|
1
|
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.
Collapse
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
| |
Collapse
|
|
2
|
Cavazza G, Motto C, Regna-Gladin C, Travi G, Di Gennaro E, Peracchi F, Monti B, Corti N, Greco R, Minga P, Riva M, Rimoldi S, Vecchi M, Rogati C, Motta D, Pazzi A, Vismara C, Bandiera L, Crippa F, Mancini V, Sessa M, Oltolini C, Cairoli R, Puoti M. Cerebral Infectious Opportunistic Lesions in a Patient with Acute Myeloid Leukaemia: The Challenge of Diagnosis and Clinical Management. Antibiotics (Basel) 2024; 13:387. [PMID: 38786116 PMCID: PMC11117374 DOI: 10.3390/antibiotics13050387] [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: 03/16/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
Central nervous system (CNS) lesions, especially invasive fungal diseases (IFDs), in immunocompromised patients pose a great challenge in diagnosis and treatment. We report the case of a 48-year-old man with acute myeloid leukaemia and probable pulmonary aspergillosis, who developed hyposthenia of the left upper limb, after achieving leukaemia remission and while on voriconazole. Magnetic resonance imaging (MRI) showed oedematous CNS lesions with a haemorrhagic component in the right hemisphere with lepto-meningitis. After 2 weeks of antibiotics and amphotericin-B, brain biopsy revealed chronic inflammation with abscess and necrosis, while cultures were negative. Clinical recovery was attained, he was discharged on isavuconazole and allogeneic transplant was postponed, introducing azacitidine as a maintenance therapy. After initial improvement, MRI worsened; brain biopsy was repeated, showing similar histology; and 16S metagenomics sequencing analysis was positive (Veilonella, Pseudomonas). Despite 1 month of meropenem, MRI did not improve. The computer tomography and PET scan excluded extra-cranial infectious-inflammatory sites, and auto-immune genesis (sarcoidosis, histiocytosis, CNS vasculitis) was deemed unlikely due to the histological findings and unilateral lesions. We hypothesised possible IFD with peri-lesion inflammation and methyl-prednisolone was successfully introduced. Steroid tapering is ongoing and isavuconazole discontinuation is planned with close follow-up. In conclusion, the management of CNS complications in immunocompromised patients needs an interdisciplinary approach.
Collapse
Affiliation(s)
- Gabriele Cavazza
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
| | - Cristina Motto
- Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.M.); (M.S.)
| | - Caroline Regna-Gladin
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Giovanna Travi
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Elisa Di Gennaro
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
| | - Francesco Peracchi
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
| | - Bianca Monti
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
| | - Nicolò Corti
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
| | - Rosa Greco
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (R.G.); (P.M.); (M.R.); (V.M.)
| | - Periana Minga
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (R.G.); (P.M.); (M.R.); (V.M.)
| | - Marta Riva
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (R.G.); (P.M.); (M.R.); (V.M.)
| | - Sara Rimoldi
- Microbiology Unit, ASST Fatebenefratelli Sacco, 20157 Milan, Italy;
| | - Marta Vecchi
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Carlotta Rogati
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Davide Motta
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Annamaria Pazzi
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Chiara Vismara
- Clinical Microbiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Laura Bandiera
- Pathology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Fulvio Crippa
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Valentina Mancini
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (R.G.); (P.M.); (M.R.); (V.M.)
| | - Maria Sessa
- Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.M.); (M.S.)
| | - Chiara Oltolini
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| | - Roberto Cairoli
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
- Department of Haematology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (R.G.); (P.M.); (M.R.); (V.M.)
| | - Massimo Puoti
- Department of Health Sciences, University of Milan Bicocca, 20126 Milan, Italy; (G.C.); (E.D.G.); (F.P.); (B.M.); (N.C.); (R.C.); (M.P.)
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.T.); (M.V.); (C.R.); (D.M.); (A.P.); (F.C.)
| |
Collapse
|
|
3
|
Limbic Encephalitis following Allogeneic Hematopoietic Stem Cell Transplantation. Case Reports Immunol 2022; 2022:4174755. [PMID: 36124252 PMCID: PMC9482550 DOI: 10.1155/2022/4174755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/05/2022] [Accepted: 08/18/2022] [Indexed: 11/27/2022] Open
Abstract
A woman with myelodysplastic syndrome (MDS) was treated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). 65 days after the transplantation, she developed fatigue and central neurological symptoms. Clinical workup including magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination revealed findings suspicious for limbic encephalitis (LE), successfully treated with intravenous immunoglobulins and intravenous corticosteroids. Although a rare complication after allo-HSCT, physicians should be aware of neurological symptoms that develop throughout the transplantation course.
Collapse
|