Polymyositis after donor lymphocyte infusion

Chronic graft-versus-host disease presenting as acute polymyositis: A case series and systematic review

Chronic graft-versus-host disease (cGvHD) remains a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Commonly targeted organs are skin, eyes, mouth, gastrointestinal tract, and liver. Muscular involvement and presentation as acute polymyositis (APM) remain a rare manifestation of cGvHD. We present a case series of three patients who presented with APM as a sole presentation of cGvHD and were treated successfully with corticosteroids and ruxolitinib. We also conducted a systematic review including 72 patients to summarize current literature regarding APM associated with cGvHD after allo-HSCT. The estimated incidence of cGvHD-associated APM is up to 3.4%, with a median time to onset of 1.6 years post-allo-HSCT. Most cases (85%) presented with myalgia and progressive bilateral proximal muscle weakness with elevated creatine kinase and/or aldolase. Over half of the patients had a prior history of acute GvHD. Isolated APM presenting without other clinical manifestations of cGvHD was rare. Biopsy of affected muscles usually shows characteristic myonecrosis, which remains the gold standard for diagnosis. Most cases respond to systemic steroids and immunosuppressive therapy. However, refractory cases remain challenging to treat and can cause significant morbidity and mortality. Ruxolitinib appears to be an effective therapy in this setting.

Clinical Characteristics of Myositis Associated with Graft-Versus-Host Disease

PURPOSE OF REVIEW

Recipients of allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk for inflammatory myositis; histological subsets reported include dermatomyositis, necrotising myopathy and chronic graft-versus-host disease (cGVHD)-related myositis. Though corticosteroids and various immunosuppressive therapies have been used, there is a lack of consensus guidelines dictating therapy.

RECENT FINDINGS

Recent evidence suggests the fascia as a preferential target in cGVHD myositis, with conditioning regimens promoting fascial microtrauma. Positron emission tomography (PET) can be a useful diagnostic tool, and case reports suggest that the Bruton's tyrosine kinase inhibitor ibrutinib may have therapeutic potential. Emerging therapies include targeted B cell depletion with rituximab, and extracorporeal photophoresis. Clinicians need to be vigilant for the development of inflammatory myositis post-allogeneic HSCT as most patients respond to treatment. Advances in immunohistochemistry to determine the dominant cell type and cytokine profile may enable targeted and individualised therapies.

Cellular Immunotherapy for Hematologic Malignancies: Beyond Bone Marrow Transplantation

Immunotherapy has changed treatment practices for many hematologic malignancies. Even in the current era of targeted therapy, chemotherapy remains the backbone of treatment for many hematologic malignancies, especially in acute leukemias, where relapse remains the major cause of mortality. Application of novel immunotherapies in hematology attempts to harness the killing power of the immune system against leukemia and lymphoma. Cellular immunotherapy is evolving rapidly for high-risk hematologic disorders. Recent advances include chimeric antigen-receptor T cells, mesenchymal stromal/stem cells, dendritic cell tumor vaccines, cytokine-induced killer cells, and virus-specific T cells. The advantages of nontransplantation cellular immunotherapy include suitability for patients for whom transplantation has failed or is contraindicated, and a potentially less-toxic treatment alternative to transplantation for relapsed/refractory patients. This review examines those emerging cellular immunotherapies that are changing treatment paradigms for patients with hematologic malignancies.

A case report and literature review of chronic graft-versus-host disease manifesting as polymyositis

Polymyositis (PM) is a rare but documented manifestation of chronic graft-versus-host disease (cGvHD) post allogeneic hematopoietic cell transplantation (HCT). We present the case of a 70-year-old male patient who developed severe cGvHD-related PM 3 years after undergoing allogeneic HCT for acute myeloid leukemia. The patient responded to steroids and was maintained long-term with hydroxychloroquine as a steroid-sparing agent. We review the literature concerning the diagnosis and treatment of PM as cGvHD as well as the differentiation of this manifestation from other forms of PM.

NIH Consensus development project on criteria for clinical trials in chronic graft-versus-host disease: II. The 2014 Pathology Working Group Report

The 2005 National Institute of Health (NIH) Consensus Conference outlined histopathological diagnostic criteria for the major organ systems affected by both acute and chronic graft-versus-host disease (GVHD). The 2014 Consensus Conference led to this updated document with new information from histopathological studies of GVHD in the gut, liver, skin, and oral mucosa and an expanded discussion of GVHD in the lungs and kidneys. The recommendations for final histological diagnostic categories have been simplified from 4 categories to 3: no GVHD, possible GVHD, and likely GVHD, based on better reproducibility achieved by combining the previous categories of "consistent with GVHD" and "definite GVHD" into the single category of "likely GVHD." Issues remain in the histopathological characterization of GVHD, particularly with respect to the threshold of histological changes required for diagnostic certainty. Guidance is provided for the incorporation of biopsy information into prospective clinical studies of GVHD, particularly with respect to biomarker validation.

Relapsing polymyositis in chronic graft versus host disease

Chronic graft versus host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation, which contributes to the morbidity and mortality of transplant patients. A polymyositis pattern of injury is a rare manifestation of chronic GVHD in skeletal muscle after hematopoietic stem cell transplantation. We report a 54-year-old man with acute myeloid lymphoma who underwent an allogeneic bone marrow transplantation and subsequently developed acute gastrointestinal GVHD 2 months post-transplantation and polymyositis 14 months post-transplantation. Upon tapering of steroids, the patient experienced a relapse of polymyositis. The literature on polymyositis in chronic GVHD is briefly reviewed.

Neuromuscular complications after hematopoietic stem cell transplantation

PURPOSE

The aim of this study was to analyze the occurrence of neuromuscular symptoms in recipients of allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of malignant hematopoietic disease.

METHODS

Among 247 outpatients after allogeneic HSCT, we conducted a prospective non-interventional study between July 2011 and August 2013. During follow-up visits, clinical and electrophysiological findings were correlated to the presence of autoantibodies/alloantibodies and to frequencies of lymphocyte subpopulations in peripheral blood.

RESULTS

Resulting in an incidence of 8.1 %, 20 patients were diagnosed with neuromuscular complications at a median onset of 12 months post-transplant. Five patients (25 %) were identified with polyneuropathy (PNP), ten patients (50 %) with combined PNP and myopathy, four patients (20 %) with myopathy or polymyositis (PM), and one patient (5 %) with myasthenia gravis (MG). Immune-mediated sensorimotor PNP after HSCT is characterized by a predominantly axonal lesion and can be overlapping with neurotoxic side effects. The latency between HSCT and development of PM varied between 60 days and 72 months. In general, PM occurs parallel to graft-versus-host disease (GvHD) after tapering of immunosuppressive medication. Typical clinical features are proximal bilateral limb weakness with muscle atrophy. Autoantibodies (Ab) were detected in 12 patients, myositis-specific Ab only in one patient. In patients with progressive neurological symptoms, a decrease in the CD4/CD8 T cell ratio was observed.

CONCLUSIONS

GvHD-related myositis appeared similar to idiopathic myositis regarding clinical and electromyographical findings. As outcome measure, sequential analysis of lymphocyte subpopulations in peripheral blood seems to be more suitable than Ab measurements. Whereas peripheral neuropathies are commonly observed shortly after HSCT, MG is a rare complication in the late post-HSCT phase.