Cytomegalovirus infections associated with leukocyte transfusions

Cytomegalovirus encephalitis occurring after bone marrow transplantation

4 months after a bone marrow transplantation performed for acute lymphocytic leukaemia, a 28-year-old man had encephalitis. A brain CT scan revealed bilateral and symmetrical temporal hypodense areas. Serological studies revealed a recent CMV conversion in serum and a higher conversion in cerebral spinal fluid. All other viral antibodies remained at low levels, especially for herpes simplex virus. Because of a high incidence of CMV infection after bone marrow transplantation, the responsibility of CMV as the cause of the encephalitis is discussed.

Early infectious complications in allogeneic marrow transplant recipients with acute leukemia: effects of prophylactic measures

One hundred eighty-two patients with acute leukemia underwent allogeneic marrow transplantation and received one of two forms of infection prophylaxis: isolation and decontamination procedures in laminar air flow rooms (90 patients) or prophylactic granulocyte transfusion from a single family member (92 patients). Infection acquisition and survival were analyzed from the time of admission to 100 days posttransplant. There were 20 major local infections in the laminar air flow group and 16 in the prophylactic granulocyte group. Of the patients in the laminar air flow group, 24 (27%) had 27 episodes of bacteremia, while 23 (25%) of the prophylactic granulocyte group had 25 episodes of bacteremia. There were no significant differences in infection acquisition between the two groups during the period of granulocytopenia or after engraftment. The mortality during the first 100 days was 28% for the laminar air flow group and 35% for the prophylactic granulocyte group. Thirteen patients (14%) in the laminar air flow group and five (5%) in the prophylactic granulocyte group died with bacterial or fungal infections. There were no statistically significant differences between the two groups in overall incidence of or mortality from interstitial pneumonitis which was the predominant cause of death. However, the subset of patients who were seronegative for cytomegalovirus antibody at the time of transplant and received granulocytes from seropositive donors had a significantly higher incidence of and mortality from cytomegalovirus interstitial pneumonitis.

Sustained post-transfusion granulocyte count increments following transfusion of leukocytes obtained from donors with chronic myelogenous leukemia

Leukocyte transfusions from patients with chronic myelogenous leukemia (CML) and elevated WBC counts were given to 14 patients with acute leukemia for the treatment of 16 infectious episodes. The WBCs were not irradiated to determine if engraftment with production of granulocytes would occur following infusion of immature myeloid elements. No recipient was alloimmunized by clinical and serologic criteria. High leukocyte yields were obtained using a variety of differential centrifugation techniques with a mean WBC yield/transfusion of 95 X 10(9) (range 19-275). A mean of 2.5 transfusions (range 1-11) were administered/recipient with a mean total dose of 235 X 10(9) WBC/transfusion episode (range 50-590). Seven patients had granulocyte counts greater than 500/microliters for four or more days (range 4-11 days) following the last transfusion. Ph1 chromosomes were documented in 2 of 4 patients tested 2-8 days following transfusion. Leukocyte alkaline phosphatase scores were increased (greater than 150) in 5/5 recipients tested post-transfusion demonstrating that production of this enzyme can be induced in CML granulocytes. Except for one severe transfusion reaction, there were no significant side effects and no recipient developed signs of graft versus host disease. All patients with sustained increments demonstrated rapid clinical improvement including 3 severely infected, poor risk patients undergoing initial induction therapy. These 3 patients all achieved complete remission with no evidence of the Ph1 chromosome. Because of the high dose of WBC which can be collected and the salutary effect of continued leukocyte production, CML WBC may be the preparation of choice for selected, non-alloimmunized, severely infected patients.

Problems of infection after bone marrow transplantation

Representatives of 17 bone marrow transplant (BMT) teams met to discuss the problems of infection after BMT. With experience of more than 2200 transplanted patients over the past 10 yr, the changes in the patterns of infection were surprisingly similar. Deaths due purely to bacterial infection have greatly diminished and the major early problems today result from fungi and cytomegalovirus. The role of non-herpes group viruses has only recently received attention. With increasing numbers of survivors, late bacterial infections are assuming importance. The meeting also provided an opportunity to document the measures adopted to prevent infection during BMT and following discharge.

Acquired immunodeficiency in an infant: possible transmission by means of blood products

An infant who received multiple transfusions during the first few days of life for rhesus disease became ill with recurrent infections when 6 months old. Hepatitis, thrush, Candida dermatitis, otitis media, and disseminated Mycobacterium avium intracellulare infection occurred by 14 months of age. Immunological studies showed raised immunoglobulin levels, decreased mononuclear-cell responses to allogeneic cells and mitogen, and a decreased helper/suppressor cell ratio. It was determined that one of the blood donors, who was well at the time of blood donation, had died 17 months after with multiple opportunistic infections and acquired immunodeficiency. The clinical and laboratory findings in our patient suggest that he acquired a transmissible infectious agent from a blood transfusion, resulting in acquired immunodeficiency, and that this agent was not cytomegalovirus, Epstein-Barr virus, or hepatitis B virus.

Factors associated with interstitial pneumonitis after bone-marrow transplantation for acute leukaemia

Data from 176 patients with acute leukaemia given allogeneic marrow transplants between Jan. 1, 1977, and Dec. 31, 1980, and reported to the International Bone Marrow Transplant Registry were analysed retrospectively for prognostic factors associated with the development of interstitial pneumonitis (IPn). The overall incidence of IPn was 20% (36/176), and the disease was fatal in 21 of the 36 cases (58%). Three of more than thirty prognostic factors studied seemed to be associated with a low risk of IPn--pretransplant total body irradiation at a dose-rate less than or equal to 5.7 cGy/min, when compared with higher dose-rates (p less than 0.001); post-transplant immunosuppression with cyclosporin-A, when compared with methotrexate (p less than 0.0003); and transplantation of cells from female donors into female recipients (p less than 0.0005). The low dose-rate of total body irradiation and the use of cyclosporin-A were considered as independent variables, but were confounded to the extent that it was not possible to determine if one or both factors were associated with a decreased incidence of IPn.

A controlled trial of prophylactic granulocyte transfusions during initial induction chemotherapy for acute myelogenous leukemia

To evaluate the role of prophylactic granulocyte transfusions during remission-induction chemotherapy for acute myelogenous leukemia (AML) we randomized 102 infected patients either to receive daily granulocyte transfusions when blood granulocytes fell below 0.5 x 10(9) per liter (54 patients) or not to receive them (48). Although the percentage of patients acquiring any infection was similar in the transfusion and control groups (46 and 42 per cent, respectively), granulocyte transfusions decreased the proportion of patients with bacterial septicemia (9 per cent of those with transfusions vs. 27 per cent of the controls; P = 0.01). Granulocyte transfusions did not reduce the incidence of other infections or improve bone-marrow recovery, remission rate and duration, or survival. Seventy-two per cent of the patients given transfusions had transfusion reactions. Pulmonary infiltrates were more common in the transfusion group than in the control group (57 per cent vs. 27 per cent; P = 0.002). Thirty-five per cent of the patients with pulmonary filtrates died, as compared with 5 per cent of those without filtrates. We conclude that prophylactic granulocyte transfusions should not be used during remission-induction chemotherapy in AML because the risks outweigh the benefits.