Bone marrow transplantation for diseases of childhood

Bone marrow transplantation in childhood is an established treatment modality for aplastic anemia, the acute and chronic leukemias, and severe combined immune deficiency. Recently, experience with this treatment has also been favorable with small numbers of children who have Wiskott-Aldrich syndrome, several types of inherited storage diseases, Fanconi's anemia, thalassemia, infantile malignant osteopetrosis, and selected cases of lymphoma and other solid tumors. The psychosocial impact and financial costs of bone marrow transplantation can be substantial. Multi-institutional, prospective, randomized trials that would compare transplantation and conventional therapy are necessary to establish the indications and precise timing for this procedure. Further development of monoclonal antibodies, a better understanding of the histocompatibility antigen systems, and improvement in pretransplantation conditioning regimens should increase the spectrum of effectiveness for bone marrow transplantation in the coming years.

Bone marrow transplantation--an expanding approach to treatment of many diseases

Thus, we can conclude that marrow transplantation has already influenced medical practice greatly. It has offered a treatment which often cures patients of more than 20 otherwise lethal diseases. The treatment so horrendously difficult and dangerous at first has already been greatly improved, simplified, and made much safer. The availability of a suitable donor has been much extended and real progress has been made in prevention and perhaps even in treatment of graft-versus-host disease. This has made possible the option of marrow transplantation for every patient in whom we think the treatment may be beneficial. The problem underlying many cases of interstitial pneumonia has been identified and patients are already benefitting clinically from this progress. Progress has also been made which promises antiviral therapy which could reduce, prevent, and ultimately eliminate the intercurrent virus infections which limit the applicability of marrow transplantation, especially for children with severe immunodeficiencies. I do not know how far this line of investigation can be taken. However, just as we have learned stepwise to use marrow transplants from matched siblings to treat many diseases, to use fetal liver in place of bone marrow, to employ matched relative donors when a matched sibling is not available, and, finally, even to use parental donors to achieve correction of SCID, we now have good reason to believe that, ultimately, we can use marrow transplantation without fear of GVHD to address many additional genetically determined and acquired diseases; certainly, for those diseases that involve any of the cells that are derived from bone marrow cells, and perhaps for those attributable even to cells of other organs and tissues, the functions of which are, in whole or in part, a consequence of interactions of marrow-derived cells and cells of ectodermal or endodermal origin, marrow transplantation may be useful. To us, the future of marrow transplantation as a major modality of treatment or prevention of many diseases, including hemoglobinopathesis, immunodeficiencies, hematologic abnormalities, abnormalities of function of marrow-derived cells, and even inborn errors of function of cells of organs and tissues not of marrow origin, seems bright, indeed. Further, with the capacity to introduce resistance genes against viruses and malignancies, autoimmune diseases, and diseases dependent on anomalies of immune response genes, marrow transplantation for many other diseases seems a more remote possibility.(ABSTRACT TRUNCATED AT 400 WORDS)

Bone marrow transplantation in the Wiskott-Aldrich syndrome. Complete hematological and immunological reconstitution

A 21-month-old boy with the Wiskott-Aldrich syndrome conditioned with cyclophosphamide and dimethyl myleran received bone marrow from an HLA-matched sibling. Complete hematological chimerism was achieved. During the first 3 months after transplantation, in vitro B cell function, measured by a direct plaque assay, was abnormal, T cell helper activity impaired, and suppressor T cell function was excessive. These abnormalities resolved gradually over 16 months. Antibody responses to the T-dependent antigen, bacteriophage phi X174, were initially low, then became normal; antibody responses to keyhole limpet hemocyanin (KLH) and to 4 of 12 type-specific pneumococcal polysaccharide antigens were adequate when studied 9 months after transplantation. The clinical response was excellent: the patient has been free of infection, no longer has a bleeding tendency, and has shown normal growth and development.

Abnormal immune responses in the ocular presentation of Wiskott-Aldrich syndrome

Wiskott-Aldrich syndrome is an x-linked disorder characterized by a triad of thrombocytopenia, eczema, and recurrent infections. Until recently, survival into the second decade was rare. In the last few years, a better understanding of the syndrome has been achieved, and earlier recognition and newer modes of treatment have improved life. These patients are living longer and ophthalmologic presentation reflects this change. We present three case histories of patients followed for the past 15 years who have had, in association with this syndrome, eczema of the eyelids, episcleritis, marginal keratitis, and blepharitis.

Immunologic studies before and after splenectomy in a patient with the Wiskott-Aldrich syndrome

Sequential studies of cellular and humoral immunity were conducted in an infant with the Wiskott-Aldrich syndrome prior to and after a splenectomy for uncontrollable hemorrhage. All measures of cellular immunity showed gradual improvement during the 8-month period after surgery. Serum isohemagglutinins, diphtheria and tetanus antibodies, and the percentage of immunoglobulin-bearing B cells did not change significantly from presplenectomy values. The serum IgE concentration declined from a high of 10,800 IU/ml at 1 month postsplenectomy to a low of 860 IU/ml at 5 months after surgery and the IgG concentration gradually decreased from a high of 1880 mg/dl presplenectomy to a low of 620 mg/dl 8 months later. The platelet count ranged from 64,000 to 206,000/mm3 for the first 6 months after splenectomy. It decreased precipitously 6.5 months after the operation; at the same time there was a marked rise in platelet-bound IgG antibody (PB-IgG). The PB-IgG declined rapidly following vincristine therapy and, after another rise, declined more gradually following steroid therapy.

Nephropathy in the Wiskott-Aldrich syndrome

Nephropathy was detected in five of 32 patients with the Wiskott-Aldrich syndrome who were participating in a study of transfer factor (TF) therapy. In two patients, nephropathy was present before TF and did not appear changed by TF therapy. One of these patients subsequently developed progressive renal failure requiring dialysis beginning 5 1/2 years after TF therapy. In two patients, decreased renal function appeared very soon after the administration of TF. One patient showed gradually decreasing renal function beginning after two years of TF therapy. An additional patient was identified who died with renal failure without having received TF. The results suggest that renal failure occurs in the Wiskott-Aldrich syndrome more frequently than generally recognized and that administration of TF may precipitate or accelerate the renal disease in patients with this syndrome.

Splenectomy in the management of the thrombocytopenia of the Wiskott-Aldrich syndrome

The Wiskott-Aldrich syndrome is an X-linked immunodeficiency disorder consisting of the triad of frequent infections, eczema, and profound thrombocytopenia. We evaluated the effects of splenectomy on hemostatic improvement and subsequent clinical course in 16 patients with the Wiskott-Aldrich syndrome. All 16 had an increase in platelet counts to at least 100,000 per cubic millimeter after splenectomy, with the mean increasing from 19,900 per cubic millimeter preoperatively to 262,700 per cubic millimeter after splenectomy. In addition, platelet size, which is characteristically small in this disease, also became normal. Survival after splenectomy correlated with the prophylactic use of antibiotics. Five of seven patients not taking prophylactic antibiotics died of sepis within 33 months of surgery. The mean survival of the nine patients maintained with prophylactic antibiotics, however, was at least 91.4 months, with six of these patients still alive an average of 11.0 years or more after splenectomy. Thus, splenectomy is a useful therapy for a major cause of morbidity and mortality in this complex syndrome.

Wiskott-Aldrich syndrome: review of literature and report of case

Wiskott-Aldrich syndrome has been described. Other reports and studies of the syndrome have been compiled. Discussion of the incompletely understood pathogenesis and current treatment modalities are included with a differential diagnosis of related conditions. Although this syndrome is uncommon, it is not rare. The patient's susceptibility to infection and propensity to bleed makes early recognition and vigorous treatment an important and challenging task. It is hoped that this report will foster awareness of such patients and the complications involved in treatment.

Transfer factor therapy in the Wiskott-Aldrich syndrome. Results of long-term follow-up in 32 patients

Thirty-two patients with the Wiskott-Aldrich syndrome have been treated with transfer factor provided by this laboratory. Apparent clinical benefit was observed in 44 per cent of them. The mean age of the patients who showed clinical benefit was significantly greater than that of the patients who showed no benefit. Conversion of immunologic reactivity correlated with clinical benefit. Thirteen of the patients who received transfer factor are alive, and 17 have died (43 per cent survival). Clinical benefit was correlated with survival. The median survival was greater than five years in the patients who showed clinical benefit, whereas it was 18 months in those who did not show clinical benefit. We conclude that transfer factor caused conversion of immunologic parameters, apparent clinical benefit and prolonged survival in some, but not all, patients with the Wiskott-Aldrich syndrome.

[A new approach to immunotherapy: the transfer factor]

The transfer factor is a tiny molecule capable of transferring the function of the T lymphocytes (immunological memory and retarded hypersensitivity) from a sensitized to a non-sensitized individual. The exact structure and action modalities of the molecule have not yet been precisely established. The difficulties involved in the study of the transfer factor are aggravated by the lack of any suitable experimental model. The attention of immunologists is attracted by this factor which opens up new prospects for the treatment of cancer, immunological deficiencies and certain infectious and autoimmune diseases. More profound research would appear useful to evaluate if and in what cases a potentiation of the immune mechanism can represent an alternative to immunosuppression.

Cellular immunity in patients with the Wiskott-Aldrich syndrome before and after administration of transfer factor: a follow-up study

Four patients with Wiskott-Aldrich syndrome were treated with transfer factor (TF), in an attempt to improve their clinical condition. Before and during treatment, cellular reactivity was followed in vivo (delayed type skin reactivity) and in vitro (lymphocyte transformation). In all patients positive skin reactions were occasionally observed during TF treatment. The lymphocyte reactivity in vitro to phytohaemagglutinin (PHA) was slightly diminished, the responding capacity of the mixed lymphocyte culture (MLC) severely impaired and the response to bacterial, viral and fungal antigens absent before and during TF treatment. No clinical improvement was observed after large doses of TF. No correlation between skin test reversal and TF administration was found, and lymphocyte transformation in vitro did not improve. Subsequently, a double blind trial, in which we compared the effect of TF and placebo, was carried out in these patients, which revealed no effect of TF therapy. It is concluded that the results of treatment with TF in these patients are highly controversial.

Wiskott-Aldrich syndrome with partial response to transfer factor

A male infant presented with dermatitis, purpura and susceptibility to bacterial infections. The clinical diagnosis of Wiskott-Aldrich syndrome was confirmed and after full immunological assessment, treatment with transfer factor was commenced. This has resulted in a rise in the platelet count and improvement in the bleeding tendency. This improvement in the haematological aspect of the disease has, however, been accompanied by exacerbations of the cutaneous lesions.

Complete correction of the Wiskott-Aldrich syndrome by allogeneic bone-marrow transplantation

Two patients with the Wiskott-Aldrich syndrome had complete donor lymphoid and hematopoietic engraftment after successful allogeneic bone-marrow transplantation. One patient had had only a temporary donor T-lymphocyte graft after a previous transplantation, for which he had been prepared with cytarabine and cyclophosphamide; the patient's own T lymphocytes returned six months later. A repeat transplant, for which the patient was prepared with anti-human thymocyte serum, total-body irradiation and procarbazine, resulted in complete donor engraftment. The second patient underwent a successful transplantation after similar preparation, except that procarbazine was omitted. At 11 and five months after transplantation both had normal hematopoiesis and no evidence of graft-versus-host disease. This treatment of the Wiskott-Aldrich syndrome may be a model for the correction of other genetically determined immune and hematologic bone-marrow disorders.

Randomized trial of transfer factor treatment of human warts

Dialysed transfer factor, prepared from the leucocytes of a donor whose warts had undergone recent spontaneous regression, was used in the treatment of a child with the Wiskott--Aldrich syndrome. The child then had a spontaneous regression at multiple warty areas. A similar relationship was seen in four otherwise healthy patients in a pilot study. A randomized double-blind study of thirty patients failed to confirm a causal relationship between the transfer factor therapy (equivalent to 2-1 X 10(8) leucocytes) and wart regressions. The need for randomized trials of transfer factor therapy for diseases with a variable natural history is emphasized.

Effect of transfer factor therapy on mixed lymphocyte culture reactivity

We have studied the effect of dialyzable transfer factor therapy on three patients with immunodeficiency disease and in one patient who demonstrated no evidence of deficiency of either humoral or cellular immunity. We found evidence for nonspecificity in the effect of transfer factor on mixed lymphocyte culture reactivity. The data suggest that in patients with immunodeficiency disease a maturation of lymphocytes may lead to a generalized increased immune responsiveness. More profoundly, our data show that transfer factor may induce changes in the expression of histocompatibility determinants. We observed changes in the expression of determinants capable of stimulating in the mixed lymphocyte culture reaction as well as an increase in the capacity of lymphocytes to respond.