Assessment of Stem Cell Transplant Eligibility in Recipients with Oral Foci of Infection: Appropriate Conditioning Regimens

OBJECTIVES

It is unclear whether patients with oral foci of infection should be approved for hematopoietic stem cell transplant with or without posttransplant cyclophosphamide. We compared the presence of oral foci of infection status on the effects of various conditioning regimens for such patients.

MATERIALS AND METHODS

Three groups were classified as autologous (carmustine-etoposide-cytarabinemelphalan, mitoxantrone-melphalan, and melphalan 200 mg/m² groups; n = 502 patients), and 6 groups were classified as allogeneic (busulfan-fludarabinerabbit anti-T-lymphocyte globulin, busulfanfludarabine-posttransplant cyclophosphamide, fludarabine-cyclophosphamide-anti-T-lymphocyte globulin, busulfan-fludarabine-anti-T-lymphocyte globulin-posttransplant cyclophosphamide, total body irradiation-posttransplant cyclophosphamide, and other; n = 428 patients). Data were collected from a database that met international accreditation requirements. We evaluated dental radiological findings and calculated interobserver reliability.

RESULTS

Oral foci of infections increased febrile neutropenia and bacterial infection frequencies in both groups but only increased mucositis frequency in patients with allogeneic treatment. The frequencies of oral foci of infection-related complications were similar in both the autologous and allogeneic groups. Rate of graft-versus-host disease was not affected by oral foci of infection status. Periodontitis/cysts and periapical lesions increased the risk of infections at day 100 in the mitoxantrone-melphalan group versus the melphalan 200 mg/m² group. We observed no differences among the autologous transplant groups in terms of early mortality. Similarly, no differences in early mortality were observed among the allogeneic groups.

CONCLUSIONS

Transplant is a valid option in patients with oral foci of infections undergoing various autologous and allogeneic transplant protocols when time is of the essence, even at myeloablative dose intensities.

The Turkish perspective on apheresis activity: The Turkish apheresis registry report

Therapeutic apheresis is an extracorporeal treatment that selectively removes abnormal cells or harmful substances in the blood that are associated with or cause certain diseases. During the last decades the application of therapeutic apheresis has expanded to a broad spectrum of hematological and non-hematological diseases due to various studies on the clinical efficacy of this procedure. In this context there are more than 30 centers performing therapeutic apheresis and registered in the apheresis database in Turkey. Herein, we, The Turkish Apheresis Registry, aimed to analyze some key articles published so far from Turkey regarding the use of apheresis for various indications.

Gonadal Status and Sexual Function at Long-Term Follow-up after Allogeneic Stem Cell Transplantation in Adult Patients with Sickle Cell Disease

OBJECTIVES

Patients with adult sickle cell disease and severe sequelae are treated with nonmyeloablative allogeneic hematopoietic stem cell transplant. So far, data on gonadal effects are lacking for older cured patients. We assessed the gonadal reserve and sexual function of patients cured of sickle cell disease with transplant and with anti-T-lymphocyte globulin and posttransplant cyclophosphamide-containing regimen within the context of the Baskent Organ Damage Mitigation and Medical Care Development Program.

MATERIALS AND METHODS

All adult patients (≥18 years) with sickle cell disease who underwent peripheral stem cell transplant from September 2013 to July 2019 and were graft-versus-host disease free for 2 years and not immunosuppressed were invited to participate in this prospective observational study. Of 61 eligible patients, 43 participants (~10% from international registries) were included (median age at transplant was 29 years; range, 18-45 years). Gonadal status, risk of gonadal damage posttransplant, conception, and sexual function posttransplant were evaluated.

RESULTS

Allogeneic hematopoietic stem cell transplant was associated with increased risk of secondary amenorrhea (odds ratio of 93; 95% CI, 4.94-17.50; P = .002) and ovarian insufficiency (odds ratio of 37.8; 95% CI, 2.03 to -700.94; P = .014) but not with female sexual dysfunction. Secondary ovarian insufficiency developed in all women posttransplant. Transplant was associated with significant risk of azoospermia (odds ratio of 4.35; 95% CI, 1.02-18.45; P = .017). Moderate-to-severe erectile dysfunction developed in 2 men (10%). Among female participants, 1 had spontaneous conception that ended in miscarriage and 1 had term delivery after in vitro fertilization. Among male participants, 1 had a child by in vitro fertilization and 1 experienced spontaneous conception.

CONCLUSIONS

Although spontaneous conception was shown in our patient group, gonadal damage was evident at >2 years posttransplant. This risk was associated with age in female patients. Better fertility preservation measures should be incorporated into medical care development programs.

Is It Possible to be a Stem Cell Donor for the Second Time: A Single-Center Report of 12 Consecutive Procedures

OBJECTIVES

The use of unrelated donors as a source of stem cells for patients with blood disorders continues to increase. Approximately 5% to 7% of unrelated stem cell donors are asked to donate stem cells a subsequent time to the same or a different patient. We investigated donors who accepted to be a donor for the second time between 2015 and 2021; donors were evaluated in terms of procedure-related complications, product quality, and donor follow-up in a JACIEaccredited (Joint Accreditation Committee of the International Society for Cellular Therapy and European Society for Blood and Marrow Transplantation).

MATERIALS AND METHODS

Stem cell collections were performed in accordance with relevant standard operating procedures from healthy volunteer donors. Data on sequence of peripheral blood stem cell, bone marrow, and donor lymphocyte collection procedures; presence of complications during procedures; time between 2 donations; need for granulocyte colonystimulating factor again; and first and second donation types were noted. Data on donor and stem cell products were determined using the hospital information management system.

RESULTS

Our study included 12 donors (9 men and 3 women) who donated a second time within the specified date range. In the evaluation of the second donation types, 7 were lymphocyte collection donations, 4 were peripheral blood stem cell donations, and 1 was a bone marrow stem cell donation. In shortterm and long-term follow-ups, there were no complications among the donors. In the second donations, targeted product values were reached.

CONCLUSIONS

Although it is safe to have a second donation from a donor for the same patient, collection centers may collect more products than requested from eligible donors.

A Rare and Successfully Managed Complication of Stem Cell Transplantation in an Adult Patient With Sickle Cell Disease: Bone Marrow Necrosis

Sickle cell disease is the most common genetic disorder in the Eastern Mediterranean region where our transplant center is located. Today, adult patients with sickle cell disease can also be successfully treated with allogeneic hematopoietic stem cell transplantation. Bone marrow necrosis is a rare and serious clinical condition. Herein, we present this complication for the first time in the literature, which developed in the course of allogeneic hematopoietic stem cell transplantation and was successfully managed with additional bone marrow support. The recognition, prevention, and management of this rare and potentially fatal complication, bone marrow necrosis, are vitally important, especially in regions with high prevalence of sickle cell disease.

Comparison of the clinical course of COVID-19 infection in sickle cell disease patients with healthcare professionals

It is highly expected that COVID-19 infection will have devastating consequences in sickle cell disease (SCD) patients due to endothelial activation and decreased tissue and organ reserve as a result of microvascular ischemia and continuous inflammation. In this study, we aimed to compare the clinical course of COVID-19 in adult SCD patients under the organ injury mitigation and clinical care improvement program (BASCARE) with healthcare professionals without significant comorbid conditions. The study was planned as a retrospective, multicenter and cross-sectional study. Thirty-nine SCD patients, ages 18 to 64 years, and 121 healthcare professionals, ages 21 to 53, were included in the study. The data were collected from the Electronic Health Recording System of PRANA, where SCD patients under the BASCARE program had been registered. The data of other patients were collected from the Electronic Hospital Data Recording System and patient files. In the SCD group, the crude incidence of COVID-19 was 9%, while in healthcare professionals at the same period was 23%. Among the symptoms, besides fever, loss of smell and taste were more prominent in the SCD group than in healthcare professionals. There was a significant difference between the two groups in terms of development of pneumonia, hospitalization, and need for intubation (43 vs 5%, P < 0.00001; 26 vs 7%, P = 0.002; and 10 vs 1%, P = 0.002, respectively). Prophylactic low molecular weight heparin and salicylate were used more in the SCD group than in healthcare professionals group (41 vs 9% and 28 vs 1%; P < 0.0001 for both). The 3-month mortality rate was demonstrated as 5% in the SCD group, while 0 in the healthcare professionals group. One patient in the SCD group became continously dependent on respiratory support. The cause of death was acute chest syndrome in the first case, hepatic necrosis and multi-organ failure in the second case. In conclusion, these observations supported the expectation that the course of COVID-19 in SCD patients will get worse. The BASCARE program applied in SCD patients could not change the poor outcome.

Comparison of Outcomes of Transplant and Nontransplant High-Risk Chronic Lymphocytic Leukemia Patients in the Novel Targeted Therapy Era

OBJECTIVES

Our aim was to compare patients with high-risk chronic lymphocytic leukemia referred to our transplant center who underwent allogeneic stem cell transplant with those who did not receive this treatment. Factors compared included demographics, clinical characteristics, and survival rates in the novel targeted therapy era.

MATERIALS AND METHODS

All 33 patients with high-risk chronic lymphocytic leukemia who were referred to the hematopoietic stem cell transplant center were enrolled in this retrospective, single-center nonrandomized study. Outcomes of patients who received allogeneic stem cell transplant were compared with those of nontransplant patients. Chemoimmunotherapy and ibrutinib were given when indicated. Factors related to overall and progression-free survival were assessed.

RESULTS

Thirteen patients underwent allotransplant, and transplant was not done in 20 patients for various reasons. Demographic and clinical features of the transplant and nontransplant groups were similar. The estimated cumulative overall survival was 72.6 ± 15 and 84.3 ± 13 months in the nontransplant and transplant groups, respectively. The 5-year overall and progression-free survival rates in the transplant and nontransplant groups were 57.3%/36.0% and 40%/20.6%, respectively. In the nontransplant group, overall survival of those who used ibrutinib was longer than overall survival in patients in the transplant group who used the same drug, but the difference was not statistically significant. Although not significant, overall survival in patients who did not use ibrutinib was longer in the transplant group than in the nontransplant group. Cox regression analyses showed that transplant, relapse, and Binet stage were independent predictors of overall survival.

CONCLUSIONS

In patients who do not use ibrutinib, allogeneic stem cell transplant improved survival compared with nontransplant patients. Addition of ibrutinib provided comparable life expectancies, showing that allogeneic stem cell transplant and ibrutinib may have complementary roles. Transplant is still an independent predictor of overall survival.

The Impact of the Ferric Carboxymaltose on Hemoglobin and Ferritin Levels

BACKGROUND

Anemia is a frequent disorder worldwide. Iron deficiency anemia (IDA) is the most common form of anemia. Although oral iron is the first choice for treatment, the efficacy of oral iron preparations may be limited. Ferric carboxymaltose (FCM) is a novel parenteral iron preparation which can rapidly replenish iron stores. The aim of the present study is to investigate the impact of FCM dose on hemoglobin (Hb) and ferritin levels and the frequency of hypersensitivity reactions.

METHODS

This study was conducted with 765 IDA patients between September 1, 2016 and September 1, 2018. He-moglobin (Hb), serum ferritin, transferrin saturation values were examined at the time of diagnosis, Hb and ferritin values at first month.

RESULTS

Post-treatment Hb and ferritin levels significantly increased. The mean Hb level alteration was 2.43 ± 1.2 g/dL, the median ferritin level alteration was 157.3 ng/mL. The mean Hb level was lower and the mean change in Hb level was higher in higher doses. Allergic reactions were more frequent in higher doses.

CONCLUSIONS

Ferric carboxymaltose is a novel treatment option with a low risk of hypersensitivity reactions and well tolerated even in high doses.

Factors Associated With Overall Survival in Acute Myeloid Leukemia Patients Before and After Hematopoietic Stem Cell Transplant

OBJECTIVES

Our aim was to identify factors associated with overall survival and the efficacy of postrelapse treatment protocols and to determine whether pretransplant consolidation therapy and minimal residual disease status pose a survival benefit.

MATERIALS AND METHODS

Patients with acute myeloid leukemia who underwent stem cell transplant between 2007 and 2018 were enrolled retrospectively. The effects of pretransplant cytogenetic and minimal residual disease status, pretransplant consolidation therapies, development of graft-versus-host disease, postrelapse treatment protocols, and type of con-ditioning regimens on overall survival were analyzed.

RESULTS

In 76 study patients, the cumulative overall 1- and 5-year relapse probabilities were 67.8% and 58.7%, respectively. Overall survival rates at 3 and 5 years in patients with and without relapse were 23.5% and 0% and 95.9% and 91.1% (P < .001), respectively. Although mean postrelapse overall survival was better with intensive salvage plus donor lymphocyte infusion, no significant differences were shown versus other therapies (intensive salvage, nonintensive salvage, intensive salvage or nonintensive salvage plus donor lymphocyte infusion, or supportive therapy). Twenty-three patients (30.3%) died during the study period with a median survival of 9.6 months. Patients with favorable, intermediate, and unfavorable cytogenetic status showed overall survival of 46.6 ± 10.4, 54.6 ± 4.4, and 36.9 ± 5.9 months (P = .807). Patients with and without minimal residual disease and patients who received or did not receive consolidation therapy had similar overall survival. Relapse was an independent predictor of overall survival (increased mortality risk of 26.22). Patients who developed graft-versus-host disease showed decreased relapse.

CONCLUSIONS

Relapse is the most important predictor of overall survival and is associated with poor prognosis. Pretransplant minimal residual status and cytogenetic status showed no effect on relapse rates and overall survival, and consolidation therapy did not improve outcomes.

Comparative efficacy in red blood cell exchange transfusions with different apheresis machines in patients with sickle cell disease

The purpose of this study is to compare the efficacy and side effects of two red blood cell exchange (RBCX) transfusion systems in sickle cell disease (SCD). The data is collected retrospectively from the January 2010 to March 2015. 447 RBCX transfusions were performed to 165 patients. Side effects, clinical and technical efficacy were compared in between procedures with Cobe Spectra (CS) and Spectra Optia (SO) systems. Furthermore a subgroup analyses was performed for 40 patients who had RBCX transfusions with both system at least two times. Vasoocclusive crises, preoperative period and foot ulcers (49.6, 13, and 15.2% respectively) were the common indications of RBCX transfusion. While the levels of post-RBCX HbS and the actual fraction of cells remaining (FCRa) were found significantly higher in the SO compared to CS system (p = 0.018 and p = 0.016 respectively), the rate of targeted hemoglobin S (HbS) levels (< 30%) were same in both. The length of procedure and replacement volume were significantly lower in SO compared to CS system (p = 0.025 and 0.044 respectively). Subgroup analyses of 40 patients did not reveal any statistically significant differences regarding post-procedure HbS levels, FCRa levels, replacement volume and procedure duration. The inter-rater correlation coefficient for FCRa was calculated to be 0.82. Serious adverse reactions were not observed from either system. Both systems are efficiently achieved the targeted post-procedure HbS level. The recently introduced SO apheresis system is as effective and safe as the CS system, which has been used for all indications of SCD for years.

Frequency of Finding Family Donors: A Single Center Experience

OBJECTIVES

Allogeneic hematopoietic stem cell transplant is a curative treatment option for many hematologic diseases. The existence of a fully compatible donor for recipients is the first condition for minimized transplant-related mortality and morbidity. The best donor for hematopoietic stem cell transplant is an HLA-matched sibling donor. The possibility of finding an HLA-matched sibling is less than 30% worldwide. Hematopoietic stem cell transplant is needed for an increasing number of patients every year, but the ability to find a fully compatible donor has limited its use.

MATERIALS AND METHODS

From August 2012 to May 2017, we screened 412 adult patients who required AHSCT and their families for HLA tissue groups who were seen at our center (Baskent University Adana Dr. Turgut Noyan Research and Medical Center Hematology Unit). To screen tissue groups at our center, we perform lowresolution typing for HLA-A, -B, -C, -DRB1, and -DQB. If an HLA genotype cannot be identified, verification typing is done using highresolution testing.

RESULTS

We found matched family donors in 227 (55%) of 412 patients screened at our center. The ratio of HLAmatched related donors was 83% for 279 patients who received allogeneic stem cell transplant.

CONCLUSIONS

The likelihood of finding eligible unrelated donors has been gradually increasing, in part due to the development of the National Bone Marrow Bank. However, a careful screening for related donors is still important. Our findings indicate the importance of careful examination of family genealogy and of careful family screening in our region.

Organ damage mitigation with the Baskent Sickle Cell Medical Care Development Program (BASCARE)

The Eastern Mediterranean is among the regions where sickle cell disease (SCD) is common. The morbidity and mortality of this disease can be postponed to adulthood through therapies implemented in childhood. The present study focuses on the organ damage-reducing effects of the Baskent Sickle Cell Medical Care Development Program (BASCARE), which was developed by a team who lives in this region and has approximately 25 years of experience. The deliverables of the program included the development of an electronic health recording system (PRANA) and electronic vaccination system; the use of low citrate infusion in routine prophylactic automatic erythrocyte exchange (ARCE) programs including pregnant women; the use of leukocyte-filtered and irradiated blood for transfusion; the use of magnetic resonance imaging methods (T2) for the management of transfusion-related hemosiderosis; and the implementation of an allogeneic hematopoietic stem cell transplantation protocol for adult patients. The sample was composed of 376 study subjects and 249 control subjects. The hospital's Data Management System and the central population operating system were used for data collection. BASCARE enabled better analysis and interpretation of complication and mortality data. Vaccination rates against influenza and pneumococcal disease improved (21.5% vs 50.8% and 21.5% vs 49.2%, respectively). Effective and safe ARCE with low citrate infusion were maintained in 352 subjects (1003 procedures). Maternal and fetal mortality was prevented in 35 consecutive pregnant patients with ARCE. Chelating therapy rates reduced from 6.7% to 5%. Successful outcomes could be obtained in all 13 adult patients who underwent allogeneic peripheral stem cell transplantation from a fully matched, related donor. No patients died by day 100 or after the first year. Cure could be achieved without graft loss, grades III to IV acute graft versus host disease, extensive chronic graft versus host disease, or other major complications. The BASCARE program significantly improved patient care and thereby prolonged the life span of SCD patients (42 ± 13 years vs 29 ± 7 years, P < .001). We may recommend using such individualized programs in centers that provide health care for patients with SCD, in accordance with holistic approach due to the benign nature but malignant course of the disease.

Anti-HLA Antibody Levels Are Associated With the Risk of Graft Failure After Allogeneic Hematopoietic Stem Cell Transplant

OBJECTIVES

Allogeneic hematopoietic stem cell transplant provides a curative treatment for a considerable amount of hematologic diseases, and it is widely used today. Successful allogeneic stem cell transplant can be compromised by treatment-related toxicity, graft-versus-host disease, infectious complications, disease relapse, and graft failure. Primary graft failure is an important cause of hematopoietic stem cell transplant failure. Primary graft failure correlates with the level of complement-binding, donor-specific anti-HLA antibodies prior to transplant.

MATERIALS AND METHODS

We evaluated 15 patients who underwent hematopoietic stem cell transplant using peripheral blood stem cells in terms of graft failure and anti-HLA antibody levels before transplant. All were treated between January 2015 and June 2016. Pretreatment serum anti-HLA class I and anti-HLA class II antibody levels were measured in all patients.

RESULTS

Anti-HLA class I antibodies were present in 7 patients (46.6%) and anti-HLA class II antibodies in 8 (53.3%). All three patients who developed primary graft failure were anti-HLA-positive.

CONCLUSIONS

Anti-HLA antibodies are a significant cause of graft failure. It is a situation that must be understood with caution. Our results support the considerations that allogeneic hematopoietic stem cell transplant, especially when a fully compatible sibling donor is not present, should include screening of donor-specific antibodies of alternative donors and desensitization therapy for allosensitized patients before transplant.

QTc prolongation during peripheral stem cell apheresis in healthy volunteers

BACKGROUND AND AIM

Today, voluntary donation of peripheral blood stem cells by healthy donors for allogeneic hemopoietic cell transplantation is common worldwide. Such donations are associated with small but measurable risks of morbidity and mortality. Most complications are associated with citrate infusion during cell collection. We studied the effects of citrate infusion on the QTc and other vital parameters during and after peripheral stem cell apheresis in volunteers.

METHOD

To ensure that donors were healthy, screening included taking a detailed medical history, physical examination, and laboratory measurements of plasma calcium and magnesium. Corrected QT (QTc) values were assessed using a 12-lead electrocardiographic platform that derived QTc values automatically.

RESULTS

In all, 141 apheresis procedures were performed. The mean QTc values at baseline, at 2 and 4 h during the procedure, and at 30 min after the procedure, were 347.6 ± 59.5, 349.9 ± 52.8, 391.8 ± 54.0, and 404.8 ± 59.2 ms, respectively. The baseline and 2 h QTcs did not differ significantly, but the baseline QTc did differ significantly from the 4 h and 30 min after the procedure values. The plasma levels of calcium and magnesium did not significantly differ before and after the procedure.

CONCLUSION

QTc prolongation may develop during leukopheresis, particularly if the procedure takes more than 2 h. Thus, to enhance donor safety, QTc measurement should be standard for all donors. In addition, any family history of sudden death should be noted, to prevent the development of possible fatal arrhythmia in susceptible donors.

Effectiveness of Visual Methods in Information Procedures for Stem Cell Recipients and Donors

OBJECTIVE

Obtaining informed consent from hematopoietic stem cell recipients and donors is a critical step in the transplantation process. Anxiety may affect their understanding of the provided information. However, use of audiovisual methods may facilitate understanding. In this prospective randomized study, we investigated the effectiveness of using an audiovisual method of providing information to patients and donors in combination with the standard model.

MATERIALS AND METHODS

A 10-min informational animation was prepared for this purpose. In total, 82 participants were randomly assigned to two groups: group 1 received the additional audiovisual information and group 2 received standard information. A 20-item questionnaire was administered to participants at the end of the informational session.

RESULTS

A reliability test and factor analysis showed that the questionnaire was reliable and valid. For all participants, the mean overall satisfaction score was 184.8±19.8 (maximum possible score of 200). However, for satisfaction with information about written informed consent, group 1 scored significantly higher than group 2 (p=0.039). Satisfaction level was not affected by age, education level, or differences between the physicians conducting the informative session.

CONCLUSION

This study shows that using audiovisual tools may contribute to a better understanding of the informed consent procedure and potential risks of stem cell transplantation.

East Mediterranean region sickle cell disease mortality trial: retrospective multicenter cohort analysis of 735 patients

Sickle cell disease (SCD), one of the most common genetic disorders worldwide, is characterized by hemolytic anemia and tissue damage from the rigid red blood cells. Although hydroxyurea and transfusion therapy are administered to treat the accompanying tissue injury, whether either one prolongs the lifespan of patients with SCD is unknown. SCD-related mortality data are available, but there are few studies on mortality-related factors based on evaluations of surviving patients. In addition, ethnic variability in patient registries has complicated detailed analyses. The aim of this study was to investigate mortality and mortality-related factors among an ethnically homogeneous population of patients with SCD. The 735 patients (102 children and 633 adults) included in this retrospective cohort study were of Eti-Turk origin and selected from 1367 patients seen at 5 regional hospitals. A central population management system was used to control for records of patient mortality. Data reliability was checked by a data supervision group. Mortality-related factors and predictors were identified in univariate and multivariate analyses using a Cox regression model with stepwise forward selection. The study group included patients with homozygous hemoglobin S (Hgb S) disease (67 %), Hb S-β(0) thalassemia (17 %), Hgb S-β(+) thalassemia (15 %), and Hb S-α thalassemia (1 %). They were followed for a median of 66 ± 44 (3-148) months. Overall mortality at 5 years was 6.1 %. Of the 45 patients who died, 44 (6 %) were adults and 1 (0.1 %) was a child. The mean age at death was 34.1 ± 10 (18-54) years for males, 40.1 ± 15 (17-64) years for females, and 36.6 ± 13 (17-64) years overall. Hydroxyurea was found to have a notable positive effect on mortality (p = 0.009). Mortality was also significantly related to hypertension and renal damage in a univariate analysis (p = 0.015 and p = 0.000, respectively). Acute chest syndrome, splenic sequestration, and prolonged painful-crisis-related multiorgan failure were the most common causes of mortality. In a multivariate analysis of laboratory values, only an elevated white blood cell count was related to mortality (p = 0.009). These data show that despite recent progress in the treatment of SCD, disease-related factors continue to result in mortality in young adult patients. Our results highlight the importance of evaluating curative treatment options for patients who have an appropriate stem cell donor in addition to improving patient care and patient education.

Active Invasive Fungal Infection in a Patient With Severe Aplastic Anemia

Severe aplastic anemia is almost always fatal unless treated. Invasive fungal infections, particularly those caused by Aspergillus species, have long been recognized as a major cause of death in severe aplastic anemia. However, there are few specific reports about infections and their therapy in patients with aplastic anemia. Despite improvements in the last few years, the response rate of new antifungal drugs, such as voriconazole and liposomal amphotericin B, has only about a 30% recovery rate in patients with severe neutropenia and persistent fever. There is a paucity of data available about hematopoietic stem cell transplant under active invasive fungal infection in the literature. Therefore, we aimed to discuss the treatment scenarios for 2 severe aplastic anemia patients who have invasive fungal infections.

Tacrolimus-Induced Diabetic Ketoacidosis After Allogeneic Bone Marrow Transplant

New-onset diabetes mellitus after solid-organ transplant makes for complicated tacrolimus immunosuppression. However, tacrolimus-associated diabetic ketoacidosis has not been reported in bone marrow transplant. We report 24-year-old women, hospitalized with diabetic ketoacidosis, 70 days after undergoing a bone marrow transplant with tacrolimus immunosuppression. Clinicians should be wary about tacrolimus levels and the risk of hyperglycemic states after bone marrow transplant as with other solid-organ transplants.

Tunnelled central venous catheter-related problems in the early phase of haematopoietic stem cell transplantation and effects on transplant outcome

OBJECTIVE

Haematopoietic stem cell recipients need central venous catheters (CVCs) for easy administration of intravenous fluid, medications, apheresis, or dialysis procedures. However, CVCs may lead to infectious or non-infectious complications such as thrombosis. The effect of these complications on transplantation outcome is not clear. This manuscript presents the complication rates of double-lumen tunnelled CVCs and their effect on transplantation outcome.

MATERIALS AND METHODS

Data from 111 consecutive patients, of whom 75 received autologous and 36 received allogeneic peripheral blood stem cell transplantations, were collected retrospectively. The data were validated by the Record Inspection Group of the related JACIE-accredited transplantation centre.

RESULTS

Thrombosis developed in 2.7% of recipients (0.9 per 1000 catheter days). Catheter-related infection was identified in 14 (12.6%) patients (3.6 per 1000 catheter days). Coagulase-negative Staphylococcus was the most common causative agent. Engraftment time, rate of 100-day mortality, and development of grade II-IV graft-versus-host disease were not found to be associated with catheter-related complications.

CONCLUSION

These results indicate that adverse events related with tunnelled CVCs are manageable and have no negative effects on transplant outcome.

Clinical Relevance of Apheretic Graft Composition in Patients With Acute Myeloblastic Leukemia Who Received a Busulfan-Fludarabine-Antithymocyte Globulin Conditioning Regimen for Allogeneic Transplant

OBJECTIVES

Sparse data are available about the effects of apheretic graft composition on the clinical transplant outcome in allotransplanted patients who have hematologic malignant disease. Major obstacles in recent studies have included heterogeneity of patient populations and differences in the conditioning regimens used.

MATERIALS AND METHODS

This prospective study included 50 patients who had acute myeloblastic leukemia and received busulfan-fludarabine-antithymocyte globulin-based conditioning for peripheral allogeneic stem cell transplant. The concentration of CD34+ cells, T-cell subsets, B cells, and natural killer cells in the graft were analyzed by flow cytometry in the donors who were matched for human leukocyte antigen.

RESULTS

In univariate analysis, infusion with a higher dose of natural killer cells (> 1.55 × 106/kg) was associated with improved survival (P = .007 for disease-free survival; P = .024 for overall survival) in patients with acute myeloblastic leukemia. Cox regression models revealed that increased concentration of natural killer cells and CD34+ cells positively affected the clinical outcome of allotransplanted patients (P = .005 for both cell types). According to univariate analysis, these findings were dependent on minimal residual disease and acute graft-versus-host disease. Graft-versus-host disease (acute and chronic forms) was not affected by graft composition.

CONCLUSIONS

Our results suggest that increased concentration of natural killer cells and CD34+ cells in the apheretic product may predict better survival. In contrast, busulfan-fludarabine-antithymocyte globulin-based conditioning eliminates the disadvantages that resulted from the high content of T-cell subsets and B cells, and the course of the transplant and clinical parameters were not affected by the amount of T and B cells.

[An unusual cause of febrile neutropenia: brucellosis]

Febrile neutropenia which is a common complication of cancer treatment, is one of the major causes of morbidity and mortality. Several gram-negative and gram-positive bacteria are responsible for infections in neutropenic patients, however the most common microorganisms are Escherichia coli and coagulase-negative staphylococci, in decreasing order. Although Brucella spp. infections are endemic in Turkey, brucellosis-related febrile neutropenia has only rarely been reported. In this report, a case of brucellosis-related febrile neutropenia in a patient with acute myeloblastic leukemia (AML) was presented. A 56-year-old male patient presenting with fever, petechiae/purpura, leukocytosis, thrombocytopenia, and anemia was admitted to our hospital. Laboratory studies revealed a hemoglobin level of 8.27 g/dl, leukocyte count of 77.100 k/ml, absolute neutrophil count of 200 k/ml, and platelets at 94.200 k/ml. The patient was diagnosed as AML-M1 and piperacillin/tazobactam was started as the first-line antibiotic therapy due to the febrile neutropenia. On admission, blood and urine cultures were negative. Once the fever was controlled, remission/induction chemotherapy was initiated. However, fever developed again on the eight day, and vancomycin was added to the therapy. Since the fever persisted, the antibiotic therapy was gradually replaced with meropenem and linezolid. However, fever continued and the patient's general condition deteriorated. Subsequently performed Brucella tube agglutination test revealed positivity at 1/320 titer and the microorganism grown in blood culture (Bactec 9050; BD, USA) was identified as B.melitensis by conventional methods. Rifampicin and doxycycline therapy was started immediately, however, the patient died due to septic shock. If the tests for brucellosis were performed earlier when response to second step antibiotic therapy lacked in this patient, it was assumed that mortality could be prevented by the prompt initiation of the appropriate treatment. Thus, since brucellosis is endemic in Turkey, it should be considered as a possible agent of febrile neutropenia especially in patients unresponsive to empiric antibiotherapy and appropriate diagnostic tests should be performed.

Effectiveness of fludarabine- and busulfan-based conditioning regimens in patients with acute myeloblastic leukemia: 8-year experience in a single center

OBJECTIVE

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for acute myeloblastic leukemia (AML). Because the conditioning regimen of busulfan plus cyclophosphamide carries significant risks of toxicity, we evaluated the factors affecting survival after fludarabine replacement instead of cyclophosphamide.

METHODS

The study included 55 patients who underwent allo-HSCT for AML and received busulfan, fludarabine, and antithymocyte globulin (ATG).

RESULTS

Forty-eight patients received a myeloablative regimen; 7 patients received a reduced-intensity conditioning regimen. The neutrophil and platelet engraftment times were 12 days (range 9 to 20) and 12 days (range 7 to 19), respectively. Graft-vs-host disease (GvHD) developed in 10% and 50% of the patients, respectively. Seven patients received donor lymphocyte infusion. Of them, 5 patients developed grade I or II GvHD, one grade IV GvHD. The median follow-up period was 20.6 months. The predicted progression-free survival (PFS) at 1 and 3 years after transplantation was 78% and 74%, respectively. The overall survival (OS) at 1, 3, and 5 years was 76%, 74%, and 62%, respectively. Treatment-related mortality (infection in 1 patient, GvHD in 2 patients) occurred in 3 patients (5.5%). Multivariate analysis revealed that OS and PFS were not influenced by age, dose of busulfan or ATG, or presence of cytomegalovirus antigenemia. Acute GvHD and pretransplantation minimal residual disease positivity negatively affected the transplant outcome. The presence of active disease at the time of transplantation was found as an independent risk factor for AML.

CONCLUSIONS

Busulfan- and fludarabine-based conditioning regimens are effective for AML, and have acceptable toxicity, morbidity, and mortality.

A Rare Complication Developing After Hematopoietic Stem Cell Transplantation: Wernicke's Encephalopathy

Thiamine is a water-soluble vitamin. Thiamine deficiency can present as a central nervous system disorder known as Wernicke’s encephalopathy, which classically manifests as confusion, ataxia, and ophthalmoplegia. Wernicke’s encephalopathy has rarely been reported following hematopoietic stem cell transplantation. Herein, we report Wernicke’s encephalopathy in a patient with acute myeloid leukemia who had been receiving prolonged total parenteral nutrition after haploidentical allogeneic hematopoietic stem cell transplantation. To the best of our knowledge, this is the first case reported from Turkey in the literature.

Use of mesenchymal cells to modulate immune suppression and immune reconstruction in a patient with aplastic anemia complicated by invasive sino-orbital aspergillosis

Cultured human bone marrow mesenchymal cells (MSCs) have immunomodulatory and tissue regenerative properties. This report summarizes the result of post-transplant treatment with MSCs of a 26-year-old patient with aplastic anemia complicated by invasive sino-orbital aspergillosis. The patient was treated with MSCs to benefit from the dual effects of MSCs in immune reconstitution: suppression against alloreactive T cells and facilitation of the re-engraftment process. The patient did not develop acute or chronic graft-versus-host disease. The aspergillus infection healed completely. The engraftment failure was also ended without any complications. During his last visit in his fourth year after transplantation, the patient was in hematological remission. Human bone marrow-derived MSCs seem to have an important role in preventing or overcoming immunological complications in patients who undergo stem cell transplantation.

Plasma-exchange treatment for severe carbamazepine intoxication: a case study

Acute poisoning is an important cause of morbidity and mortality during childhood. This manuscript reports the positive outcome of a pediatric case with a history of accidental carbamazepine intake treated using plasma exchange. A 3-year-old male presented with severe carbamazepine intoxication. He was comatose and had generalized tonic clonic seizure, ventricular tachycardia, and hypotension. Although he did not respond to classical therapies, we performed two sessions of plasma exchange. The patient recovered rapidly and was discharged from the hospital six days from the time of carbamazepine ingestion with no complication or neurologic impairment. Plasma exchange can be performed safely in very small children, and it might be the first line treatment, particularly for intoxication with drugs that have high plasma-protein-binding properties.

Assessment of corrected QT interval in sickle-cell disease patients who undergo erythroapheresis

Extension of the QT interval is characterized by syncope and cardiac arrest and often occurs in association with medical therapies and procedures. Whether erythroapheresis (EPH) could influence the QT interval duration in patients with sickle cell disease (SCD) is not known. We aimed to investigate the effects of EPH on the heart rate-corrected QT (QTc) interval. The study included 25 patients with SCD who underwent 34 EPH procedures. Two independent observers measured QTc interval duration from electrocardiograms performed continuously for 3 min at three different points during the EPH procedures (prior to EPH, after completion of 50% EPH and 15 min after EPH). Multiple regression analysis was used to determine if the ionized plasma calcium, the level of plasma magnesium, citrate infusion rate and painful crisis significantly contributed to the QTc interval. There was a non-significant trend (P = 0.184) towards increased QTc in sickle cell patients during EPH compared with pre-EPH values. QTc prolongation (>440 ms) occurred in 72% of the procedures. Fifty percent QTc values returned to baseline after the procedure. The independent variables were not significantly associated with QTc interval. Exchange procedures can induce QTc prolongation in patients with SCD.

A dramatic response to rituximab in a patient with resistant thrombotic thrombocytopenic purpura (TTP) who developed acute stroke

BACKGROUND

Refractory condition can occur in 10-30% of all cases of thrombotic thrombocytopenic purpura despite increased frequency of total plasma exchange. Rituximab can affect the clinical outcome of the refractory cases. However, little is known about usefulness of rituximab on central nervous system involvement mimicking acute ischemic stroke.

METHODS

We report the case of a woman with refractory thrombotic thrombocytopenic purpura who developed an acute onset right sided paralysis, dysarthria, and central facial paralysis, suggestive of cerebrovascular accident while under plasma exchange, corticosteroid, and vincristine therapy.

RESULTS

After initiation of rituximab (375 mg/m(2) weekly for 4 weeks), a dramatic response occurred and the patient's neurologic function recovered fully within days. Sustained remission was achieved, and the patient was well 1 year after her admission, while she was on azathioprine treatment.

CONCLUSION

This report suggests that rituximab can provide a good outcome of the dramatic central nervous system involvement in patients with thrombotic thrombocytopenic purpura.

Lemierre syndrome variant: Staphylococcus aureus associated with thrombosis of both the right internal jugular vein and the splenic vein after the exploration of a river cave

BACKGROUND

Lemierre syndrome is a rare and potentially fatal entity characterized by septic emboli from thrombosis of the internal jugular vein after oropharyngeal infection. The etiologic agent is not always an anaerobic bacterium. We report a patient with a Lemierre syndrome variant who presented with thrombosis of both the right internal jugular vein and the splenic vein as well as septic pulmonary emboli caused by Staphylococcus aureus, which proved resistant to methicillin, amoxicillin, and ciprofloxacin. The patient was thought to have acquired the infection during the exploration of a river cave in Turkey 10 days before his admission to the hospital. Such caves are natural reservoirs of infectious microorganisms.

METHODS

The patient had a physical examination, coagulation screening tests, tests of thrombin generation and fibrinolysis, coagulation inhibitors, activated protein C resistance, early and late serological tests (including autoantibodies), computed tomographic studies of the chest and abdomen, and bacterial examination of peripheral blood. Bacterial investigations were made on samples collected from the river cave.

RESULTS

After having undergone a 6 week course of antimicrobial treatment and anticoagulant therapy, the patient recovered from the infection with no residual complications, and the signs and symptoms of Lemierre syndrome resolved.

CONCLUSION

The results probably indicate an exposure of the patient to soil-based Staphylococcus aureus. This observation suggests the action of environmental factors that may contribute to the development of this rare syndrome.