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Ascunce M, Coccolo A, Mozo Y, Baquero-Artigao F, Rodriguez-Molino P, Toro-Rueda C, García-Clemente P, Sánchez-Zapardiel E, López-Granados E, Corral-Sánchez D, Bueno D, Sisinni L, Pérez-Martínez A, Calvo C, Del Rosal T. Severe Impairment of T-cell Immunity and Pulmonary GvHD Are Major Risk Factors for Nontuberculous Mycobacterial Infection After Pediatric Allogeneic Hematopoietic Stem Cell Transplantation. Pediatr Infect Dis J 2024:00006454-990000000-00857. [PMID: 38713829 DOI: 10.1097/inf.0000000000004380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
Hematopoietic stem cell transplant recipients are prone to infectious complications. Infections caused by nontuberculous mycobacteria have increased in adults but literature in children is scarce. We report 6 episodes of disseminated or pulmonary nontuberculous mycobacteria infection among 5 pediatric hematopoietic stem cell transplant recipients. All but one were caused by Mycobacterium avium complex. Four patients died, 2 related to nontuberculous mycobacteria infection.
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Affiliation(s)
- Marina Ascunce
- From the Pediatrics Department, La Paz University Hospital
| | | | - Yasmina Mozo
- Pediatric Hemato-Oncology Department, La Paz University Hospital
| | - Fernando Baquero-Artigao
- Pediatrics and Infectious Disease Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Translational Research Network of Pediatric Infectious Diseases (RITIP)
- Center for Biomedical Research Network on Infectious Diseases (CIBERINFEC), Carlos III Health Institute
| | - Paula Rodriguez-Molino
- Pediatrics and Infectious Disease Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Translational Research Network of Pediatric Infectious Diseases (RITIP)
- Center for Biomedical Research Network on Infectious Diseases (CIBERINFEC), Carlos III Health Institute
| | | | | | - Elena Sánchez-Zapardiel
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Immunology Department, La Paz University Hospital
| | - Eduardo López-Granados
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Immunology Department, La Paz University Hospital
- Center for Biomedical Research Network on Rare Diseases (CIBERER U767), Carlos III Health Institute
| | | | - David Bueno
- Pediatric Hemato-Oncology Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
| | - Luisa Sisinni
- Pediatric Hemato-Oncology Department, La Paz University Hospital
| | - Antonio Pérez-Martínez
- Pediatric Hemato-Oncology Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Cristina Calvo
- Pediatrics and Infectious Disease Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Translational Research Network of Pediatric Infectious Diseases (RITIP)
- Center for Biomedical Research Network on Infectious Diseases (CIBERINFEC), Carlos III Health Institute
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Teresa Del Rosal
- Pediatrics and Infectious Disease Department, La Paz University Hospital
- Hospital La Paz Institute for Health Research (IdiPAZ)
- Translational Research Network of Pediatric Infectious Diseases (RITIP)
- Center for Biomedical Research Network on Rare Diseases (CIBERER U767), Carlos III Health Institute
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2
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Albert J, Daley CL, Lin PL. Nontuberculous Mycobacterial Infections in Pediatric Solid Organ Transplant and Hematopoietic Cell Transplant Recipients. J Pediatric Infect Dis Soc 2024; 13:S58-S67. [PMID: 38417083 DOI: 10.1093/jpids/piae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/03/2024] [Indexed: 03/01/2024]
Abstract
The diagnosis of nontuberculous mycobacterial infections is challenging in pediatric solid organ transplant and hematopoietic cell transplant recipients due to the absence of specific clinical manifestations, limitations of sampling, prolonged times for culture and identification, and difficulty discerning colonization from clinical disease. Treatment is dependent on the nontuberculous mycobacterial species, disease type, and pattern of drug resistance. Treatment of nontuberculous mycobacterial infections involves prolonged durations of therapy using multiple medications, which are limited by toxicities and drug-drug interactions.
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Affiliation(s)
- Jonathan Albert
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles L Daley
- National Jewish Health and University of Colorado Health Sciences, Department of Medicine, Denver, Colorado, USA
| | - Philana Ling Lin
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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3
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Cinicola BL, Ottaviano G, Hashim IF, Zainudeen ZT, Hamid IJA, Elfeky R. Prevalence and Characteristics of Non-tuberculous Mycobacteria (NTM) Infection in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: a Systematic Review and Meta-analysis. J Clin Immunol 2023; 44:23. [PMID: 38129624 PMCID: PMC10739425 DOI: 10.1007/s10875-023-01615-3] [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] [Received: 07/31/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE Non-tuberculous mycobacteria (NTM) infections in hematopoietic stem cell transplantation (HSCT) recipients represent a diagnostic and therapeutic challenge. Here, we aimed to review and analyze current literature on incidence, clinical presentation, and outcome of NTM infection after allogeneic HSCT. METHODS We performed a systematic review and meta-analysis of available literature regarding NTM infection in children and adults receiving allogeneic HSCT. RESULTS We identified 56 articles eligible for the analysis. Among 15 studies, describing 15,798 allogeneic HSCT, we estimated a prevalence of 1.26% (95% CI 0.72, 1.93) of NTM after transplant. Analysis of 175 patients with NTM infection showed a median time of diagnosis of 318 days after HSCT, an increased prevalence in adults (82.9%), and a most frequent pulmonary involvement (44%). Comparison between children and adults revealed an earlier post-transplant disease onset (median 130 days vs 287 days) and most frequent non-pulmonary presentation in children. A vast heterogeneity of therapeutic approach reflected the lack of universal recommendations regarding drug combination and duration of therapy. Overall, NTM-related mortality accounted for 33% in this systematic review. CONCLUSION Although rare, NTM infections can complicate post-transplant course with a high mortality rate in children and adults. The lack of prospective studies and guidelines prevents identification of risk factors and therapeutic recommendations.
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Affiliation(s)
- Bianca Laura Cinicola
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giorgio Ottaviano
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Ilie Fadzilah Hashim
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Zarina Thasneem Zainudeen
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Intan Juliana Abd Hamid
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia.
| | - Reem Elfeky
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK.
- GOS Hospital for Children NHS Foundation Trust, University College London GOS Institute of Child Health, and NIHR GOSH BRC, London, UK.
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4
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Daenen LGM, van der Bruggen JT, Leguit RJ, van der Wagen LE, van Rhenen A, Wunderink HF, de Witte MA, Bruns AHW, Kuball J. Disseminated nontuberculous mycobacterial infections after allogeneic hematopoietic stem cell transplantation: a risk-based strategy for early diagnosis. Bone Marrow Transplant 2023; 58:956-958. [PMID: 37210471 DOI: 10.1038/s41409-023-02011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Laura G M Daenen
- Department of Hematology, University Medical Center, Utrecht, the Netherlands.
| | - Jan-Tom van der Bruggen
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roos J Leguit
- Department of Pathology, University Medical Center, Utrecht, the Netherlands
| | | | - Anna van Rhenen
- Department of Hematology, University Medical Center, Utrecht, the Netherlands
| | - Herman F Wunderink
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Moniek A de Witte
- Department of Hematology, University Medical Center, Utrecht, the Netherlands
| | - Anke H W Bruns
- Department of Infectious Diseases, University Medical Center, Utrecht, the Netherlands
| | - Jurgen Kuball
- Department of Hematology, University Medical Center, Utrecht, the Netherlands
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5
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Dual Nature of Relationship between Mycobacteria and Cancer. Int J Mol Sci 2021; 22:ijms22158332. [PMID: 34361097 PMCID: PMC8347776 DOI: 10.3390/ijms22158332] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/21/2021] [Accepted: 07/29/2021] [Indexed: 12/29/2022] Open
Abstract
Although the therapeutic effect of mycobacteria as antitumor agents has been known for decades, recent epidemiological and experimental studies have revealed that mycobacterium-related chronic inflammation may be a possible mechanism of cancer pathogenesis. Mycobacterium tuberculosis and non-tuberculous Mycobacterium avium complex infections have been implicated as potentially contributing to the etiology of lung cancer, whereas Mycobacterium ulcerans has been correlated with skin carcinogenesis. The risk of tumor development with chronic mycobacterial infections is thought to be a result of many host effector mechanisms acting at different stages of oncogenesis. In this paper, we focus on the nature of the relationship between mycobacteria and cancer, describing the clinical significance of mycobacteria-based cancer therapy as well as epidemiological evidence on the contribution of chronic mycobacterial infections to the increased lung cancer risk.
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6
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Wobma H, Chang AK, Jin Z, Baker C, Garvin J, George D, Satwani P, Foca M, Bhatia M. Low CD4 count may be a risk factor for non-tuberculous mycobacteria infection in pediatric hematopoietic cell transplant recipients. Pediatr Transplant 2021; 25:e13994. [PMID: 33704868 DOI: 10.1111/petr.13994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/31/2020] [Accepted: 01/22/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND HCT leaves patients in a relative state of immune deficiency both during their initial transplant admission and for several years following discharge. NTM are generally harmless colonizers of the outside environment, but for immunocompromised patients, they can cause significant disease due to a paucity of T-cell defense. While routine prophylaxis against NTM is recommended for patients with low CD4 counts in certain clinical settings (eg, AIDS), this is not yet established for HCT patients despite their higher risk. METHODS Here we build upon our prior work to determine risk factors for NTM in pediatric HCT patients by comparing NTM patient characteristics to matched HCT controls. RESULTS We followed 272 patients across a 13-year time period, with 11 cases of NTM. Patients with NTM had a significantly lower CD4 count at Day 365 than matched HCT controls (105.5 ± 97.0 cells/µl vs. 856.2 ± 446.1 cells/µl, respectively; p = .001). No other potential risk factors (eg, CMV, GvHD, disease type) were found to be statistically significant, including use of T-cell depleting agents. This is consistent with an average diagnosis of NTM at Day +323 (ie, outside immediate post-transplant period). All-cause mortality was similar between NTM and control HCT groups, with an NTM attributable mortality of <10%. CONCLUSION Since reduced CD4 counts are associated with NTM, and cost and morbidity are high, azithromycin prophylaxis for CD4 count <200 cells/µl in high-risk patients should be considered.
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Affiliation(s)
- Holly Wobma
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Alicia K Chang
- Pediatric Hematology/Oncology, Dell Children's Medical Center, Austin, TX, USA
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Courtney Baker
- Department of Pediatrics, Hackensack University Medical Center-Children's Cancer Institute, Hackensack, NJ, USA
| | - James Garvin
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Diane George
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Prakash Satwani
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Marc Foca
- Division of Infectious Disease, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Monica Bhatia
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
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7
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Abstract
We report an 18-year-old female individual with septic arthritis due to Mycobacterium kansasii. Three years and 6 months before arthritis, the patient underwent bone marrow transplantation and developed severe chronic graft-versus-host disease. The arthritis was refractory to medication, and she underwent joint lavage of the right foot, hip joint, and elbow joint. After surgery, her joint symptoms were relieved, and chronic graft-versus-host disease remitted more easily. It is important that we maintain a high index of suspicion for mycobacterial arthritis and diagnose it early when immunosuppressed patients experience chronic pain and joint swelling.
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8
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Heston SM, Young RR, Hong H, Akinboyo IC, Tanaka JS, Martin PL, Vinesett R, Jenkins K, McGill LE, Hazen KC, Seed PC, Kelly MS. Microbiology of Bloodstream Infections in Children After Hematopoietic Stem Cell Transplantation: A Single-Center Experience Over Two Decades (1997-2017). Open Forum Infect Dis 2020; 7:ofaa465. [PMID: 33209953 PMCID: PMC7652097 DOI: 10.1093/ofid/ofaa465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022] Open
Abstract
Background Bloodstream infections (BSIs) occur frequently after hematopoietic stem cell transplantation (HSCT). We examined the microbiology of BSI in pediatric HSCT recipients over a 2-decade period at our institution to inform empirical antimicrobial prescribing and infection prevention strategies. Methods We conducted a retrospective cohort study of children (<18 years) who underwent HSCT at Duke University between 1997 and 2015. We used recurrent-event gap-time Cox proportional hazards models to determine the hazards of all-cause and cause-specific BSI according to HSCT year. We compared the median time to BSI by causative organism type and evaluated for temporal trends in the prevalence of antibiotic resistance among causative organisms. Results A total of 865 BSI occurred in 1311 children, including 412 (48%) Gram-positive bacterial, 196 (23%) Gram-negative bacterial, 56 (6%) fungal, 23 (3%) mycobacterial, and 178 (21%) polymicrobial BSI. The hazard of all BSIs did not change substantially over time during the study period, but the hazard of fungal BSIs declined over time during the study period (P = .04). Most fungal BSIs (82%) occurred in the first 100 days after HSCT, whereas mycobacterial BSIs occurred later after HSCT than BSIs caused by other organisms (P < .0001). The prevalence of vancomycin resistance among BSIs caused by Enterococcus faecium increased during the study period (P = .0007). The risk of 2-year mortality in children was increased with BSI (P = .02), Gram-negative bacterial BSI (P = .02), and fungal BSI (P < .0001). Conclusions Despite expanded practices for BSI prevention over the past several decades, the incidence of BSI remains high in pediatric HSCT recipients at our institution. Additional strategies are urgently needed to effectively prevent BSIs in this high-risk population.
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Affiliation(s)
- Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ibukunoluwa C Akinboyo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - John S Tanaka
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul L Martin
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard Vinesett
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren E McGill
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C Hazen
- Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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9
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Sabulski A, Davies SM, Paulsen G, Kumar A, Grimley M, Chandra S. Non-Tuberculous Mycobacterial Infection in Hematopoietic Cell Transplant. J Clin Immunol 2020; 40:1171-1175. [PMID: 32860169 DOI: 10.1007/s10875-020-00853-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Anthony Sabulski
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Grant Paulsen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ashish Kumar
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Michael Grimley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
| | - Sharat Chandra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA
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10
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Nagata A, Sekiya N, Najima Y, Horiuchi M, Fukushima K, Toya T, Igarashi A, Kobayashi T, Kakihana K, Ohashi K, Doki N. Nontuberculous mycobacterial bloodstream infections after allogeneic hematopoietic stem cell transplantation. Int J Infect Dis 2020; 97:131-134. [PMID: 32474198 DOI: 10.1016/j.ijid.2020.05.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 11/27/2022] Open
Abstract
Non-tuberculous mycobacteria (NTM) bacteremia following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is rare, and limited data exist. We described the features of NTM bacteremia following allo-HSCT recipients in our hospital with a comprehensive review of the literature. Among the four cases of NTM bacteremia after allo-HSCT recipients in our hospital, two were catheter-related bloodstream infections (CRBSI), one was disseminated, and one was an unknown source of infection. Based on our report and the past literature, the incidence rate of NTM bacteremia was 0.1-1.3%. CRBSI (57%) was more common than disseminated infection (29%). Most cases with CRBSI were caused by rapidly growing mycobacteria (88%) and showed good prognoses under appropriate antimicrobial therapies. In contrast, slowly growing mycobacteria (71%) was more common than rapidly growing mycobacteria in disseminated NTM bacteremia. Although disseminated NTM bacteremia can remain stable with appropriate long-term management, three out of seven cases died of multi-organ failure. Background immunodeficiency after allo-HSCT and transplant-related comorbidities may be attributable to subsequent poor prognosis.
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Affiliation(s)
- Akihito Nagata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Noritaka Sekiya
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan; Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masao Horiuchi
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan; Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kazuaki Fukushima
- Department of Infectious disease, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kazuhiko Kakihana
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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11
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Safdar A, Pouch SM, Scully B. Infections in Allogeneic Stem Cell Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2018. [PMCID: PMC7121717 DOI: 10.1007/978-1-4939-9034-4_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a widely used modality of therapy for a variety of malignant and nonmalignant diseases. Despite advances in pharmacotherapy and transplantation techniques, infection remains one of the most severe and frequently encountered complications of allo-HSCT. This chapter will address the risk factors for development of infection following allo-HSCT, including those related to the host, the conditioning regimen, and the graft, as well as the timing of opportunistic infections after allo-HSCT. The most common bacterial, viral, fungal, and parasitic infections, as well as issues surrounding their diagnostics and treatment, will be discussed. Finally, this chapter will address vaccination and other preventative strategies to be utilized when caring for patients undergoing allo-HSCT.
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Affiliation(s)
- Amar Safdar
- grid.416992.10000 0001 2179 3554Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
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12
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Hashimoto Y, Ikeda A, Tokuyasu Y, Omura H, Tanaka T. Cutaneous Mycobacterium chelonae infection following autologous peripheral blood stem cell transplantation for POEMS syndrome. J Infect Chemother 2018; 24:983-986. [DOI: 10.1016/j.jiac.2018.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 12/19/2022]
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13
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Hirama T, Brode SK, Beswick J, Law AD, Lam W, Michelis FV, Thyagu S, Viswabandya A, Lipton JH, Messner HA, Kim D(DH, Marras TK. Characteristics, treatment and outcomes of nontuberculous mycobacterial pulmonary disease after allogeneic haematopoietic stem cell transplant. Eur Respir J 2018; 51:13993003.02330-2017. [DOI: 10.1183/13993003.02330-2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/24/2018] [Indexed: 01/08/2023]
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14
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Boisson-Dupuis S, Bustamante J, El-Baghdadi J, Camcioglu Y, Parvaneh N, El Azbaoui S, Agader A, Hassani A, El Hafidi N, Mrani NA, Jouhadi Z, Ailal F, Najib J, Reisli I, Zamani A, Yosunkaya S, Gulle-Girit S, Yildiran A, Cipe FE, Torun SH, Metin A, Atikan BY, Hatipoglu N, Aydogmus C, Kilic SS, Dogu F, Karaca N, Aksu G, Kutukculer N, Keser-Emiroglu M, Somer A, Tanir G, Aytekin C, Adimi P, Mahdaviani SA, Mamishi S, Bousfiha A, Sanal O, Mansouri D, Casanova JL, Abel L. Inherited and acquired immunodeficiencies underlying tuberculosis in childhood. Immunol Rev 2015; 264:103-20. [PMID: 25703555 DOI: 10.1111/imr.12272] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (M.tb) and a few related mycobacteria, is a devastating disease, killing more than a million individuals per year worldwide. However, its pathogenesis remains largely elusive, as only a small proportion of infected individuals develop clinical disease either during primary infection or during reactivation from latency or secondary infection. Subacute, hematogenous, and extrapulmonary disease tends to be more frequent in infants, children, and teenagers than in adults. Life-threatening primary TB of childhood can result from known acquired or inherited immunodeficiencies, although the vast majority of cases remain unexplained. We review here the conditions conferring a predisposition to childhood clinical diseases caused by mycobacteria, including not only M.tb but also weakly virulent mycobacteria, such as BCG vaccines and environmental mycobacteria. Infections with weakly virulent mycobacteria are much rarer than TB, but the inherited and acquired immunodeficiencies underlying these infections are much better known. Their study has also provided genetic and immunological insights into childhood TB, as illustrated by the discovery of single-gene inborn errors of IFN-γ immunity underlying severe cases of TB. Novel findings are expected from ongoing and future human genetic studies of childhood TB in countries that combine a high proportion of consanguineous marriages, a high incidence of TB, and an excellent clinical care, such as Iran, Morocco, and Turkey.
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Affiliation(s)
- Stéphanie Boisson-Dupuis
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA; Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale, INSERM-U1163, Paris, France; Paris Descartes University, Imagine Institute, Paris, France
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15
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Apiwattankul N, Flynn PM, Hayden RT, Adderson EE. Infections Caused by Rapidly Growing Mycobacteria spp in Children and Adolescents With Cancer. J Pediatric Infect Dis Soc 2015; 4:104-13. [PMID: 26407409 PMCID: PMC4608491 DOI: 10.1093/jpids/piu038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 04/08/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Rapidly growing mycobacteria (RGM) infections in pediatric oncology patients have not been completely characterized. METHODS We reviewed medical records of oncology patients at St. Jude Children's Research Hospital (St. Jude) from 1990 to 2010 with RGM infections and summarized the results of previously published cases. RESULTS Twenty-five St. Jude patients had 27 episodes of infection. Approximately half of the cases occurred in patients with hematological malignancies and in males; infections were more common in white patients. Most patients were not neutropenic or lymphopenic. The most common causative species were Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium fortuitum. Most isolates were susceptible to amikacin and clarithromycin; all were susceptible to at least 1 of these. Treatment regimens varied considerably, particularly with respect to the duration of antimicrobial chemotherapy. Two St. Jude patients died; both had pulmonary infections. The literature search identified an additional 58 cases of infection. Localized catheter-associated infections were more common than bloodstream infections in the current series than in previous reports, and outbreaks were not recognized. Otherwise, the demographic and clinical characteristics of patients were similar. CONCLUSIONS Localized catheter-associated infections were most common in this largest reported single center experience reported to date. Pulmonary infection is uncommon in children but, as in adults, has a high mortality rate. Relatively short-term antimicrobial treatment and surgical debridement of infected tissue, if present, may be as effective for catheter-associated infections as prolonged antimicrobial use and may reduce adverse drug effects in these patients, who are vulnerable to drug-drug interactions and toxicity.
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Affiliation(s)
| | - Patricia M. Flynn
- Departments of Infectious Diseases,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis
| | - Randall T. Hayden
- Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Elisabeth E. Adderson
- Departments of Infectious Diseases,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis
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16
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Non-tuberculous mycobacteria in children: muddying the waters of tuberculosis diagnosis. THE LANCET RESPIRATORY MEDICINE 2015; 3:244-56. [DOI: 10.1016/s2213-2600(15)00062-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/11/2015] [Accepted: 01/12/2015] [Indexed: 11/24/2022]
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17
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Clinical significance of nontuberculous mycobacteria from respiratory specimens in stem cell transplantation recipients. Int J Hematol 2015; 101:505-13. [DOI: 10.1007/s12185-015-1745-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/29/2014] [Accepted: 01/15/2015] [Indexed: 11/25/2022]
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18
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Moreno-Bonilla G, Choy B, Fernandez-Peñas P. Cutaneous non-tuberculous mycobacterial infection in patients with chronic graft-versus-host disease: A case series. Australas J Dermatol 2014; 56:124-7. [PMID: 25496080 DOI: 10.1111/ajd.12269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 09/24/2014] [Indexed: 11/29/2022]
Abstract
We report the first case series of allogeneic haematopoietic stem-cell transplant patients with graft versus host disease who developed cutaneous non-tuberculous mycobacteria infection. A multidisciplinary approach, reduction of immunosuppressive medications, combination of antibiotics, close skin surveillance and excision of suitable lesions are recommended in this specific subgroup.
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19
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Miyashita E, Yoshida H, Mori D, Nakagawa N, Miyamura T, Ohta H, Seki M, Tomono K, Hashii Y, Ozono K. Mycobacterium avium complex-associated peritonitis with CAPD after unrelated bone marrow transplantation. Pediatr Int 2014; 56:e96-e98. [PMID: 25521993 DOI: 10.1111/ped.12463] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/20/2014] [Accepted: 06/25/2014] [Indexed: 11/26/2022]
Abstract
Peritonitis remains an important complication of peritoneal dialysis and is mostly caused by aerobic enteric bacteria. Non-tuberculous mycobacteria (NTM)-associated peritonitis is an unusual but serious infection, requiring special culture techniques to avoid delay in diagnosis. We report the case of an 11-year-old girl with aplastic anemia on ambulatory peritoneal dialysis who had Mycobacterium avium complex-associated peritonitis after allogeneic hematopoietic stem cell transplantation (allo-HSCT). This case emphasizes that we should be constantly cautious about NTM infection in allo-HSCT recipients, especially when standard cultures are negative and the infection is refractory to empirical antibiotic therapy.
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Affiliation(s)
- Emiko Miyashita
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hisao Yoshida
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Division of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Mori
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Natsuki Nakagawa
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideaki Ohta
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Seki
- Division of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazunori Tomono
- Division of Infection Control and Prevention, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
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20
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Al-Anazi KA, Al-Jasser AM, Al-Anazi WK. Infections caused by non-tuberculous mycobacteria in recipients of hematopoietic stem cell transplantation. Front Oncol 2014; 4:311. [PMID: 25426446 PMCID: PMC4226142 DOI: 10.3389/fonc.2014.00311] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/19/2014] [Indexed: 12/20/2022] Open
Abstract
Non-tuberculous mycobacteria (NTM) are acid-fast bacteria that are ubiquitous in the environment and can colonize soil, dust particles, water sources, and food supplies. They are divided into rapidly growing mycobacteria such as Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus as well as slowly growing species such as Mycobacterium avium, Mycobacterium kansasii, and Mycobacterium marinum. About 160 different species, which can cause community acquired and health care-associated infections, have been identified. NTM are becoming increasingly recognized in recipients of hematopoietic stem cell transplantation (HSCT) with incidence rates ranging between 0.4 and 10%. These infections are 50–600 times commoner in transplant recipients than in the general population and the time of onset ranges from day 31 to day 1055 post-transplant. They have been reported following various forms of HSCT. Several risk factors predispose to NTM infections in recipients of stem cell transplantation and these are related to the underlying medical condition and its treatment, the pre-transplant conditioning therapies as well as the transplant procedure and its complications. Clinically, NTM may present with: unexplained fever, lymphadenopathy, osteomyelitis, soft tissue and skin infections, central venous catheter infections, bacteremia, lung, and gastrointestinal tract involvement. However, disseminated infections are commonly encountered in severely immunocompromised individuals and bloodstream infections are almost always associated with catheter-related infections. It is usually difficult to differentiate colonization from true infection, thus, the threshold for starting therapy remains undetermined. Respiratory specimens such as sputum, pleural fluid, and bronchoalveolar lavage in addition to cultures of blood, bone, skin, and soft tissues are essential diagnostically. Susceptibility testing of mycobacterial isolates is a basic component of optimal care. Currently, there are no guidelines for the treatment of NTM infections in recipients of stem cell transplantation, but such infections have been successfully treated with surgical debridement, removal of infected or colonized indwelling intravascular devices, and administration of various combinations of antimicrobials. Monotherapy can be associated with development of drug resistance due to new genetic mutation. The accepted duration of treatment is 9 months in allogeneic stem cell transplantation and 6 months in autologous setting. Unfortunately, eradication of NTM infections may be impossible and their treatment is often complicated by adverse effects and interactions with other transplant-related medication.
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Affiliation(s)
- Khalid Ahmed Al-Anazi
- Section of Adult Hematology and Oncology, Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University , Riyadh , Saudi Arabia
| | - Asma M Al-Jasser
- Central Regional Laboratory, Ministry of Health , Riyadh , Saudi Arabia
| | - Waleed Khalid Al-Anazi
- Section of Microbiology, Department of Pathology, King Khalid University Hospital, College of Medicine, King Saud University , Riyadh , Saudi Arabia
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21
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Hazara AM, Edey M, Roy A, Bhandari S. Rapidly growing non-tuberculous mycobacterial infection in a renal transplant patient after alemtuzumab induction. Transpl Infect Dis 2014; 16:847-52. [PMID: 25040696 DOI: 10.1111/tid.12269] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 02/17/2014] [Accepted: 05/04/2014] [Indexed: 11/27/2022]
Abstract
Renal transplant recipients are at high risk of developing opportunistic infections particularly in the first 6 months after transplantation. Organisms causing such infections include rapidly growing non-tuberculous mycobacteria (NTM). Lymphocytes have a central role in combating mycobacterial infections. The use of lymphocyte-depleting agents, such as alemtuzumab, in the renal transplant population has increased in recent years. A case of multifocal osteomyelitis caused by one of the NTM, Mycobacterium chelonae, in a renal transplant recipient, after alemtuzumab induction, is presented.
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Affiliation(s)
- A M Hazara
- Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
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22
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Singh S, Yosypiv IV, Iorember FM. Disseminated mycobacterium avium complex infection in a pediatric renal transplant recipient. Clin Pediatr (Phila) 2012; 51:892-5. [PMID: 21669902 DOI: 10.1177/0009922811411476] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Shipra Singh
- Tulane University Health Sciences Center, New Orleans, LA 70118, USA
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23
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Peinemann F, Smith LA, Kromp M, Bartel C, Kröger N, Kulig M. Autologous hematopoietic stem cell transplantation following high-dose chemotherapy for non-rhabdomyosarcoma soft tissue sarcomas. Cochrane Database Syst Rev 2011:CD008216. [PMID: 21328307 DOI: 10.1002/14651858.cd008216.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) are a highly heterogeneous group of rare malignant solid tumors. Non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) comprise all STS except rhabdomyosarcoma. In patients with advanced local or metastatic disease, autologous hematopoietic stem cell transplantation (HSCT) applied after high-dose chemotherapy (HDCT) is a planned rescue therapy for HDCT-related severe hematologic toxicity. OBJECTIVES To assess the effectiveness and safety of HDCT followed by autologous HSCT for all stages of soft tissue sarcomas in children and adults. SEARCH STRATEGY We searched the electronic databases CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE and EMBASE (February 2010). Online trial registers, congress abstracts and reference lists of reviews were searched and expert panels and authors were contacted. SELECTION CRITERIA Terms representing STS and autologous HSCT were required in the title, abstract or keywords. In studies with aggregated data, participants with NRSTS and autologous HSCT had to constitute at least 80% of the data. Comparative non-randomized studies were included because randomized controlled trials (RCTs) were not expected. Case series and case reports were considered for an additional descriptive analysis. DATA COLLECTION AND ANALYSIS Study data were recorded by two review authors independently. For studies with no comparator group, we synthesised results for studies reporting aggregate data and conducted a pooled analysis of individual participant data using the Kaplan-Meyer method. The primary outcomes were overall survival (OS) and treatment-related mortality (TRM). MAIN RESULTS We included 54 studies, from 467 full texts articles screened (11.5%), reporting on 177 participants that received HSCT and 69 participants that received standard care. Only one study reported comparative data. In the one comparative study, OS at two years after HSCT was estimated as statistically significantly higher (62.3%) compared with participants that received standard care (23.2%). In a single-arm study, the OS two years after HSCT was reported as 20%. In a pooled analysis of the individual data of 54 participants, OS at two years was estimated as 49% (95% CI 34% to 64%). Data on TRM, secondary neoplasia and severe toxicity grade 3 to 4 after transplantation were sparse. All 54 studies had a high risk of bias. AUTHORS' CONCLUSIONS Due to a lack of comparative studies, it is unclear whether participants with NRSTS have improved survival from autologous HSCT following HDCT. Owing to this current gap in knowledge, at present HDCT and autologous HSCT for NRSTS should only be used within controlled trials.
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Affiliation(s)
- Frank Peinemann
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Dillenburger Str. 27, Cologne, Germany, 51105
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24
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Muñoz A, Gonzalez-Vicent M, Badell I, Diaz de Heredia C, Martinez A, Maldonado MS. Mycobacterial diseases in pediatric hematopoietic SCT recipients. Bone Marrow Transplant 2010; 46:766-8. [PMID: 20697370 DOI: 10.1038/bmt.2010.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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25
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Yamazaki R, Mori T, Nakazato T, Aisa Y, Imaeda H, Hisamatsu T, Hibi T, Okamoto S. Non-tuberculous mycobacterial infection localized in small intestine developing after allogeneic bone marrow transplantation. Intern Med 2010; 49:1191-3. [PMID: 20558941 DOI: 10.2169/internalmedicine.49.3288] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 33-year-old man with myelodysplastic/myeloproliferative disease underwent allogeneic bone marrow transplantation. Around day 80 post-transplant, he complained of abdominal pain and diarrhea. Colonoscopy and esophagogastroduodenoscopy findings were unremarkable. Double-balloon enteroscopy revealed atrophic villi and mild erosions localized in the small intestine. Histological examination revealed marked proliferation of histiocytes with numerous acid-fast bacilli in their cytoplasm. The specific polymerase chain reaction for Mycobacterium tuberculosis was negative, and a diagnosis of intestinal non-tuberculous mycobacteria (NTM) was made. Physicians should recognize that NTM infection is one of the gastrointestinal infectious complications in immunocompromised patients such as bone marrow transplant recipients, and could localize in the small intestine.
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Affiliation(s)
- Rie Yamazaki
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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26
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Razonable RR. Nontuberculous mycobacterial infections after transplantation: a diversity of pathogens and clinical syndromes. Transpl Infect Dis 2009; 11:191-4. [PMID: 19392731 DOI: 10.1111/j.1399-3062.2009.00392.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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