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Kawarada Y, Hara R, Kitahara T, Numata H, Watanabe S, Yamada M, Ando K. Aplastic Anemia with Epstein-Barr Virus Reactivation after Anti-thymocyte Globulin Therapy. Intern Med 2023; 62:2553-2557. [PMID: 36725050 PMCID: PMC10518559 DOI: 10.2169/internalmedicine.0539-22] [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] [Received: 06/22/2022] [Accepted: 12/11/2022] [Indexed: 02/03/2023] Open
Abstract
Lymphoproliferative disorders and Epstein-Barr virus reactivation (EBV-LPDs) have various forms of onset, ranging from infectious mononucleosis-like syndrome (IM-like) to lymphoma, although whether or not IM-like progresses to lymphoma remains unclear. A 61-year-old man was diagnosed with aplastic anemia (AA). Polyclonal atypical B-lymphocytes were observed in the peripheral blood, and IM-like was diagnosed. Atypical lymphocytes disappeared, but a gastrointestinal examination revealed diffuse large B-cell lymphoma (DLBCL). Rituximab was initiated but later discontinued because of severe acute respiratory syndrome coronavirus 2 infection. Pancytopenia due to AA exacerbation recurred. The patient ultimately died of multiple organ failure due to bacterial infection.
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Affiliation(s)
- Yo Kawarada
- Department of Hematology, Ebina General Hospital, Japan
| | - Ryujiro Hara
- Department of Hematology, Ebina General Hospital, Japan
- Division of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | | | - Hiroki Numata
- Department of Hematology, Ebina General Hospital, Japan
- Division of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | | | | | - Kiyoshi Ando
- Division of Hematology/Oncology, Department of Internal Medicine, Tokai University School of Medicine, Japan
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2
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Rovó A, Kulasekararaj A, Medinger M, Chevallier P, Ribera JM, Peffault de Latour R, Knol C, Iacobelli S, Kanfer E, Bruno B, Maury S, Quarello P, Koh MBC, Schouten H, Blau IW, Tichelli A, Hill A, Risitano A, Passweg J, Marsh J, Dreger P, Dufour C. Association of aplastic anaemia and lymphoma: a report from the severe aplastic anaemia working party of the European Society of Blood and Bone Marrow Transplantation. Br J Haematol 2017; 184:294-298. [PMID: 29265360 DOI: 10.1111/bjh.15074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alicia Rovó
- University Hospital of Bern, Bern, Switzerland
| | | | | | | | - Jose M Ribera
- Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Jose Carreras Research Institute, Badalona, Spain
| | | | - Cora Knol
- EBMT Data Office, Leiden, the Netherlands
| | - Simona Iacobelli
- Centro Interdipartimentale di Biostatistica e Bioinformatica, Università Tor Vergata, Rome, Italy
| | | | | | | | | | | | | | - Igor W Blau
- Charité - Campus Virchow Klinikum, Berlin, Germany
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3
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Chen CT, Yu YB, Liu CY. Antecedent presentation of aplastic anemia in a patient with diffuse large B cell lymphoma. JOURNAL OF CANCER RESEARCH AND PRACTICE 2016. [DOI: 10.1016/j.jcrpr.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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4
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Hanaoka N, Murata S, Hosoi H, Shimokado A, Mushino T, Kuriyama K, Hatanaka K, Nishikawa A, Kurimoto M, Sonoki T, Muragaki Y, Nakakuma H. B-Cell-Rich T-Cell Lymphoma Associated with Epstein-Barr Virus-Reactivation and T-Cell Suppression Following Antithymocyte Globulin Therapy in a Patient with Severe Aplastic Anemia. Hematol Rep 2015; 7:5906. [PMID: 26487932 PMCID: PMC4591498 DOI: 10.4081/hr.2015.5906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/10/2015] [Accepted: 09/02/2015] [Indexed: 11/23/2022] Open
Abstract
B-cell lymphoproliferative disorder (B-LPD) is generally characterized by the proliferation of Epstein-Barr virus (EBV)-infected B lymphocytes. We here report the development of EBV-negative B-LPD associated with EBV-reactivation following antithymocyte globulin (ATG) therapy in a patient with aplastic anemia. The molecular autopsy study showed the sparse EBV-infected clonal T cells could be critically involved in the pathogenesis of EBV-negative oligoclonal B-LPD through cytokine amplification and escape from T-cell surveillances attributable to ATG-based immunosuppressive therapy, leading to an extremely rare B-cell-rich T-cell lymphoma. This report helps in elucidating the complex pathophysiology of intractable B-LPD refractory to rituximab.
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Affiliation(s)
| | | | | | - Aiko Shimokado
- First Department of Pathology, Wakayama Medical University , Japan
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5
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Tzankov A, Medinger M. Aplastic anemia: possible associations with lymphoproliferative neoplasms. Int J Lab Hematol 2014; 36:382-7. [DOI: 10.1111/ijlh.12224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/28/2014] [Indexed: 01/20/2023]
Affiliation(s)
- A. Tzankov
- Pathology; University Hospital Basel; Basel Switzerland
| | - M. Medinger
- Hematology; University Hospital Basel; Basel Switzerland
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6
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Colonic EBV-Associated Lymphoproliferative Disorder in a Patient Treated with Rabbit Antithymocyte Globulin for Aplastic Anemia. Case Rep Gastrointest Med 2012; 2012:395801. [PMID: 23050175 PMCID: PMC3461615 DOI: 10.1155/2012/395801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 08/28/2012] [Indexed: 12/22/2022] Open
Abstract
Epstein-Barr-virus- (EBV-) associated lymphoproliferative disorder (LPD) after immunosuppressive therapy for aplastic anemia (AA), in a nontransplant setting, has not been well described. We report one case of colonic EBV-LPD after a single course of immunosuppressive therapy for AA. The patient developed multiple colonic tumors 3 months after receiving immunosuppressive therapy, which consisted of rabbit antithymocyte globulin (ATG), cyclosporine, and methyl-predonisolone. The histological findings of biopsy specimens revealed that atypical lymphocytes had infiltrated colonic glands. Immunohistochemical staining for CD20 was positive, and in situ hybridization for EBV-encoded small RNAs was also positive. The EBV viral load in peripheral blood was slightly increased to 140/106 white blood cells. After the cessation of immunosuppressant, the colonic tumors spontaneously regressed, and the EBV viral load decreased to undetectable levels. This is the first report of the single use of rabbit ATG inducing colonic EBV-LPD. Because a single use of immunosuppressive therapy containing rabbit ATG can cause EBV-LPD, we should carefully observe patients receiving rabbit ATG for AA.
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7
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Ohata K, Iwaki N, Kotani T, Kondo Y, Yamazaki H, Nakao S. An Epstein-Barr virus-associated leukemic lymphoma in a patient treated with rabbit antithymocyte globulin and cyclosporine for hepatitis-associated aplastic anemia. Acta Haematol 2012; 127:96-9. [PMID: 22178718 DOI: 10.1159/000333609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 09/25/2011] [Indexed: 11/19/2022]
Abstract
Lymphoproliferative disorders (LPDs) are generally caused by uncontrolled B-cell proliferation induced by the Epstein-Barr virus (EBV) in the setting of impaired EBV-specific T-cell immunity, particularly when there is pharmacological immunosuppression including antithymocyte globulin. We herein present an unusual case of EBV associated with LPD (EBV-LPD) in which LPD occurred 3 weeks after the use of rabbit antithymocyte globulin administered for severe hepatitis-associated aplastic anemia; the patient died of fulminant leukemic lymphoma 5 days after the onset. We also review the pertinent literature on EBV-LPD after immunosuppressive therapy and document the efficacy of EBV viral load monitoring and the need for preemptive therapy.
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Affiliation(s)
- Kinya Ohata
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Japan
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Scheinberg P, Fischer SH, Li L, Nunez O, Wu CO, Sloand EM, Cohen JI, Young NS, John Barrett A. Distinct EBV and CMV reactivation patterns following antibody-based immunosuppressive regimens in patients with severe aplastic anemia. Blood 2006; 109:3219-24. [PMID: 17148582 PMCID: PMC1852232 DOI: 10.1182/blood-2006-09-045625] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The natural history of EBV and CMV reactivation and the potential for serious complications following antibody-based immunosuppressive treatment for bone marrow failure syndromes in the absence of transplantation is not known. We monitored blood for EBV and CMV reactivation by polymerase chain reaction (PCR) weekly in 78 consecutive patients (total of 99 immunosuppressive courses) with aplastic anemia. Four regimens were studied: (1) HC, horse ATG/cyclosporine; (2) HCS, horse ATG/CsA/sirolimus; (3) RC, rabbit ATG/CsA; and (4) CP, alemtuzumab. There were no cases of EBV or CMV disease, but EBV reactivation occurred in 82 (87%) of 94 and CMV reactivation in 19 (33%) of 57 seropositive patients after starting immunosuppression. The median peak EBV copies were higher in the RC group when compared with HC, HCS, and alemtuzumab (P < .001). The median duration of PCR positivity for EBV was higher in the RC group compared with HC, HCS, and alemtuzumab (P = .001). Subclinical reactivation of both EBV and CMV is common and nearly always self-limited in patients with bone marrow failure receiving immunosuppression; different regimens are associated with different intensity of immunosuppression as measured by viral load and lymphocyte count; and viral reactivation patterns differ according to immunosuppressive regimens.
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MESH Headings
- Adolescent
- Adult
- Aged
- Alemtuzumab
- Anemia, Aplastic/blood
- Anemia, Aplastic/complications
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/virology
- Animals
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/administration & dosage
- Antibodies, Neoplasm/adverse effects
- Antilymphocyte Serum/administration & dosage
- Antilymphocyte Serum/adverse effects
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Child
- Child, Preschool
- Cyclosporine/administration & dosage
- Cyclosporine/adverse effects
- Cytomegalovirus
- Cytomegalovirus Infections/blood
- Cytomegalovirus Infections/chemically induced
- DNA, Viral/blood
- Epstein-Barr Virus Infections/blood
- Epstein-Barr Virus Infections/chemically induced
- Female
- Herpesvirus 4, Human
- Horses
- Humans
- Immunosuppression Therapy/adverse effects
- Immunosuppressive Agents/administration & dosage
- Immunosuppressive Agents/adverse effects
- Male
- Middle Aged
- Monitoring, Physiologic
- Polymerase Chain Reaction
- Rabbits
- Sirolimus/administration & dosage
- Sirolimus/adverse effects
- Time Factors
- Virus Activation/drug effects
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Affiliation(s)
- Phillip Scheinberg
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
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Ogata M, Kikuchi H, Ono K, Ohtsuka E, Gamachi A, Kashima K, Nasu M. Spontaneous Remission of Epstein-Barr Virus-Negative Non-Hodgkin's Lymphoma after Withdrawal of Cyclosporine in a Patient with Refractory Anemia. Int J Hematol 2004; 79:161-4. [PMID: 15005345 DOI: 10.1532/ijh97.03095] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 70-year-old man presented with pancytopenia in August 2000, and the results of a bone marrow examination performed in January 2001 confirmed the diagnosis of refractory anemia. He was treated with cyclosporine (CsA) at 3.3 mg/kg per day, and the pancytopenia improved. The patient complained of epigastralgia 21 months later, and a gastric endoscopic examination showed an ulcer with a cleaved bank. A biopsy revealed diffuse large B-cell lymphoma. In situ hybridization analysis detected no Epstein-Barr virus (EBV) in the lymphoma. CsA treatment was discontinued, and a gastrectomy was performed 31 days later. A detailed histologic examination revealed no infiltration of abnormal B-cells in the resected stomach. Although EBV-positive lymphoma is a known complication of immunosuppressive therapy, no causal association between immunosuppressants and EBV-negative lymphoma has been established. The spontaneous remission observed after the withdrawal of CsA treatment suggests that immunosuppressive therapy can be a pathogenic factor in a subset of EBV-negative lymphomas.
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Affiliation(s)
- Masao Ogata
- Second Department of Internal Medicine, Oita Medical University, Hasama-machi, Oita, Japan.
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Raut A, Huryn J, Pollack A, Zlotolow I. Unusual gingival presentation of post-transplantation lymphoproliferative disorder: a case report and review of the literature. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2000; 90:436-41. [PMID: 11027379 DOI: 10.1067/moe.2000.107446] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Post-transplantation lymphoproliferative disorder is a well-documented complication of solid organ or bone marrow transplantation. Histologically, it is characterized by an abnormal proliferation of lymphocytes, which can range from benign B-cell hyperplasia to malignant lymphoma. Non-Hodgkin's lymphoma (NHL) is associated with several risk factors, such as congenital or acquired immunodeficiency states, autoimmune disorders, and infectious agents (eg, Epstein-Barr virus). Primary sites of presentation in the head and neck are Waldeyer's ring, paranasal sinuses, salivary glands, the oral cavity, and the larynx. Clinical appearance of gingival NHL varies but is usually found to be an asymptomatic gingival enlargement or mass resembling a pyogenic granuloma. We present a patient with a gingival ulceration that was subsequently diagnosed as Epstein-Barr virus malignant lymphoma resulting from the immunosuppression needed to prevent graft-versus-host disease after bone marrow transplantation.
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MESH Headings
- Adult
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents/therapeutic use
- Bone Marrow Transplantation/adverse effects
- Burkitt Lymphoma/etiology
- Burkitt Lymphoma/pathology
- Burkitt Lymphoma/therapy
- Diagnosis, Differential
- Gingival Neoplasms/etiology
- Gingival Neoplasms/pathology
- Gingival Neoplasms/therapy
- Graft vs Host Disease/complications
- Graft vs Host Disease/etiology
- Humans
- Immunosuppression Therapy/adverse effects
- Lymphoma, Large B-Cell, Diffuse/etiology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Neoplasm Staging
- Rituximab
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Affiliation(s)
- A Raut
- Memorial Sloan-Kettering Cancer Center, Dental Service, Department of Surgery, New York, NY 10021, USA
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Immunosuppressive therapy using antithymocyte globulin, cyclosporine, and danazol with or without human granulocyte colony-stimulating factor in children with acquired aplastic anemia. Blood 2000. [DOI: 10.1182/blood.v96.6.2049] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
A prospective multicenter trial of 119 children 1 to 18 years of age with newly diagnosed aplastic anemia (AA) was conducted, comparing treatment using antithymocyte globulin (ATG), cyclosporine (CyA), and danazol (DAN) with or without rhG-CSF (400 μg/m2, day on days 1-90). All children with very severe AA received rhG-CSF (VSAA group, n = 50). The other children were randomized to receive ATG, CyA, DAN, and rhG-CSF (G-CSF+ group, n = 35) or ATG, CyA, and DAN without rhG-CSF (G-CSF− group, n = 34). After 6 months, the hematologic response rate was 71%, 55%, and 77% in the VSAA group, G-CSF+ group, and G-CSF− group, respectively. There was no difference in the incidence of febrile episodes and documented infections between the G-CSF+ and G-CSF− groups. Bone marrow transplantation (BMT) was attempted in 22 patients in whom initial immunosuppressive therapy (IST; n = 18) failed or in whom a relapse occurred after an initial response (n = 4). Nineteen of the 22 patients are alive and well after a median follow-up of 18 months (range, 3 to 66 months) since BMT. The probability of survival at 4 years was 83% ± 7% in the VSAA group, 91% ± 5% in the G-CSF+ group, and 93% ± 6% in the G-CSF− group. Myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) developed in one patient in each of the three groups; the overall risk for MDS/AML was 3% ± 2% at 4 years. Because the results of IST were encouraging, it is suggested that children with AA receive IST as first-line therapy if there is no human leukocyte antigen-matched sibling donor.
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12
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Immunosuppressive therapy using antithymocyte globulin, cyclosporine, and danazol with or without human granulocyte colony-stimulating factor in children with acquired aplastic anemia. Blood 2000. [DOI: 10.1182/blood.v96.6.2049.h8002049_2049_2054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A prospective multicenter trial of 119 children 1 to 18 years of age with newly diagnosed aplastic anemia (AA) was conducted, comparing treatment using antithymocyte globulin (ATG), cyclosporine (CyA), and danazol (DAN) with or without rhG-CSF (400 μg/m2, day on days 1-90). All children with very severe AA received rhG-CSF (VSAA group, n = 50). The other children were randomized to receive ATG, CyA, DAN, and rhG-CSF (G-CSF+ group, n = 35) or ATG, CyA, and DAN without rhG-CSF (G-CSF− group, n = 34). After 6 months, the hematologic response rate was 71%, 55%, and 77% in the VSAA group, G-CSF+ group, and G-CSF− group, respectively. There was no difference in the incidence of febrile episodes and documented infections between the G-CSF+ and G-CSF− groups. Bone marrow transplantation (BMT) was attempted in 22 patients in whom initial immunosuppressive therapy (IST; n = 18) failed or in whom a relapse occurred after an initial response (n = 4). Nineteen of the 22 patients are alive and well after a median follow-up of 18 months (range, 3 to 66 months) since BMT. The probability of survival at 4 years was 83% ± 7% in the VSAA group, 91% ± 5% in the G-CSF+ group, and 93% ± 6% in the G-CSF− group. Myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) developed in one patient in each of the three groups; the overall risk for MDS/AML was 3% ± 2% at 4 years. Because the results of IST were encouraging, it is suggested that children with AA receive IST as first-line therapy if there is no human leukocyte antigen-matched sibling donor.
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Sarangi JN, Kashyap R, Choudhry VP, Mishra DK, Saxena R, Gurbaxani S, Bhargava M. Severe aplastic anemia evolving into T cell acute lymphoblastic leukemia. Eur J Haematol 1999; 63:269-71. [PMID: 10530417 DOI: 10.1111/j.1600-0609.1999.tb01889.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Severe aplastic anemia is a disorder characterized by peripheral pancytopenia and marrow hypoplasia. Although its pathophysiology is understood poorly, the majority of patients appear to have some immunologic destruction or suppression of hematopoietic cells. The only curative therapy to date is allogeneic stem cell transplantation, although the success of palliative immunosuppressive therapies has improved over the last two decades. Making the best therapy choice is complex and often requires balancing very divergent toxicity profiles, both acute and long-term.
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Affiliation(s)
- E C Guinan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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