Myositis Associated with Graft-Versus-Host Disease. Curr Rheumatol Rep 2021; 23:30. [PMID: 33893887 DOI: 10.1007/s11926-021-00996-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk for inflammatory myositis; histological subsets reported include dermatomyositis, necrotising myopathy and chronic graft-versus-host disease (cGVHD)-related myositis. Though corticosteroids and various immunosuppressive therapies have been used, there is a lack of consensus guidelines dictating therapy. RECENT FINDINGS Recent evidence suggests the fascia as a preferential target in cGVHD myositis, with conditioning regimens promoting fascial microtrauma. Positron emission tomography (PET) can be a useful diagnostic tool, and case reports suggest that the Bruton's tyrosine kinase inhibitor ibrutinib may have therapeutic potential. Emerging therapies include targeted B cell depletion with rituximab, and extracorporeal photophoresis. Clinicians need to be vigilant for the development of inflammatory myositis post-allogeneic HSCT as most patients respond to treatment. Advances in immunohistochemistry to determine the dominant cell type and cytokine profile may enable targeted and individualised therapies.
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Affiliation(s)
- Sandhya Limaye
- Department of Immunology, Concord Hospital, Hospital Road, Concord, NSW, 2139, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Vidya Limaye
- Department of Rheumatology, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia. .,Discipline of Medicine, University of Adelaide, Adelaide, Australia.
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11
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Saw JL, Sidiqi MH, Mauermann ML, Alkhateeb H, Naddaf E. Immune-mediated neuromuscular complications of graft-versus-host disease. Muscle Nerve 2021; 63:852-860. [PMID: 33651380 DOI: 10.1002/mus.27214] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/20/2021] [Accepted: 02/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION/AIMS We aimed to describe the clinical phenotype, histopathological findings and overall survival (OS) of the immune-mediated neuromuscular complications of graft-versus-host disease (GVHD). METHODS We conducted a retrospective chart review of adult patients presenting with immune-mediated neuromuscular complications of GVHD to Mayo Clinic, between April 2013 and July 2018.We collected clinical and laboratory characteristics, histopathological findings, response to treatment and survival data. RESULTS We identified 20 patients with a mean age at presentation of 55 y. Mean time from transplant to neurological presentation was 14 mo. Myositis was the most common complication seen in 17 patients, manifesting with predominantly axial and/or proximal weakness. Eleven patients had a muscle biopsy showing diffuse perimysial, predominantly macrophagic infiltration in 10, 3 of them with perimysial perivascular lymphocytic collections, and endomysial and perimysial lymphocytic infiltration in 1. Only two patients had a neuropathic complication: one each with acute inflammatory demyelinating polyradiculoneuropathy and neuralgic amyotrophy. A single patient had a myasthenic syndrome presenting with fluctuating foot drop. Nineteen patients were treated and all responded to immunosuppressive agents; however, 11 had further GVHD flares requiring escalation of therapy. After a median follow-up of 83 mo, seven (35%) patients died: five from progressive GVHD and two from infections. The 5-y OS from time of transplant was 68%. DISCUSSION Myositis is the most common immune-mediated neuromuscular complication of GVHD while peripheral neuropathy and myasthenic syndromes appear less common. The macrophage-predominant infiltration on muscle biopsy deserves further study to better clarify the role of macrophages in GVHD pathogenesis.
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Affiliation(s)
- Jacqui-Lyn Saw
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hasib Sidiqi
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hassan Alkhateeb
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Patel DM, Newallo DS, Barron B. Graft-Versus-Host Disease Presenting as a Myositis and Myonecrosis. Clin Nucl Med 2020; 45:e495-e497. [PMID: 32701802 DOI: 10.1097/rlu.0000000000003201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Graft-versus-host disease (GVHD) is a major complication of bone marrow transplantation. Polymyositis with myonecrosis is a rare manifestation of GVHD. Here, we report the case of a 32-year-old man with acute myeloid leukemia who developed GVHD after transplant. He subsequently developed polymyositis, which was diagnosed on PET/CT and confirmed on pathology. Treatment with corticosteroids resulted in the resolution of the symptoms. Abnormal muscular FDG uptake resolved on the follow-up PET/CT.
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Affiliation(s)
- Dhruv M Patel
- From the Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University
| | - Domnique S Newallo
- From the Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University
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13
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Pestronk A. Chronic Graft Versus Host Myopathies: Noninflammatory, Multi-Tissue Pathology With Glycosylation Disorders. J Neuropathol Exp Neurol 2019; 79:102-112. [DOI: 10.1093/jnen/nlz111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/28/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
Myopathies during chronic graft-versus-host disease (cGvHD) are syndromes for which tissue targets and mechanisms of muscle damage remain incompletely defined. This study reviewed, and pathologically analyzed, 14 cGvHD myopathies, comparing myopathology to other immune myopathies. Clinical features in cGvHD myopathy included symmetric, proximal weakness, associated skin, gastrointestinal and lung disorders, a high serum aldolase (77%), and a 38% 2-year survival. Muscle showed noninflammatory pathology involving all 3 tissue components. Perimysial connective tissue had damaged structure and histiocytic cells. Vessel pathology included capillary loss, and reduced α-l-fucosyl and chondroitin sulfate moieties on endothelial cells. Muscle fibers often had surface pathology. Posttranslational glycosylation moieties on α-dystroglycan had reduced staining and abnormal distribution in 86%. Chondroitin-SO4 was reduced in 50%, a subgroup with 3-fold longer times from transplant to myopathy, and more distal weakness. cGvHD myopathies have noninflammatory pathology involving all 3 tissue components in muscle, connective tissue, small vessels, and myofibers. Abnormal cell surface glycosylation moieties are common in cGvHD myopathies, distinguishing them from other immune myopathies. This is the first report of molecular classes that may be immune targets in cGvHD. Disordered cell surface glycosylation moieties could produce disease-related tissue and cell damage, and be biomarkers for cGvHD features and activity.
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Affiliation(s)
- Alan Pestronk
- Departments of Neurology, and Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri (AP)
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14
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New-Tolley J, Smith C, Koszyca B, Otto S, Maundrell A, Bardy P, Hiwase D, Yong ASM, Lewis I, Limaye V. Inflammatory myopathies after allogeneic stem cell transplantation. Muscle Nerve 2018; 58:790-795. [DOI: 10.1002/mus.26341] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 08/27/2018] [Accepted: 09/01/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Julia New-Tolley
- University of Adelaide, North Terrace; Adelaide South Australia 5000 Australia
| | | | | | - Sophia Otto
- SA Pathology; Adelaide South Australia Australia
| | - Adam Maundrell
- Department of Rheumatology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Peter Bardy
- Department of Haematology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Devendra Hiwase
- Department of Haematology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Agnes S. M. Yong
- University of Adelaide, North Terrace; Adelaide South Australia 5000 Australia
| | - Ian Lewis
- University of Adelaide, North Terrace; Adelaide South Australia 5000 Australia
| | - Vidya Limaye
- Department of Rheumatology; Royal Adelaide Hospital; Adelaide South Australia Australia
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15
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Full-body physical therapy evaluation for pre- and post-hematopoietic cell transplant patients and the need for a modified rehabilitation musculoskeletal specific grading system for chronic graft-versus-host disease. Bone Marrow Transplant 2018; 53:625-627. [PMID: 29348574 DOI: 10.1038/s41409-017-0075-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/12/2017] [Accepted: 12/03/2017] [Indexed: 11/09/2022]
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16
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John S, Antonia SJ, Rose TA, Seifert RP, Centeno BA, Wagner AS, Creelan BC. Progressive hypoventilation due to mixed CD8 + and CD4 + lymphocytic polymyositis following tremelimumab - durvalumab treatment. J Immunother Cancer 2017; 5:54. [PMID: 28716137 PMCID: PMC5514517 DOI: 10.1186/s40425-017-0258-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 06/14/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The combination of CTLA-4 and PD-L1 inhibitors has a manageable adverse effect profile, although rare immune-related adverse events (irAE) can occur. CASE PRESENTATION We describe an autoimmune polymyositis following a partial response to combination tremelimumab and durvalumab for the treatment of recurrent lung adenocarcinoma. Radiography revealed significant reduction in all metastases; however, the patient developed progressive neuromuscular hypoventilation due to lymphocytic destruction of the diaphragmatic musculature. Serologic testing revealed a low level of de novo circulating antibodies against striated muscle fiber. Immunohistochemistry revealed type II muscle fiber atrophy with a mixed CD8+ and CD4+ lymphocyte infiltrate, indicative of inflammatory myopathy. CONCLUSIONS This case supports the hypothesis that muscle tissue is a target for lymphocytic infiltration in immune checkpoint inhibitor-associated polymyositis. Further insights into the autoimmune mechanism of PM will hopefully contribute to the prevention and treatment of this phenomenon.
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Affiliation(s)
- Sooraj John
- Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd., Tampa, FL 33612 USA
| | - Scott J. Antonia
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612 USA
| | - Trevor A. Rose
- Department of Diagnostic Radiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612 USA
| | - Robert P. Seifert
- Department of Pathology and Cell Biology, University of South Florida, 12901 Bruce B. Downs Blvd., MDC 11, Tampa, FL 33612 USA
| | - Barbara A. Centeno
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612 USA
| | - Aaron S. Wagner
- Orlando Health Pathology, 1414 Kuhl Ave., MP 44, Orlando, FL 32806 USA
| | - Ben C. Creelan
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612 USA
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Carpenter PA, Kitko CL, Elad S, Flowers MED, Gea-Banacloche JC, Halter JP, Hoodin F, Johnston L, Lawitschka A, McDonald GB, Opipari AW, Savani BN, Schultz KR, Smith SR, Syrjala KL, Treister N, Vogelsang GB, Williams KM, Pavletic SZ, Martin PJ, Lee SJ, Couriel DR. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group Report. Biol Blood Marrow Transplant 2015; 21:1167-87. [PMID: 25838185 DOI: 10.1016/j.bbmt.2015.03.024] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 03/27/2015] [Indexed: 12/26/2022]
Abstract
The 2006 National Institutes of Health (NIH) Consensus paper presented recommendations by the Ancillary Therapy and Supportive Care Working Group to support clinical research trials in chronic graft-versus-host disease (GVHD). Topics covered in that inaugural effort included the prevention and management of infections and common complications of chronic GVHD, as well as recommendations for patient education and appropriate follow-up. Given the new literature that has emerged during the past 8 years, we made further organ-specific refinements to these guidelines. Minimum frequencies are suggested for monitoring key parameters relevant to chronic GVHD during systemic immunosuppressive therapy and, thereafter, referral to existing late effects consensus guidelines is advised. Using the framework of the prior consensus, the 2014 NIH recommendations are organized by organ or other relevant systems and graded according to the strength and quality of supporting evidence.
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Affiliation(s)
- Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Carrie L Kitko
- Blood and Marrow Transplantation Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juan C Gea-Banacloche
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jörg P Halter
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Flora Hoodin
- Department of Psychology, Eastern Michigan University, Ypsilanti, Michigan
| | - Laura Johnston
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Anita Lawitschka
- St. Anna Children's Hospital, Medical University, Vienna, Austria
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anthony W Opipari
- Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital and University of BC, Vancouver, British Columbia
| | - Sean R Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Karen L Syrjala
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel R Couriel
- Blood and Marrow Transplantation Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
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Magge RS, DeAngelis LM. The double-edged sword: Neurotoxicity of chemotherapy. Blood Rev 2014; 29:93-100. [PMID: 25445718 DOI: 10.1016/j.blre.2014.09.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 09/17/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023]
Abstract
The number of available therapies for hematologic malignancies continues to grow at a rapid pace. Unfortunately, many of these treatments carry both central and peripheral nervous system toxicities, potentially limiting a patient's ability to tolerate a full course of treatment. Neurotoxicity with chemotherapy is common and second only to myelosuppression as a reason to limit dosing. This review addresses the neurotoxicity of newly available therapeutic agents including brentuximab vedotin and blinatumomab as well as classic ones such as methotrexate, vinca alkaloids and platinums. Although peripheral neuropathy is common with many drugs, other complications such as seizures and encephalopathy may require more immediate attention. Rapid recognition of adverse neurologic effects may lead to earlier treatment and appropriate adjustment of dosing regimens. In addition, knowledge of common toxicities may help differentiate chemotherapy-related symptoms from actual progression of cancer into the CNS.
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Affiliation(s)
- Rajiv S Magge
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurology, Weill Cornell Medical College, New York, NY 10065, USA.
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Abstract
Complex multiorgan failure may require simultaneous transplantation of several organs, including heart-lung, kidney-pancreas, or multivisceral transplantation. Solid organ transplantation can also be combined with hematopoietic stem cell transplantation to modulate immunologic response to a solid organ allograft. Combined multiorgan transplantation may offer a lower rate of allograft rejection and lower immunosuppression needs. In recent years, intestinal and multivisceral transplantations became viable as a rescue treatment for patients with irreversible intestinal failure who can no longer tolerate total parenteral nutrition with 70% survival after 5 years which is comparable to other types of solid organ allografts. Post-transplant neurologic complications were reported in up to 86% of allograft recipients and greatly overlap in intestinal and multivisceral allograft recipients, without a significant effect on the outcome of transplantation. Other common organ combinations in multiorgan transplantation include kidney-pancreas, which is mostly used for patients with renal failure and uncontrolled diabetes, and heart-lung for patients with congenital heart disease and idiopathic pulmonary arterial hypertension. Kidney-pancreas transplantation frequently results in an improvement of diabetic complications, including diabetic neuropathy. Heart-lung allograft recipients have very similar clinical course and spectrum of neurologic complications to lung transplant recipients. At this time there are no reports of an increased risk of graft-versus-host disease with combined transplantation of solid organ allograft and hematopoietic stem cells. Chronic immunosuppression and complex toxic-metabolic disturbances after multiorgan transplantation create a permissive environment for development of a wide spectrum of neurologic complications which largely resemble complications after transplantations of individual components of complex multiorgan allografts.
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Affiliation(s)
- Saša A Zivković
- Neurology Service, Department of Veterans Affairs and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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20
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Marks C, Stadler M, Häusermann P, Wolff D, Buchholz S, Stary G, Lee S, Lawitschka A, Bertz H. German-Austrian-Swiss Consensus Conference on clinical practice in chronic graft-versus-host disease (GVHD): guidance for supportive therapy of chronic cutaneous and musculoskeletal GVHD. Br J Dermatol 2011; 165:18-29. [DOI: 10.1111/j.1365-2133.2011.10360.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Bergeron A, Bengoufa D, Feuillet S, Meignin V, de Latour RP, Rybojad M, Gossot D, Azoulay E, Socié G, Tazi A. The spectrum of lung involvement in collagen vascular-like diseases following allogeneic hematopoietic stem cell transplantation: report of 6 cases and review of the literature. Medicine (Baltimore) 2011; 90:146-157. [PMID: 21358437 DOI: 10.1097/md.0b013e31821160af] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Multisystem autoimmune diseases occurring after allogeneic hematopoietic stem cell transplantation are infrequent, late-onset manifestations that resemble well-defined collagen vascular disorders. Because the lung is frequently involved in the course of connective tissue disorders, we focused on lung manifestations occurring in autoimmune diseases following allogeneic stem cell transplantation. In the present series, we report 6 patients with systemic lupus erythematous, mixed connective tissue disease, Sjögren syndrome, polymyositis, and ANCA-positive vasculitis who presented with a spectrum of pulmonary manifestations affecting the airways, lung parenchyma, and probably respiratory muscles. We identified 3 different histopathologic patterns of interstitial pneumonia consistent with the underlying autoimmune disorder: lymphocytic interstitial pneumonia and non-specific interstitial pneumonia in 2 patients with Sjögren syndrome and diffuse alveolar damage in 1 patient with ANCA-positive vasculitis. These lung manifestations had poor prognoses. Further studies are needed to determine the optimal therapy for these complications.
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Affiliation(s)
- Anne Bergeron
- From Service de Pneumologie (AB, SF, AT), Service d' Immunologie (DB), Service de Pathologie (VM), Service d'Hématologie-Greffe de moelle (RPdL, GS), Service de Dermatologie (MR), Service de Réanimation (EA), Hôpital Saint-Louis, Université Paris 7, UFR Denis Diderot; Assistance Publique-Hôpitaux de Paris, Paris; and Service de Chirurgie thoracique (DG), Institut Mutualiste Montsouris, Paris, France
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23
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Grauer O, Wolff D, Bertz H, Greinix H, Kühl JS, Lawitschka A, Lee SJ, Pavletic SZ, Holler E, Kleiter I. Neurological manifestations of chronic graft-versus-host disease after allogeneic haematopoietic stem cell transplantation: report from the Consensus Conference on Clinical Practice in chronic graft-versus-host disease. Brain 2010; 133:2852-65. [PMID: 20846944 DOI: 10.1093/brain/awq245] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A major obstacle of allogeneic haematopoietic stem cell transplantation is graft-versus-host disease, an immune-mediated disorder that affects multiple tissues and organs with varying severity. Neurological complications of acute and chronic graft-versus-host disease are rare but can produce severe clinical problems with significant morbidity and mortality. In this article, we review neurological manifestations of chronic graft-versus-host disease that comprise immune-mediated neuropathies, myasthenia gravis and myositis in the peripheral nervous system and various cerebrovascular complications, demyelination and immune-mediated encephalitis in the central nervous system. The National Institutes of Health consensus on criteria for clinical trials in chronic graft-versus-host disease recommended that the diagnosis of chronic graft-versus-host disease of the nervous system can be made only when other organs are affected by graft-versus-host disease and frequent neurological differential diagnoses such as drug-induced toxicities or opportunistic infections are excluded. The Consensus Conference on Clinical Practice in chronic graft-versus-host disease, held in autumn 2009 in Regensburg, aimed to summarize the literature and to provide guidelines for the diagnostic approach in children and adults with neurological manifestations of chronic graft-versus-host disease. Moreover, we present therapeutic recommendations and their level of evidence for the management of these complications. Overlapping symptoms and comorbidities after allogeneic haematopoietic stem cell transplantation and the limited knowledge about the underlying biological mechanisms of chronic graft-versus-host disease affecting the nervous system emphasize the need for further experimental and clinical investigations.
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Affiliation(s)
- Oliver Grauer
- Department of Neurology, University Medical Centre Regensburg, Universitätsstraße 84, Regensburg, Germany
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IgD Multiple Myeloma Paraproteinemia as a Cause of Myositis. Neurol Res Int 2010; 2010:808474. [PMID: 21188228 PMCID: PMC3003993 DOI: 10.1155/2010/808474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 06/16/2010] [Indexed: 11/18/2022] Open
Abstract
A 48-years old man was diagnosed an IgD-k multiple myeloma (MM) at age 38 years for which he successfully underwent chemotherapy and bone marrow transplant. He then developed a graft-versus-host disease (GVHD) whose manifestations included, three years later, a polymyositis, diagnosed at muscle biopsy and successfully treated with steroids. Few months after polymyositis remission, myeloma relapsed and the patient was treated with thalidomide for six years with good remission. Soon after thalidomide suspension, MM relapsed again and the patient came to our observation for a new onset of neuromuscular symptoms. He underwent both muscle and peripheral nerve biopsy to discriminate between myositis (paraproteinemia versus GVHD), amyloidosis, and thalidomide toxicity. The first muscle biopsy showed an inflammatory pattern with necrotic fibres, macrophagical invasion (CD68 positive), rare interstitial cellular infiltrates (CD8 positive and CD4 negative), widespread anti-HLA positivity and negative antiMAC. The second muscle biopsy showed the same inflammatory pattern plus an involvement of blood vessels. Direct immunofluorescence for IgD showed diffuse positivity along the sarcolemmal in both muscle biopsies. Sural nerve biopsy demonstrated both demyelinating and axonal aspects with no inflammatory infiltrates, but positivity for HLA and MAC. Congo Red was negative in both skeletal muscle and peripheral nerve.
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25
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Allen JA, Greenberg SA, Amato AA. Dermatomyositis-like muscle pathology in patients with chronic graft-versus-host disease. Muscle Nerve 2009; 40:643-7. [PMID: 19670319 DOI: 10.1002/mus.21353] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Myositis is a rare complication of chronic graft-versus-host disease (cGVHD) following hematopoietic stem cell transplantation (HSCT). Almost all such patients have been reported to have polymyositis (PM). We describe clinical, pathologic, and molecular studies of 3 patients with cGVHD following allogeneic HSCT who developed myopathy. In each case, perifascicular atrophy, the pathognomonic histologic feature of dermatomyositis (DM), was observed.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, Division of Neuromuscular Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115, USA.
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26
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Okazaki T, Maeda A, Inoue M, Kitazono T, Shibata T, Ozaki S. [A case of chronic graft-versus-host disease presenting with polymyositis]. NIHON RINSHO MEN'EKI GAKKAI KAISHI = JAPANESE JOURNAL OF CLINICAL IMMUNOLOGY 2009; 32:124-8. [PMID: 19404011 DOI: 10.2177/jsci.32.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Polymyositis is an uncommon manifestation as a complication of chronic graft-versus-host disease (GVHD). We report a case of a 55 years' old woman diagnosed as polymyositis 2 years after bone marrow transplantation against T-cell lymphoma. Muscle weakness and the elevation of CPK value were compatible with pathognomonic findings of polymyositis. However, the muscle weakness was distributed particularly into distal lower extremities and neck. It is different from that of the typical findings in autoimmune polymyositis. Histological findings showed atrophy and anisocytosis of muscles without invasion of mononuclear cells. This might be a case of GVHD-induced polymyositis occurring symptomatically after substantially progressing under the treatment with immunosuppressive agents to control chronic GVHD after bone marrow transplantation. The treatment with prednisone (1 mg/kg) brought the rapid improvement of muscle weakness and CPK value as well as mouth dryness and cholestatic liver dysfunction like in primary biliary cirrhosis. Moreover, dose up of cyclosporine and addition of mizolibine allowed for the use of lower dose of prednisone. This case suggested that the mononuclear cells invasion into muscles in a chronic GVHD patient could not always be a definitive finding of chronic GVHD-associated polymyositis because of prior use of immunosuppressive agents.
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Affiliation(s)
- Takahiro Okazaki
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine
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27
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MR findings in patients with disabling musculocutaneous chronic graft-versus-host disease. Skeletal Radiol 2008; 37:885-94. [PMID: 18622607 DOI: 10.1007/s00256-008-0535-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 05/23/2008] [Accepted: 05/25/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe musculocutaneous MR-findings responsible for disability in chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (HCT). MATERIAL AND METHODS Between June 2005 and February 2008, we performed whole-body musculoskeletal magnetic resonance imaging (MRI; n = 12) or regional MRI (n = 4) in 16 consecutive patients presenting with disabling sclerodermatous cGVHD (e.g., skin edema, fixed deep dermal sclerosis, joint contractures, painful muscular contractures, or myalgia). RESULTS In all patients, MRI showed musculocutaneous abnormalities reflecting different degrees of inflammation and collagen tissue involvement of the skin (n = 10), subcutaneous fat tissue (n = 13), muscle fasciae (n = 16), subfascial muscular septae (n = 6), or findings compatible with myositis (n = 3). The most frequently involved muscle fasciae comprised those of the vastus lateralis muscle (n = 12), biceps femoris muscle (n = 11), gastrocnemius medialis muscle (n = 8), serratus anterior muscle, and latissimus dorsi muscle (each, n = 5). Increased signal of involved tissues on STIR-images and fat-saturated postgadolinium T1-weighted images represented the most frequent MR-signal abnormalities. CONCLUSION MR imaging of musculocutaneous cGVHD allows accurate evaluation including assessment of deep tissue infiltration and assists in the differential diagnosis.
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Oda K, Nakaseko C, Ozawa S, Nishimura M, Saito Y, Yoshiba F, Yamashita T, Fujita H, Takasaki H, Kanamori H, Maruta A, Sakamaki H, Okamoto S. Fasciitis and myositis: an analysis of muscle-related complications caused by chronic GVHD after allo-SCT. Bone Marrow Transplant 2008; 43:159-67. [DOI: 10.1038/bmt.2008.297] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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31
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Bergeron A, Feuillet S, Meignin V, Socie G, Tazi A. Les complications pulmonaires tardives non infectieuses après allogreffe de cellules souches hématopoïétiques. Rev Mal Respir 2008; 25:173-83. [DOI: 10.1016/s0761-8425(08)71515-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Klein R, Franck P, Ehl S, Schmitt-Graeff A, Duffner U, Niemeyer CM. Polymyositis--an unusual presentation of cGvHD in children. Pediatr Transplant 2007; 11:225-7. [PMID: 17300507 DOI: 10.1111/j.1399-3046.2006.00615.x] [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: 11/29/2022]
Abstract
Polymyositis is a rare manifestation of cGvHD in adult patients following allogeneic BMT. Here, we report on a 2.1-yr-old girl who presented with a facial swelling and rapidly developing respiratory failure eight months after BMT for severe combined immunodeficiency. Possible infectious agents and autoimmune origin other than cGvHD were excluded. The girl responded promptly to steroid therapy and remains well without other signs of cGvHD four months later.
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Affiliation(s)
- R Klein
- Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany.
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Couriel D, Carpenter PA, Cutler C, Bolaños-Meade J, Treister NS, Gea-Banacloche J, Shaughnessy P, Hymes S, Kim S, Wayne AS, Chien JW, Neumann J, Mitchell S, Syrjala K, Moravec CK, Abramovitz L, Liebermann J, Berger A, Gerber L, Schubert M, Filipovich AH, Weisdorf D, Schubert MM, Shulman H, Schultz K, Mittelman B, Pavletic S, Vogelsang GB, Martin PJ, Lee SJ, Flowers MED. Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report. Biol Blood Marrow Transplant 2006; 12:375-96. [PMID: 16545722 DOI: 10.1016/j.bbmt.2006.02.003] [Citation(s) in RCA: 270] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Accepted: 02/07/2006] [Indexed: 12/23/2022]
Abstract
The Ancillary Therapy and Supportive Care Working Group had 3 goals: (1) to establish guidelines for ancillary therapy and supportive care in chronic graft-versus-host disease (GVHD), including treatment for symptoms and recommendations for patient education, preventive measures, and appropriate follow-up; (2) to provide guidelines for the prevention and management of infections and other common complications of treatment for chronic GVHD; and (3) to highlight the areas with the greatest need for clinical research. The definition of "ancillary therapy and supportive care" embraces the most frequent immunosuppressive or anti-inflammatory interventions used with topical intent and any other interventions directed at organ-specific control of symptoms or complications resulting from GVHD and its therapy. Also included in the definition are educational, preventive, and psychosocial interventions with this same objective. Recommendations are organized according to the strength and quality of evidence supporting them and cover the most commonly involved organs, including the skin, mouth, female genital tract, eyes, gastrointestinal tract, and lungs. Recommendations are provided for prevention of infections, osteoporosis, and steroid myopathy and management of neurocognitive and psychosocial adverse effects related to chronic GVHD. Optimal care of patients with chronic GVHD often requires a multidisciplinary approach.
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Affiliation(s)
- Daniel Couriel
- University of Texas MD Anderson Cancer Center, Houston, 77030, USA.
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Rosenfeld MR, Pruitt A. Neurologic complications of bone marrow, stem cell, and organ transplantation in patients with cancer. Semin Oncol 2006; 33:352-61. [PMID: 16769425 DOI: 10.1053/j.seminoncol.2006.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bone marrow and peripheral blood stem cell transplantation are part of the standard of care for a variety of oncologic and non-oncologic disorders and are associated with a large spectrum of neurologic complications. These complications may arise at any time during and after the transplantation process, especially in subjects requiring chronic immunosuppression, and are most frequently related to infections, cerebrovascular or metabolic events, and toxicity from radiation or chemotherapy. Due to the unique circumstances and treatments surrounding each step in the transplantation process, there is a higher incidence of some neurologic complications during discrete time periods. Being aware of the temporal relationship of the neurologic disorder within the transplantation process can therefore facilitate diagnosis and institution of appropriate therapy. Neurologic complications after solid organ transplantation are often due to similar mechanisms as in patients after bone marrow and stem cell transplantation although there are several complications unique to these patients such as transmission of infectious agents by the donated organ. For these patients, the clinician needs to have a high index of suspicion that the neurologic problem is related to the transplant.
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Affiliation(s)
- Myrna R Rosenfeld
- Department of Neurology, University of Pennsylvania, Philadelphia, 19104, USA.
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Abstract
Chronic graft-versus-host disease (GVHD) is the major cause of non-relapse morbidity and mortality after hematopoietic stem cell transplant (HSCT). GVHD also is associated with a potent anti-leukemic effect. Chronic GVHD resembles autoimmune diseases and can likely affect any organ or tissue of the body. Skin, oral, liver, and lacrimal gland involvement are most common. The incidence and presentation have been in evolution as new stem cell sources and transplant approaches have been introduced. Although progress in the diagnosis and treatment of chronic GVHD has been limited for many years, there is renewed interest in this disorder. New prognostic scores and animal models of chronic GVHD have been developed. Large, multicenter phase III therapy and biology studies have been undertaken. The challenge for the future will be the discovery of targeted approaches that allow the anti-leukemic effect to be retained and for the reconstitution of normal immunity, thereby reducing infectious complications.
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Affiliation(s)
- Andrew L Gilman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27517, USA.
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Schmidt-Hieber M, Okuducu AF, Stoltenburg G, Mackert BM, Benzian N, Thiel E, Blau IW. Hemosiderin deposits in chronic graft-vs.-host disease related myopathy. Eur J Haematol 2005; 75:522-6. [PMID: 16313267 DOI: 10.1111/j.1600-0609.2005.00548.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic graft-vs.-host disease (cGVHD) occurs in 20-50% of patients who survive for at least 100 d after allogeneic stem cell transplantation (SCT). cGVHD includes scleroderma-like skin changes, chronic cholangitis, obstructive lung disease and general wasting syndrome. Polymyositis or myopathy are rare manifestations of cGVHD with approximately 40 reported cases. Polymyositis accompanied by hemosiderin deposits in cGVHD has been reported only once, and there are no reports on lipofuscin deposits in skeletal muscle cells in cGVHD. We report here on a 56-yr-old male who underwent allogeneic SCT in 1999 for osteomyelofibrosis and progressive hematopoietic insufficiency. In February 2004, the patient was hospitalized for progressive muscular weakness with loss of the ability to walk. Laboratory tests demonstrated normal values for serum creatine kinase, aldolase and lactic dehydrogenase; the ferritin level was highly elevated. The femoral muscle biopsy showed mostly perifascicular atrophy as well as numerous subsarcolemmal hemosiderin and lipofuscin deposits. Intravenous administration of the chelating agent deferoxamine was ineffective. Three weeks later the patient died of aspiration pneumonia. Interestingly, autopsy disclosed moderate hemosiderin deposits in the liver, the organ usually involved in hemosiderosis.
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Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III (Hämatologie, Onkologie und Transfusionsmedizin), Charité- Campus, Benjamin Franklin, Hindenburgdamm, Berlin, Germany.
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White AC, Terrin N, Miller KB, Ryan HF. Impaired Respiratory and Skeletal Muscle Strength in Patients Prior to Hematopoietic Stem-Cell Transplantation. Chest 2005; 128:145-52. [PMID: 16002928 DOI: 10.1378/chest.128.1.145] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The primary aim was to determine if respiratory and skeletal muscle strength and submaximal exercise capacity were reduced in subjects prior to sibling- or unrelated-donor hematopoietic stem-cell transplantation (HSCT). DESIGN Prospective observational study. SETTING Tufts-New England Medical Center, a tertiary referral center in Boston, MA. PATIENTS All patients (n = 56) undergoing either sibling- or unrelated-donor HSCT from January 1, 2002, to December 31, 2002. MEASUREMENTS Demographic data, chemotherapy burden, pulmonary function tests (PFTs), maximal inspiratory muscle strength (PImax), maximal expiratory muscle strength (PEmax), dominant hand grip strength (GS), 6-min walk test (6MWT), and survival as of May 21, 2004. RESULTS PImax was reduced to < 80% predicted in 42% of subjects and to < 60% predicted in 18% of subjects. PEmax was reduced to < 80% predicted in 89% of subjects and to < 60% of predicted in 80% of subjects. A significant correlation was observed between PImax and PEmax (r = 0.65, p < 0.0001). GS was reduced to < 80% predicted in 39% of subjects and < 60% predicted in 15% of subjects. The 6MWT was reduced to < 80% predicted in 58% of subjects and to < 60% predicted in 9.6% of subjects. Diffusing capacity of the lung for carbon monoxide (Dlco) was the only PFT that was significantly correlated with 6MWT distance (r = 0.44, p = 0.015). The mean calculated load of chemotherapy was 14.8 +/- 16.5 U (+/- SD). The mean time elapsed from date of hematologic diagnosis to date of HSCT was 874 +/- 1,109 days. The median survival of the cohort was 374 days (95% confidence interval, 177 to 665 days). Respiratory or skeletal muscle strength, 6MWT distance, or calculated burden of chemotherapy did not predict survival. CONCLUSIONS Respiratory and skeletal muscle strength and submaximal exercise capacity are reduced in a significant percentage of patients prior to undergoing HSCT. These observations may help explain musculoskeletal weakness that has been reported in the posttransplant period.
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Affiliation(s)
- Alexander C White
- Pulmonary, Critical Care and Sleep Division, New England Medical Center, NEMC #369, 750 Washington St, Boston, MA 02111, USA.
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Abstract
Polymyositis usually occurred along with other manifestations of chronic graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) had been reported. However, polymyositis with a sole manifestation of acute GVHD following donor lymphocyte infusion (DLI) is rare. We reported a 45-yr-old man of acute lymphoid leukemia post-allogeneic HSCT 6 months developed acute polymyositis after DLI. He did not develop any symptoms, signs of acute or chronic GVHD following allogeneic HSCT, despite withdraw of immuosuppresive agents, cyclosporin A (CsA). As the DNA-STR of bone marrow analysis showed mixed chimerism, he received the DLI for remission on May 16, 2002. Acute polymyositis developed following DLI 22 d later. The clinical presentation of polymyositis is compatible with a manifestation of acute GVHD following DLI. It also responds to the treatment of steroid and CsA.
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Affiliation(s)
- Peng-Chan Lin
- Department of Medical Oncology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
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40
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Mitomo M, Miyazaki C, Mukai M, Usami Y, Nagano S, Nakamura N, Kubo K. Tc-99m MDP bone scintigraphy of myositis as a manifestation of chronic graft-versus-host disease after non-myeloablative peripheral stem cell transplantation. Ann Nucl Med 2005; 19:41-5. [PMID: 15770972 DOI: 10.1007/bf02986334] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 27-year-old man developed polymyositis as a manifestation of chronic graft-versus-host disease (GVHD) after non-myeloablative peripheral blood stem cell transplantation (PBSCT). Bone scintigraphy showed intense, striped, and heterogeneous accumulation of Tc-99m methylene diphosphonate (MDP) in the soft-tissue of his lower limbs, while faint activities were seen in the right upper limb. Tc-99m MDP scintigraphy was very useful for accurate and objective evaluation of the severity of the muscle injury and the extent of polymyositis caused by chronic GVHD.
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Affiliation(s)
- Maki Mitomo
- Department of Medical Imaging, Sapporo City General Hospital, Japan
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41
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Vinzio S, Lioure B, Grunenberger F, Schlienger JL, Goichot B. [Auto-immune-like disease post-bone marrow transplantation]. Rev Med Interne 2004; 25:514-23. [PMID: 15219370 DOI: 10.1016/j.revmed.2003.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2003] [Accepted: 12/21/2003] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Bone marrow transplantation (BMT) is based on destruction of the patient's bone marrow with rescue of haematopoietic stem cells from a donor. Chronic graft-vs-host disease (GVH) is the major complication post-BMT and mimics some autoimmune diseases, such as scleroderma, sicca syndrome, primary biliary cirrhosis and an increased prevalence of various autoantibodies. Other autoimmune-like manifestations have been reported as case reports or short series. The most common are myasthenia gravis, polymyositis, autoimmune cytopenias and Graves' disease or autoimmune hypothyroidism. CURRENT KNOWLEDGE AND KEY POINTS These diseases occur mainly in association with chronic GVH. The pathophysiology of chronic GVH and other autoimmune-like diseases post-BMT remains poorly understood. Different mechanisms have been postulated. Most of the autoimmune events (either chronic GVH or more specific diseases) seem to be related to a poor or inadequate immunologic recovery post-BMT with an imbalance between autoregulatory and autoreactive lymphocytes. Microchimerism and molecular mimicry have been recently evocated. A minority of cases (autoimmune thyroid disorders) is attributed to the direct transfer of autoreactive cells from donor to patient (adoptive immunity). FUTURE PERSPECTIVES Despite physiopathologic uncertainty, these autoimmune-like disorders post-BMT are an interesting model for primary autoimmune diseases.
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Affiliation(s)
- S Vinzio
- Service de médecine interne et nutrition, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg cedex, France.
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42
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Sostak P, Reich P, Padovan CS, Gerbitz A, Holler E, Straube A. Cerebral endothelial expression of adhesion molecules in mice with chronic graft-versus-host disease. Stroke 2004; 35:1158-63. [PMID: 15073401 DOI: 10.1161/01.str.0000125865.01546.bb] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Graft-versus-host disease (GvHD) is a major complication after allogeneic bone marrow transplantation (BMT). The theory that the central nervous system (in addition to the peripheral nervous system) participates in GvHD has been supported by detection of cerebral lymphomononuclear infiltrates in experimental GvHD and the observation of cerebral angiitis-like disease in patients with chronic GvHD. METHODS In a murine BMT model, we investigated the expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) on cerebral endothelium after allogeneic and syngeneic transplantation. Through the use of ICAM-1-knockout mice, the effect of ICAM-1 deficiency on cellular infiltration was evaluated. As an indicator of enhanced apoptotic cell death, we examined the cerebral expression of Fas antigen (Fas), the occurrence of the poly-ADP ribose polymerase p85 fragment, and the distribution of TUNEL positive-stained cells. RESULTS In close correlation with earlier findings of cerebral infiltration in the same animals, we found cerebral endothelial upregulation of ICAM-1 and especially of VCAM-1 in allogeneic recipients compared with syngeneic animals without GvHD and unmanipulated controls. In ICAM-1-knockout mice, leukocytic infiltration did not differ from that in wild-type animals. Neither cerebral histopathologic changes nor an apoptotic effect of cellular infiltrates on brain parenchyma could be detected. CONCLUSIONS In this model of experimental GvHD, VCAM-1 may play a critical role in leukocyte recruitment into the central nervous system of animals with chronic GvHD.
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Affiliation(s)
- Petra Sostak
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-University, Marchioninistr 15, 81377 Munich, Germany.
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43
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Stevens AM. Foreign cells in polymyositis: Could stem cell transplantation and pregnancy-derived chimerism lead to the same disease? Curr Rheumatol Rep 2003; 5:437-44. [PMID: 14609488 DOI: 10.1007/s11926-003-0054-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A growing number of hematopoietic stem cell transplantation centers have reported that patients with chronic graft versus host disease (GVHD) can develop polymyositis (PM). GVHD-PM is similar to idiopathic PM in signs, symptoms, laboratory values, electromyography, radiography, and histology, suggesting that the two conditions may share a similar mechanism in pathogenesis. In chronic GVHD-PM, interactions between allogeneic donor cells and host cells lead to chronic inflammation. In idiopathic PM, the foreign cells could be partially human leukocyte antigen-matched maternal or fetal cells acquired during pregnancy. Thus, PM can be added to the list of potentially allo-autoimmune diseases in which pregnancy-derived microchimerism may play a role.
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Affiliation(s)
- Anne M Stevens
- Immunogenetics Department, Fred Hutchinson Cancer Research Center, PO Box 19024, D2-100, 1100 Fairview Avenue NE, Seattle, WA 98109, USA.
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44
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Selva-O'Callaghan A, Mijares-Boeckh-Behrens T, Prades EB, Solans-Laqué R, Simeón-Aznar CP, Fonollosa-Pla V, Vilardell-Tarrés M. Lack of evidence of foetal microchimerism in female Spanish patients with systemic sclerosis. Lupus 2003; 12:15-20. [PMID: 12587821 DOI: 10.1191/0961203303lu248oa] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Our objective was to study the presence of microchimerism in a series of 47 female Spanish patients with scleroderma (SSc) and to compare with a control group. Polymerase chain reaction was used to identify Y-chromosome sequences in DNA extracted from peripheral blood cells. Y-chromosome sequences were found in DNA from peripheral blood cells in four out of 47 (8.5%) patients with scleroderma (two limited and two diffuse) and in two out of 40 (5%) healthy women (no statistical differences were found). When we compared SSc patients and healthy controls who had had at least one male child, four out of 29 (13.7%) and two out of 26 (7.6%) had microchimerism respectively (no statistically significant differences were found). Patients with both scleroderma and persistent microchimerism had had a male offspring. Foetal microchimerism does not seem to play a major role in most cases of female Spanish patients with SSc.
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Affiliation(s)
- A Selva-O'Callaghan
- Vall d'Hebron General Hospital, Internal Medicine Department, Barcelona, Spain.
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45
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Tsunemi Y, Ihn H, Nakamura K, Tamaki K. Post-transplantation chronic graft-versus-host disease with overlapping features similar to those of various collagen diseases. Int J Dermatol 2003; 42:292-4. [PMID: 12694496 DOI: 10.1046/j.1365-4362.2003.01690.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Y Tsunemi
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan.
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46
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Canninga-van Dijk MR, Sanders CJ, Verdonck LF, Fijnheer R, van den Tweel JG. Differential diagnosis of skin lesions after allogeneic haematopoietic stem cell transplantation. Histopathology 2003; 42:313-30. [PMID: 12653943 DOI: 10.1046/j.1365-2559.2003.01591.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation (i.e. bone marrow or peripheral blood stem cell transplantation) is a common procedure in the treatment of various haematological disorders such as aplastic anaemia, (pre)leukaemias, some malignant lymphomas, multiple myeloma and immunodeficiency states. Many of these patients develop erythematous skin lesions following transplantation. Although graft- versus-host disease is the major differential diagnosis in these situations, many other causes of erythema are encountered. The large number of transplant patients means that more and more pathologists are confronted with the challenging problem of making a correct diagnosis in these situations. In this review article we therefore describe the different causes of erythema and their differential diagnoses. In most cases the clinical presentation is related to the microscopical features. Besides acute and chronic graft-versus-host disease, we discuss the (common) drug reactions and non-specific features such as Sweet's syndrome, erythema nodosum and eosinophilic folliculitis. In addition, we deal with the recurrence of original diseases and infections. With this knowledge every pathologist should feel comfortable when looking at skin biopsies of patients after haematological stem cell transplantation.
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Affiliation(s)
- M R Canninga-van Dijk
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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47
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Reed AM, Ytterberg SR. Genetic and environmental risk factors for idiopathic inflammatory myopathies. Rheum Dis Clin North Am 2002; 28:891-916. [PMID: 12506777 DOI: 10.1016/s0889-857x(02)00029-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although the studies discussed are beginning to reveal a number of genetic and possible environmental risk factors for myositis, further investigations are needed to fully understand and classify these syndromes. The difficulties in this process include small numbers of subjects with varying disease phenotypes available for study, polygenic risk factors for which it remains unclear which are primary and which are secondary or linked genes, and the lack of validated environmental exposure assessment tools. New technologies and international collaborative approaches, however, may overcome some of these difficulties and allow us to identify genetic and environmental risk factors, as well as the critical gene-environment interactions in the IIM and its subgroups. Nonetheless, our understanding of these diseases is still in the early stages. Although we have learned a great deal about these disorders through detailed investigations over the last several decades, we have even further to go to understand the environmental triggers and genetic susceptibilities for the myositis syndromes.
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Affiliation(s)
- Ann M Reed
- Division of Pediatric Rheumatology, Departments of Pediatrics and Internal Medicine, Mayo Clinic Rochester, Mayo Medical School, 200 First Street SW, Rochester, MN 55905, USA.
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48
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Couriel DR, Beguelin GZ, Giralt S, De Lima M, Hosing C, Kharfan-Dabaja MA, Anagnostopoulos A, Champlin R. Chronic graft-versus-host disease manifesting as polymyositis: an uncommon presentation. Bone Marrow Transplant 2002; 30:543-6. [PMID: 12379897 DOI: 10.1038/sj.bmt.1703711] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2002] [Accepted: 06/26/2002] [Indexed: 11/09/2022]
Abstract
Graft-versus-host disease (GVHD) remains a major complication of allogeneic hematopoietic stem cell transplantation. Polymyositis can occur in association with chronic GVHD and mimics the idiopathic form of the disease. We report two cases of chronic GVHD-associated polymyositis and review the published literature. The two patients presented 13 and 19 months after allogeneic transplantation with characteristic features of muscular hypotrophy, proximal muscle weakness, pain, elevated creatine phosphokinase (CPK), aldolase and SGPT. Interestingly, both patients had HLA DR52 genes, which is frequently reported in association with idiopathic polymyositis. Electromyogram (EMG) and muscle biopsy confirmed the diagnosis. Treatment with cyclosporine or tacrolimus resulted in complete and sustained remission of polymyositis in both cases. A review of the literature shows cyclosporine and steroids are well-described treatment options for patients with myositis in post transplant, as well as idiopathic cases. The duration of immunosuppressive treatment has varied in different reports, and there is a risk of recurrence when immunosuppression is tapered.
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Affiliation(s)
- D R Couriel
- Department of Blood and Marrow Transplantation, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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49
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Kojima K, Kurokawa MS, Tanimoto K, Kojima Y, Hara M, Yoshino T, Harada M, Tanimoto M, Nishioka K, Kato T. Clonal expansion of limited T cell clonotypes in affected muscle from a patient with post-transplant polymyositis. Bone Marrow Transplant 2002; 30:467-70. [PMID: 12368961 DOI: 10.1038/sj.bmt.1703665] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2001] [Accepted: 06/11/2002] [Indexed: 11/09/2022]
Abstract
Critical roles of T cells in idiopathic polymyositis have been suggested, but, those in polymyositis occurring as GVHD after BMT are poorly understood. We thus investigated T cell clonality in a patient with post- transplant polymyositis. As a result, T cell receptor beta chains used various BV families in peripheral blood, but only one BV family (BV7) in affected muscle. Importantly, T cells proliferated oligoclonally both in the peripheral blood and the muscle, however, the expanded clonotypes were completely different. Taken together, T cells expanded in the muscle, possibly stimulated by limited kinds of antigens, may drive myositis.
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Affiliation(s)
- K Kojima
- The Second Department of Medicine and the Second Department of Pathology, Okayama University Medical School, Okayama, Japan
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50
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Sato N, Okamoto S, Mori T, Watanabe R, Hamano Y, Kawamura J, Ishihara D, Ikeda Y. Recurrent acute myositis after allogeneic bone marrow transplantation for myelodysplasia. Hematology 2002; 7:109-12. [PMID: 12186701 DOI: 10.1080/10245330290022115] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
A 54-year-old woman developed polymyositis 6 months after allogeneic bone marrow transplantation (BMT) for acute myelogenous leukemia transformed from myelodysplasia. At the onset of myositis, the patient had oral dryness, and the histology of oral mucosa was compatible with chronic graft-versus-host disease (GVHD). Muscle biopsy revealed focal muscle necrosis with massive lymphocytic infiltration. She was diagnosed with polymyositis, and the dose of cyclosporine was increased. Three months later, a complete resolution of myositis had been obtained, and the cyclosporine was tapered off. However, 51 months after the first episode of myositis, she again noted severe myalgia and was diagnosed with a recurrence of polymyositis based on high serum creatinine kinase (CK) and the findings of magnetic resonance imaging (MRI). At that time, chronic GVHD in other organs was not present. She achieved a second remission of polymyositis with cyclosporine, and has remained in remission for 4 years. The pathogenesis of myositis can be attributed to the immunologic imbalance characteristic of the post-allogeneic BMT setting.
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Affiliation(s)
- N Sato
- Keio Bone Marrow Transplant Program, Division of Hematology, Department of Medicine, School of Medicine, Keio University, 35-Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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