Management of BK virus-associated haemorrhagic cystitis in allogeneic stem cell transplant recipients

An expert consensus on prevention, diagnosis, and management of hemorrhagic cystitis in pediatric hematopoietic cell transplantation, on behalf of the Infectious Disease and Hematopoietic Cell Transplant Working groups of Italian Pediatric Hematology Oncology Association (AIEOP)

The optimal management of hemorrhagic cystitis (HC) in hematopoietic stem cell transplantation (HCT) is debated, both for early onset HC (EOHC) secondary to chemotherapy toxicity and BK Polyomavirus (BKPyV)-related HC, due to the lack of controlled trials, particularly referred to pediatric setting. Actually, clinical practice is mainly based on guidelines of the European Conference on Infections in Leukemia, 6th edition, which considers both adult and pediatric populations but concludes that, despite much progress in understanding the pathogenesis, epidemiology, and risk factors, this complication still represents a disabling unmet clinical need with limited prophylactic and therapeutic options. Additionally, the Guidelines of the American Society of Clinical Oncology define the management of chemotherapeutic toxicity independently from the patients' population. A panel of experts belonging to the Hematopoietic Cell Transplant and Infectious Disease Working Group (WG) of Associazione Italiana di Emato-Oncologia Pediatrica (AIEOP) developed a consensus to define the best practices in prevention, diagnosis, and management of HC in pediatric HCT setting.

The effect of myeloablative radiation on urinary bladder mast cells

Radiation-induced cystitis is an inflammatory condition affecting the urinary bladder, which can develop as a side effect of abdominopelvic radiotherapy, specifically external-beam radiation therapy or myeloablative radiotherapy. A possible involvement of mast cells in the pathophysiology of radiation-induced cystitis has been indicated in cases of external-beam radiation therapy; however, there is no evidence that these findings apply to the myeloablative aetiology. As such, this study investigated potential changes to urinary bladder mast cell prevalence when exposed to myeloablative radiation. Lethally irradiated C57BL/6J mice that received donor rescue bone marrow cells exhibited an increased mast cell frequency amongst host leukocytes 1 week following irradiation. By 4 weeks, no significant difference in either frequency or cell density was observed. However mast cell diameter was smaller, and a significant increase in mast cell number in the adventitia was observed. This study highlights that mast cells constitute a significant portion of the remaining host leukocyte population following radiation exposure, with changes to mast cell distribution and decreased cell diameter four weeks following radiation-induced injury.

Primary renal leukaemia in a young adult male as an extramedullary presentation of T cell acute lymphoblastic leukaemia

Primary renal involvement by T lymphoblasts is rare among adults with T acute lymphoblastic leukaemia. We report a 28-year-old man presenting with acute renal failure due to infiltration by T lymphoblasts and his response to paediatric-inspired modified BFM-90 protocol. The patient achieved an initial complete remission (CR) but developed central nervous system relapse. He achieved CR2 with cranial irradiation and intrathecal chemotherapy. He underwent a haploidentical transplant in CR2 and remains in remission post-transplant day 330. An early kidney biopsy helped confirm the diagnosis. Such presentations remain responsive to modified BFM-90. An early allotransplant in CR2 remains the standard of care.

Decreased lymphocyte count before conditioning is associated with BK virus-associated hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation

BACKGROUND

BK virus-associated hemorrhagic cystitis (BKV-HC) is a serious complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). It can cause morbidity and may increase treatment-related mortality. Previous studies showed that the occurrence of BKV-HC was related to various factors. However, there are still many controversial factors. It is not clear whether BKV-HC will affect the long-term prognosis of patients.

OBJECTIVE

We aimed to identify risk factors for BKV-HC after allo-HSCT and evaluate the effect of BKV-HC on overall survival (OS) and progression- free survival (PFS) of patients.

STUDY DESIGN

We retrospectively analyzed the clinical data of 93 patients who underwent allo-HSCT. Univariate and multivariate analysis were used to identify risk factors for BKV-HC. The Kaplan-Meier method was used to estimate OS and PFS. A difference was considered statistically significant if P < 0.05.

RESULTS

A total of 24 patients developed BKV-HC. The median occurrence time of BKV-HC was 30 (range:8-89) days after transplantation, and the median duration was 25.5 (range:6-50) days. Multivariate logistic regression analysis indicated that peripheral blood lymphocyte count <1 × 10⁹/L before conditioning (OR = 4.705, P = 0.007) and haploidentical transplantation (OR = 13.161, P = 0.018) were independent risk factors for BKV-HC. The 3-year OS rate was 85.9% (95%CI:62.1%-95.2%) in the BKV-HC group and 73.1% (95%CI: 58.2%-88.0%) in the non-BKV-HC group. There was no significant difference between the two groups (P = 0.516). The 3-year PFS rate was 76.3% (95%CI: 57.9%-94.7%) in the BKV-HC group and 58.1% (95%CI: 39.5%-76.7%) in the non-BKV-HC group. There was no significant difference in the two groups (P = 0.459). The severity of BKV-HC was not related to the OS and PFS of the patients (P value was 0.816 and 0.501, respectively).

CONCLUSION

Haploidentical transplantation and decreased peripheral blood lymphocyte count before conditioning increased the risk of BKV-HC after allo-HSCT. The occurrence of BKV-HC after allo-HSCT and the severity of which did not affect OS and PFS of the patients.

BK-Virus-Induced Hemorrhagic Cystitis in a Patient With Graft-Versus-Host Disease

The BK virus is a polyomavirus known to particularly affect transplant recipients. An important complication caused by BK virus infection in bone marrow transplant patients is hemorrhagic cystitis. We present a 31-year-old male with a history of bone marrow transplantation complicated by graft-versus-host disease (GVHD) and was diagnosed with BK virus-related hemorrhagic cystitis. He presented with gross hematuria and suprapubic and penile pain for one week. He has a significant past medical history of acute B-cell lymphocytic leukemia for which he has successfully undergone allogenic bone marrow transplantation, which was complicated by GVHD. Imaging revealed significant bladder wall thickening which prompted an evaluation for BK virus-induced hemorrhagic cystitis. A urinary specimen was sent for BK virus polymerase chain reaction (PCR) which was strongly positive, confirming the infection. He was managed supportively throughout his hospitalization and improved with symptomatic management alone. Our case demonstrates one of the main complications caused by the BK virus in allogeneic bone marrow transplant patients in the setting of GVHD and is an important differential to keep in mind when treating patients presenting with hematuria after bone marrow transplantation.

Evaluation of the risk factors for BK virus-associated hemorrhagic cystitis in pediatric bone marrow transplantation patients: Does post-transplantation cyclophosphamide increase the frequency?

BACKGROUND

BKV-HC is one of the most significant complications of HSCT. This retrospective study aimed to determine the frequency of BKV-HC in pediatric patients undergoing HSCT, detect the associated risk factors for the development of BKV-HC, and explore the effects of post-transplantation Cy use.

METHODS

Three hundred twenty-seven patients (girls: 121, boys: 206) were analyzed according to sex, conditioning regimen, transplantation type, donor relatedness, stem cell source, the presence and grade of aGVHD, CMV co-existence, and Cy use.

RESULTS

Multivariate analysis confirmed the prognostic importance of age (OR: 4.865), TBI use, the presence of aGVHD (OR: 2.794), CMV coinfection (OR: 2.261), and Cy use (OR: 27.353). A statistically significant difference was found between the mean BKV-HC follow-up times compared with post-transplantation Cy intake (p < .001). The BKV-HC rate increased as the number of risk factors of the patient increased.

CONCLUSION

BKV-HC is an essential complication of HSCT primarily associated with Cy use, the presence of aGVHD, and donor relatedness. The present study shows that the use of Cy in the post-transplantation period further increases BKV-HC risk in pediatric patients, regardless of dose.

Medical emergencies in pediatric blood & marrow transplant and cellular therapies

Hematopoietic stem cell transplant (HCT) is used for many pediatric malignant and non-malignant diseases. However, these patients are at a high risk for emergencies post-transplant, related to prior comorbidities and treatments for the underlying disease, high dose chemotherapy regimen related toxicities, prolonged myelosuppression, and opportunistic infections due to their immunocompromised state. Emergencies can be during preparative regimen and hematopoietic progenitor cell (HPC) infusion, acute post-transplant (pre-engraftment) and late during post engraftment. Infectious complications are the most common cause of morbidity and mortality in the peri-transplant period. Sinusoidal obstructive syndrome is another life-threatening emergency seen in children undergoing HCT, especially in infants. Timely recognition and administration of defibrotide with/without steroids is key to the management of this complication. Another complication seen is transplant associated thrombotic microangiopathy. It can cause multiorgan failure if left untreated and demands urgent identification and management with complement blockade agents such as eculizumab. Cytokine release syndrome and cytokine storm is an important life-threatening complication seen after cellular therapy, and needs emergent intervention with ICU supportive care and tocilizumab. Other complications in acute period include but are not limited to: seizures from busulfan or other chemotherapy agents, PRES (posterior reversible encephalopathy syndrome), diffuse alveolar hemorrhage, idiopathic pulmonary syndrome and allergic reaction to infusion of stem cells. Acute graft versus host disease (GvHD) is a major toxicity of allogeneic HCT, especially with reduced intensity conditioning, that can affect the skin, liver, upper and lower gastrointestinal tract. There has been major development in new biomarkers for early identification and grading of GvHD, which enables application of treatment modalities such as post-transplant cyclophosphamide and JAK/STAT inhibitors to prevent and treat GvHD. Myelosuppression secondary to the chemotherapy increases risk for engraftment syndrome as well as coagulopathies, thus increasing the risk for clotting and bleeding in the pediatric population. The purpose of this article is to review recent literature in these complications seen with pediatric hematopoietic cell transplant (HCT) and cellular therapies and provide a comprehensive summary of the major emergencies seen with HCT.

A rare case of BK virus non-hemorrhagic cystitis following lung transplant

BK virus cystitis is known to occur following hematopoietic stem cell transplant (HSCT), but few cases exist in the literature following lung transplant. Because of the rarity of this presentation, patients may have missed diagnoses and prescribed ineffective treatments. We present our case of an atypical presentation of BK virus cystitis appearing as bladder carcinoma in situ in a lung transplant patient.

Pentosan polysulfate for the treatment of hemorrhagic cystitis after allogeneic hematopoietic cell transplant

INTRODUCTION

Hemorrhagic cystitis can commonly occur following an allogeneic hematopoietic cell transplant and treatment options are currently limited. Pentosan polysulfate, a heparin-like, sulfated polysaccharide, is used to relieve bladder pain and discomfort associated with interstitial cystitis. Initial reports in patients with hemorrhagic cystitis demonstrate that pentosan polysulfate may hasten hemorrhagic cystitis resolution and control symptoms.

METHODS AND RESULTS

This report includes a retrospective case series of six patients who received pentosan polysulfate for the treatment of hemorrhagic cystitis following an allogeneic hematopoietic cell transplant. Pentosan polysulfate was initiated at a median of 4.5 days (range: 3-18) following hemorrhagic cystitis onset and continued for a median duration of 17.5 days (range: 7-64). Four patients were tested for BK virus and all were found to have BK viremia and viruria around the time of pentosan polysulfate initiation. The median number of red blood cell transfusions seemed to decrease in the patients initiated on pentosan polysulfate. All patients received a multi-agent treatment regimen, which included pentosan polysulfate, and half the patients had symptom resolution. The median time to symptom resolution from pentosan polysulfate initiation was 9 days (range: 7-10).

CONCLUSION

Pentosan polysulfate was well-tolerated and seemed to assist with symptom resolution. Future studies are needed to confirm the impact of pentosan polysulfate on the treatment of hemorrhagic cystitis.

BKV Related Hemorrhagic Cystitis-An Insight into Risk Factors and Later Complications-An Analysis on Behalf of Polish Adult Leukemia Group

Simple Summary

Despite noticeable progress in allogeneic hematopoietic stem cell transplantation, potential viral reactivations are still one of the most challenging complications. The aim of our study was to identify predictive and risk factors associated with the occurrence of the BK virus related hemorrhagic cystitis following hematopoietic stem cell transplantation. Furthermore, we investigated the impact of various factors on the clinical course of patients after hematopoietic stem cell transplantation. We confirmed that >0.75 × 10³ BK virus copies/mL in serum at day +21 after allogeneic hematopoietic stem cell transplantation has a strong predictive ability for hemorrhagic cystitis. Thus, we believe that our findings could be helpful in establishing the predictive validity of the BK viral load measurement in polyomavirus BK-associated hemorrhagic cystitis and survival.

Abstract

BK virus reactivation increases the likelihood of hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplant (HCT). In this study, we aimed to identify predictive and risk factors associated with the increased occurrence of this condition following HCT. On a group of 124 patients aged ≤71 years old (median 40 years) who underwent HCT, we analyzed sex, age, time from diagnosis to transplantation, type of conditioning, donor’s relationship, age, and sex, the impact of immunosuppression with different drugs, and acute and chronic GVHD, BK viremia and viruria as potential factors increasing the risk of BK-related HC after HCT. HC occurred among 24 patients (24/124; 29.2%). A significant correlation was observed between HC incidences after HCT, BK viremia and viruria, and acute GVHD occurrence. Furthermore, the level of BKV DNA in serum at day +21 (>0.75 × 10³) significantly impacted the patients’ survival time. According to our results, the likelihood ratio of BKV-DNA on day +21 in serum is 6.25, indicating that this diagnostic test has the potential to be utilized in a clinical setting. These findings may be used as a voice in the discussion on implementing an optimal preemptive treatment in BKV reactivation after allogeneic HCT.

A 5-Year Retrospective Analysis of Raoultella planticola Bacteriuria

Introduction

Raoultella planticola is an aerobic gram-negative rod predominantly found in soil and aquatic environments. The typical reservoirs of Raoultella spp. include the gastrointestinal tract and the upper respiratory tract. It usually causes pneumonia, biliary tract infections, and bacteremia. Urinary tract infection (UTI) secondary to R. planticola is an uncommon entity. Less than 10 cases of R. planticola-associated UTIs in adults have been published in the literature to date.

Objective

This is a single institution retrospective study undertaken to identify the epidemiology, patient characteristics, clinical spectrum, predisposing risk factors and the outcome of patients with UTI caused by R. planticola.

Results

A total of 37 R. planticola isolates were identified in urine samples over a 5-year study period. The mean age of the patient population was 77 years. The most common comorbidity was diabetes mellitus, which was present in 16 patients. Only 3 patients had a history of steroid use, an immunosuppressive condition, or were on chemotherapy. The most common presenting complaint was altered mental status followed by fever. Resistance to ampicillin was found in 35 isolates which seems to be an intrinsic characteristic of Raoultella spp. and 2 isolates were multidrug-resistant, but still susceptible to ciprofloxacin. The average length of stay was 3 days, and the average duration of antibiotic administration was 8 days. Ciprofloxacin was the most frequently prescribed antibiotic (9 patients). The severity of infection ranged from simple cystitis in 15 patients to urosepsis in 2 patients and septic shock in 2 patients. There were no mortalities in our cohort.

Conclusion

Our study revealed that patients with R. planticola UTI had higher proportion of diabetes mellitus, renal failure compared to the general population. Our study also confirms the intrinsic resistance to ampicillin of Raoultella spp., which has been documented previously in the literature.