Defective neutrophil chemotaxis in bone marrow transplant patients

Infection is a frequent cause of death in patients receiving bone marrow transplants. Although lymphocyte dysfunction has been observed in a few such patients, no systematic study of neutrophil function has yet been reported. Neutrophil chemotaxis was evaluated by a 51Cr-radioassay after bone marrow transplantation in 34 patients with acute leukemia or aplastic anemia. The response to a chemotactic stimulus (C5a) was severely depressed (less than 35% of normal) in 18 patients, moderately depressed (35-65% of normal) in an additional 6, and normal in 10 subjects. The mean response in the absence of graft vs. host disease and antithymocyte globulin administration was 73.3+/-9.2% (SE) in contrast to 29.7+/-9.6% (P is less than 0.01) in patients with graft vs. host disease treated with antithymocyte golbulin. Both graft vs. host disease and antithymocyte globulin were implicated since the presence of either factor alone was associated with depressed chemotaxis (31.1+/-4.9% for graft vs. host disease, P is less than 0.01; 17.0+/-7.8% for antithymocyte globulin, P is less than 0.02). When normal neutrophils were incubated with antithymocyte globulin in vitro, their chemotactic response was markedly suppressed in the absence of a cytotoxic effect. Transplant patients with defective chemotaxis experienced significantly more infections than those with normal chemotaxis, and analysis of specific etiologic agents showed that this was predominantly related to bacterial pathogens. Chemotactic inhibitors were detected in the sera of seven patients and elevated IgE levels were found in nine subjects, eight of whom had graft vs. host disease. Generation of chemotactic activity by endotoxin activation of serum was reduced in five patients. The results demonstrate a severe defect in neutrophil chemotaxis in some bone marrow transplant patients and suggest that neutrophil dysfunction may predispose to infection in such patients.

Marrow transplantation in aplastic anemia and leukemia

Human marrow transplantation has resulted in observations of fundamental significance in understanding both aplastic anemia and acute leukemia. For example, the observation that transplanted marrow can grow successfully in patients with aplastic anemia indicates that the disease is due to a defect in the marrow precursor cells and not in the marrow microenvironment. Similarly, the observation of recurrent leukemia in donor cells has important implications. Nonetheless, marrow transplantation is sufficiently established therapeutically to be considered the treatment of choice for patients with severe aplastic anemia, and a realistic alternative for patients with recurrent acute leukemia. We suggest that patients be managed with regard to marrow transplantation according to the general approach outlined in Table 3. Marrow transplantation and histocompatibility typing are available at increasing numbers of institutions throughout the world. More and more patients with either severe aplastic anemia or recurrent acute leukemia should have marrow transplantation available to them when it is indicated as part of optimal management of these no longer hopeless diseases.

Studies on pure red cell aplasia. VII. Presence of proerythroblasts and response to splenectomy: a case report

An 18-yr-old female with chronic active hepatitis developed a severe anemia due to a lack of red cell production. Her bone marrow showed many large proerythroblasts but an almost complete lack of more mature erythroblasts. Incubation of the marrow cells in a normal medium with erythropoietin concentrate led to increased erythropoiesis as indicated by the development of mature erythroblasts as well as a ninefold increase in hemoglobin synthesis. The patient's plasma was cytotoxic for erythroblasts. Following splenectomy, a remission of the disease occurred. This study indicates that in some cases the anemia associated with abundant marrow proerythroblasts and the absence of mature erythroblasts has the same pathogenesis as pure red cell aplasia and that splenectomy may be beneficial when there is a lack of response to immunosuppressive drugs.

Immunological studies in the postsplenectomy syndrome

Variations in the serial immunoglobulins of 52 children splenectomized for a variety of indications were studied and compared with two groups of children, one postoperative and one without operation. The most significant finding was the constant decrease in Ig M in every instance. Our series of splenectomized children seems to confirm the facts noted by other authors. The incidence of serious infections has been clearly significant and is clearly postsplenectomy sepsis. The age of the patients has a great influence on the seriousness of the septic process, these being more severe on younger children. The influence has also been revealed of the cause which motivated the operation, this corresponding in the first place to thalassemia and in the second place through spherocytosis and pseudohormones. It is evident that the immunologic role of the spleen during early childhood, especially under the age of 5 yr is important. The greatest risk or postsplenectomy sepsis is in the first 2 yr of life. Splenectomy should be delayed until after the age of 5 if clinical circumstances permit. If not, prophylactic chemotherapy should be carried out during the first 18 mo after splenectomy.

The medical ethics of bone marrow transplantation in childhood

Bone marrow transplantation has been utilized for the treatment of severe aplastic anemia in a program at The Children's Hospital Medical Center. A protocol has been developed to help ensure that the interests and rightful claims of all involved parties will be taken into account. Three cases are presented. In one case all involved parties concurred with the plan for bone marrow transplantation. In a second case the prospective donor was deemed mentally incompetent to give truly informed consent for the procedure. In a third case the parents were unwilling to have their child undergo transplantation. The ethical issues raised in these cases suggest the need for further development of a moral technology to enhance decision-making competence and to aid in the recognition and application of the rights of children without impeding the advancement of pediatric medicine.

Hematopoietic and immunologic tissue grafting. Current concepts and indications in pediatric patients

During the next few years investigations may provide many final solutions to the immunologic complications of hematopoietic and immunocompetent tissue grafting.