Graves' disease following allogenic hematopoietic stem cell transplantation for severe aplastic anemia: case report and literature review

Evolution of Graves' Disease during Immune Reconstitution following Nonmyeloablative Haploidentical Peripheral Blood Stem Cell Transplantation in a Boy Carrying Germline SAMD9L and FLT3 Variants

Graves’ disease, characterized by hyperthyroidism resulting from loss of immune tolerance to thyroid autoantigens, may be attributable to both genetic and environmental factors. Allogeneic hematopoietic stem cell transplantation (HSCT) represents a means to induce immunotolerance via an artificial immune environment. We present a male patient with severe aplastic anemia arising from a germline SAMD9L missense mutation who successfully underwent HSCT from his HLA-haploidentical SAMD9L non-mutated father together with nonmyeloablative conditioning and post-transplant cyclophosphamide at 8 years of age. He did not suffer graft-versus-host disease, but Graves’ disease evolved 10 months post-transplant when cyclosporine was discontinued for one month. Reconstitution of peripheral lymphocyte subsets was found to be transiently downregulated shortly after Graves’ disease onset but recovered upon antithyroid treatment. Our investigation revealed the presence of genetic factors associated with Graves’ disease, including HLA-B*46:01 and HLA-DRB1*09:01 haplotypes carried by the asymptomatic donor and germline FLT3 c.2500C>T mutation carried by both the patient and the donor. Given his current euthyroid state with normal hematopoiesis, the patient has returned to normal school life. This rare event of Graves’ disease in a young boy arising from special HSCT circumstances indicates that both the genetic background and the HSCT environment can prompt the evolution of Graves’ disease.

Thyroid function disorders and secondary cancer following haematopoietic stem cell transplantation in pediatrics: State of the art and practical recommendations for a risk-based follow-up

Thyroid disorders (TD) represent a remarkable share of all the late morbidities experienced following pediatric haematopoietic stem cell transplantation (HSCT), with long-term reported occurrence often exceeding 70%. In addition, the data collected on wide cohorts of survivors assessed longitudinally outlined a progressive increase in the cumulative incidence of TD as far as 30 years following transplantation. Accordingly, a life-long monitoring of thyroid health is warranted among patients exposed to HSCT in childhood, in order to early detect TD and undertake a prompt dedicated treatment. Although several national and international consortia have provided recommendations for the early detection of thyroid disorders among childhood cancer survivors exposed to radiotherapy and alkylating agents, no guidelines specifically and thoroughly focused on HSCT-related TD have been published to date. As stem cell transplantation has become the standard-of-care in a growing body of non-oncological conditions, this urge has become pivotal. To highlight the challenging issues specifically involving this cohort of patients and to provide clinicians with the proposal of a practical follow-up protocol, we reviewed published literature in the light of the shared experience of a multidisciplinary team of pediatric oncologists, transplantologists, pathologists and endocrinologists involved in the long-term care of HSCT survivors. As a final result, we hereby present the proposals of a practical and customized risk-based approach to tailor thyroid health follow-up based on HSCT-related detrimental factors.

Graft-vs-Host Disease-Induced Hyperthyroidism in a Recipient of Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report

BACKGROUND

Hyperthyroidism after hematopoietic stem cell transplantation (HSCT) is rare, and only a few cases have been reported. What is more important, the fundamental mechanisms of hyperthyroidism after HSCT remained unclear.

CASE

A 28-year-old man received an HLA haploidentical related-donor HSCT for acute myeloid leukemia and developed hyperthyroidism 31 months after HSCT. He presented with periodic paralysis as the initial symptom, his serum levels of free triiodothyronine (fT3), free thyroxine (fT4), and anti-thyroid autoantibodies increased, and thyroid-stimulating hormone level decreased. As a result, he was diagnosed with hyperthyroidism. Although systemic symptoms, signs, and laboratory findings of graft-vs-host disease (GVHD) were absent, thyroid histopathologic examination revealed thyroid follicular destruction and infiltrations of lymphocytes, which mainly consisted of CD20⁺ B lymphocytes and CD4⁺ and CD3⁺ T lymphocytes by immunohistochemistry. These were in accordance with the pathologic features of GVHD. The symptom of periodic paralysis resolved after treatment with prednisolone and methimazole for 1 month. The treatments lasted for 4 months, and the plasma levels of fT3, fT4, TSH, and anti-thyroid peroxidase normalized. He did not relapse after drug withdrawal with observation for 24 months to date.

CONCLUSIONS

To the best of our knowledge, the present case was the first to be confirmed with thyroid-specific GVHD-induced hyperthyroidism after allogeneic HSCT.