Rapid progression of fibrosing alveolitis and thyrotoxicosis after antithymocyte globulin therapy for aplastic anemia

Antithymocyte globulin (ATG) therapy is an established form of treatment for aplastic anaemia and has also been used as prophylaxis against graft rejection of bone marrow and renal allografts. Administration of ATG preparations has been associated with many mild clinical reactions, as have other forms of immunomodulatory therapy. However, serious adverse effects appear to be rare. We report a case of rapidly progressive fibrosing alveolitis and thyrotoxicosis in relation to ATG therapy, highlighting its potential toxicity and emphasising that its administration should be undertaken by experienced physicians in specialised centres.

IL-3 is produced by normal stroma in long-term bone marrow cultures

Interleukin-3 (IL-3) has been shown to have significant effects on haemopoiesis in vitro, but early investigations of normal human long-term bone marrow cultures (LTBMC) have failed to demonstrate IL-3 production by stromal cells, either by Northern blotting for mRNA, or assaying for bioactivity in culture supernatants. One recent report, using reverse transcription-polymerase chain reaction (RT-PCR), demonstrated IL-3 expression in only one of eight cultures. We have developed a sensitive bioassay for the detection of IL-3 production from normal stroma in LTBMC. LTBMC were grown until confluent, irradiated, and stroma harvested by trypsinization to yield single-cell suspensions. These cells were then cocultured with target bone marrow mononuclear cells (BMMC), or CD34+ cells in clonogenic assays, either in the presence or absence of anti-IL-3 neutralizing antibodies. We have demonstrated IL-3 production in 32/34 cases. In addition, by separating stroma from target cells using cell culture inserts, we have shown that direct stroma:stem cell contact is not necessary for colony growth, suggesting that IL-3 diffuses into the supernatant. However, when supernatants from LTBMC were assayed by enzyme-linked immunoassay (ELISA), no IL-3 was detected. This suggests that IL-3 is probably produced at low levels and has a short-range interaction. Stroma production of IL-3 was confirmed by the detection by RT-PCR of IL-3 mRNA in 3/3 cases. The simultaneous detection of CD2 mRNA demonstrated that T cells are part of the bone marrow stroma. It is therefore possible and probably likely that these cells are the source of IL-3.

A phase I/II trial of recombinant human interleukin-6 in patients with aplastic anaemia

In a phase I/II study, 11 patients with marrow failure (10 with acquired aplastic anaemia and one with pancytopenic Fanconi anaemia) were treated with recombinant human interleukin-6 (rhIL-6) to assess the safety and tolerability of rhIL-6 and its effects on peripheral blood counts, bleeding complications and transfusion requirements. All patients with acquired aplastic anaemia were refractory to immunosuppressive treatment or had relapsed after immunosuppressive therapy and were not bone marrow transplantation candidates. Recombinant hIL-6 was to be given as a once-daily subcutaneous injection for 28 d at doses ranging from 0.5 to 5.0 micrograms/kg. After an observation period of 2 weeks, five patients received a second treatment course of 28 d. Only one patient had a sustained increase in platelet count from 18,000 to 72,000/microliters. Bleeding occurred in four patients and caused premature discontinuation of rhIL-6 therapy in three patients. A deterioration of pre-existing anaemia was observed in nine patients. No significant changes of leucocyte counts were observed during the first cycle. During the second cycle the peripheral blood monocyte counts decreased significantly. No significant changes in bone marrow cellularity were observed. Recombinant hIL-6 induced a dose-dependent increase in acute-phase reactants in all patients. Other adverse events included fever, headache, arthralgia, tachycardia and hypertension. In conclusion, rhIL-6 given alone at low doses does not increase platelet counts in the majority of patients with aplastic anaemia and can precipitate a sudden worsening of pre-existing anaemia and thrombocytopenia. This study was discontinued prematurely on account of the toxicity of rhIL-6 seen in patients with aplastic anaemia.

The in vitro effects of granulocyte and granulocyte-macrophage colony-stimulating factor on interleukin-3-dependent proliferation of human neonatal circulating progenitor cells

Recombinant human granulocyte (rhG) colony-stimulating factor (CSF) and recombinant human granulocyte-macrophage (rhGM) CSF have been used to enhance neonatal neutrophil host defense. We aimed to determine the comparative efficacy of rhG-CSF and rhGM-CSF in increasing numbers of granulocyte colony-forming unit (CFU-G) and granulocyte-macrophage colony-forming unit (CFU-GM) in recombinant human (rh) IL-3-dependent cultures of human neonatal circulating hematopoietic progenitor cells, including cells from infants born to hypertensive mothers. We also investigated the relationship between fractional increase in CFU-G and endogenous plasma concentration of G-CSF. Circulating mononuclear cells were harvested from 25 neonates, and standard short-term assays in semisolid agar were established in the presence of rhIL-3 alone, rhIL-3 with rhG-CSF and rhGM-CSF, and both rhG-CSF and rhGM-CSF. CFU-G and CFU-GM were counted on d 14. Total colony number and CFU-G were significantly greater in cultures supplemented with rhG-CSF, with or without rhGM-CSF (p < 0.001 and p < 0.0005 for total colony number and CFU-G, respectively), when compared with cultures with rhIL-3 alone. Progenitor cells from three infants born to hypertensive mothers responded similarly. Total colony numbers and CFU-G were not increased by rhGM-CSF alone or by addition of rhGM-CSF to rhG-CSF; however, the proportions of CFU-GM were (p < 0.05 and p < 0.001, respectively, compared with rhIL-3 alone).(ABSTRACT TRUNCATED AT 250 WORDS)

Diamond-Blackfan anaemia: three patterns of in vitro response to haemopoietic growth factors

Culture of bone marrow from patients with Diamond-Blackfan anaemia (DBA) has previously shown a variable progenitor response to growth factor stimulation. An extensive standardized study has now been undertaken to investigate the presence of distinct sub-groups in this disorder. In vitro response of bone marrow progenitors to recombinant human growth factors, including stem cell factor, was examined in 18 DBA patients and five normal donors, assessing BFU-E, CFU-GM and CFU-GEMM development. In 16 of the DBA patients a synergistic response to combinations of growth factors was observed with optimal growth in cultures containing erythropoietin, interleukin-3 and stem cell factor. Growth factor induced erythroid response formed three distinct groups, based on BFU-E numbers: type I (mean age 4.87 years) showed > 70% normal erythroid response; type II (mean age 13.87 years) showed < 70% normal; and type III (mean age 15.29 years) < 5% normal. CFU-GM response also followed the trigrouping. The results suggest more than one pathogenic mechanism for the erythroid failure in DBA, indicating DBA may be composed of more than one distinct disorder, and further suggest the defect in DBA may not be confined to the erythroid series.

c-kit protein (stem cell factor receptor) expression on cells with erythroid characteristics and on normal human bone marrow without the use of monoclonal antibodies

Stem cell factor (SCF) is a determining and crucial element in the development of early hematopoietic cells. The SCF receptor protein has been identified as the product of the protooncogene c-kit and has been detected using monoclonal antibodies (MAbs) on a broad selection of erythroid, myeloid, and lymphoid cell lines as well as on bone marrow mononuclear cells (BMMNC). SCF is known to increase both the number and size of burst-forming unit-erythroid (BFU-E) colonies in normal human BM culture in a dose-dependent fashion. A detailed study of the involvement of SCF and its receptor c-kit in normal erythropoiesis will help elucidate intrinsic irregularities of anemias such as Diamond Blackfan Anemia, an aregenerative congenital anemia. Abnormalities of this heterogeneous disorder are confined to the red cell lineage and are thought to arise through a defect at the stem/progenitor cell level. Our in vitro studies suggest that SCF therapy will influence BFU-E production in at least a portion of these patients, although in another group, SCF response is limited or absent. Additionally, further investigations have shown a possible c-kit signaling defect that clearly necessitates further c-kit characterization. To parallel this, we, therefore, attempted to study the relationship of c-kit with its ligand. This report describes a nonradioactive method for detecting SCF receptors that varies from conventional assays in that the fluorescent label conjugated to the SCF/c-kit complex is connected via an extended-ester linkage that reduces steric influence and promotes full normal structural ligand binding of the SCF to its receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

The binding of acute myeloid leukemia blast cells to human endothelium

AML blast cell adhesion to endothelium is in all likelihood a prerequisite for blast cell migration across the vascular wall in the periphery and the subsequent establishment of leukemic extravascular disease. A general feature of malignant cells is their acquisition of altered or aberrant adhesive capabilities which appear to be associated with their ability to metastasize. Aberrant expression of integrin adhesion molecules and of membrane oligosaccharide structures is found in AML and various solid tumors. With respect to AML, these alterations in adhesive phenotype may confer a proliferative advantage on the malignant cells in the marrow, may facilitate egress from the bone marrow into the peripheral vasculature and may enable AML blast cells to traverse the vessel wall and so establish extravascular disease. Oncogenes may be directly involved in the acquisition of such aberrant adhesive phenotypes. Neutrophil extravasation is described as a model for leukocyte migration across the vessel wall and brief summaries of experimental work involving aspects of AML blast cell and normal CD34+ bone marrow cell adhesion to endothelium in vitro are described.

A phase II study of recombinant human granulocyte-colony stimulating factor (rHuG-CSF, lenograstim) in the treatment of agranulocytosis in children

The present study evaluated the clinical efficacity and tolerability of the subcutaneous (SC) administration of lenograstim, a glycosylated form of rHuG-CSF identical to human G-CSF, in the treatment of congenital agranulocytosis. Assessment criteria included neutrophil response and response stability, incidence and severity of infection and gingivostomatitis and quality of life. Lenograstim, at induction dosages of 5 (n = 9), 10 (n = 2) or 20 (n = 1) microgram/kg/day SC, produced neutrophil recovery in all of 12 children with congenital agranulocytosis. There was a median delay of 7 days to recovery after establishment of the effective induction dose. Whereas this dosage maintained a stable neutrophil response in 7 patients, the remaining 5 required dosage increases and dose reduction during maintenance therapy was not possible in these 5 cases. Among 4 patients stabilised at a dosage of 5 micrograms/kg/day, in 2 cases a lower minimum effective dose of 2 micrograms/kg/day was attained over the maintenance phase. Administration of twice the daily dose of lenograstim on alternate days was feasible in 3 of 8 patients. Lenograstim therapy reduced the incidence of infection and hospitalisation for infection relative to the prestudy period, while in 6 of 9 cases there was complete recovery from gingivostomatitis. Only one patient discontinued treatment on account of adverse events. Finally, perceived health and disease related symptoms showed a significant (p < 0.001) amelioration in the course of the study. Thus, lenogastrim produced sustained neurotrophil recovery in patients with congenital agranulocytosis, decreased the incidence and severity of infection and improved the quality of life.

Platelets in ulcerative colitis and Crohn's disease express functional interleukin-1 and interleukin-8 receptors

Tissue and plasma concentrations of several cytokines are increased in patients with inflammatory bowel disease (IBD). Platelets play an important role in inflammation and circulate in an activated state in patients with IBD. This study assesses the expression of IL-8 and IL-1 receptors on the surface of platelets from patients with IBD using phycoerythrin (PE)-labelled recombinant human rhIL-1 beta and rhIL-8 and flow cytometry. The percentage IL-1R expressing platelets (median and interquartile range IQR) in the IBD group was 8.7% (5.5-18.2) compared to 4.2% (2.3-6.1) in controls (P = 0.02). The percentage IL-8R expressing platelets in the IBD group was 22.5% (16.5-27.9) and 9.2% (4.3-9.6) in controls (P < 0.001). Furthermore, platelet IL-1R expression in patients with IBD was inversely related to the total daily dose of steroids (r = 0.71, P < 0.01 linear regression analysis). Finally, platelet rich plasma from healthy controls was stimulated with rhIL-1 beta and rhIL-8 and assessed for activation dependent expression of platelet aGPIIb/IIIa and CD62 (p-selectin, GMP-140). IL-1 beta and IL-8 in vitro significantly and specifically activated the platelets. The surface membrane of platelets is able to express functional IL-1R and IL-8R, the expression of which is significantly increased in IBD. Interleukin-1 beta and IL-8 modulate platelet activation in vitro indicating a target role for platelet function in inflammation.

Aplastic anaemia following exposure to 3,4-methylenedioxymethamphetamine ('Ecstasy')

We report two cases of aplastic anaemia following exposure to 'Ecstasy' (MDMA, 3,4-methylenedioxymethamphetamine). In both cases the aplastic anaemia resolved spontaneously 7-9 weeks after presentation. Long-term bone marrow culture study of one patient demonstrated complete normalization of haemopoiesis at time of haematological recovery, suggesting either that damage to the haemopoietic stem cell had been only transient, or that a more mature, committed progenitor cell was the target. Because MDMA may have been a factor in the aetiology of the bone marrow suppression in these two cases, we recommend close haematological monitoring of young adults presenting with toxicity from MDMA, and a detailed history of exposure to recreational drugs in all new patients presenting with aplastic anaemia.

Successful bone marrow transplant for Fanconi anaemia in transformation

We present a patient who was diagnosed as suffering from Fanconi anaemia at the age of 36 years. At the time of diagnosis his bone marrow showed features of pre-leukaemic transformation. He received an allogeneic bone marrow transplant (BMT) from his HLA-identical sibling. The post-transplant course was unremarkable with evidence of trilineage engraftment at day +32 and no acute or chronic GVHD. He is well with sustained engraftment and no haematological evidence of Fanconi anaemia 18 months post-transplant.

SLe(x) expression of normal CD34 positive bone marrow haemopoietic progenitor cells

We investigated sialylated Lewis x (sLe(x)) antigen expression on CD34 positive (CD34+) haemopoietic progenitors in the bone marrow of eight healthy volunteers using monoclonal antibodies. We found that in all the samples examined, CD34+ bone marrow progenitors strongly expressed the sLe(x) antigen. This contradicts previous publications which reported sLe(x) expression on malignant blast cells but not on normal CD34+ progenitor cells.

Differential sensitivity to cryopreservation of clonogenic progenitor cells and stromal precursors from leukemic and normal bone marrow

The survival of human leukemic and normal progenitor cells was determined after cryopreservation. Thirteen marrows from patients with acute myeloid leukemia (AML) were studied as fresh and eight as cryopreserved samples. Marrows from five normal donors were studied as both fresh and cryopreserved samples. Although the number of bone marrow mononuclear cells (BMMC) recovered after cryopreservation was always lower than that originally stored, no significant difference was observed between the clonogenic potential of fresh and cryopreserved BMMC from either the leukemic or the normal samples. When grown in long-term bone marrow culture (LTBMC), the cultures initiated with cryopreserved BMMC failed to form a confluent stroma, and the duration of nonadherent and progenitor cell production was significantly lower than that from fresh samples. However, when these cryopreserved samples were recharged onto preformed irradiated stroma, the duration of the cultures improved significantly. We conclude that it is the bone marrow stromal cells rather than the clonogenic progenitors which are sensitive to the effects of cryopreservation. Thus cryopreservation does not appear to influence the activity of AML progenitor cells. Our results also indicate that frozen marrow can be used for LTBMC experiments if cultured on a preformed stromal layer.

In vitro response of normal and aplastic anemia bone marrow to mast cell growth factor and in combination with granulocyte-macrophage colony-stimulating factor and interleukin-3

We have examined the effect of mast cell growth factor (MGF), granulocyte-macrophage colony-stimulating factor (GM-CSF), and interleukin-3 (IL-3), singly or in combination, on the growth of normal and aplastic anemia (AA) bone marrow in clonogenic assay and long-term bone marrow culture (LTBMC). MGF stimulated colony-forming unit-granulocyte/macrophage (CFU-GM), burst-forming unit-erythroid (BFU-E), and mixed colony-forming unit (consisting of granulocyte-macrophage and erythroid elements) (CFU-GEM) colony formation from both normal and AA marrow. The three-factor combination stimulated the greatest number of colonies. Marrow from less severely affected AA patients was stimulated to produce the highest number of colonies, and a normal response was possible if progenitors were present. When added to LTBMC, MGF alone had little effect. GM-CSF and IL-3 stimulated increased numbers of progenitor cells harvested each week from normal and AA LTBMC. This resulted in normal colony numbers in some patients, the majority of whom were less severely affected than the patients who did not respond in LTBMC. The three-factor combination was additive for normal CFU-GM production. However, no further increases in AA LTBMC resulted from the addition of MGF to GM-CSF and IL-3. The partial correction in clonogenic assay with MGF in some AA patients raises the possibility of therapeutic benefit. We failed to demonstrate increased progenitor cell numbers in AA LTBMC, however. Further studies may overcome possible limitations to progenitor cell proliferation.

Plasma granulocyte-colony stimulating factor concentrations ([G-CSF]) in the early neonatal period

We studied G-CSF concentrations ([G-CSF]) at birth and their relationship with neutrophil count, incidence of infection, gestational age, labour, and the presence of maternal pregnancy-induced hypertension. Plasma [G-CSF] were significantly elevated in babies with suspected infection and in those of hypertensive mothers, compared to healthy babies delivered by elective caesarian section (median [range] = 3101 [75- > 5000] pg/ml and 153 [45-857] pg/ml versus 32 [11-266] pg/ml; P < 0.0001); and were unrelated to neutrophil count and gestational age. Initial high concentrations (> 100 pg/ml) declined by 7 d (P < 0.0001).

Haemopoietic progenitor cells are reduced in aplastic anaemia

We investigated the frequencies of early populations of progenitors in aplastic anaemia (AA) bone marrow, from patients with a range of disease severity, compared with normal. Double-colour immunofluorescent staining for CD34 and CD33 was carried out on bone marrow mononuclear cells (BMMC) and analysed using fluorescence activated cell sorting (FACS). AA CD34+ cells were reduced by 68% compared to normal. In addition, AA CD33+ cells and the three progenitor subsets (CD34+/CD33-, CD34+/CD33+ and CD34-/CD33+) were reduced by 44-80%. Our data lend further support for an early stem cell deficiency in AA.

Persistence of an activating N-RAS oncogene mutation in clonogenic progenitor cells from an acute myeloid leukaemia patient in remission

A patient with acute myeloid leukaemia (AML) with an activating N-RAS oncogene mutation was studied in a haemopoietic clonogenic progenitor cell assay. Individual colonies and clusters were analysed by polymerase chain reaction and oligonucleotide hybridization for the original mutation. The mutation was detected in a majority of leukaemic clusters, but also in almost half of the differentiated colonies. After chemotherapy the patient entered clinical remission. However, the mutation could still be detected in the bone marrow. Only differentiated colonies and no leukaemic clusters were grown from the remission bone marrow, but the original mutation was still detectable in almost half of the colonies.

Response of aplastic anaemia and scleroderma to cyclosporin

Scleroderma and aplastic anaemia (AA) occurred simultaneously in a patient. Treatment with antilymphocyte globulin (ALG) resulted in some improvement of the scleroderma and a partial, temporary response of the AA. Both the scleroderma and AA then responded dramatically to cyclosporin (CSA) therapy. Subsequently, a positive Ham's test, together with a reduction in the phosphatidyl-inositolglycan (PIG) anchored membrane proteins decay accelerating factor (DAF, CD55) and membrane inhibitor of reactive lysis (MIRL, CD59), confirmed a diagnosis of paroxysmal nocturnal haemoglobinuria (PNH) affecting erythroid, myeloid and lymphoid cell lineages. We hypothesize that the pathogenesis of the bone marrow failure in this patient was a stem cell defect with a secondary immune response involving T-lymphocytes that may have simultaneously triggered the pancytopenia and scleroderma.

Acute myeloid leukaemia blast cells bind to human endothelium in vitro utilizing E-selectin and vascular cell adhesion molecule-1 (VCAM-1)

The adhesion of acute myeloid leukaemia (AML) blast cells to human umbilical vein endothelial cells (HUVECs) was investigated in vitro. Adhesion of blast cells from 10 cases of AML to unstimulated and interleukin-1 beta (IL-1) stimulated HUVECs was similar to or greater than that of control neutrophils. The extent to which endothelial E-selectin and vascular cell adhesion molecule-1 (VCAM-1) were involved in this adhesive process was investigated using blocking monoclonal antibodies to these proteins. In the majority of cases studied (7/8), anti-E-selectin significantly inhibited adhesion to IL-1 stimulated endothelium (26-65% inhibition) and in 5/8 cases so did anti-VCAM-1 (maximum of 31% inhibition). All cases were found to express the sialylated Lewis x antigen and very late activation antigen-4, ligands for E-selectin and VCAM-1 respectively. Our results indicate that leukaemic blast cells adhere to human endothelium and that there are E-selectin and, to a lesser extent, VCAM-1-dependent components to this process. Such adhesive interactions are likely to confer on AML blast cells the ability to migrate across the vascular wall and so to establish extravascular disease.

Avascular necrosis after treatment of aplastic anaemia with antilymphocyte globulin and high-dose methylprednisolone

Avascular necrosis of bone (AVN) occurring in patients with aplastic anaemia (AA) treated with antilymphocyte globulin (ALG) followed by high-dose methylprednisolone (HDMP) has been studied retrospectively. Out of 49 patients treated at two centres, seven have developed AVN at a median of 14 months (range 6-30) following treatment. The cumulative incidence of AVN is 21% (95% confidence intervals 7-35%). The hip was involved in six patients, bilaterally in five. Two patients had more than two joints affected. Surgical intervention was necessary in five patients, three of whom required total hip replacement. In contrast, there were no cases of AVN in a historical group of 61 patients with aplastic anaemia treated with an identical regimen of ALG but using a short course of low-dose prednisolone. Lack of convincing evidence for benefit, the considerable morbidity from AVN, and increased risk of early life-threatening infection, suggest that high-dose methyl prednisolone should be omitted from ALG treatment protocols for aplastic anaemia.

In vitro revelations of aplastic anemia

Aplastic anemia (AA) is a most difficult disease to study in vitro. By the time the disease presents, the marrow is already hypocellular and the peripheral blood shows pancytopenia, leaving little material remaining for study. However, an understanding of its pathogenesis could provide insight into the control of normal hemopoiesis since AA is an in vivo manifestation of failure of normal hemopoiesis and may provide a way of examining stromal cell-stem cell relationships. Recent interest in the pathogenesis of AA has resulted from a) new laboratory techniques, such as stem cell purification used with modifications of the long-term bone marrow culture system and analysis of stem cells at the molecular level with X-linked DNA probes, and b) the availability of recombinant human hemopoietic growth factors (HGF) in large quantities. Consequently, analyses of the function of some of the individual components of stromal cell mediated hemopoiesis in AA patients have been performed. This has been paralleled, and in some instances preceded, by clinical trials of HGF in patients with AA.