Severe autologous GVHD after hematopoietic progenitor cell transplantation for multiple myeloma

Autologous Gastrointestinal Graft-vs-Host Disease in a Patient With Multiple Myeloma and Hematopoietic Stem Cell Transplantation

Graft-vs-host disease (GVHD) of the gastrointestinal (GI) tract is notably a serious complication of allogeneic hematopoietic stem cell transplant (HSCT). However, GI GVHD has rarely been reported in autologous HSCT, and the pathophysiology remains unclear. Diagnosing GVHD after autologous HSCT requires a high level of clinical suspicion, given its nonspecific clinical presentation and endoscopic findings necessitating a histological diagnosis for confirmation. We present a case of autologous GVHD involving the GI tract in a patient with multiple myeloma who responded well to corticosteroids, highlighting the importance of early identification of this rare entity to initiate therapy and improve outcomes.

Acute auto-aggression syndrome following autologous hematopoietic stem cell transplant and lenalidomide for multiple myeloma

INTRODUCTION

Autologous hematopoietic stem cell transplant is an important treatment modality used to achieve long-term remission in people with multiple myeloma. Complications include chemotherapy-related toxicity or infection. Rarely, clinical features consistent with autologous graft-versus-host disease, otherwise known as auto-aggression syndrome, is possible. Auto-aggression syndrome appears more commonly in patients with multiple myeloma, hypothesized to be a result of underlying immune dysregulation, conditioning chemotherapy, or treatment with immunomodulating agents.

CASE REPORT

A 66-year-old female with multiple myeloma underwent an autologous stem cell transplant with melphalan conditioning chemotherapy followed by maintenance therapy with lenalidomide. Transplant was complicated by engraftment syndrome versus auto-aggression syndrome. After lenalidomide maintenance therapy initiation, she required hospitalization for auto-aggression syndrome.

MANAGEMENT AND OUTCOME

Auto-aggression syndrome with gastrointestinal, hepatic, and dermatologic involvement as demonstrated by skin punch biopsy, elevated reg3α, ST2, elafin, eosinophilia, transaminitis, and persistent diarrhea beyond the engraftment period were noted. Topical and systemic steroids with a prolonged taper resulted in symptom resolution.

DISCUSSION

Acute graft-versus-host disease is a complication once considered unique to allogeneic stem cell transplant recipients, but a similar syndrome termed "auto-aggression syndrome" may be seen following autologous transplant. Auto-aggression syndrome should be suspected when complications extend beyond the normal engraftment syndrome period following autologous transplant, particularly in people with multiple myeloma, and/or those who have received prior immunomodulating therapy. There should be a low threshold for obtaining biopsies in the setting of suspected auto-aggression syndrome. Early recognition and prompt initiation of corticosteroids with prolonged tapers may prevent auto-aggression syndrome relapse and readmissions.

Graft-versus-host disease in a child with neuroblastoma after autologous stem cell transplantation

In the pediatric population, hematopoietic stem cell transplantation (HSCT) is used to treat a wide variety of diseases, both malignant and nonmalignant. For many of these diseases, HSCT is a well-established treatment. Acute graft-versus-host disease (GVHD) continues to be a leading cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Graft versus host disease is a common complication of allo-SCT which is induced by donor T cell recognition of recipient alloantigens. The occurrence of autologous GVHD suggests that inappropriate recognition of host self-antigens may occur. GVHD in patients who received autologous HSCT is extremely rare compared to patients who received allogeneic HSCT. We present the case of a 4-year-old girl with metastatic neuroblastoma who spontaneously developed autologous GVHD after autologous HSCT.

Colonic graft-vs.-host disease in autologous versus allogeneic transplant patients: earlier onset, more apoptosis, and lack of regulatory T-cell attenuation

Histologic characterization of graft-vs.-host disease in autologous stem cell transplant patients has been limited. The aims of this study were to characterize colonic graft-vs.-host disease in autologous stem cell transplant patients and compare to a control group of allogeneic stem cell transplant patients, to determine whether graft-vs.-host disease can be diagnosed < 21 days post transplantation in autologous stem cell transplant recipients, and to quantify colonic T-cell populations in autologous stem cell transplant patients. Colonic biopsies taken to evaluate for graft-vs.-host disease in both allogenic and autologous stem cell transplant patients were reviewed for the maximum number of apoptotic bodies per 10 contiguous crypts. Immunohistochemical stains for CD4, CD8, and FoxP3 were performed. Clinical information was collected from chart review. The study group consisted of 122 colonic biopsies from 84 patients. Sixteen patients underwent autologous stem cell transplant and 68 allogeneic stem cell transplant. Autologous stem cell transplant patients underwent biopsy significantly earlier compared with allogeneic stem cell transplant patients (median 20 vs. 87 days, p = 0.0002), had significantly higher apoptotic counts compared with matched-related donor patients (7.5 vs. 3.9, p = 0.03), and had higher FoxP3-positive lamina propria lymphocytes counts compared to allogeneic stem cell transplant patients (9.2 vs. 5.3, p = 0.03). In patients undergoing biopsy < 21 days post transplantation, allogeneic stem cell transplant patients showed less CD8-positive lamina propria lymphocytes and a trend of less FoxP3- and CD4-positive lamina propria lymphocytes compared with autologous stem cell transplant patients. Autologous stem cell transplant patients have more prominent crypt apoptosis compared with allogenic stem cell transplant patients and do not have numerically decreased FoxP3-positive lamina propria lymphocytes. Presence of robust T-cell populations in the early period following transplantation suggest that the 21-day cutoff for diagnosis of graft-vs.-host disease is not applicable to autologous stem cell transplant patients.

Autologous Graft-Versus-Host Disease of the Gastrointestinal Tract in Patients With Multiple Myeloma and Hematopoietic Stem Cell Transplantation

Multiple myeloma (MM) is the most common indication for autologous hematopoietic stem cell transplantation (HSCT) in North America. Despite occurring in up to 50% of patients undergoing allogeneic HSCT, the incidence of graft-versus-host disease (GVHD) after autologous HSCT is reportedly only 5-20%. Gastrointestinal involvement with graft-versus-host disease (GI GVHD) is a common and serious complication of allogeneic HSCT. GI GVHD after autologous transplant, which is referred to as autologous GVHD (auto-GVHD), has also been described. Auto-GVHD is usually less severe than allogeneic GVHD, and it can be one of the manifestations of engraftment syndrome with release of inflammatory cytokines and infiltration of auto-reactive T cells into affected tissue. Seventy-nine percent of patients respond well to corticosteroids without evidence of recurrence. However, cases of severe auto-GVHD lacking good response to corticosteroids have been reported, most notably in MM patients. Here we present two cases of autologous GI GVHD in recipients of autologous HSCT for treatment of MM. Our cases demonstrate two distinct clinical and endoscopic presentations of this uncommon entity. In the first case, the patient had more severe clinical symptoms accompanied by radiographic, endoscopic, and pathologic findings. The hospital course was complicated by cryptosporidium enteritis and acute cholecystitis in the setting of increased immunosuppression with a corticosteroid for presumed auto-GVHD. In contrast, the second case presented a patient with normal radiologic and endoscopic findings. Pathology revealing frequent apoptotic bodies led to auto-GVHD as a diagnosis. Both our patients received similar courses of chemotherapy prior to autologous HSCT (four cycles of a proteasome inhibitor, lenalidomide, and dexamethasone). Our work highlights the importance of maintaining a high level of clinical suspicion for auto-GVHD in patients presenting with GI symptoms after autologous HSCT, as it is a potentially treatable pathology that may be easily confused with other conditions. Health care providers should be aware of the potential complications of auto-GVHD after autologous HSCT and should be suspicious of auto-GVHD if GI symptoms occur, especially in patients receiving immunomodulatory therapy for MM, even in the absence of gross endoscopic findings.

Mucosal Biopsy After Bone Marrow Transplantation

Gastrointestinal mucosal biopsies in the hematopoietic stem cell transplantation setting are challenging because histologic features of graft-versus-host disease (GVHD), which is treated by increasing immunosuppression, overlap with those of other conditions, such as infection, which can get worse with GVHD treatment. More than one condition can occur at the same time. It is important to understand the histologic features of GVHD, drug toxicity, infection, and clinical factors surrounding patients, including timing of biopsy in relation to transplantation, medication history, and laboratory data. Rendering a correct diagnosis and generating a pathology report with standard language that can direct clinical management ensure proper management.

Group-Based Trajectory Modeling of Distress and Well-Being Among Caregivers of Children Undergoing Hematopoetic Stem Cell Transplant

Objective

To examine the trajectories of caregiver psychological responses in the year following their child's hematopoetic stem cell transplant (HSCT), and whether cognitive and social processing strategies differentiated between trajectories.

Method

One hundred and eight caregivers randomized to the control condition of a cognitive-behavioral intervention study completed measures of distress, coping, and social support at baseline, 1 month, 6 months, and 1 year post HSCT of their child.

Results

The majority reported moderate or low anxiety, depression, or distress that decreased over time, but a small group demonstrated high anxiety, depression, or distress that persisted or increased over time. Maladaptive coping was highest among caregivers in the high-persistent distress subgroup compared with the moderate-decreasing and low-stable groups. Adaptive coping was minimally associated with trajectory subgroups.

Conclusions

Screening HSCT caregivers for distress and maladaptive coping may be useful in identifying caregivers likely to experience persistently high distress who may benefit from psychological intervention.

Graft versus self (GvS) against T-cell autoantigens is a mechanism of graft-host interaction

Graft-versus-host disease (GVHD) represents the major nonrelapse complication of allogeneic hematopoietic cell transplantation. Although rare, the CNS and the eye can be affected. In this study, manifestation in the retina as part of the CNS and T-cell epitopes recognized by the allogeneic T cells were evaluated. In 2 of 6 patients with posttransplantation retina diseases and 6 of 22 patients without ocular symptoms, antigen-specific T-cell responses against retina-specific epitopes were observed. No genetic differences between donor and recipient could be identified indicating T-cell activation against self-antigens (graft versus self). Transplantation of a preexisting immunity and cross-reactivity with ubiquitous epitopes was excluded in family donors and healthy individuals. In summary, an immunological reaction against retina cells represents a mechanism of graft-versus-host interaction following hematopoietic cell transplantation.

A Comprehensive Assessment of Toxicities in Patients with Central Nervous System Lymphoma Undergoing Autologous Stem Cell Transplantation Using Thiotepa, Busulfan, and Cyclophosphamide Conditioning

High-dose therapy and autologous stem cell transplantation (ASCT) with thiotepa, busulfan, and cyclophosphamide (TBC) conditioning has emerged as an effective postinduction treatment strategy for patients with primary central nervous system lymphoma (PCNSL) or secondary central nervous system lymphoma (SCNSL), but it is associated with considerable toxicity and transplantation-related mortality (TRM) in the modern era. Forty-three adult patients with chemosensitive PCNSL or SCNSL underwent TBC-conditioned ASCT between 2006 and 2015. Twenty-eight of these patients received pharmacokinetically (PK)-targeted busulfan dosing. The median number of clinically relevant individual grade ≥3 nonhematologic toxicities per patient was 5. We found no association between pretransplantation patient characteristics and the presence of more than 5 grade ≥3 nonhematologic toxicities. Patients with elevated first-dose busulfan area under the curve values did not experience more toxicity. Paradoxically, patients treated with more than 2 regimens before undergoing ASCT had lower first-dose busulfan AUC values. With a median follow-up among survivors of 20 months, 1-year progression-free survival (PFS) and overall survival (OS) from the time of ASCT were 83% and 87%, respectively. Although this study reaffirms the favorable PFS and OS associated with TBC-conditioned ASCT for PCNSL or SCNSL, this treatment strategy carries a large toxicity burden.

Engraftment Syndrome after Autologous Stem Cell Transplantation: An Update Unifying the Definition and Management Approach

Engraftment syndrome (ES) encompasses a continuum of periengraftment complications after autologous hematopoietic stem cell transplantation. ES may include noninfectious fever, skin rash, diarrhea, hepatic dysfunction, renal dysfunction, transient encephalopathy, and capillary leak features, such as noncardiogenic pulmonary infiltrates, hypoxia, and weight gain with no alternative etiologic basis other than engraftment. Given its pleiotropic clinical presentation, the transplant field has struggled to clearly define ES and related syndromes. Here, we present a comprehensive review of ES in all documented disease settings. Furthermore, we discuss the proposed risk factors, etiology, and clinical relevance of ES. Finally, our current approach to ES is included along with a proposed treatment algorithm for the management of this complication.

Graft-Versus-Host Disease of the Upper Gastrointestinal Tract After an Autologous Stem Cell Transplant

Graft-versus-host disease (GVHD) in recipients of autologous stem cell transplantation (SCT) is less common compared to recipients of allogeneic SCT, but its existence has been well documented. Similarly, the diarrheal component of the disease is highlighted when discussing its gastrointestinal (GI) manifestations, with less emphasis given to upper GI symptoms like nausea and vomiting. We present a case illustrating the upper GI tract signs and symptoms of GVHD after autologous SCT, and emphasize that prompt treatment can rapidly improve morbidity and prevent disease progression.

Acute graft-versus-host disease and bronchiolitis obliterans after autologous stem cell transplantation in a patient with multiple myeloma

Sixty-seven-year-old patient, diagnosed with multiple myeloma who had received autologous stem cell transplantation, following bortezomib, dexamethasone and thalidomide conventional regimen, achieving complete response, developed rash, diarrhea, and severe respiratory failure, 80 days after the transplantation procedure. He was diagnosed with graft-versus-host disease and bronchiolitis obliterans syndrome.

Autologous graft-versus-host disease in a child with stage IV neuroblastoma

Graft-versus-host disease (GVHD) is an underappreciated complication of autologous hematopoietic stem cell transplantation (AHSCT) that can affect the skin, gastrointestinal tract, and liver. The development of this rare condition is probably due to an impairment of immunologic tolerance that can occur spontaneously through T-cell dysregulation, possibly from intensive conditioning chemotherapy regimens, or intentionally through administration of cyclosporine in the hopes of promoting an antitumor response. We present the case of a 2-year-old boy with metastatic neuroblastoma who spontaneously developed autologous GVHD after AHSCT. Severe pruritus and an inability to taper his oral steroids without a disease flare marked his disease. Eventually partial relief was achieved with initiation of cyclosporine and a strict soak and smear protocol using topical triamcinolone 0.1% ointment.

Autologous Graft versus Host Disease: An Emerging Complication in Patients with Multiple Myeloma

Autologous graft versus host disease (autoGVHD) is a rare transplant complication with significant morbidity and mortality. It has been hypothesized that patients with multiple myeloma might be predisposed to autoGVHD through dysregulation of the immune response resulting from either their disease, the immunomodulatory agents (IMiDs) used to treat it, or transplant conditioning regimen. Hematopoietic progenitor cell (HPC) products were available from 8 multiple myeloma patients with biopsy-proven autoGVHD, 16 matched multiple myeloma patients who did not develop autoGVHD, and 7 healthy research donors. The data on number of transplants prior to developing autoGVHD, mobilization regimens, exposure to proteasome inhibitors, use of IMiDs, and class I human leukocyte antigen types (HLA A and B) were collected. The HPC products were analyzed by flow cytometry for expression of CD3, CD4, CD8, CD25, CD56, and FoxP3. CD3⁺ cell number was significantly lower in autoGVHD patients compared to unaffected controls (P = 0.047). On subset analysis of CD3⁺ cells, CD8⁺ cells (but not CD4⁺ cells) were found to be significantly lower in patients with autoGVHD (P = 0.038). HLA-B55 expression was significantly associated with development of autoGVHD (P = 0.032). Lower percentages of CD3⁺ and CD8⁺ T-cells and HLA-B55 expression may be predisposing factors for developing autoGVHD in myeloma.

Divergent effects of novel immunomodulatory agents and cyclophosphamide on the risk of engraftment syndrome after autologous peripheral blood stem cell transplantation for multiple myeloma

Engraftment syndrome (ES) is an increasingly observed and occasionally fatal complication after autologous peripheral blood stem cell transplantation (PBSCT). In this study, we demonstrate that the incidence of ES is significantly increased in patients undergoing autologous PBSCT for multiple myeloma in comparison to patients with non-Hodgkin lymphoma or Hodgkin lymphoma. Multivariate analysis revealed that age > 60 (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.12 to 2.62; P = .013) and transplantation for multiple myeloma (HR, 2.80; 95% CI, 1.60 to 4.90; P = .0003) were associated with an increased risk of this complication. When stratified for myeloma patients only, age > 60 (HR, 1.80; 95% CI, 1.13 to 2.87; P = .013) and prior treatment with both lenalidomide and bortezomib (HR, 1.83; 95% CI, 1.11 to 3.04; P = .0001) were associated with an increased incidence of ES. Conversely, lack of exposure to cyclophosphamide from either chemomobilization or as a component of the pretransplantation therapeutic regimen increased the risk of this complication (HR, 3.05; 95% CI, 1.91 to 4.87; P <.0001). These studies demonstrate that the pretransplantation exposure of multiple myeloma patients to novel immunomodulatory agents and cyclophosphamide significantly affects the subsequent risk of developing ES.

Skin Graft-versus-host Disease Following Autologous Stem Cell Transplantation for Multiple Myeloma

Graft-versus-host disease (GVHD) is a common complication of allogeneic stem cell transplantation (allo-SCT). However, a similar syndrome has been reported in autologous stem cell transplantation (ASCT) as well. The target organs of GVHD in ASCT are the skin, liver and gastrointestinal (GI) tract, which are consistent with those in allo-SCT. Histologic findings from the skin and the mucosa of the GI tract also show similar features. Here we describe a case of autologous GVHD involving the skin of a patient who underwent ASCT for multiple myeloma. In this patient, the response to a total prednisone dose of 0.5 mg/kg/day was unsatisfactory, and the patient required more intensive and prolonged immunosuppressive therapy with slow tapering.

Cellular immunotherapy for plasma cell myeloma

Allogeneic hematopoietic cell transplantation for plasma cell myeloma can lead to graft-vs-myeloma immunity and long-term survivorship, but limited efficacy and associated toxicities have prevented its widespread use. Cellular immunotherapies seek to induce more specific, reliable and potent antimyeloma immune responses with less treatment-related risk than is possible with allogeneic transplantation. Strategies under development include infusion of vaccine-primed and ex vivo expanded/costimulated autologous T cells after high-dose melphalan, genetic engineering of autologous T cells with receptors for myeloma-specific epitopes, administration of DC/plasma cell fusions and administration expanded marrow-infiltrating lymphocytes. In addition, novel immunomodulatory drugs such as inhibitors of the programmed death-1 T cell regulatory pathway may synergize with cellular immunotherapies.

Autologous Hematopoietic Stem Cell Transplantation for Multiple Myeloma without Cryopreservation

High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation is considered the standard of care for multiple myeloma patients who are eligible for transplantation. The process of autografting comprises the following steps: control of the primary disease by using a certain induction therapeutic protocol, mobilization of stem cells, collection of mobilized stem cells by apheresis, cryopreservation of the apheresis product, administration of high-dose pretransplant conditioning therapy, and finally infusion of the cryopreserved stem cells after thawing. However, in cancer centers that treat patients with multiple myeloma and have transplantation capabilities but lack or are in the process of acquiring cryopreservation facilities, alternatively noncryopreserved autologous stem cell therapy has been performed with remarkable success as the pretransplant conditioning therapy is usually brief.

Muscle-specific kinase-antibody-positive myasthenia gravis after autologous bone marrow transplantation

A 44-year-old man presented with oculobulbar weakness approximately 5 years after autologous bone marrow transplantation (BMT). His workup led to the diagnosis of muscle-specific kinase-antibody-related myasthenia gravis (MG). There has been only one case report of muscle-specific kinase-antibody-positive MG after BMT, which was allogeneic. We report the first case of autologous BMT-associated MG with muscle-specific kinase antibody. The pathogenic mechanisms of immune dysregulation leading to MG after BMT are discussed.

Acquired Omenn-like syndrome, a novel posttransplant autoaggression syndrome reversed by rapamycin

Graft-versus-host disease is uncommon in autologous hematopoietic cell transplantation (HCT) and is typically brief and mild. We report unusual, protracted, and severe Omenn syndrome-like autoaggression following autologous HCT. We identified a profound FOXP3(+) regulatory T cell defect that coincided with hyperinflammatory T cell responses which were reversible with rapamycin in vitro.

Gastrointestinal pathology of autologous graft-versus-host disease following hematopoietic stem cell transplantation: a clinicopathological study of 17 cases

Graft-versus-host disease is the major complication after allogeneic hematopoietic stem cell transplantation and is attributable to donor T-cell recognition of recipient alloantigens. In patients undergoing autologous hematopoietic stem cell transplantation in which there is no genetic disparity to induce an alloresponse, a syndrome similar to allogeneic graft-versus-host disease has been described. Designated as autologous graft-versus-host disease, it typically involves the skin and has reportedly caused little morbidity in this patient population. Recent data, however, suggest that autologous graft-versus-host disease can cause significant disease in the gastrointestinal tract, but its pathological spectrum of abnormalities and disease incidence are not well established. We report the development of autologous graft-versus-host disease following hematopoietic stem cell transplantation in 17 patients (15 with multiple myeloma) based on 388 autologous stem cell transplants carried out at our institution over a 6-year period. This represents a total incidence rate of 4% and among those transplanted for multiple myeloma, 6%. In all, 16 of the 17 patients had colonic biopsies performed for the diagnostic evaluation of persistent diarrhea. Biopsies in all 16 patients showed pathological evidence for graft-versus-host disease and were graded using standard grading criteria established for allogeneic graft-versus-host disease. Grades ranged from mild (grade 1/4) to severe (grade 4/4). Changes secondary to medication or infection were excluded. Responses to steroid and immunosuppressive therapy were variable but improved with continuing institutional experience. Outcomes ranged from a prompt, complete resolution of symptoms to death. Patients treated with autologous hematopoietic stem cell transplantation, particularly those with multiple myeloma, may develop a potentially life-threatening syndrome pathologically identical to allogeneic graft-versus-host disease. This diagnosis must be considered when interpreting biopsies from patients with gastrointestinal symptoms following autologous hematopoietic stem cell transplantation.

Recurrent spontaneous gastrointestinal graft-versus-host disease in autologous hematopoietic stem cell transplantation

Acute graft-versus-host disease (GVHD) is a major complication after allogeneic stem cell transplantation (SCT). A similar manifestation involving skin, gastrointestinal (GI) mucosa, and liver can occur after autologous hematopoietic SCT (autoHSCT), either spontaneously or after treatment with cyclosporine or interferon. Severity of spontaneous GI GVHD among patients treated with autoHSCT is variable. Recurrent spontaneous GI GVHD induced by succeeding cycles of chemotherapy has rarely been reported and is poorly understood. Enteric-coated budesonide has been studied extensively in Crohn's disease, and beclomethasone has been studied in GI GVHD. There are no comparative studies between these drugs for GI GVHD. Furthermore, GI GVHD has to be considered when microbiologic workup remains negative during the workup of persistent diarrhea in autoHSCT. Endoscopic appearances can be normal, and pathologic diagnosis is essential. Further research into risk factors involving type of chemotherapy, interval between chemotherapies, and gene polymorphisms have to be considered for better understanding of autologous GVHD. We report for the first time a patient with spontaneous recurrent GI GVHD after autoHSCT for multiple myeloma with predominant lower GI symptoms and excellent response to enteric-coated budesonide therapy.