Chemotherapy for a secondary malignancy nearly restores complete chimerism in an SCID-patient after HSCT

For patients with inborn errors of immunity (IEI) and other inborn diseases, mixed donor chimerism is a well-accepted outcome of hematopoietic stem cell transplantation (HSCT). Cytoreductive chemotherapy for a secondary malignancy is a potential challenge for the stability of the graft function after HSCT. We report on a boy with X-SCID who developed Ewing sarcoma ten years after HSCT which was successfully treated with cytoreductive chemotherapy, surgery and local radiation. Surprisingly, this treatment had a positive impact on mixed chimerism with an increase of donor-cell proportions from 40% for neutrophils and 75% for non-T-mononuclear cells (MNCs) to >90% for both. T-cell counts remained stable with 100% of donor origin. This is -to our knowledge- the first report on the impact of cytoreductive chemotherapy on post-HSCT mixed chimerism and provides an important first impression for future patients.

Spectrum of diabetes mellitus in patients with Shwachman-Diamond syndrome: case report and review of the literature

BACKGROUND

Shwachman-Diamond syndrome (SDS) is a rare congenital disorder caused by mutations in the SBDS gene and characterized by exocrine pancreatic deficiency, hematologic dysfunction, and skeletal growth failure. Although the hematologic features and characteristics of the somatic disorders commonly associated with SDS are well known, emerging data from case reports and patient registries suggest that SDS may also be associated with an increased risk of diabetes mellitus. However, currently available data on SDS-associated diabetes are limited and do not allow conclusions regarding prevalence and incidence rates, clinical course, and outcomes.

CASE PRESENTATION

Here we report the case of a 5-year-old girl with SDS who underwent bone marrow transplantation at the age of 3 months and developed autoantibody-positive type 1 diabetes mellitus at the age of 1.8 years. The manifestation and course of diabetes development were mild, complicated by concurrent spontaneous episodes of hypoglycemia even before the onset of antidiabetic treatment. Currently, adequate metabolic control can be achieved by dietary intervention.

CONCLUSIONS

Considering that the SBDS protein regulates mitosis and ribosomal biosynthesis and that its suppression may cause immunologic instability and chronic inflammation, this case provides insight into the phenotype of rare Shwachman-Diamond syndrome-associated diabetes mellitus, which may be characterized by significant age-dependent differences in clinical course.

Matched Family Donor Lymphocyte Infusions as First Cellular Therapy for Patients with Severe Primary T Cell Deficiencies

Patients with primary immunodeficiencies caused by severe defects in T cell immunity are at risk of acquiring life-threatening infections. Cellular therapies are necessary to establish normal T cell function and to allow for long-term survival. This is most commonly achieved by hematopoietic stem cell transplantation (HSCT), but the outcome of this procedure is impaired if active infections are present at the time of HSCT. Donor lymphocyte infusions (DLIs) are a well-established therapeutic strategy following HSCT to treat viral infections, improve donor cell engraftment, or achieve graft-versus-leukemia activity in malignant disease. Here we present a cohort of 6 patients with primary T cell deficiencies who received transfusions of unselected mature donor lymphocytes prior and not directly related to allogeneic HSCT. DLIs obtained from the peripheral blood of HLA-identical (10/10) family donors were transfused without prior conditioning to treat or prevent life-threatening infections. All patients are alive with a follow-up of 0.5 to 16.5 years after the initial T cell administration. Additional cellular therapies were administered in 5 of 6 patients at 0.8 to 15 months after the first DLI. Mild cutaneous graft-versus-host disease (GVHD, stage ≤2) was observed in 3 of 6 patients and resolved spontaneously. We provide evidence that unselected HLA-identical DLIs can effectively prevent or contribute to overcome infections with a limited risk for GVHD in T cell deficient patients. The T cell system established by this readily available source can provide T cell function for years and can serve as a bridge to additional cellular therapies or, in specific conditions, as definite treatment.

Unmistakable Morphology? Infantile Malignant Osteopetrosis Resembling Juvenile Myelomonocytic Leukemia in Infants

The initial clinical and hematologic presentation of infantile malignant osteopetrosis may be indistinguishable from that of juvenile myelomonocytic leukemia in infants. Timely radiographic imaging, however, allows straightforward delineation of these 2 severe diseases and facilitates immediate initiation of appropriate therapy.

Sequential acquisition of IgH and TCR rearrangements during the preleukemic phase of acute lymphoblastic leukemia in an adolescent patient

Acute lymphoblastic leukemia (ALL) can be preceded by a prodromal phase of bone marrow failure. In serial trephine biopsies in a girl with acquired bone marrow hypoplasia, we have identified a monoclonal B-cell precursor population characterized by a clone-specific IgH-FR3 gene rearrangement. Progression to ALL more than 4 months later was accompanied by acquisition of an additional T-cell receptor rearrangement. Thus, hypoplastic pre- and overt leukemia share a common clonal origin. Prospective biobanking and extended molecular analysis can help to better understand the nature and sequence of genetic events during progression of a covert (pre)leukemic clone.

Hematopoietic stem cell transplantation for advanced myelodysplastic syndrome in children: results of the EWOG-MDS 98 study

We report on the outcome of children with advanced primary myelodysplastic syndrome (MDS) transplanted from an HLA-matched sibling (MSD) or an unrelated donor (UD) following a preparative regimen with busulfan, cyclophosphamide and melphalan. Ninety-seven patients with refractory anemia with excess blasts (RAEB, n=53), RAEB in transformation (RAEB-T, n=29) and myelodysplasia-related acute myeloid leukemia (MDR-AML, n=15) enrolled in the European Working Group of MDS in Childhood (EWOG-MDS) 98 study and given hematopoietic stem cell transplantation (HSCT) were analyzed. Median age at HSCT was 11.1 years (range 1.4-19.0). Thirty-nine children were transplanted from an MSD, whereas 58 were given the allograft from a UD (n=57) or alternative family donor (n=1). Stem cell source was bone marrow (n=69) or peripheral blood (n=28). With a median follow-up of 3.9 years (range 0.1-10.9), the 5-year probability of overall survival is 63%, while the 5-year cumulative incidence of transplantation-related mortality (TRM) and relapse is 21% each. Age at HSCT greater than 12 years, interval between diagnosis and HSCT longer than 4 months, and occurrence of acute or extensive chronic graft-versus-host disease were associated with increased TRM. The risk of relapse increased with more advanced disease. This study indicates that HSCT following a myeloablative preparative regimen offers a high probability of survival for children with advanced MDS.

Germline CBL mutations cause developmental abnormalities and predispose to juvenile myelomonocytic leukemia

CBL encodes a member of the Cbl family of proteins, which functions as an E3 ubiquitin ligase. We describe a dominant developmental disorder resulting from germline missense CBL mutations, which is characterized by impaired growth, developmental delay, cryptorchidism and a predisposition to juvenile myelomonocytic leukemia (JMML). Some individuals experienced spontaneous regression of their JMML but developed vasculitis later in life. Importantly, JMML specimens from affected children show loss of the normal CBL allele through acquired isodisomy. Consistent with these genetic data, the common p.371Y>H altered Cbl protein induces cytokine-independent growth and constitutive phosphorylation of ERK, AKT and S6 only in hematopoietic cells in which normal Cbl expression is reduced by RNA interference. We conclude that germline CBL mutations have developmental, tumorigenic and functional consequences that resemble disorders that are caused by hyperactive Ras/Raf/MEK/ERK signaling and include neurofibromatosis type 1, Noonan syndrome, Costello syndrome, cardiofaciocutaneous syndrome and Legius syndrome.

Developing skeletal muscle cells express functional muscarinic acetylcholine receptors coupled to different intracellular signaling systems

This study analyzed the expression of muscarinic acetylcholine receptors (mAChRs) in the rat cultured skeletal muscle cells and their coupling to G protein, phospholipase C and adenylyl cyclase (AC). Our results showed the presence of a homogeneous population of [(3)H]methyl-quinuclidinyl benzilate-binding sites in the membrane fraction from the rat cultured muscle (K(D) = 0.4 nM, B(max) = 8.9 fmol mg protein(-1)). Specific muscarinic binding sites were also detected in denervated diaphragm muscles from adult rats and in myoblasts isolated from newborn rats. Activation of mAChRs with carbachol induced specific [(35)S]GTPgammaS binding to cultured muscle membranes and potentiated the forskolin-dependent stimulation of AC. These effects were totally inhibited by 0.1-1 microM atropine. In addition, mAChRs were able to stimulate generation of diacylglycerol (DAG) in response to acetylcholine, carbachol or selective mAChR agonist oxotremorine-M. The carbachol-dependent increase in DAG was inhibited in a concentration-dependent manner by mAChR antagonists atropine, pirenzepine and 4-DAMP mustard. Finally, activation of these receptors was correlated with increased synthesis of acetylcholinesterase, via a PKC-dependent pathway. Taken together, these results indicate that expression of mAChRs, coupled to G protein and distinct intracellular signaling systems, is a characteristic of noninnervated skeletal muscle cells and may be responsible for trophic influences of acetylcholine during formation of the neuromuscular synapse.

Ectopic development of skeletal muscle induced by subcutaneous transplant of rat satellite cells

The present study analyzes the ectopic development of the rat skeletal muscle originated from transplanted satellite cells. Satellite cells (10(6) cells) obtained from hindlimb muscles of newborn female 2BAW Wistar rats were injected subcutaneously into the dorsal area of adult male rats. After 3, 7, and 14 days, the transplanted tissues (N = 4-5) were processed for histochemical analysis of peripheral nerves, inactive X-chromosome and acetylcholinesterase. Nicotinic acetylcholine receptors (nAChRs) were also labeled with tetramethylrhodamine-labeled alpha-bungarotoxin. The development of ectopic muscles was successful in 86% of the implantation sites. By day 3, the transplanted cells were organized as multinucleated fibers containing multiple clusters of nAChRs (N = 2-4), resembling those from non-innervated cultured skeletal muscle fibers. After 7 days, the transplanted cells appeared as a highly vascularized tissue formed by bundles of fibers containing peripheral nuclei. The presence of X chromatin body indicated that subcutaneously developed fibers originated from female donor satellite cells. Differently from the extensor digitorum longus muscle of adult male rat (87.9 +/- 1.0 microm; N = 213), the diameter of ectopic fibers (59.1 microm; N = 213) did not obey a Gaussian distribution and had a higher coefficient of variation. After 7 and 14 days, the organization of the nAChR clusters was similar to that of clusters from adult innervated extensor digitorum longus muscle. These findings indicate the histocompatibility of rats from 2BAW colony and that satellite cells transplanted into the subcutaneous space of adult animals are able to develop and fuse to form differentiated skeletal muscle fibers.

Middle cerebral artery velocity waveforms in fetuses with absent umbilical artery end-diastolic flow

Middle cerebral artery (MCA) velocity waveforms were analyzed in 21 fetuses with absent umbilical artery end-diastolic flow (AEDF). Resistance index (RI) was measured from MCA velocity waveforms when AEDF was observed for the first time and at consecutive examinations. Fetal distress defined by fetal heart rate monitoring was found in 19 cases (90%). The difference between MCA RI values of first and last examinations was statistically significant (p < 0.01). There was a positive correlation between MCA RI values at the first examination and the time passing to delivery (r = 0.52; p < 0.05). There was no significant correlation between MCA RI values and the incidence of an adverse perinatal outcome. Pregnancies with AEDF are of high risk for the development of fetal distress. MCA resistance index values decrease gradually in fetuses with AEDF suggesting continuous reduction of cerebral vascular resistance during chronic fetal hypoxia.

[Risk of abnormal absorption of lead in glass decoration workers]

Following the observation of an abnormal lead absorption (PbB 72 micrograms/100 ml) in a young female glass decorator on a routine laboratory test, blood lead levels were measured in glass decorators of the entire area of the Local Health Unit of Treviso (Northern Italy). Abnormal lead absorption was found in a large number of glass workers, the source of exposure being the high content of inorganic lead in the "low-melting" paints that were used (brush and spray painting). Most of the exposed workers were females of fertile age, for whom even a moderate exposure to inorganic lead may constitute a risk during pregnancy. Attempts to reduce lead exposure levels by means of a health education programme and environmental improvements at the workplace were unsuccessful. In conclusion, a reduction in lead absorption in female glass decoration workers can only be achieved by using "low-melting" paints with a lower lead content.