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Sala E, Neagoie AM, Lewerenz J, Saadati M, Benner A, Gantner A, Wais V, Döhner H, Bunjes D. Neurologic Complications of the Central Nervous System after Allogeneic Stem Cell Transplantation: The Role of Transplantation-Associated Thrombotic Microangiopathy as a Potential Underreported Cause. Transplant Cell Ther 2024; 30:586.e1-586.e11. [PMID: 38508452 DOI: 10.1016/j.jtct.2024.03.017] [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: 01/31/2024] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
Neurologic complications (NCs), especially those of the central nervous system (CNS), represent a severe complication after allogeneic stem cell transplantation (allo-HSCT) and are associated with relevant morbidity and mortality. We aimed to characterize the potential risk factors for the development of CNS-NC, with a special focus on the role of calcineurin inhibitors (CNIs) as a predisposing factor. For this purpose, we compared cyclosporin A (CsA) versus tacrolimus (TAC) with respect to their influence on the incidence and type of CNS-NC after allo-HSCT. We retrospectively analyzed the incidence, risk factors, and impact on outcomes of CNS-NC diagnosed during the post-transplantation follow-up in patients with different high-risk hematologic malignancies who underwent allo-HSCT at our institution over a 20-year period. All patients included in the analysis received CNI (CsA or TAC) as graft-versus-host disease (GVHD) prophylaxis. We evaluated a total of 739 consecutive patients who underwent transplantation between December 1999 and April 2019. During a median follow-up of 6.8 years, we observed a CNS-NC incidence of 17%. The development of CNS-NC was associated with decreased overall survival (OS) and increased transplantation-related mortality (TRM). The most frequent CNS-NCs were infections (30%) and neurologic adverse events related to the administration of CNI, TAC, or CsA as GVHD prophylaxis (42%). In the multivariable analysis, age, total body irradiation (TBI), and severe acute GVHD and chronic GVHD were significant risk factors in the development of CNS-NCs. TAC compared with CsA emerged as an independent predisposing factor for CNS-NCs. The TAC-associated risk of CNS-NCs was related mostly to the occurrence of transplantation-associated thrombotic microangiopathy (TA-TMA) with neurologic manifestations (neuro-TA-TMA), although the general TA-TMA incidence was comparable in the 2 CNI subgroups. CNS-NCs are associated with poor prognosis after allo-HSCT, with TAC emerging as a potential yet insufficiently characterized predisposing factor.
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Affiliation(s)
- Elisa Sala
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany.
| | - Adela M Neagoie
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Jan Lewerenz
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Maral Saadati
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andrea Gantner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Verena Wais
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Donald Bunjes
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
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2
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von dem Borne PA, Kemps-Mols BM, de Wreede LC, van Beek AA, Snijders TJF, van Lammeren D, Tijmensen J, Sijs-Szabó A, Oudshoorn MA, Halkes CJM, van Balen P, Marijt WAE, Tjon JML, Vermaat JSP, Veelken H. The degree of HLA matching determines the incidence of cytokine release syndrome and associated nonrelapse mortality in matched related and unrelated allogeneic stem cell transplantation with post-transplant cyclophosphamide. Leuk Lymphoma 2024:1-11. [PMID: 38710017 DOI: 10.1080/10428194.2024.2344060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
Cytokine release syndrome (CRS) occurs frequently after haplo-identical allogeneic stem cell transplantation (alloSCT) with post-transplant cyclophosphamide (PTCy), increasing nonrelapse mortality (NRM) and decreasing survival. Data on CRS in HLA-matched alloSCT are limited and effects of specific HLA-mismatches on CRS development unknown. We hypothesized that in HLA-matched alloSCT increasing degrees of HLA-mismatching influence CRS incidence, NRM and survival. Retrospective analysis of 126 HLA-matched PTCy-alloSCT patients showed that higher degrees of HLA-mismatching significantly increased CRS incidence (26%, 75% and 90% CRS with 12/12, 10/10 and 9/10 matched donors, respectively). Maximum temperature during CRS increased with higher HLA-mismatch. Specific associations between HLA-mismatches and CRS could be determined. Grade 2 CRS and CRS-induced grade 3 fever were associated with significantly increased NRM (p < 0.001 and p = 0.003, respectively) and inferior survival (p < 0.001 and p = 0.005, respectively). NRM was mainly caused by disease conditions that may be considered CRS-induced inflammatory responses (encephalopathy, cryptogenic organizing pneumonia and multi-organ failure).
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Affiliation(s)
| | - Berit M Kemps-Mols
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Adriaan A van Beek
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tjeerd J F Snijders
- Department of Hematology, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Janneke Tijmensen
- Department of Hematology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Aniko Sijs-Szabó
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mirjam A Oudshoorn
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Peter van Balen
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - W A Erik Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jennifer M L Tjon
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost S P Vermaat
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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3
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Doering J, Perl M, Weber D, Banas B, Schulz C, Hamer OW, Angstwurm K, Holler E, Herr W, Edinger M, Wolff D, Fante MA. Incidence and Outcome of Atypical Manifestations of Chronic Graft-versus-Host Disease: Results From a Retrospective Single-Center Analysis. Transplant Cell Ther 2023; 29:772.e1-772.e10. [PMID: 37777112 DOI: 10.1016/j.jtct.2023.09.016] [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: 08/25/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is the leading cause of late nonrelapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (alloHSCT) and defined by 8 diagnostic target organs. Recently, provisional criteria for atypical manifestations of cGVHD that include manifestations in nonclassic organs as well as atypical manifestations in National Institutes of Health (NIH)-defined organs, were proposed by a NIH task force. Little is known about the incidence, risk factors, and impact on survival of atypical cGVHD, however. The aim of the present study was to analyze these parameters in a sequential patient population. We retrospectively screened 623 patients who underwent alloHSCT at the University Medical Center Regensburg between January 2008 and December 2020 for atypical cGVHD manifestations, applying the provisional NIH taskforce criteria. A total of 102 patients (16.4%) met the criteria, representing 25% of all cGVHD cases, and 14 patients (2.2%) had only atypical cGVHD. The most frequent manifestations were immune-mediated cytopenias (24.5%), renal cGVHD (13.7%) and (poly)serositis (13.7%). Multivariate analysis identified prior acute GVHD (odds ratio [OR], 2.28 and 2.93) and infusion of donor lymphocytes (OR, 1.77 for both) as risk factors for classic cGVHD and atypical cGVHD, whereas total body irradiation was an independent risk factor for atypical cGVHD manifestations only (OR, 1.76). Compared to patients without cGVHD, those with atypical and NIH-defined cGVHD showed similarly better overall survival (P = .034 and < .001) and low relapse-related mortality (P < .001 for both). NRM was significantly increased by atypical GVHD, but not by NIH-defined cGVHD (P = .019 and .10), which was driven only by a few atypical organ manifestations (eg, renal, restrictive lung disease, peripheral neuropathy), whereas others did not contribute to NRM (eg, thyroid gland, musculoskeletal, pancreas). In summary, atypical cGVHD is more common than previously estimated and has both similarities with and differences from NIH-defined cGVHD. In particular, the increased NRM and a subset of patients with only atypical cGVHD point to the urgent need to capture these manifestations in cGVHD cohorts, including analysis of treatment outcomes.
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Affiliation(s)
- Jana Doering
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Perl
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Banas
- Department of Nephrology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Schulz
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Okka W Hamer
- Department of Diagnostic Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany; Leibniz Institute for Immunotherapy (LIT), Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias A Fante
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany.
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Balaguer-Roselló A, Gil-Perotín S, Montoro J, Bataller L, Lamas B, Villalba M, Facal A, Guerreiro M, Chorão P, Bataller A, Granados P, Gómez I, Solves P, Louro A, de la Rubia J, Sanz MÁ, Sanz J. Reduced Incidence of Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Calcineurin-Free Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2023; 29:610.e1-610.e12. [PMID: 37451486 DOI: 10.1016/j.jtct.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Calcineurin inhibitors (CNIs), including cyclosporine and tacrolimus, are frequently associated with neurologic complications after allogeneic hematopoietic stem cell transplantation (HSCT). However, there is a lack of studies comparing the incidence and characteristics of neurologic complications in patients undergoing HSCT based on CNI-free or CNI-based GVHD prophylaxis. This retrospective single-center study analyzed the neurologic complications in 2 cohorts of patients undergoing HSCT with either CNI-based GVHD prophylaxis (n = 523) or CNI-free prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil (n = 371). The latter cohort included older patients and received more reduced-intensity conditioning and transplants from matched unrelated and haploidentical donors. The 2-year cumulative incidence of neurologic complications was significantly lower in the CNI-free cohort (6.9% versus 11.9%; P = .016), and GVHD prophylaxis was the sole statistically significant variable in multivariate analysis (hazard ratio, 2.2; 95% confidence interval [CI], .25 to 3.13; P = .0017). The distribution of neurologic types was similar in the 2 cohorts, with encephalopathy the most prevalent complication, except for headaches and myopathy, which decreased equally from 15% in the CNI-based cohort to 4% in the CNI-free cohort. Neurologic complications had negative impacts on mortality and survival rates, with a significantly higher 2-year cumulative incidence of nonrelapse mortality (NRM) (44% [95% CI, 34% to 54%] versus 16% [95% CI, 13% to 18%]; P < .0001) and inferior overall survival (66% [95% CI, 62% to 69%] versus 46% [95% CI, 37% to 58%]; P < .0001) in patients with neurologic complications. This study suggests that CNI-free GVHD prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil may reduce not only the incidence of GVHD incidence, but also the rates of neurologic complications and NRM, leading to improved survival outcomes in patients undergoing HSCT.
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Affiliation(s)
- Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain.
| | - Sara Gil-Perotín
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Facal
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Alberto Louro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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5
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Camacho Pérez E, Mayo S, Lipton JH, Chang E, De Souza L, Santa Mina D. Evaluation of a group-based exercise and relaxation rehabilitation program during hospitalization for allogeneic hematopoietic stem cell transplant. PM R 2023; 15:51-64. [PMID: 35150088 DOI: 10.1002/pmrj.12784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/06/2022] [Accepted: 01/31/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Exercise and relaxation interventions have demonstrated benefits in allogeneic hematopoietic stem cell transplant (allo-HSCT) patients; however, little is known about the implementation enablers and barriers for inpatient rehabilitation or its impact on health outcomes. OBJECTIVE To conduct a program evaluation of group-based rehabilitation consisting of exercise and relaxation classes for allo-HSCT inpatients. DESIGN Prospective program evaluation using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. SETTING Inpatient hospital unit at a tertiary care center. PARTICIPANTS Forty-five adult patients admitted for allo-HSCT. INTERVENTIONS Standard of care rehabilitation. MAIN OUTCOME MEASURES Program attendance, safety, satisfaction, and fidelity were assessed. Exploratory effectiveness analyses were conducted via the measurement of physical, psychosocial, clinical, and health resource use outcomes at hospital admission and discharge. RESULTS Forty-seven of the 63 patients receiving allo-HSCT between November 2019 and March 2020 were consented. Data presented in this publication are from the 33 participants who completed study assessments (high attrition due to cancellation of research during the COVID-19 pandemic). Eighty-two percent of participants attended at least one class; however, 55% of the participants invited to the classes on a daily basis were not able to attend. Barriers to participation included transplant complications, isolation for infection prevention, and fatigue. There were no adverse events associated with the intervention and 82% of participants adhered to the prescribed activities. Participants reported satisfaction with the program and enjoyed the motivational support and social interaction. Between hospital admission and discharge, anxiety scores improved; however, fatigue, depression, grip strength, functional mobility, and quality of life scores declined. Physical activity volume and lower body strength were maintained. CONCLUSIONS Group-based exercise and relaxation classes seem to be feasible and safe during hospitalization for allo-HSCT; however, there are pragmatic barriers to be considered for optimal program implementation. Further research examining program effectiveness and adoption is warranted.
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Affiliation(s)
- Encarna Camacho Pérez
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada
| | - Samantha Mayo
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology-Hematology, Princess Margaret Cancer Centre, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Eugene Chang
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Lyndsey De Souza
- Department of Medical Oncology-Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, Canada
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Neurological complications in adult allogeneic hematopoietic stem cell transplant patients: Incidence, characteristics and long-term follow-up in a multicenter series. Bone Marrow Transplant 2022; 57:1133-1141. [PMID: 35513485 DOI: 10.1038/s41409-022-01690-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/20/2022]
Abstract
Neurological complications (NCs) represent a diagnostic and clinical challenge in allogeneic hematopoietic stem cell transplant (alloHSCT) patients. We retrospectively analyzed NC incidence, etiology, timing, characteristics, outcome, and long-term effects in 2384 adult patients transplanted in seven Italian institutions between January 2007 and December 2019. Ninety-three (3.9%) patients were affected by 96 NCs that were infectious (29.2%), immune/inflammatory (26%), drug-related (12.5%), cerebrovascular (5.2%), metabolic (3.1%), related to central nervous system disease relapse (11.5%) and malignancy (3.1%), or undefined (9.4%). Six patients (6.4%) had neurological manifestations of chronic graft-versus-host disease (GVHD). NCs occurred on average at day +128 (from -5 to +4063). Early (< day +120) and late NCs had similar frequencies (46.9% vs 53.1%, p = 0.39). Thirty-one patients (33.3%) were affected by acute or chronic GVHD at the NC onset. With a median follow-up of 25.4 (0.4-163) months, the overall mortality due to NCs was 22.6%. The median time between NC onset and death was 36 (1-269) days. Infectious NCs were the main cause (61.9%) of NC-related mortality. A persistent neurological impairment occurred in 20.4% patients, 57.9% of whom being affected by immune/inflammatory NCs. This study highlights the rare, yet severe impact of alloHSCT-associated NCs on patient survival and long-term functional ability.
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Muñoz AM, Conca ADG, Luzzi AA, Sosa PS, Sberna F, Comacchio FB, Schutz NP, Bendek GE. Multiple mononeuritis as a manifestation of graft versus host disease. Hematol Transfus Cell Ther 2022:S2531-1379(22)00046-3. [PMID: 35624017 DOI: 10.1016/j.htct.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 01/13/2022] [Accepted: 02/13/2022] [Indexed: 11/26/2022] Open
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8
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Siegal T, Benouaich-Amiel A, Bairey O. Neurologic complications of acute myeloid leukemia. Diagnostic approach and therapeutic modalities. Blood Rev 2021; 53:100910. [PMID: 34836656 DOI: 10.1016/j.blre.2021.100910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 12/17/2022]
Abstract
Acute myeloid leukemia (AML) comprises a heterogeneous group of aggressive blood malignancies that arise from clonal expansion of malignant hematopoietic precursor cells in the bone marrow. Neurologic manifestations of these malignancies are manifolds. AML is the most common form of acute leukemia in adults and this review describes the neurologic complications in this age group. Neurologic symptoms and signs may develop in AML either from a direct neoplastic involvement of the central or the peripheral nervous system or as an indirect effect of the disease process. Direct involvement of the nervous system includes invasion of the central or the peripheral nervous system (parenchymal and leptomeningeal dissemination, myeloid sarcoma, neuroleukemiosis). Thrombotic and hemorrhagic events are common manifestations of indirect involvement of the nervous system and they are the outcome of hyperleukocytosis, thrombocytopenia and coagulopathy. Many neurologic complications are iatrogenic and include diverse categories such as lumbar puncture and intrathecal or systemic chemotherapy and targeted therapies, radiotherapy and allogeneic stem cell transplantation. Most neurologic manifestations require urgent treatment and confer a poor prognosis. This review describes the neurologic complications of acute myeloid malignancies in the era of contemporary treatment. Those manifestations require expert consideration of their origin as they are being identified with increasing frequency as patients survive longer.
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Affiliation(s)
- Tali Siegal
- Neuro-Oncology Center, Davidoff Institute of Oncology, Rabin Medical Center, Petach Tiqva, Israel; Hebrew University, Jerusalem, Israel.
| | | | - Osnat Bairey
- Hematology Institute, Davidoff Cancer Center, Rabin Medical Center, Petach Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Vinnakota JM, Zeiser R. Acute Graft- Versus-Host Disease, Infections, Vascular Events and Drug Toxicities Affecting the Central Nervous System. Front Immunol 2021; 12:748019. [PMID: 34691059 PMCID: PMC8527894 DOI: 10.3389/fimmu.2021.748019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a curative therapy for patients with hematological malignancies. Acute Graft versus host diseases (GVHD) is a major immune mediated side effect of allo-HCT that can affect the central nervous system (CNS) in addition to post-allo-HCT vascular events, drug toxicity or infections. Here we summarize and discuss recent preclinical data on the CNS as a target of acute GVHD and the known mechanisms contributing to neurotoxicity with a focus on microglia and T cells. We also discuss open questions in the field and place the findings made in mouse models in a clinical context. While in mice the neurological deficits can be assessed in a controlled fashion, in patients the etiology of the CNS damage is difficult to attribute to acute GVHD versus infections, vascular events, and drug-induced toxicity. Ultimately, we discuss novel therapies for GVHD of the CNS. Our understanding of the biological mechanisms that lead to neurotoxicity after allo-HCT increased over the last decade. This review provides insights into CNS manifestations of GVHD versus other etiologies of CNS damage in mice and patients.
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Affiliation(s)
- Janaki Manoja Vinnakota
- Department of Medicine I - Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Biology, Albert-Ludwigs-University, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I - Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Signalling Research Centres BIOSS and CIBSS – Centre for Integrative Biological Signalling Studies, University of Freiburg, Freiburg, Germany
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10
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Zhang B, Zhou J, Gui R, Li Z, Zu Y, Wang J, Yu F, Zhang Y, Zhao H, Ji Z, Song Y. Metagenomic Next Generation Sequencing in the Detection of Pathogens in Cerebrospinal Fluid of Patients After Alternative Donor Transplantation: A Feasibility Analysis. Front Cell Infect Microbiol 2021; 11:720132. [PMID: 34595132 PMCID: PMC8476959 DOI: 10.3389/fcimb.2021.720132] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
Central nervous system (CNS) complications can occur in 9%–15% of patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical manifestations of the CNS complications are non-specific, with most of them being disturbances of consciousness, convulsions, headaches, fever, and epilepsy, making it difficult to infer the cause of the complications based on clinical manifestations. We retrospectively analyzed the sensitivity and feasibility of metagenomic next generation sequencing (mNGS) in the diagnosis of CNS infections after allo-HSCT. Lumbar punctures were performed on 20 patients with CNS symptoms after receiving alternative donor HSCT(AD-HSCT) at the Affiliated Cancer Hospital of Zhengzhou University from February 2019 to December 2020, and their cerebrospinal fluid (CSF) was collected. The mNGS technique was used to detect pathogens in the CSF. Routine CSF testing, biochemical analyses, G experiments, GM experiments, ink staining, acid-fast staining, and bacterial cultures were carried out, and quantitative PCR (qPCR) tests were used to detect cytomegalovirus (CMV), Epstein-Barr virus (EBV), BK polyomavirus (BKPyV), and human alphaherpesvirus (HHV). A total of 29 tests were performed with 21 of them being positive. Of the five negative patients, three were diagnosed with a posterior reversible encephalopathy syndrome, one as having transplantation-associated thrombotic microangiopathy, and one with transient seizure caused by hypertension. Fifteen patients tested positive, of which four had single infections and eleven had mixed infections. Five cases of fungal infections, six cases of bacterial infections, and 13 cases of viral infections were detected. Among the 13 cases of viral infections, ten cases were CMV(HHV-5); three were BKPyV; two were Torque teno virus (TTV); Two were HHV-1,two were EBV(HHV4), and one each of HpyV5 and HHV-6B. Thirteen patients tested positive for virus while the qPCR detection method of 6 identical specimens were below the minimum detection limit(<1×103 U/ml). The mNGS technique is highly sensitive, and it can be used to diagnose CNS infections after allo-HSCT.
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Affiliation(s)
- Binglei Zhang
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China.,Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China.,Henan Academy of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jian Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ruirui Gui
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Zhen Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Yingling Zu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Juan Wang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Fengkuan Yu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Yanli Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Huifang Zhao
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Zhenyu Ji
- Henan Academy of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
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11
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Lestak J, Mlcak P, Kuba A, Maresova K, Kyncl M, Tintera J, Fus M. Bilateral optic neuropathy as a complication of allogeneic hematopoietic stem cell transplantation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021. [PMID: 34602613 DOI: 10.5507/bp.2021.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The authors present a case study which describes the development of bilateral optic neuropathy as a complication of allogeneic hematopoietic stem cell transplantation (HSCT) in a patient who underwent a transplant for B-cell acute lymphoblastic leukemia (B-ALL). The patient, who was in remission with regard to the underlying hematological disease, developed edema of both optic discs and maculas three months after transplantation. The morphological finding regressed after treatment with corticoids and comprehensive systemic anti-infective therapy. However, the loss of function was not entirely restored. CASE REPORT One year after the healing, the atrophy of the optic discs persisted, with corresponding findings in vessel density (VD), retinal nerve fibre layer (RNFL) and visual field changes. Electrophysiological examination by pattern electroretinogram (PERG) showed an alteration in retinal ganglion cells in the left eye, but with significant damage to nerve fibres on both sides. Visual evoked potential (VEP) verified bilateral non-inflammatory neurogenic lesions. This finding was also confirmed by functional magnetic resonance imaging (fMRI). Examination by structural magnetic resonance imaging (MRI) showed inflammatory changes in the optic nerve sheaths over time and a consequent marked narrowing of them. CONCLUSION The authors believe that edema of the optic discs and maculas was caused by a combination of several factors. Firstly, MRI showed inflammatory changes in the optic nerve sheaths, which led to a blockade of axoplasmic transport. Another factor that may have played a part in the outcome was endothelial damage to blood vessels with impaired microcirculation supplying the optic nerve fibres, which contributed to the occurrence of macular edema.
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Affiliation(s)
- Jan Lestak
- JL Opthalmology Clinic, Faculty of Biomedical Engineering, Czech Technical University in Prague, Czech Republic
| | - Petr Mlcak
- Department of Ophthalmology, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Czech Republic.,Department of Physiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Adam Kuba
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Czech Republic
| | - Klara Maresova
- Department of Ophthalmology, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Czech Republic
| | - Martin Kyncl
- JL Opthalmology Clinic, Faculty of Biomedical Engineering, Czech Technical University in Prague, Czech Republic
| | - Jaroslav Tintera
- JL Opthalmology Clinic, Faculty of Biomedical Engineering, Czech Technical University in Prague, Czech Republic
| | - Martin Fus
- JL Opthalmology Clinic, Faculty of Biomedical Engineering, Czech Technical University in Prague, Czech Republic
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12
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Non-classical manifestations of acute GVHD. Blood 2021; 138:2165-2172. [PMID: 34482399 DOI: 10.1182/blood.2021012431] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022] Open
Abstract
Acute graft-versus-host disease (GVHD) is a major life-threatening complication after allogeneic hematopoietic cell transplantation (allo-HCT). The classical target organs of acute GVHD include the intestines, liver, and skin. The damage of these organs is relatively easy to detect for the clinician as diarrhea, increased bilirubin, and rash. However, there is increasing evidence that also other organs, where the acute damage is less apparent or more difficult to distinguish from drug toxicity, such as the central nervous system, the lungs, the ovaries and testis, the thymus, the bone marrow and the kidney, can be target organs of acute GVHD. Here, we review current evidence for non-classical manifestations of acute GVHD in rodent models and in patients and discuss them in the context of novel emerging therapies for GVHD. A better understanding of the involvement of the non-classical GVHD target organs may help to improve patient outcomes after allo-HCT.
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13
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Cardiorespiratory fitness and physical performance after childhood hematopoietic stem cell transplantation: a systematic review and meta-analysis. Bone Marrow Transplant 2021; 56:2063-2078. [PMID: 34155356 DOI: 10.1038/s41409-021-01370-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 02/05/2023]
Abstract
The effects of childhood hematopoietic stem cell transplantation (HSCT) on key organs can impair cardiorespiratory fitness, muscle strength, and physical performance. We aimed to provide an overview of childhood HSCT survivors' status on these parameters compared with healthy controls and discuss current insights into clinical risk factors. We performed a systematic search in six scientific databases, including studies published before April 2019 and performed a meta-analysis on cardiorespiratory fitness. Muscle strength and physical performance status were presented narratively. We included ten studies embodying 517 childhood HSCT survivors (mean 17.8 years at follow-up). The meta-analysis (n = 4 studies) showed that childhood HSCT survivors have lower cardiorespiratory fitness compared with healthy controls (Standard mean difference (SMD) -1.32 [95% CI -1-58 to -1.07]; I2 2%, p < 0.00001). Collectively, the studies indicated that childhood HSCT survivors have lower muscle strength (n = 4 studies) and physical performance (n = 3 studies) compared with healthy controls. Childhood HSCT survivors have impaired cardiorespiratory fitness years after ended treatment. Muscle strength and physical performance seem to be impaired, although these measures are insufficiently investigated. Associations between HSCT-specific clinical risk factors and cardiorespiratory fitness, muscle strength, and physical performance are required.
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14
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Wang Z, Zhao M, Gao S. Epileptic Seizures After Allogeneic Hematopoietic Stem Cell Transplantation. Front Neurol 2021; 12:675756. [PMID: 34335446 PMCID: PMC8322618 DOI: 10.3389/fneur.2021.675756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
Technique in allogeneic hematopoietic stem cell transplantation has greatly advanced over the past decades, which has led to an increase in the number of patients receiving transplantation, but the complex procedure places these transplant recipients at high risk of a large spectrum of complications including neurologic involvement. As a common manifestation of neurological disorders, epileptic seizures after transplantation have been of great concern to clinicians because it seriously affects the survival rate and living quality of those recipients. The aim of this review is to elucidate the incidence of seizures after allogeneic hematopoietic stem cell transplantation, and to further summarize in detail its etiologies, possible mechanisms, clinical manifestations, therapeutic schedule, and prognosis, hoping to improve doctors' understandings of concurrent seizures following transplantation, so they can prevent, process, and eventually improve the survival and outlook for patients in a timely manner and correctly.
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Affiliation(s)
- Zhuo Wang
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Munan Zhao
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
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15
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Relapsing Bickerstaff Brainstem Encephalitis After Autologous Stem Cell Transplant. J Clin Neuromuscul Dis 2021; 21:225-229. [PMID: 32453098 DOI: 10.1097/cnd.0000000000000282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bickerstaff brainstem encephalitis, widely considered to be associated with Miller Fisher and Guillain-Barré syndromes, is a rare disease state defined by the triad of ophthalmoplegia, ataxia, and decreased consciousness. The presence of central nervous system involvement, commonly in the form of impaired arousal, solidifies it as a unique entity. We present a case of this rare syndrome after autologous stem cell transplant.
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16
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Ferro JM, Infante J. Cerebrovascular manifestations in hematological diseases: an update. J Neurol 2021; 268:3480-3492. [PMID: 33586004 PMCID: PMC8357668 DOI: 10.1007/s00415-021-10441-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 01/04/2023]
Abstract
Patients with hematological diseases often experience cerebrovascular complications including ischemic stroke, intracerebral and subarachnoid hemorrhage, microbleeds, posterior reversible encephalopathy syndrome, and dural sinus and cerebral vein thrombosis (CVT). In this update, we will review recent advances in the management of cerebrovascular diseases in the context of myeloproliferative neoplasms, leukemias, lymphomas, multiple myeloma, POEMS, paroxysmal nocturnal hemoglobinuria (PNH), thrombotic thrombocytopenic purpura (TTP), and sickle-cell disease. In acute ischemic stroke associated with hematological diseases, thrombectomy can in general be applied if there is a large vessel occlusion. Intravenous thrombolysis can be used in myeloproliferative neoplasms and sickle-cell anemia, but in other diseases, a case-by-case evaluation of the bleeding risks is mandatory. Patients with sickle-cell disease and acute stroke need very often to be transfused. In PNH, acute ischemic stroke patients must be anticoagulated. Most patients with CVT can be treated with low-molecular weight heparin (LMWH) acutely, even those with leukemias. Prevention of recurrence of cerebral thrombotic events depends on the control of the underlying disease, combined in some conditions with antithrombotic drugs. The recent introduction of specific monoclonal antibodies in the treatment of PHN and TTP has dramatically reduced the risk of arterial and venous thrombosis.
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Affiliation(s)
- José M Ferro
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal. .,Faculdade de Medicina, Universidade de Lisboa, Hospital de Santa Maria, Neurology, 6th Floor, Avenida Professor Egas Moniz s/n, 1649-035, Lisbon, Portugal.
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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17
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Gabriel M, Hoeben BAW, Uhlving HH, Zajac-Spychala O, Lawitschka A, Bresters D, Ifversen M. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:774853. [PMID: 35004543 PMCID: PMC8734594 DOI: 10.3389/fped.2021.774853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.
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Affiliation(s)
- Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Hilde Hylland Uhlving
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anita Lawitschka
- Haematopoietic Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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18
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Balaguer-Rosello A, Piñana JL, Bataller L, Montoro J, Romero S, Navarro I, Lorenzo I, Andreu R, Guerreiro M, Aguilar C, Gorriz D, Dominguez L, de la Puerta R, Gómez I, Solves P, Jarque I, Sanz MÁ, Sanz G, Sanz J. Central Nervous System Involvement in Epstein-Barr Virus-Related Post-Transplant Lymphoproliferative Disorders after Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2020; 27:261.e1-261.e7. [PMID: 33781531 DOI: 10.1016/j.jtct.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 11/12/2022]
Abstract
Central nervous system (CNS) involvement in Epstein-Barr virus-related post-transplant lymphoproliferative disorders (EBV-PTLDs) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is poorly defined. We analyzed the incidence, clinical and pathological characteristics, and impact on outcomes of EBV-PTLDs with CNS involvement (CNS-PTLDs) in 1009 consecutive adult patients undergoing allo-HSCT at a single-center institution. Four hundred eighty-two patients received matched sibling donor (MSD) transplants, 388 umbilical cord blood transplants (UCBTs), 56 matched unrelated donor (MUD) transplants, and 83 haploidentical transplants. We detected 25 cases of biopsy-proven EBV-PTLDs. Of these, nine patients (36%) had CNS-PTLDs: six after UCBT (67%), one after MSD transplantation (11%), one after MUD transplantation (11%), and one after haploidentical transplantation (11%). The 5-year cumulative incidence risk of CNS-PTLDs was 0.9%. Median time from transplant to CNS-PTLDs was 187 days, and all patients had neurological symptoms at diagnosis. Six out of the nine cases (67%) occurred with systemic involvement, and three cases (33%) had isolated CNS involvement. The most frequent histological subtype was monomorphic EBV-PTLD, and laboratory characteristics were similar to EBV-PTLDs without CNS involvement. We observed statistical differences in the rate of positive EBV DNA detection in plasma between isolated CNS-PTLDs (detection in one out of three, 33%) and the rest of the EBV-PTLDs (100%) (P = .01). Treatment strategies included chemotherapy, radiotherapy, and T cell therapy. However, seven out of nine patients died due to progression of the CNS-PTLDs at a median time of 17 days (range, 8 to 163) from diagnosis. The 5-years overall survival in patients who developed CNS-PTLDs was 22% (95% confidence interval [CI], 7% to 75%) and 5-year treatment-related mortality was 78% (95% CI, 51% to 100%), with no statistically significant differences between CNS-PTLDs and the rest of the EBV-PTLDs. In conclusion, despite advances in EBV monitoring and treatment strategies, CNS-PTLDs remain an uncommon but serious complication after allo-HSCT, with very poor prognosis.
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Affiliation(s)
- Aitana Balaguer-Rosello
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - José Luis Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Samuel Romero
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Irene Navarro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ignacio Lorenzo
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael Andreu
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Cristobal Aguilar
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - David Gorriz
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Lara Dominguez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rosalia de la Puerta
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isidro Jarque
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Guillermo Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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19
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Mathew NR, Vinnakota JM, Apostolova P, Erny D, Hamarsheh S, Andrieux G, Kim JS, Hanke K, Goldmann T, Chappell-Maor L, El-Khawanky N, Ihorst G, Schmidt D, Duyster J, Finke J, Blank T, Boerries M, Blazar BR, Jung S, Prinz M, Zeiser R. Graft-versus-host disease of the CNS is mediated by TNF upregulation in microglia. J Clin Invest 2020; 130:1315-1329. [PMID: 31846439 DOI: 10.1172/jci130272] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023] Open
Abstract
Acute graft-versus-host disease (GVHD) can affect the central nervous system (CNS). The role of microglia in CNS-GVHD remains undefined. In agreement with microglia activation, we found that profound morphological changes and MHC-II and CD80 upregulation occurred upon GVHD induction. RNA sequencing-based analysis of purified microglia obtained from mice with CNS-GVHD revealed TNF upregulation. Selective TNF gene deletion in microglia of Cx3cr1creER Tnffl/- mice reduced MHC-II expression and decreased CNS T cell infiltrates and VCAM-1+ endothelial cells. GVHD increased microglia TGF-β-activated kinase-1 (TAK1) activation and NF-κB/p38 MAPK signaling. Selective Tak1 deletion in microglia using Cx3cr1creER Tak1fl/fl mice resulted in reduced TNF production and microglial MHC-II and improved neurocognitive activity. Pharmacological TAK1 inhibition reduced TNF production and MHC-II expression by microglia, Th1 and Th17 T cell infiltrates, and VCAM-1+ endothelial cells and improved neurocognitive activity, without blocking graft-versus-leukemia effects. Consistent with these findings in mice, we observed increased activation and TNF production of microglia in the CNS of GVHD patients. In summary, we prove a role for microglia in CNS-GVHD, identify the TAK1/TNF/MHC-II axis as a mediator of CNS-GVHD, and provide a TAK1 inhibitor-based approach against GVHD-induced neurotoxicity.
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Affiliation(s)
- Nimitha R Mathew
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Janaki M Vinnakota
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center.,Faculty of Biology
| | - Petya Apostolova
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, Medical Center
| | - Daniel Erny
- Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, Medical Center.,Institute for Neuropathology, Faculty of Medicine; and
| | - Shaimaa Hamarsheh
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Geoffroy Andrieux
- Institute of Medical Bioinformatics and Systems Medicine (IBSM); Medical Center-University of Freiburg, Medical Faculty, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jung-Seok Kim
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
| | - Kathrin Hanke
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | | | | | - Nadia El-Khawanky
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Gabriele Ihorst
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Dominik Schmidt
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Justus Duyster
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Jürgen Finke
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center
| | - Thomas Blank
- Institute for Neuropathology, Faculty of Medicine; and
| | - Melanie Boerries
- Institute of Medical Bioinformatics and Systems Medicine (IBSM); Medical Center-University of Freiburg, Medical Faculty, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Masonic Cancer Center and Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Steffen Jung
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
| | - Marco Prinz
- Institute for Neuropathology, Faculty of Medicine; and.,Centre for Integrative Biological Signalling Studies (CIBSS), Signalling Research Centres; and.,Center for Basics in NeuroModulation, Faculty of Medicine; Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Faculty of Medicine, Medical Center.,Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Medical Center.,Centre for Integrative Biological Signalling Studies (CIBSS), Signalling Research Centres; and
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20
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Mannina D, Berneking L, Both A, Timm W, Urbanowicz T, Wolschke C, Ayuketang Ayuk F, Fischer N, Fiehler J, Grzyska U, Rösner S, Choe C, Kröger N, Christopeit M. Major central nervous system complications after allogeneic stem cell transplantation: A large retrospective study on 888 consecutive adult patients. Eur J Haematol 2020; 105:722-730. [DOI: 10.1111/ejh.13489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/04/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Daniele Mannina
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
- Hematology and Bone Marrow Transplantation Unit San Raffaele Scientific InstituteVita‐Salute San Raffaele University Milano Italy
| | - Laura Berneking
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
- Institute for Medical Microbiology, Virology and Hygiene University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Anna Both
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
- Institute for Medical Microbiology, Virology and Hygiene University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Wiebke Timm
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Tatiana Urbanowicz
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Francis Ayuketang Ayuk
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Nicole Fischer
- Institute for Medical Microbiology, Virology and Hygiene University Medical Center Hamburg‐Eppendorf Hamburg Germany
- German Center for Infection Research (DZIF) Partner Site Hamburg‐Borstel‐Lübeck Hamburg Germany
| | - Jens Fiehler
- Department of Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Ulrich Grzyska
- Department of Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Sabine Rösner
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Chi‐Un Choe
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation University Medical Center Hamburg‐Eppendorf Hamburg Germany
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21
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Krenn M, Grisold A, Wohlfarth P, Rath J, Cetin H, Koneczny I, Zimprich F. Pathomechanisms and Clinical Implications of Myasthenic Syndromes Exacerbated and Induced by Medical Treatments. Front Mol Neurosci 2020; 13:156. [PMID: 32922263 PMCID: PMC7457047 DOI: 10.3389/fnmol.2020.00156] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/28/2020] [Indexed: 12/21/2022] Open
Abstract
Myasthenic syndromes are typically characterized by muscle weakness and increased fatigability due to an impaired transmission at the neuromuscular junction (NMJ). Most cases are caused by acquired autoimmune conditions such as myasthenia gravis (MG), typically with antibodies against the acetylcholine receptor (AChR). Different drugs are among the major factors that may complicate pre-existing autoimmune myasthenic conditions by further impairing transmission at the NMJ. Some clinical observations are substantiated by experimental data, indicating that presynaptic, postsynaptic or more complex pathomechanisms at the NMJ may be involved, depending on the individual compound. Most robust data exist for the risks associated with some antibiotics (e.g., aminoglycosides, ketolides, fluoroquinolones) and cardiovascular medications (e.g., class Ia antiarrhythmics, beta blockers). Apart from primarily autoimmune-mediated disorders of the NMJ, de novo myasthenic manifestations may also be triggered by medical treatments that induce an autoimmune reaction. Most notably, there is growing evidence that the immune checkpoint inhibitors (ICI), a modern class of drugs to treat various malignancies, represent a relevant risk factor to develop severe and progressive medication-induced myasthenia via an immune-mediated mechanism. From a clinical perspective, it is of utmost importance for the treating physicians to be aware of such adverse treatment effects and their consequences. In this article, we aim to summarize existing evidence regarding the key molecular and immunological mechanisms as well as the clinical implications of medication-aggravated and medication-induced myasthenic syndromes.
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Affiliation(s)
- Martin Krenn
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Anna Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Philipp Wohlfarth
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jakob Rath
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Inga Koneczny
- Department of Neurology, Medical University of Vienna, Vienna, Austria.,Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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