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Takahashi K, Katayama T, Ichikawa T, Matsuoka S, Kakinoki Y, Yoneda M, Kimura A, Koyama S, Yahara O. Possible Chronic Graft-versus-host Disease in the Central Nervous System Manifesting as Cerebellar Ataxia after Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia. Intern Med 2023; 62:779-786. [PMID: 35945030 PMCID: PMC10037021 DOI: 10.2169/internalmedicine.9720-22] [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] [Indexed: 11/06/2022] Open
Abstract
A 44-year-old woman was admitted to our hospital with a fever, dizziness, and gait disturbance after undergoing allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia followed by graft-versus-host disease. She presented with cerebellar ataxia, nystagmus, and numbness of the lower extremities. Brain magnetic resonance imaging and perfusion scintigraphy showed progressive cerebellar involvement. Cerebrospinal fluid tests showed mildly elevated protein and IgG levels without pleocytosis. Anti-ganglioside antibodies were detected, but their levels did not follow the patient's clinical course. The patient did not respond sufficiently to steroids or other immunotherapies. We herein report the clinical characteristics of this case and a literature review.
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Affiliation(s)
- Kae Takahashi
- Department of Neurology, Asahikawa City Hospital, Japan
| | | | | | | | | | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Science, Fukui Prefectural University, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University, Japan
| | - Satoshi Koyama
- Department of Internal Medicine, Asahikawa Rehabilitation Hospital, Japan
| | - Osamu Yahara
- Department of Neurology, Asahikawa City Hospital, Japan
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2
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Cerebral vascular injury in transplant-associated thrombotic microangiopathy. Blood Adv 2022; 6:4310-4319. [PMID: 35877136 PMCID: PMC9327538 DOI: 10.1182/bloodadvances.2022007453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) and atypical hemolytic uremic syndrome (aHUS) are complement-mediated TMAs. The central nervous system (CNS) is the most common extrarenal organ affected by aHUS, and, despite mechanistic overlap between aHUS and TA-TMA, CNS involvement is rarely reported in TA-TMA, suggesting that CNS involvement in TA-TMA may be underdiagnosed and that these patients may benefit from complement blockers. In addition, there are no widely used histologic or radiologic criteria for the diagnosis of TMA in the brain. Thirteen recipients of pediatric hematopoietic cell transplants (HCTs) who had TA-TMA and who underwent autopsy were studied. Seven of 13 brains had vascular injury, and 2 had severe vascular injury. Neurologic symptoms correlated with severe vascular injury. Classic TMA histology was present and most often observed in the cerebellum, brainstem, and cerebral white matter. Abnormalities in similar anatomic regions were seen on imaging. Brain imaging findings related to TMA included hemorrhages, siderosis, and posterior reversible encephalopathy syndrome. We then studied 100 consecutive HCT recipients to identify differences in neurologic complications between patients with and those without TA-TMA. Patients with TA-TMA were significantly more likely to have a clinical concern for seizure, have an electroencephalogram performed, and develop altered mental status. In summary, our study confirms that TA-TMA involves the brains of recipients of HCT and is associated with an increased incidence of neurologic symptoms. Based on these findings, we propose that patients with low- or moderate-risk TA-TMA who develop neurologic complications should be considered for TA-TMA-directed therapy.
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3
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Ide T, Iida K, Katsuya H, Ito H, Aishima S, Hara H. [Central nervous system involvement of graft versus host disease after allogeneic hematopoietic stem cell transplantation for adult T cell leukemia]. Rinsho Shinkeigaku 2022; 62:33-38. [PMID: 34924471 DOI: 10.5692/clinicalneurol.cn-001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A 54-year-old woman was diagnosed with acute adult T-cell leukemia (ATL) in November 2015 and underwent allogeneic hematopoietic stem cell transplantation in March 2016. Cognitive impairment appeared suddenly around May 2019, and MRI of the brain showed cerebral white matter lesions. Cerebrospinal fluid examination showed no significant findings other than elevated protein. Brain biopsy showed inflammatory cells, (mainly CD8-positive T lymphocytes), infiltrating the white matter. Based on the pathological findings and the history of chronic graft versus host disease (GVHD) in the lungs and intestines, we diagnosed central nervous system involvement of GVHD (CNS-GVHD). Immunotherapy with steroids and mycophenolate mofetil resulted in improvement of the cognitive dysfunction and inflammatory findings in the spinal fluid. This case is the first report of CNS-GVHD in ATL, suggesting the importance of diagnosis by brain biopsy and the efficacy of immunotherapy.
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Affiliation(s)
- Toshihiro Ide
- Division of Neurology, Department of Internal Medicine, Saga University, Faculty of Medicine
| | - Kotaro Iida
- Division of Neurology, Department of Internal Medicine, Saga University, Faculty of Medicine
| | - Hiroo Katsuya
- Division of Hematology, Department of Internal Medicine, Saga University, Faculty of Medicine
| | - Hiroshi Ito
- Department of Neurosurgery, Saga University, Faculty of Medicine
| | - Shinichi Aishima
- Department of Pathology and Microbiology, Saga University Faculty of Medicine
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University, Faculty of Medicine
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4
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Li M, Zhang Y, Guan Y, Zhang Z, Dong H, Zhao Y, Deng H. A Case Report of Central Nervous System Graft-Versus-Host Disease and Literature Review. Front Neurol 2021; 12:621392. [PMID: 33776885 PMCID: PMC7987907 DOI: 10.3389/fneur.2021.621392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/18/2021] [Indexed: 12/16/2022] Open
Abstract
As an adverse immune phenomenon, graft-versus-host disease often occurs after allogeneic hematopoietic stem cell transplantation. The incidence of acute and chronic graft-versus-host disease is about 40–60% and the mortality rate can reach 15%, which is a potentially fatal disease. There are rare GvHD cases involving the central nervous system. We reported a rare case of diffuse white matter changes after haploid bone marrow transplantation, summarizing its clinical manifestations and diagnosis and treatment in conjunction with the literature.
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Affiliation(s)
- Mingming Li
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Yue Zhang
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Yujia Guan
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Zunwei Zhang
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Hanbing Dong
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Yang Zhao
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Hui Deng
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
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5
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Lyu HR, He XY, Hao HJ, Lu WY, Jin X, Zhao YJ, Zhao MF. Noninvasive tools based on immune biomarkers for the diagnosis of central nervous system graft- vs-host disease: Two case reports and a review of the literature. World J Clin Cases 2021; 9:1359-1366. [PMID: 33644203 PMCID: PMC7896680 DOI: 10.12998/wjcc.v9.i6.1359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Central nervous system graft-vs-host disease (CNS-GVHD) is a rare cause of CNS disorders after allogeneic hematopoietic stem cell transplantation. Currently, establishing a diagnosis of CNS-GVHD is challenging because the diagnostic criteria and diagnostic methods are not well defined and many confounding factors need to be ruled out.
CASE SUMMARY Here, we present two patients with CNS-GVHD. Both patients with a history of acute GVHD or chronic GVHD developed neurological symptoms that could not be explained by other causes, and had abnormal cerebrospinal fluid (CSF) studies as determined by CSF and blood immune biomarker examinations, suggestive of suspected CNS-GVHD. Due to the lack of specific magnetic resonance imaging abnormalities and the rapid clinical deterioration of the patients, we did not attempt to perform a brain biopsy, but prompted the initiation of empirical immunosuppressive therapy. In view of the rapid and favorable response to local and systematic immunosuppressive treatment and the aforementioned neurologic manifestations together with CSF abnormalities and other negative findings, a final diagnosis of CNS-GVHD was made.
CONCLUSION CSF and blood immune biomarker examinations facilitated the diagnosis of CNS-GVHD, which are particularly suitable for patients who are critically ill and require urgent treatment and for those who are unsuitable for invasive diagnostic procedures.
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Affiliation(s)
- Hai-Rong Lyu
- Department of Hematology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Xiao-Yuan He
- Department of Hematology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Hong-Jun Hao
- Department of Neurology, Peking University First Hospital, Beijing 100034, China
| | - Wen-Yi Lu
- Department of Hematology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Xin Jin
- School of Medicine, Nankai University, Tianjin 300071, China
| | - Yu-Jiao Zhao
- Department of Radiology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Ming-Feng Zhao
- Department of Hematology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
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6
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Kaito Y, Yui S, Inai K, Onai D, Kinoshita R, Yamanaka S, Okamoto M, Wada R, Ohashi R, Inokuchi K, Yamaguchi H. Central Nervous System-related Graft-versus-host Disease after Allogeneic Hematopoietic Stem Cell Transplantation. Intern Med 2021; 60:3299-3304. [PMID: 34657908 PMCID: PMC8580761 DOI: 10.2169/internalmedicine.6351-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Allogeneic hemopoietic stem cell transplantation (allo-HSCT) is the only curative therapy for refractory hematological malignancies. However, there are many treatment-related complications, including organ disorders, graft-versus-host disease (GVHD), and infectious diseases. Furthermore, there are many unclear points regarding central nervous system (CNS) complications, and the prognosis in patients with CNS complications is extremely poor. We herein report a 49-year-old woman who developed CNS-GVHD after a second transplantation for therapy-related myelodysplastic syndrome. CNS-GVHD in this case was refractory to all treatments, including steroids, and progressed. We also present a review of the literature about the symptoms, diagnosis, and treatment of CNS-GVHD.
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Affiliation(s)
- Yuta Kaito
- Department of Hematology, Nippon Medical School, Japan
| | - Shunsuke Yui
- Department of Hematology, Nippon Medical School, Japan
| | - Kazuki Inai
- Department of Hematology, Nippon Medical School, Japan
| | - Daishi Onai
- Department of Hematology, Nippon Medical School, Japan
| | | | | | - Muneo Okamoto
- Department of Hematology, Nippon Medical School, Japan
| | - Ryuichi Wada
- Department of Diagnostic Pathology, Nippon Medical School Hospital, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
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7
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Buxbaum NP, Pavletic SZ. Autoimmunity Following Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:2017. [PMID: 32983144 PMCID: PMC7479824 DOI: 10.3389/fimmu.2020.02017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022] Open
Abstract
Autoimmune manifestations after allogeneic hematopoietic stem cell transplantation (AHSCT) are rare and poorly understood due to the complex interplay between the reconstituting immune system and transplant-associated factors. While autoimmune manifestations following AHSCT have been observed in children with graft-versus-host disease (GvHD), an alloimmune process, they are distinct from the latter in that they are generally restricted to the hematopoietic compartment, i.e., autoimmune hemolytic anemia, thrombocytopenia, and/or neutropenia. Autoimmune cytopenias in the setting of ASHCT represent a donor against donor immune reaction. Non-hematologic autoimmune conditions in the post-AHSCT setting have been described and do not currently fall under the GvHD diagnostic criteria, but could represent alloimmunity since they arise from the donor immune attack on the antigens that are shared by the donor and host in the thyroid, peripheral and central nervous systems, integument, liver, and kidney. As in the non-transplant setting, autoimmune conditions are primarily antibody mediated. In this article we review the incidence, risk factors, potential pathophysiology, treatment, and prognosis of hematologic and non-hematologic autoimmune manifestations in children after AHSCT.
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Affiliation(s)
- Nataliya Prokopenko Buxbaum
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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8
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A case of central nervous system graft-versus-host disease following allogeneic stem cell transplantation. Int J Hematol 2019; 110:635-639. [PMID: 31309419 DOI: 10.1007/s12185-019-02702-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 12/27/2022]
Abstract
Graft-versus-host disease (GVHD) is a serious complication of allogeneic stem cell transplantation (SCT). Here, we report a rare case of GVHD involving the central nervous system (CNS). A 35-year-old woman was diagnosed with myelodysplastic syndrome unclassifiable and underwent allogeneic peripheral blood SCT for disease progression to myelodysplastic syndrome with excess blasts-2. One year following SCT, she experienced chronic oral and hepatic GVHD symptoms, which were managed with oral steroids and tacrolimus. Sixteen months after SCT, she developed sudden-onset, generalized, tonic-clonic-type seizures. Magnetic resonance imaging and cerebrospinal fluid evaluation showed multiple discrete white lesions and elevated IgG levels. Brain biopsy revealed periventricular plaques with the destruction of axons, representing a demyelinating disease of the CNS. We diagnosed the case as CNS GVHD. Neurologic symptoms gradually improved with methylprednisolone pulse therapy and total plasma exchange combined with a calcineurin inhibitor; the brain lesions nearly disappeared after decreasing steroid maintenance dosage, and were completely resolved 1 year after the onset of CNS GVHD. The patient is CNS GVHD-symptom-free, 3-year post-transplantation. Thus, CNS GVHD should be considered in cases of newly developed neurologic symptoms in SCT recipients showing evidence of preceding chronic GVHD.
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9
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Pirotte M, Forte F, Lutteri L, Willems E, Duran U, Belle L, Baron F, Beguin Y, Maquet P, Bodart O, Servais S. Neuronal surface antibody-mediated encephalopathy as manifestation of chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. J Neuroimmunol 2018; 323:115-118. [PMID: 30189384 DOI: 10.1016/j.jneuroim.2018.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 12/21/2022]
Abstract
Although it remained controversial for a long time, central nervous system (CNS) involvement of graft-versus-host disease (GVHD) is now becoming recognized as a real nosological entity. Previous case reports have suggested heterogeneous clinical presentations and it is not excluded that the whole spectrum of manifestations has not yet been fully described. Here, we report the case of a 58-year-old man with chronic GVHD who developed a rapidly ingravescent encephalopathy. There was no evidence for CNS immune-mediated lesions on conventional imaging nor for cellular infiltration in the cerebrospinal fluid. Serum analyses revealed the presence of anti-neuronal antibodies directed against anti-contactin-associated protein 2 (anti-Caspr2), a protein associated with voltage-gated potassium neuronal channels. Functional imaging with 2-deoxy-2-[fluorine-18] fluoro- d-glucose integrated with computed tomography (18F-FDG PET-CT) demonstrated diffuse cortical and subcortical hypometabolism. The patient was treated with a combination of immunosuppressive agents (corticosteroids, cyclophosphamide and rituximab) and progressively recovered normal neurocognitive functions. Taken together, these data suggest that CNS-GVHD may manifest as a reversible antibody-mediated functional encephalopathy. This report suggests for the first time the interest of screening for anti-neuronal antibodies and functional imaging with brain 18F-FDG PET-CT in diagnosing this severe complication of allogeneic hematopoietic cell transplantation (alloHSCT).
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Affiliation(s)
- Michelle Pirotte
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Florence Forte
- Department of Neurology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Laurence Lutteri
- Department of Clinical Biology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Evelyne Willems
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Unal Duran
- Department of Radiology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Ludovic Belle
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Frédéric Baron
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Yves Beguin
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Pierre Maquet
- Department of Neurology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Olivier Bodart
- Department of Neurology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium
| | - Sophie Servais
- Department of Hematology, CHU of Liège and ULiege, CHU Sart-Tilman, 4000 Liège, Belgium.
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10
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Polchlopek Blasiak K, Simonetta F, Vargas MI, Chalandon Y. Central nervous system graft-versus-host disease (CNS-GvHD) after allogeneic haematopoietic stem cell transplantation. BMJ Case Rep 2018; 2018:bcr-2017-221840. [PMID: 29330269 DOI: 10.1136/bcr-2017-221840] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A 60-year-old man presented with impaired consciousness and psychomotor agitation after a second allogeneic haematopoietic stem cell transplantation (HSCT) from a matched unrelated donor for acute myeloid leukaemia. Clinical, biological and radiological evidence suggested a diagnosis of central nervous system graft-versus-host disease (CNS-GvHD). After intrathecal infusion of methylprednisolone, the clinical symptoms as well as the radiological abnormalities disappeared. The present report illustrates the difficulties in the diagnosis and the management of CNS-GvHD, a very rare and still challenging neurological complication that can occur after allogeneic HSCT.
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Affiliation(s)
| | - Federico Simonetta
- Division of Hematology, Department of Oncology, Hopitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Yves Chalandon
- Division of Hematology, Department of Oncology, Hopitaux Universitaires de Genève, Geneva, Switzerland
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11
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Ruggiu M, Cuccuini W, Mokhtari K, Meignin V, Peffault de Latour R, Robin M, de Fontbrune FS, Xhaard A, Socié G, Michonneau D. Case report: Central nervous system involvement of human graft versus host disease: Report of 7 cases and a review of literature. Medicine (Baltimore) 2017; 96:e8303. [PMID: 29049232 PMCID: PMC5662398 DOI: 10.1097/md.0000000000008303] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Central nervous system (CNS) involvement of graft versus host disease (GvHD) is a rare cause of CNS disorders after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Chronic CNS GvHD symptoms are heterogeneous and include cerebrovascular manifestations, demyelinating disease and immune-mediated encephalitis. CNS-Acute GvHD is not formally defined in literature. PATIENTS CONCERNS AND DIAGNOSES We report 7 cases of CNS-GvHD among which two had histological-proven disease. We reviewed 32 additional cases of CNS GvHD published in literature since 1990. In this cohort, 34 patients were transplanted for hematologic malignancies, and 5 for non-malignant hematopoiesis disorders. Of these patients, 25 had a history of chronic GvHD and immunosuppressive treatment had been decreased or discontinued in 14 patients before neurological symptoms onset. Median neurological disorder onset was 385 days [7-7320]. Patients had stroke-like episodes (n = 7), lacunar syndromes (n = 3), multiple sclerosis-like presentations (n = 7), acute demyelinating encephalomyelitis-like symptoms (n = 4), encephalitis (n = 14), mass syndrome (n = 1), and 3 had non-specific symptoms. Median neurological symptoms onset was 81.5 days [7-1095] for patients without chronic GVHD history versus 549 days [11-7300] for patients with chronic GVHD (P = 0.001). Patients with early involvement of CNS after allo-HSCT and no chronic GVHD symptoms were more frequently suffering from encephalitis (64% versus 28%, P = 0.07), whereas stroke-like episodes and lacunar symptoms were less frequent (9% versus 36%, P = 0.13). INTERVENTIONS 34 patients with CNS-GvHD were treated with immunosuppressive therapy, including corticosteroids for 31 of them. Other treatments were intravenous immunoglobulin, plasmapheresis, cyclophosphamide, calcineurin inhibitors, mycophenolic acid, methotrexate and etoposide. OUTCOMES 27 patients achieved a response: 10 complete responses, 15 partial responses and 2 transient responses. Of 25 patients with sufficient follow-up, 7 were alive and 18 patients deceased after CNS-GvHD diagnosis. LESSONS CNS-related GvHD is a rare cause of CNS disorders after allo-HSCT and is associated with a poor prognosis.
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Affiliation(s)
- Mathilde Ruggiu
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
| | - Wendy Cuccuini
- Université Paris Diderot, Sorbonne Paris Cité
- Laboratoire de Cytogénétique, Hôpital Saint Louis
| | - Karima Mokhtari
- Laboratoire d’anatomie pathologique, Hôpital La Pitié Salpétrière, APHP
- Université Pierre et Marie Curie, Sorbonne Paris Cité
| | - Véronique Meignin
- Université Paris Diderot, Sorbonne Paris Cité
- Laboratoire d’Anatomie Pathologique, Hôpital Saint Louis, APHP
| | - Régis Peffault de Latour
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
- EA3518, Université Paris Diderot
| | - Marie Robin
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
- INSERM U1131, Université Paris Diderot
| | - Flore Sicre de Fontbrune
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
| | - Aliénor Xhaard
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
| | - Gérard Socié
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
- INSERM UMR1160, Institut Universitaire d’Hématologie, Centre Hayem, Paris, France
| | - David Michonneau
- Service d’Hématologie Greffe, Hôpital Saint Louis, APHP
- Université Paris Diderot, Sorbonne Paris Cité
- INSERM UMR1160, Institut Universitaire d’Hématologie, Centre Hayem, Paris, France
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12
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Enriquez-Marulanda A, Sierra-Ruiz M, Jaramillo FJ, Escobar LA, Granados AM, Rodríguez-Rojas LX, Lees AJ, Orozco JL. Hemichoreo-hemibalism as a Manifestation of Central Nervous System Chronic Graft-versus-Host Disease. Mov Disord Clin Pract 2017; 4:495-498. [PMID: 30713967 DOI: 10.1002/mdc3.12497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/06/2017] [Accepted: 04/09/2017] [Indexed: 11/07/2022] Open
Affiliation(s)
| | | | | | - Luis Alberto Escobar
- Fundación Valle del Lili Cali Colombia.,Clinical Research Center Cali Colombia.,Universidad Icesi Cali Colombia
| | - Ana María Granados
- Fundación Valle del Lili Cali Colombia.,Clinical Research Center Cali Colombia.,Universidad Icesi Cali Colombia
| | | | - Andrew J Lees
- Department of Molecular Neuroscience Queen Square Brain Bank for Neurological Disorders University College London London United Kingdom
| | - Jorge Luis Orozco
- Fundación Valle del Lili Cali Colombia.,Clinical Research Center Cali Colombia.,Universidad Icesi Cali Colombia
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13
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Terada M, Nakamagoe K, Obara N, Ogawa S, Sakamoto N, Sato T, Nohara S, Chiba S, Tamaoka A. Chronic Graft-versus-host Disease Presenting with Multiple Punctate Intracranial Lesions on Contrast-enhanced Magnetic Resonance Imaging. Intern Med 2017; 56:363-368. [PMID: 28154284 PMCID: PMC5348464 DOI: 10.2169/internalmedicine.56.7329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Central nervous system graft-versus-host disease can present quite a diagnostic challenge. We herein present a case of histologically-confirmed chronic graft versus host disease (GVHD) involving the central nervous system that occurred at 19 months after peripheral blood stem cell transplantation. Cranial magnetic resonance imaging showed areas of confluent hyperintensity in the deep/subcortical white matter with multiple punctate and curvilinear gadolinium enhancements, suggesting the disruption of the blood-brain barrier. A brain biopsy revealed perivascular CD3-positive T cell infiltration around the small vessels. We propose that the detection of punctate-enhanced lesions by magnetic resonance imaging may be a useful finding that facilitates the early diagnosis of chronic GVHD involving the central nervous system.
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Affiliation(s)
- Makoto Terada
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Japan
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14
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Robuccio A, Ssentongo P, Sather MD, Claxton DF, Gilliam FG. Intractable myoclonic seizures in an allogeneic stem cell transplant recipient: A rare case of myoclonic epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2015; 4:48-51. [PMID: 26288756 PMCID: PMC4536288 DOI: 10.1016/j.ebcr.2015.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
Introduction Myoclonus may be a rare complication of stem cell transplant but has limited discussion in the scientific literature. Case We present a case of an acute myeloid leukemia survivor who developed refractory myoclonic epilepsy four years after graft versus host disease (GVHD) developed six days following matched unrelated allogeneic hematopoietic stem cell transplant. Discussion Graft versus host disease occurs in 30–50% of allogenic hematopoietic stem cell transplant patients and may cause pharmacoresistant myoclonic epilepsy; however, the mechanisms by which GVHD leads to recurrent myoclonic seizures are not well understood (Lee, 2005) [1]. The paucity of clinical reports of such manifestation makes it difficult to diagnose and effectively manage these patients.
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Affiliation(s)
- Anna Robuccio
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Paddy Ssentongo
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Michael D Sather
- Department of Neurosurgery, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - David F Claxton
- Penn State Cancer Institute, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Frank G Gilliam
- Center for Neural Engineering, Science and Mechanics, The Pennsylvania State University, University Park, PA 16802, USA ; Department of Neurology, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA ; Department of Neurosurgery, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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15
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Cocito D, Romagnolo A, Rosso M, Peci E, Lopiano L, Merola A. CIDP-like neuropathies in graft versus host disease. J Peripher Nerv Syst 2015; 20:1-6. [DOI: 10.1111/jns.12108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/04/2015] [Accepted: 03/11/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Dario Cocito
- Department of Neuroscience; University of Turin; Torino Italy
| | | | - Michela Rosso
- Department of Neuroscience; University of Turin; Torino Italy
| | - Erdita Peci
- Department of Neuroscience; University of Turin; Torino Italy
| | | | - Aristide Merola
- Department of Neuroscience; University of Turin; Torino Italy
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16
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Grauer O, Wolff D, Bertz H, Greinix H, Kühl JS, Lawitschka A, Lee SJ, Pavletic SZ, Holler E, Kleiter I. Neurological manifestations of chronic graft-versus-host disease after allogeneic haematopoietic stem cell transplantation: report from the Consensus Conference on Clinical Practice in chronic graft-versus-host disease. Brain 2010; 133:2852-65. [PMID: 20846944 DOI: 10.1093/brain/awq245] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A major obstacle of allogeneic haematopoietic stem cell transplantation is graft-versus-host disease, an immune-mediated disorder that affects multiple tissues and organs with varying severity. Neurological complications of acute and chronic graft-versus-host disease are rare but can produce severe clinical problems with significant morbidity and mortality. In this article, we review neurological manifestations of chronic graft-versus-host disease that comprise immune-mediated neuropathies, myasthenia gravis and myositis in the peripheral nervous system and various cerebrovascular complications, demyelination and immune-mediated encephalitis in the central nervous system. The National Institutes of Health consensus on criteria for clinical trials in chronic graft-versus-host disease recommended that the diagnosis of chronic graft-versus-host disease of the nervous system can be made only when other organs are affected by graft-versus-host disease and frequent neurological differential diagnoses such as drug-induced toxicities or opportunistic infections are excluded. The Consensus Conference on Clinical Practice in chronic graft-versus-host disease, held in autumn 2009 in Regensburg, aimed to summarize the literature and to provide guidelines for the diagnostic approach in children and adults with neurological manifestations of chronic graft-versus-host disease. Moreover, we present therapeutic recommendations and their level of evidence for the management of these complications. Overlapping symptoms and comorbidities after allogeneic haematopoietic stem cell transplantation and the limited knowledge about the underlying biological mechanisms of chronic graft-versus-host disease affecting the nervous system emphasize the need for further experimental and clinical investigations.
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Affiliation(s)
- Oliver Grauer
- Department of Neurology, University Medical Centre Regensburg, Universitätsstraße 84, Regensburg, Germany
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17
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Saad AG, Alyea EP, Wen PY, Degirolami U, Kesari S. Graft-versus-host disease of the CNS after allogeneic bone marrow transplantation. J Clin Oncol 2009; 27:e147-9. [PMID: 19667266 DOI: 10.1200/jco.2009.21.7919] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ali G Saad
- Department of Pathology, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
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18
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Ostronoff F, Ostronoff M, Fernandes HS, Buessio R, Soriano S, Souto-Maior AP, Sucupira A, Domingues M, Florencio R, Tagliari C, Calixto R. Evidence for a graft-versus-leukemia effect in the central nervous system. Leuk Lymphoma 2009; 49:365-9. [DOI: 10.1080/10428190701784417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Marchiori PE, Lino AM, Britto N, Bacchella T, Machado MC, Mies S, Massarollo P, Scaff M. Neuropsychiatric complications due to organ transplantation: a survey of 1499 Brazilian patients at a single center in São Paulo, Brazil. Transplant Rev (Orlando) 2005. [DOI: 10.1016/j.trre.2005.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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20
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Nagashima T, Sato F, Chuma T, Mano Y, Sasaki I, Mori M, Higa T, Masauji N, Kasai M, Orba Y, Shinohara T, Nagashima K. Chronic demyelinating polyneuropathy in graft-versus-host disease following allogeneic bone marrow transplantation. Neuropathology 2002. [DOI: 10.1046/j.0919-6544.2002.00419_22_1.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Sedgwick JD, Ford AL, Foulcher E, Airriess R. Central Nervous System Microglial Cell Activation and Proliferation Follows Direct Interaction with Tissue-Infiltrating T Cell Blasts. THE JOURNAL OF IMMUNOLOGY 1998. [DOI: 10.4049/jimmunol.160.11.5320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Central nervous system (CNS)-resident macrophages (microglia) normally express negligible or low level MHC class II, but this is up-regulated in graft-vs-host disease (GvHD), in which a sparse CNS T cell infiltrate is observed. Relative to microglia from the normal CNS, those from the GvHD-affected CNS exhibited a 5-fold up-regulation of characteristically low CD45, MHC class II expression was increased 10- to 20-fold, and microglial cell recoveries were enhanced substantially. Immunohistologic analysis revealed CD4+αβTCR+CD2+ T cells scattered infrequently throughout the CNS parenchyme, 90% of which were blast cells of donor origin. An unusual clustering of activated microglia expressing strongly enhanced levels of CD11b/c and MHC class II was a feature of the GvHD-affected CNS, and despite the paucity of T lymphocytes present, activated microglial cell clusters were invariably intimately associated with these T cells. Moreover, 70% of T cells in the CNS were associated with single or clustered MHC class II+ microglia, and interacting cells were predominantly deep within the tissue parenchyme. Approximately 3.7% of the microglia that were freshly isolated from the GvHD-affected CNS were cycling, and proliferating cell nuclear Ag-positive microglia were detected in situ. Microglia from GvHD-affected animals sorted to purity by flow cytometry and cultured, extended long complex processes, exhibited spineous processes, and were phagocytic and highly motile. These outcomes are consistent with direct tissue macrophage-T cell interactions in situ that lead to activation, proliferation, and expansion of the responding tissue-resident cell.
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Affiliation(s)
- Jonathon D. Sedgwick
- Centenary Institute of Cancer Medicine and Cell Biology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Andrew L. Ford
- Centenary Institute of Cancer Medicine and Cell Biology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Eléna Foulcher
- Centenary Institute of Cancer Medicine and Cell Biology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Rhonda Airriess
- Centenary Institute of Cancer Medicine and Cell Biology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
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22
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23
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de Almeida SM, Livramento JA, Pasquini R, Palou VB, de Oliveira AM, Doi EM, Ono M, Aso MC, Ferreira E. [Intrathecal immunoglobulin synthesis evaluation in bone marrow transplantation]. ARQUIVOS DE NEURO-PSIQUIATRIA 1997; 55:801-11. [PMID: 9629341 DOI: 10.1590/s0004-282x1997000500018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The central nervous system involvement in chronic graft versus host disease (GVHD) has been suggested. Chronic GVHD resembles auto immune connective tissue disorders. In order to investigate the immunoglobulin intra blood brain barrier (BBB) synthesis during chronic GVHD, and contribute to understanding the pathophysiology of the disease, we studied 33 patients who underwent allogeneic bone marrow transplants (BMT) from HLA identical related donors. Immunoglobulin intra BBB synthesis was investigated quantitative and qualitatively. The samples were collected pre BMT, pos BMT and during chronic GVHD. There were no evidence of immunoglobulin intra BBB synthesis, and no oligoclonal bands were found. Only isolated cases suggested IgO and IgA intra BBB synthesis, and in one case IgM during GVHD.
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Affiliation(s)
- S M de Almeida
- Serviço de TMO, Hospital de Clínicas, Universidade Federal do Paraná (HC-UFPR), Curitiba, Brasil
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24
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de Almeida SM, Livramento JA, Passqüini R, Palou VB, de Oliveira AM, Doi EM, Ono M, Aso MC, Ferreira E. [Blood-brain barrier evaluation in bone marrow transplantation]. ARQUIVOS DE NEURO-PSIQUIATRIA 1997; 55:812-8. [PMID: 9629342 DOI: 10.1590/s0004-282x1997000500019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The blood-brain barrier (BBB) contributes to the central nervous system (CNS) immunological isolation. BBB has never been studied in patients who developed chronic graft-versus-host disease (GVHD) after allogeneic bone marrow transplants (BMT), from HLA identical related donors. BBB disruption was investigated through the cerebrospinal fluid (CSF) proteins, quantitative and graphically, in order to detect the incidence and possible pathophysiology of the CNS involvement in chronic GVHD. Thirty three CSF and matched serum samples from chronic myeloid leukemia patients were collected pre BMT pos BMT and during chronic GVHD. There was no evidence of BBB disruption in any patient studied.
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Affiliation(s)
- S M de Almeida
- Serviço de TMO, Hospital de Clínicas, Universidade Federal do Paraná (HC-UFPR), Curitiba, Brasil
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25
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van Besien K, Forman A, Champlin R. Central nervous system relapse of lymphoid malignancies in adults: the role of high-dose chemotherapy. Ann Oncol 1997; 8:515-24. [PMID: 9261519 DOI: 10.1023/a:1008248315859] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Adults with CNS recurrence of lymphoid malignancies generally have a very poor prognosis. Although recent reports indicate that a proportion of patients may obtain prolonged remission after bone marrow transplantation, the role of high-dose chemotherapy in the management of this complication remains controversial. We reviewed the literature in order to better evaluate the relative contribution of high-dose chemotherapy to the outcome of patients with CNS recurrence. We focused mainly on results in adults, but included results on pediatric patients when relevant. Our review of the data indicates that 20% to 40% of adults with a history of CNS involvement by lymphoma or lymphoid leukemia can be cured by high-dose chemotherapy. A small fraction of patients with active CNS involvement can be cured as well. No data is available to determine superiority of a particular conditioning regimen or of allogeneic vs. autologous BMT. There is no conclusive benefit to post-transplant intrathecal therapy and the role of cranial or cranio-spinal radiation treatment and its optimal timing remains to be determined. Prospective studies are needed to resolve many of the issues regarding the treatment, and to improve the outcome of patients with CNS recurrence of lymphoid malignancies.
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Affiliation(s)
- K van Besien
- Department of Hematology, University of Texas M.D. Anderson Cancer Center, Houston, USA
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26
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Iwasaki Y, Sako K, Tsunoda I, Ohara Y. Phenotypes of mononuclear cell infiltrates in human central nervous system. Acta Neuropathol 1993; 85:653-7. [PMID: 8393262 DOI: 10.1007/bf00334676] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Using a panel of monoclonal antibodies applicable for identification of cell types in paraffin sections, the prevalence of mononuclear cell infiltrates with different phenotypes was estimated in large areas taken from 11 cases of acute and chronic inflammatory diseases in the human central nervous system. The present study clearly demonstrated a diversity of inflammatory mononuclear cell infiltrates, and the dominance of cell types in individual lesions appeared to be determined by both the nature of the diseases and the age of the lesions. The possible pathognomonic significance of a relatively high prevalence of CD4+CD45RO+ lymphocytes in acute rabies and in a convalescent stage of Japanese encephalitis and subacute sclerosing panencephalitis is discussed.
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Affiliation(s)
- Y Iwasaki
- Department of Neurological Sciences, Tohoku University School of Medicine, Sendai, Japan
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