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Tsilifis C, Lum SH, Nademi Z, Hambleton S, Flood TJ, Williams EJ, Owens S, Abinun M, Cant AJ, Slatter MA, Gennery AR. TCRαβ-Depleted Haploidentical Grafts Are a Safe Alternative to HLA-Matched Unrelated Donor Stem Cell Transplants for Infants with Severe Combined Immunodeficiency. J Clin Immunol 2022; 42:851-858. [PMID: 35305204 PMCID: PMC9166847 DOI: 10.1007/s10875-022-01239-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/21/2022] [Indexed: 12/02/2022]
Abstract
Hematopoietic stem cell transplantation and gene therapy are the only curative therapies for severe combined immunodeficiency (SCID). In patients lacking a matched donor, TCRαβ/CD19-depleted haploidentical family donor transplant (TCRαβ-HaploSCT) is a promising strategy. Conditioned transplant in SCID correlates to better myeloid chimerism and reduced immunoglobulin dependency. We studied transplant outcome in SCID infants according to donor type, specifically TCRαβ-HaploSCT, and conditioning, through retrospective cohort analysis of 52 consecutive infants with SCID transplanted between 2013 and 2020. Median age at transplant was 5.1 months (range, 0.8-16.6). Donors were TCRαβ-HaploSCT (n = 16, 31.4%), matched family donor (MFD, n = 15, 29.4%), matched unrelated donor (MUD, n = 9, 17.6%), and matched unrelated cord blood (CB, n = 11, 21.6%). Forty-one (80%) received fludarabine/treosulfan-based conditioning, 3 (6%) had alemtuzumab only, and 7 (14%) received unconditioned infusions. For conditioned transplants (n = 41), 3-year overall survival was 91% (95% confidence interval, 52-99%) for TCRαβ-HaploSCT, 80% (41-98%) for MFD, 87% (36-98%) for MUD, and 89% (43-98%) for CB (p = 0.89). Cumulative incidence of grade II-IV acute graft-versus-host disease was 11% (2-79%) after TCRαβ-HaploSCT, 0 after MFD, 29% (7-100%) after MUD, and 11% (2-79%) after CB (p = 0.10). 9/10 patients who received alemtuzumab-only or unconditioned transplants survived. Myeloid chimerism was higher following conditioning (median 47%, range 0-100%) versus unconditioned transplant (median 3%, 0-9%) (p < 0.001), as was the proportion of immunoglobulin-free long-term survivors (n = 29/36, 81% vs n = 4/9, 54%) (p < 0.001). TCRαβ-HaploSCT has comparable outcome to MUD and is a promising alternative donor strategy for infants with SCID lacking MFD. This study confirms that conditioned transplant offers better myeloid chimerism and immunoglobulin freedom in long-term survivors.
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Affiliation(s)
- Christo Tsilifis
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Su Han Lum
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Zohreh Nademi
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Sophie Hambleton
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Terence J Flood
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Eleri J Williams
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Stephen Owens
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Mario Abinun
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Andrew J Cant
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Mary A Slatter
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Andrew R Gennery
- Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital (GNCH), Clinical Resource Building, Royal Victoria Infirmary, Victoria WingFloor 4, Block 2, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
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Burns H, Collins A, Marsden P, Flood TJ, Slatter MA, Booth C, Xu-Bayford J, Leahy TR. Severe Combined Immunodeficiency (SCID)-the Irish Experience. J Clin Immunol 2021; 41:1950-1953. [PMID: 34374883 DOI: 10.1007/s10875-021-01106-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Heather Burns
- National Newborn Bloodspot Screening Programme Governance Group , Dublin, Ireland. .,Department of Public Health, Health Service Executive, Tullamore, Co Offaly, Ireland.
| | - Abigail Collins
- National Newborn Bloodspot Screening Programme Governance Group , Dublin, Ireland.,Department of Public Health, Health Service Executive, Tullamore, Co Offaly, Ireland
| | - Paul Marsden
- National Newborn Bloodspot Screening Programme Governance Group , Dublin, Ireland.,Department of Public Health, Health Service Executive, Tullamore, Co Offaly, Ireland
| | - Terence J Flood
- Department of Paediatric Haematopoietic Stem Cell Therapy and Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Mary A Slatter
- Department of Paediatric Haematopoietic Stem Cell Therapy and Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Claire Booth
- Department of Paediatric Immunology and Gene Therapy, Great Ormond Street Hospital, London WC1N 3JH, United Kingdom.,Molecular and Cellular Immunology Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jinhua Xu-Bayford
- Department of Paediatric Immunology and Gene Therapy, Great Ormond Street Hospital, London WC1N 3JH, United Kingdom
| | - Timothy Ronan Leahy
- Department of Paediatric Immunology and Infectious Diseases, Children's Health Ireland at Crumlin , Dublin, Ireland.,Department of Paediatrics, University of Dublin, Trinity College, Dublin, Ireland
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Abinun M, Lane JP, Wood M, Friswell M, Flood TJ, Foster HE. Infection-Related Death among Persons with Refractory Juvenile Idiopathic Arthritis. Emerg Infect Dis 2018; 22:1720-7. [PMID: 27648582 PMCID: PMC5038400 DOI: 10.3201/eid2210.151245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bacterial sepsis led to multiorgan failure in persons receiving immunosuppressive and antiinflammatory drugs. Severe infections are emerging as major risk factors for death among children with juvenile idiopathic arthritis (JIA). In particular, children with refractory JIA treated with long-term, multiple, and often combined immunosuppressive and antiinflammatory agents, including the new biological disease-modifying antirheumatic drugs (DMARDs), are at increased risk for severe infections and death. We investigated 4 persons with JIA who died during 1994–2013, three of overwhelming central venous catheter–related bacterial sepsis caused by coagulase-negative Staphylococus or α-hemolytic Streptococcus infection and 1 of disseminated adenovirus and Epstein-Barr virus infection). All 4 had active JIA refractory to long-term therapy with multiple and combined conventional and biological DMARDs. Two died while receiving high-dose systemic corticosteroids, methotrexate, and after recent exposure to anti–tumor necrosis factor-α biological DMARDs, and 2 during hematopoietic stem cell transplantation procedure. Reporting all cases of severe infections and especially deaths in these children is of paramount importance for accurate surveillance.
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Engelhardt KR, Xu Y, Grainger A, Germani Batacchi MGC, Swan DJ, Willet JDP, Abd Hamid IJ, Agyeman P, Barge D, Bibi S, Jenkins L, Flood TJ, Abinun M, Slatter MA, Gennery AR, Cant AJ, Santibanez Koref M, Gilmour K, Hambleton S. Identification of Heterozygous Single- and Multi-exon Deletions in IL7R by Whole Exome Sequencing. J Clin Immunol 2016; 37:42-50. [PMID: 27807805 PMCID: PMC5226981 DOI: 10.1007/s10875-016-0343-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 10/10/2016] [Indexed: 12/30/2022]
Abstract
Purpose We aimed to achieve a retrospective molecular diagnosis by applying state-of-the-art genomic sequencing methods to past patients with T-B+NK+ severe combined immunodeficiency (SCID). We included identification of copy number variations (CNVs) by whole exome sequencing (WES) using the CNV calling method ExomeDepth to detect gene alterations for which routine Sanger sequencing analysis is not suitable, such as large heterozygous deletions. Methods Of a total of 12 undiagnosed patients with T-B+NK+ SCID, we analyzed eight probands by WES, using GATK to detect single nucleotide variants (SNVs) and small insertions and deletions (INDELs) and ExomeDepth to detect CNVs. Results We found heterozygous single- or multi-exon deletions in IL7R, a known disease gene for autosomal recessive T-B+NK+ SCID, in four families (seven patients). In three families (five patients), these deletions coexisted with a heterozygous splice site or nonsense mutation elsewhere in the same gene, consistent with compound heterozygosity. In our cohort, about a quarter of T-B+NK+ SCID patients (26%) had such compound heterozygous IL7R deletions. Conclusions We show that heterozygous IL7R exon deletions are common in T-B+NK+ SCID and are detectable by WES. They should be considered if Sanger sequencing fails to detect homozygous or compound heterozygous IL7R SNVs or INDELs. Electronic supplementary material The online version of this article (doi:10.1007/s10875-016-0343-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karin R Engelhardt
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| | - Yaobo Xu
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Angela Grainger
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Mila G C Germani Batacchi
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David J Swan
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Joseph D P Willet
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Intan J Abd Hamid
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Philipp Agyeman
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dawn Barge
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Shahnaz Bibi
- NE Thames Regional Genetics Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Lucy Jenkins
- NE Thames Regional Genetics Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Terence J Flood
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mario Abinun
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mary A Slatter
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew J Cant
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Kimberly Gilmour
- Immunology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Sophie Hambleton
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Gambineri E, Ciullini Mannurita S, Robertson H, Vignoli M, Haugk B, Lionetti P, Hambleton S, Barge D, Gennery AR, Slatter M, Nademi Z, Flood TJ, Jackson A, Abinun M, Cant AJ. Gut immune reconstitution in immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome after hematopoietic stem cell transplantation. J Allergy Clin Immunol 2014; 135:260-2. [PMID: 25420685 PMCID: PMC4282727 DOI: 10.1016/j.jaci.2014.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/04/2014] [Accepted: 09/05/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Eleonora Gambineri
- Department of "NEUROFARBA," Section of Children's Health, University of Florence, Anna Meyer Children's Hospital, Florence, Italy.
| | - Sara Ciullini Mannurita
- Department of "NEUROFARBA," Section of Children's Health, University of Florence, Anna Meyer Children's Hospital, Florence, Italy
| | - Helen Robertson
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Marina Vignoli
- Department of "NEUROFARBA," Section of Children's Health, University of Florence, Anna Meyer Children's Hospital, Florence, Italy
| | - Beate Haugk
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Paolo Lionetti
- Department of "NEUROFARBA," Section of Children's Health, University of Florence, Anna Meyer Children's Hospital, Florence, Italy
| | - Sophie Hambleton
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom; Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Dawn Barge
- Immunology Laboratory, Newcastle Upon Tyne Hospitals National Health Service Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom; Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Mary Slatter
- Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Terence J Flood
- Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Anthony Jackson
- Northern Molecular Genetics Service, Institute of Genetic Medicine, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom; Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew J Cant
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, United Kingdom; Department of Pediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
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Slatter MA, Angus B, Windebank K, Taylor A, Meaney C, Lester T, Norbury G, Hambleton S, Abinun M, Flood TJ. Polymorphous lymphoproliferative disorder with Hodgkin-like features in common γ-chain–deficient severe combined immunodeficiency. J Allergy Clin Immunol 2011; 127:533-5. [DOI: 10.1016/j.jaci.2010.09.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Revised: 08/14/2010] [Accepted: 09/20/2010] [Indexed: 11/29/2022]
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Soncini E, Slatter MA, Jones LBKR, Hughes S, Hodges S, Flood TJ, Barge D, Spickett GP, Jackson GH, Collin MP, Abinun M, Cant AJ, Gennery AR. Unrelated donor and HLA-identical sibling haematopoietic stem cell transplantation cure chronic granulomatous disease with good long-term outcome and growth. Br J Haematol 2009; 145:73-83. [PMID: 19222467 DOI: 10.1111/j.1365-2141.2009.07614.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic granulomatous disease (CGD) causes recurrent infection and inflammatory disease. Despite antimicrobial prophylaxis, patients experience frequent hospitalisations and 50% mortality by 30 years. Haematopoietic stem cell transplantation (HSCT) can cure CGD with resolution of infection and colitis. This study reports the survival and long-term outcome in 20 conditioned patients treated between 1998 and 2007, using 10 matched sibling (MSD) and 10 unrelated donors (URD). Age at HSCT, graft-versus-host disease (GvHD), growth, and outcome were analysed. Fourteen had > or = 1 invasive infection, 10 had colitis and seven had growth failure before HSCT. Median age at transplantation was 75 months (range 15 months-21 years). Eighteen (90%) were alive 4-117 months (median 61) after HSCT with normal neutrophil function. Two died from disseminated fungal infection. Two experienced significant chronic GvHD, with continuing sequelae in 1. Colitis resolved within 8 weeks of HSCT. Mean weight and height for age Z scores on recovery from HSCT rose significantly (P < 0.001). HSCT with MSD or URD gave excellent engraftment and survival, remission of colitis and catch-up growth, with low incidence of significant GvHD. Transplant-associated complications were restricted to those with pre-existing infection or inflammation, supporting the argument for early HSCT for more CGD patients with a well matched donor.
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Affiliation(s)
- Elena Soncini
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
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Abinun M, Flood TJ, Cant AJ, Veys P, Gennery AR, Foster HE, Friswell M, Baildam E, Davidson J, Southwood TR, Livermore P, Wedderburn LR. Autologous T cell depleted haematopoietic stem cell transplantation in children with severe juvenile idiopathic arthritis in the UK (2000-2007). Mol Immunol 2009; 47:46-51. [PMID: 19203795 DOI: 10.1016/j.molimm.2008.12.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 12/24/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED As part of collaborative multi-centre study started in 2000, 7 children in the UK fulfilled the inclusion criteria for treatment with autologous T cell depleted (TCD) haematopoietic stem cell transplantation (HSCT) for severe juvenile idiopathic arthritis (JIA). Here we report on the outcome and transplant-related complications. OUTCOME The initial, often dramatic clinical response in all patients was followed in 4 with sustained benefit, including the withdrawal of immunosuppressive and anti-inflammatory treatment, significant catch-up growth and immense improvement of the quality of life during 5-8 years long follow-up. Two patients relapsed within 1-12 months, and one died 4 months post transplant. COMPLICATIONS Adenovirus reactivation with dissemination was lethal in one patient, whilst Epstein-Barr (EBV) and cytomegalovirus (CMV) reactivation-driven haemophagocytic syndrome responded to antiviral and immunomodulatory treatment in 2 patients. Both the conditioning and the T cell depletion of the graft, leading to severe immunosuppression and prolonged immune system function reconstitution, are the main predisposing factors for potentially life-threatening transplant-related complications. CONCLUSIONS Autologous TCD HSCT for children with severe JIA results in two-phase response. The initial remission seen in all patients is due to immunosuppressive conditioning. This is followed by sustained drug-free remission in over 50% of patients, which is due to 'immunomodulatory' effects of TCD HSCT. The procedure carries a significant morbidity and mortality risk. However, this risk should be balanced against the risks of life-threatening infections occurring in this very selective group of patients on long-term and combined immunosuppressive and anti-inflammatory therapies. How to correctly identify and appropriately assess the patients in need for autologous TCD HSCT, particularly in relation to optimizing the timing for the procedure in regards to the newly available therapies with different biologic response modifiers, are some of the most important questions awaiting answers from this on-going study.
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Affiliation(s)
- Mario Abinun
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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Jones LBKR, McGrogan P, Flood TJ, Gennery AR, Morton L, Thrasher A, Goldblatt D, Parker L, Cant AJ. Special article: chronic granulomatous disease in the United Kingdom and Ireland: a comprehensive national patient-based registry. Clin Exp Immunol 2008; 152:211-8. [PMID: 18410635 DOI: 10.1111/j.1365-2249.2008.03644.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
There are no epidemiological studies from the British Isles of chronic granulomatous disease, characterized by recurrent, life-threatening bacterial and fungal infections and inflammatory sequelae. Patients were enrolled in a national registry and medical records were analysed. Of 94 subjects, 69 had X-linked disease, 16 had autosomal recessive disease and nine were unknown. Prevalence was 7.5/million for 1990-99 and 8.5/million for 1980-89. Suppurative adenitis, abscesses and pneumonia presented commonly. Twenty-three of 30 patients who underwent high resolution computerized tomography had chronic respiratory disease. Inflammatory sequelae included bowel stricture and urogenital tract granulomata. Growth failure was common; 75% of those measured were below the population mean. All patients received prophylactic antibiotics and 93% anti-fungal prophylaxis. Interferon gamma was used to treat infection, but rarely as prophylaxis. Despite prophylaxis, estimated survival was 88% at 10 years but 55% at age 30 years. Morbidity remains significant, severe infectious complications common. Curative treatments including stem cell transplantation should be considered for patients with frequent or serious complications.
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Affiliation(s)
- L B K R Jones
- School of Clinical Medical Sciences, Child Health, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
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Gennery AR, Slatter MA, Rice J, Hoefsloot LH, Barge D, McLean-Tooke A, Montgomery T, Goodship JA, Burt AD, Flood TJ, Abinun M, Cant AJ, Johnson D. Mutations in CHD7 in patients with CHARGE syndrome cause T-B + natural killer cell + severe combined immune deficiency and may cause Omenn-like syndrome. Clin Exp Immunol 2008; 153:75-80. [PMID: 18505430 DOI: 10.1111/j.1365-2249.2008.03681.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
More than 11 genetic causes of severe combined immunodeficiency (SCID) have been identified, affecting development and/or function of T lymphocytes, and sometimes B lymphocytes and natural killer (NK) cells. Deletion of 22q11.2 is associated with immunodeficiency, although less than 1% of cases are associated with T-B + NK + SCID phenotype. Severe immunodeficiency with CHARGE syndrome has been noted only rarely Omenn syndrome is a rare autosomal recessive form of SCID with erythroderma, hepatosplenomegaly, lymphadenopathy and alopecia. Hypomorphic recombination activating genes 1 and 2 mutations were first described in patients with Omenn syndrome. More recently, defects in Artemis, RMRP, IL7Ralpha and common gamma chain genes have been described. We describe four patients with mutations in CHD7, who had clinical features of CHARGE syndrome and who had T-B + NK + SCID (two patients) or clinical features consistent with Omenn syndrome (two patients). Immunodeficiency in patients with DiGeorge syndrome is well recognized--CHARGE syndrome should now be added to the causes of T-B + NK + SCID, and mutations in the CHD7 gene may be associated with Omenn-like syndrome.
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Affiliation(s)
- A R Gennery
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK.
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11
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Slatter MA, Brigham K, Dickinson AM, Harvey HL, Barge D, Jackson A, Bown N, Flood TJ, Cant AJ, Abinun M, Gennery AR. Long-term immune reconstitution after anti-CD52-treated or anti-CD34-treated hematopoietic stem cell transplantation for severe T-lymphocyte immunodeficiency. J Allergy Clin Immunol 2007; 121:361-7. [PMID: 18086494 DOI: 10.1016/j.jaci.2007.10.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 10/25/2007] [Accepted: 10/26/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Results of treatment of severe T-lymphocyte immunodeficiencies by means of hematopoietic stem cell (HSC) transplantation have improved. T cell-depleted haploidentical transplantations are successful if there is no HLA-identical donor. Methods to remove T lymphocytes include addition of anti-CD52 antibodies and CD34(+) HSC selection. OBJECTIVE Assessment of long-term immune function is important after these treatments. We looked at immune reconstitution in 36 survivors for more than 2 years after HSC transplantation for severe T-lymphocyte immunodeficiencies and compared engraftment quality between the 2 T-lymphocyte depletion methods. METHODS Chimerism, T- and B-lymphocyte subsets, immunoglobulin levels, and specific antibody production at last follow-up were examined. The chi(2) (Fisher exact test) and Wilcoxon rank sum analyses were used to compare the groups. RESULTS Nineteen patients received anti-CD52-treated and 19 anti-CD34-treated HSCs. More anti-CD52-treated patients had full donor myeloid chimerism (P = .025). All patients had full donor T-lymphocyte chimerism. There was no difference in donor B-lymphocyte chimerism, but significantly more anti-CD52-treated patients had class-switched memory B lymphocytes (P = .024), normal IgG levels, and normal responses to tetanus and Haemophilus influenzae type B vaccination. More anti-CD52-treated patients with common gamma chain or Janus-associated kinase 3 severe combined immunodeficiency had donor B lymphocytes. CONCLUSION Long-term T-lymphocyte function is good with either treatment method, with a low incidence of graft-versus-host disease. The results imply more incomplete donor chimerism in anti-CD34-treated patients with less B-lymphocyte function.
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Affiliation(s)
- Mary A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
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Slatter MA, Rogerson EJ, Taylor CE, Galloway A, Clark JE, Flood TJ, Abinun M, Cant AJ, Gennery AR. Value of bronchoalveolar lavage before haematopoietic stem cell transplantation for primary immunodeficiency or autoimmune diseases. Bone Marrow Transplant 2007; 40:529-33. [PMID: 17637688 DOI: 10.1038/sj.bmt.1705776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary infection, often insidious, is frequent in primary immunodeficiency (PID) and acquired immunodeficiency. Pulmonary complications are serious obstacles to success of haematopoietic SCT (HSCT) for these conditions. Bronchoalveolar lavage (BAL) permits identification of lower respiratory tract pathogens that may direct specific treatment and influence prognosis. There are no reports about the utility of pre-HSCT BAL for immunodeficient patients. We prospectively studied the value of 'routine' BAL before commencing transplantation in patients undergoing HSCT for severe immunological disease. Routine non-bronchoscopic BAL was performed under general anaesthetic, a few days before commencing pre-HSCT cytoreductive chemotherapy. Patients were categorized as symptomatic or asymptomatic with respect to pulmonary disease or infection. Samples were sent for microbiological processing. Complications arising from the procedure, pathogens isolated and treatments instituted were recorded. Results were available from 69/75 patients transplanted during the study period; 26 (38%) had pathogens identified (six asymptomatic patients), 10 (14.5%) developed complications post-procedure (two asymptomatic patients)-all recovered, 21 had management changes. There was no statistically significant difference in the number of positive isolates from severe combined or other immunodeficient patients, or of symptomatic or asymptomatic patients. Routine non-bronchoscopic BAL is safe in immunodeficient patients about to undergo HSCT, and leads to management changes.
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Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
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Waruiru C, Slatter MA, Taylor C, Ramesh V, Flood TJ, Abinun M, Cant AJ, Gennery AR. Outcome of hematopoietic stem cell transplantation in severe combined immune deficiency with central nervous system viral infection. Pediatr Infect Dis J 2007; 26:129-33. [PMID: 17259874 DOI: 10.1097/01.inf.0000250621.46742.b5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with severe combined immunodeficiency and preexisting viral pneumonitis formally had a poor outcome from hematopoietic stem cell transplantation. With inhaled steroid and antitumor necrosis factor alpha antibody treatment, results improved. The poor outcome of patients with viral central nervous system infection prompted this retrospective single center review. RESULTS Eight of 71 patients with severe combined immunodeficiency transplanted since 1987 were identified with viral central nervous system infection (adenovirus [1], cytomegalovirus [2], Epstein-Barr virus [2], parvovirus [1], varicella zoster virus [1], human herpesvirus 6 [1]). Nonspecific neurologic symptoms included drowsiness, irritability, head lag, fisting and floppiness. Later symptoms included unresponsiveness, apnea, posturing, hypotonia, hyperreflexia and seizures. All had neuroradiologic investigations. Only one had an initially normal computed tomography scan. Magnetic resonance image abnormalities included cerebral atrophy, basal ganglia changes, diffuse leukoencephalopathy, and multifocal mass lesions. Five patients had virus identified from cerebrospinal fluid by polymerase chain reaction and brain tissue examination from 3 patients identified human herpesvirus 6, adenovirus type 41 and varicella zoster virus. Three children remain alive, 2 received replete marrow and one remains untransplanted. Others who received T cell depleted marrow died of neurologic sequelae. CONCLUSION Outcome of viral central nervous system infection after hematopoietic stem cell transplantation for severe combined immunodeficiency is poor, particularly associated with T cell depleted marrow.
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Affiliation(s)
- Cathy Waruiru
- Paediatric Immunology Department, Newcastle General Hospital, Newcastle upon Tyne, UK
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Slatter MA, Bhattacharya A, Flood TJ, Abinun M, Cant AJ, Gennery AR. Use of two unrelated umbilical cord stem cell units in stem cell transplantation for Wiskott-Aldrich syndrome. Pediatr Blood Cancer 2006; 47:332-4. [PMID: 16007596 DOI: 10.1002/pbc.20450] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Wiskott-Aldrich syndrome, an X-linked primary immunodeficiency can be cured by bone marrow transplantation. Umbilical cord haemopoietic stem cells are increasingly used as an alternative to bone marrow; advantages include ready availability, no risk to the donor, low rate of viral contamination, and low risk of graft versus host disease. Disadvantages include low stem cell dose for larger patients and lack of stem cells for boost infusions following the initial procedure. We report the case of a child with Wiskott-Aldrich syndrome who underwent cord blood stem cell transplantation with two separate cord blood units, 8 days apart.
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Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Newcastle, United Kingdom
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Lakshman R, Bruce S, Spencer DA, Crawford D, Galloway A, Cooper PN, Barge D, Roos D, Flood TJ, Abinun M. Postmortem diagnosis of chronic granulomatous disease: how worthwhile is it? J Clin Pathol 2006; 58:1339-41. [PMID: 16311362 PMCID: PMC1770789 DOI: 10.1136/jcp.2004.025098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A previously healthy 11 year old boy died unexpectedly after a rapid course of progressive pneumonia. Postmortem microbiology and histopathology suggested an underlying diagnosis of chronic granulomatous disease. This was confirmed by neutrophil oxidative burst and gene mutation analysis of other family members, one of whom benefited from early bone marrow transplantation.
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Affiliation(s)
- R Lakshman
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne NE4 6BE, UK
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Bhattacharya A, Slatter MA, Chapman CE, Barge D, Jackson A, Flood TJ, Abinun M, Cant AJ, Gennery AR. Single centre experience of umbilical cord stem cell transplantation for primary immunodeficiency. Bone Marrow Transplant 2005; 36:295-9. [PMID: 15968287 DOI: 10.1038/sj.bmt.1705054] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Primary immunodeficiencies (PID) are an important cause of childhood mortality. Haematopoietic stem cell transplantation (HSCT) is the best treatment for many PID. Umbilical cord stem cells are an alternative source of HSC. There is little data regarding outcome of umbilical cord stem cell transplantation (UCSCT) for PID. Our single centre experience is reported. A retrospective study of 14 of 148 patients transplanted for PID, who have received 15 UCSCT was performed, with specific regard to graft-versus-host disease (GvHD) and immune reconstitution. Eight patients with severe combined immunodeficiency (SCID), and six with other combined immunodeficiencies were treated. Of the patients, 12 received unrelated cords, and two had sibling transplants. Median age at transplant was 3.5 months, median nucleated cell dose was 0.8 x 10(8)/kg. All engrafted. Median time to neutrophil engraftment was 22 days, median time to platelet engraftment was 51 days. One developed significant grade III GvHD post transplantation. In total, 11 patients had full donor T and six full donor B-cell chimerism, six of nine patients >1 year post-BMT had normal IgG levels and specific antibody responses to tetanus and Hib vaccines; two are being assessed. Two patients died of multi-organ failure related to pre-existing infection and inflammatory complications respectively. UCSCT should be considered for patients requiring stem cell therapy for PID.
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Affiliation(s)
- A Bhattacharya
- Paediatric Immunology Department, Newcastle General Hospital, Newcastle upon Tyne, UK
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Slatter MA, Bhattacharya A, Abinun M, Flood TJ, Cant AJ, Gennery AR. Outcome of boost haemopoietic stem cell transplant for decreased donor chimerism or graft dysfunction in primary immunodeficiency. Bone Marrow Transplant 2005; 35:683-9. [PMID: 15723084 DOI: 10.1038/sj.bmt.1704872] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Haemopoietic stem cell transplants (HSCT) cure increasing numbers of primary immunodeficiencies (PID): residual recipient T-cell function increases risk of incomplete or decreasing immune reconstitution, which may resolve following a second, unconditioned, infusion from the same donor (boost infusion). We assessed the outcome of 20 boost infusions in 19/139 patients transplanted for PID patients at our centre since 1987. Boost infusion was given 64-1226 days after the original HSCT. Follow-up was 4-124 months. In all, 12 of 19 patients cleared viral infection (6), or showed sustained increase in donor chimerism, T- and B-cell numbers and function, or other markers (6). In 7/12 patients, immunoglobulin replacement has been discontinued. Four were partially successful with stable low-level chimerism (two patients) or improved T-cell function, but not B cell function (two patients). Four failed with no change in donor chimerism or cell number. No significant association with donor source, T-cell depletion, conditioning regimen, boost infusion stem cell dose or time from original HSCT to boost was found. One patient developed grade III acute graft-versus-host disease despite cyclosporine, and one developed severe pneumonitis; both have recovered. Boost infusion was successful or partially successful in 84% of patients. The risk of adverse effects is low.
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Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology, University of Newcastle upon Tyne, Newcastle General Hospital, NHS Trust, Newcastle upon Tyne, UK
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Slatter MA, Read S, Taylor CE, Crooks BNA, Abinun M, Flood TJ, Cant AJ, Wright C, Gennery AR. Adenovirus type F subtype 41 causing disseminated disease following bone marrow transplantation for immunodeficiency. J Clin Microbiol 2005; 43:1462-4. [PMID: 15750134 PMCID: PMC1081290 DOI: 10.1128/jcm.43.3.1462-1464.2005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Adenovirus causes disseminated disease following bone marrow transplantation (BMT). We report a child who underwent T-cell-depleted BMT. Adenovirus subgenus F serotype 41 was detected antemortem by PCR in cerebrospinal fluid and postmortem in other tissues. Serotypes 40 and 41, associated with gastrointestinal disease, have not previously been implicated in disseminated disease.
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Affiliation(s)
- Mary A Slatter
- Paediatric Immunology Unit, Ward 23, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, United Kingdom
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Slatter MA, Gennery AR, Cheetham TD, Bhattacharya A, Crooks BNA, Flood TJ, Cant AJ, Abinun M. Thyroid dysfunction after bone marrow transplantation for primary immunodeficiency without the use of total body irradiation in conditioning. Bone Marrow Transplant 2004; 33:949-53. [PMID: 15004542 DOI: 10.1038/sj.bmt.1704456] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thyroid dysfunction, a common long-term complication following bone marrow transplantation (BMT), is frequently associated with total body irradiation (TBI) given in the pre-BMT conditioning protocol. We report our preliminary observation of the prevalence of thyroid dysfunction in children transplanted for primary immunodeficiency (PID) who were given cytoreductive conditioning with busulphan and cyclophosphamide, but without TBI. We evaluated thyroid-stimulating hormone (TSH) and free thyroxine (fT4) in 83 survivors transplanted between 1987 and 2002. We found nine children (10.8%) with clinical and/or biochemical thyroid dysfunction at 4 months to 4.5 years post-BMT of which three had positive antithyroid microsomal antibodies. Two patients were classified as primary and seven as compensated hypothyroidism (hyperthyrotropinaemia). Four patients with clinical features of hypothyroidism received replacement thyroxine, while five of the seven patients with compensated hypothyroidism remain off thyroxine because we suspect this may be a transient phenomenon. Abnormalities of thyroid function including severe primary hypothyroidism may occur post-BMT in children receiving chemotherapy conditioning without TBI. Thyroid function should be assessed regularly in this group of patients.
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Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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21
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Gennery AR, Slatter MA, Bhattacharya A, Barge D, Haigh S, O'Driscoll M, Coleman R, Abinun M, Flood TJ, Cant AJ, Jeggo PA. The clinical and biological overlap between Nijmegen Breakage Syndrome and Fanconi anemia. Clin Immunol 2004; 113:214-9. [PMID: 15451479 DOI: 10.1016/j.clim.2004.03.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 03/12/2004] [Indexed: 11/17/2022]
Abstract
Fanconi anemia (FA), an autosomal recessive chromosomal instability syndrome, is characterized clinically by developmental abnormalities, growth retardation, progressive bone marrow failure, pancytopenia, and pronounced cancer predisposition. Nijmegen Breakage Syndrome (NBS) is a related disorder that shares overlapping clinical features, principally, developmental delay, microcephaly, and cancer predisposition. The diagnosis has relied on chromosomal instability following exposure to DNA cross-linking agents in FA and to ionizing radiation (IR) in NBS. We describe two patients who clinically had FA, but showed sensitivity to both DNA cross-linking agents and ionizing radiation, and who were found to have a rare mutation in the NBS gene. The importance of genetic diagnosis with respect to treatment and prognosis is discussed.
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Affiliation(s)
- A R Gennery
- School of Clinical Medical Sciences, University of Newcastle-upon-Tyne, UK.
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22
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Slatter MA, Bhattacharya A, Flood TJ, Spickett GP, Cant AJ, Abinun M, Gennery AR. Polysaccharide antibody responses are impaired post bone marrow transplantation for severe combined immunodeficiency, but not other primary immunodeficiencies. Bone Marrow Transplant 2003; 32:225-9. [PMID: 12838289 DOI: 10.1038/sj.bmt.1704109] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Established treatment of severe combined immunodeficiencies (SCID) and other primary immunodeficiencies (PID) is bone marrow transplantation (BMT). Normal lymphocyte numbers and protein antigen responses are present within 2 years of BMT, polysaccharide antibody responses appear last. Streptococcus pneumoniae infection causes significant morbidity and mortality post-BMT. Previous studies have shown good protein antigen responses post-BMT for SCID and PID, but had not examined the polysaccharide responses. We retrospectively analysed pneumococcal polysaccharide (PPS) responses in our patient series. In total, 22 SCID and 12 non-SCID PID were evaluated, all >2 years post BMT: 17 SCID, 12 PID received chemotherapy conditioning; 17 SCID, three PID had T-cell depleted (TCD) BMT, others had nonconditioned whole marrow BMT. All had normal Haemophilus influenza B and tetanus antibody responses. Of 22 SCID, 13 vs 11/12 PID responded to PPS vaccine (P=0.05). There was no association with donor age, GvHD, B-cell chimerism, or IgG2 level. Fewer TCD marrow recipients responded to PPS (P=0.04). Analysis of the SCID group showed no association of PPS response with type of marrow received. This is the first study to specifically examine PPS antibody responses following SCID and PID BMT. Pneumococcal conjugate vaccine antibody responses should be examined in these children.
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Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK
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Abstract
Anhidrotic (hypohidrotic) ectodermal dysplasia associated with immunodeficiency (EDA-ID; OMIM 300291) is a newly recognised primary immunodeficiency caused by mutations in NEMO, the gene encoding nuclear factor kappaB (NF-kappaB) essential modulator, NEMO, or inhibitor of kappaB kinase (IKK-gamma). This protein is essential for activation of the transcription factor NF-kappaB, which plays an important role in human development, skin homoeostasis, and immunity.
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Affiliation(s)
- E D Carrol
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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25
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Bajwa RPS, Cant AJ, Abinun M, Flood TJ, Hodges S, Hale JP, Skinner R. Recombinant tissue plasminogen activator for treatment of hepatic veno-occlusive disease following bone marrow transplantation in children: effectiveness and a scoring system for initiating treatment. Bone Marrow Transplant 2003; 31:591-7. [PMID: 12692627 DOI: 10.1038/sj.bmt.1703881] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hepatic veno-occlusive disease (HVOD) following bone marrow transplantation is potentially fatal. Criteria for diagnosis and starting treatment are mainly based on adult studies. Recombinant tissue plasminogen activator (rtPA) has been used with variable success. rtPA and heparin were given to 12 children (nine with immunodeficiency, two malignancy, one thalassaemia) with moderate to severe HVOD. Of the 12, 10 responded with a fall in bilirubin concentration; eight survived with complete resolution of HVOD. Four of the five patients with associated multiorgan failure (MOF) died despite rtPA treatment. One child suffered significant, and one minor, bleeding during rtPA treatment. A scoring system for quantifying the severity of HVOD in children is proposed, incorporating the criteria used to diagnose HVOD, risk factors for its development and also parameters reflective of the patient's general condition. This will facilitate early diagnosis and management of those cases which, if not treated promptly, are likely to deteriorate with an adverse outcome. Our experience suggests rtPA and heparin are an effective treatment for HVOD in children, with relatively little toxicity provided therapy is started before MOF develops.
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Affiliation(s)
- R P S Bajwa
- Childrens Bone Marrow Transplant Unit, Newcastle General Hospital, Newcastle upon Tyne, UK
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26
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Bhattacharya A, Slatter M, Curtis A, Chapman CE, Barge D, Jackson A, Flood TJ, Abinun M, Cant AJ, Gennery AR. Successful umbilical cord blood stem cell transplantation for chronic granulomatous disease. Bone Marrow Transplant 2003; 31:403-5. [PMID: 12634733 DOI: 10.1038/sj.bmt.1703863] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic granulomatous disease (CGD) causes growth failure, inflammatory lung damage and often early death. Prophylactic cotrimoxazole improves medium-term survival, but cannot prevent inflammatory sequelae. We report the first patient with CGD who underwent successful HLA identical sibling umbilical cord stem cell transplantation (UCSCT) after myeloablative conditioning. The patient presented with colitis, confirmed as CGD at 2 years of age. Following BU16/CY200 conditioning, he had UCSCT from his unaffected HLA identical sister. A year post-transplant, his colitis had resolved clinically and on radioisotope scan growth has improved. Neutrophil oxidative burst was 92% normal with full donor lymphocyte reconstitution.
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Affiliation(s)
- A Bhattacharya
- Newcastle upon Tyne Hospitals, NHS Trust, University of New Castle upon Tyne, UK
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Gennery AR, Dickinson AM, Brigham K, Barge D, Spickett GP, Curtis A, Spencer V, Jackson A, Cavanagh G, Carter V, Palmer P, Flood TJ, Cant AJ, Abinun M. CAMPATH-1M T-cell depleted BMT for SCID: long-term follow-up of 19 children treated 1987-98 in a single center. Cytotherapy 2002; 3:221-32. [PMID: 12171729 DOI: 10.1080/146532401753174052] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND SCID can be cured by BMT. Depletion of mature T cells from BM has enabled HLA non-identical stem-cell transplantation. We report the outcome of 30 patients treated with 37 T-cell depleted BMT procedures using CAMPATH-1M in vitro between 1987-98 in a single center. METHODS Immune reconstitution and quality-of-life were assessed in 19 longterm survivors. All but two received pre-transplant conditioning. T- and B-cell chimerism, numbers and function were analyzed during a median follow-up of 5.3 years (range 1.33-12). RESULTS The overall engraftment rate was 59%, six children required repeated BMT and the survival rate was 63%. All have donor T cells, 58% normal T-cell numbers and 74% normal T-cell function. Of 17 evaluated, 16 patients (94%) have normal IgM and IgG levels, and production of specific Abs to protein Ags, but only 5/16 (31%) have a good response to pneumococcal polysaccharide. Early and late post-BMT complications were rare and there were no delayed deaths. Only one child continues on long-term i.v. Ig 4-years post-BMT. Eleven children died (37%). DISCUSSION CAMPATH-1M T-cell depleted BMT for SCID resulted in 63% survival. Deaths of 11 children were mainly due to pre-existing infections. Seventeen of 19 long-term survivors have normal immune function and good quality-of-life.
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Affiliation(s)
- A R Gennery
- Children's Bone Marrow Transplantation Unit, Newcastle upon Tyne Hospitals NHS Trust, UK
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Affiliation(s)
- K Tanner
- Department of Paediatric Infectious Diseases and Immunology, Newcastle upon Tyne NE4 6BE
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Abstract
BACKGROUND Although severe T cell immunodeficiency in DiGeorge anomaly is rare, previous studies of humoral function in these patients have found no antibody abnormalities but have not examined the response to polysaccharide antigens. Isolated cases of autoimmunity have been reported. Several patients with 22q11.2 deletion attending our immunology clinic suffered recurrent sinopulmonary infection or autoimmune phenomena. AIMS To investigate humoral immunodeficiency, particularly pneumococcal polysaccharide antibody deficiency, and autoimmune phenomena in a cohort of patients with 22q11.2 deletion. METHODS A history of severe or recurrent infection and autoimmune symptoms were noted. Lymphocyte subsets, immunoglobulins, IgG subclasses, specific vaccine antibodies, and autoantibodies were measured. Subjects were vaccinated with appropriate antigens as indicated. RESULTS Of 32 patients identified, 26 (81%) had severe or recurrent infection, of which 13 (50%) had abnormal serum immunoglobulin measurements and 11/20 >/=4 years old (55%) had an abnormal response to pneumococcal polysaccharide. Ten of 30 patients (33%) had autoimmune phenomena; six (20%) were symptomatic. CONCLUSIONS Humoral immunodeficiency is more common than previously recognised in patients with 22q11.2 deletion. Normal T cell function and immunoglobulin levels do not exclude poor specific antibody responses. Patients should be referred for formal immunological assessment of cellular and humoral immune function.
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Affiliation(s)
- A R Gennery
- Department of Paediatric Immunology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK.
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Abstract
AIMS To evaluate outcome following neonatal bone marrow transplantation (BMT) for severe combined immunodeficiency (SCID) when there is a family history of a previously affected sibling, and to compare results with those published for in utero BMT. METHODS A retrospective review of cases referred and transplanted between 1987 and 1999, focusing on infectious and graft versus host disease (GvHD) complications after BMT, and T and B lymphocyte function. Thirteen patients received 18 stem cell transplants: four whole marrow, one cord blood, 10 parental T cell depleted (TCD) haplo-identical, and three TCD unrelated donor BMT. Nine were conditioned with busulphan and cyclophosphamide. RESULTS All are alive and well (six months to 11.5 years after BMT). Six had grade I-II acute GvHD and two chronic GvHD (now resolved). Three had a top up BMT for poor T cell function, one had a third BMT for graft failure and chronic GvHD, and one had a third BMT for graft failure. Twelve have good in vitro proliferation to T cell mitogens, and all have normal serum IgA levels. Three receive intravenous immunoglobulin; for one of these, it is less than one year since BMT. Nine are above the 2nd centile, and 10 of 12 old enough to be assessed have normal neurodevelopment. CONCLUSION These results are better than those published for in utero BMT for SCID. Early postnatal BMT should be the preferred option in neonatal SCID.
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Affiliation(s)
- L Kane
- Department of Paediatric Immunology, Newcastle General Hospital, Newcastle upon Tyne, UK
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Carrol ED, Latif AH, Misbah SA, Flood TJ, Abinun M, Clark JE, Pugh RE, Cant AJ. Lesson of the week: Recurrent bacterial meningitis: the need for sensitive imaging. BMJ 2001; 323:501-3. [PMID: 11532847 PMCID: PMC1121082 DOI: 10.1136/bmj.323.7311.501] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- E D Carrol
- Department of Paediatric Infectious Diseases and Immunology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
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Abstract
BACKGROUND CD40 ligand (CD40L) deficiency is a rare X linked immunodeficiency disorder leading to recurrent bacterial infection, with cryptosporidial enteritis and subsequent hepatic cirrhosis. Bone marrow transplantation offers the only cure. OBJECTIVE To analyse retrospectively the outcome of bone marrow transplantation for this condition in one centre. DESIGN A retrospective case note analysis was performed, identifying all patients with CD40L deficiency who had undergone bone marrow transplantation between May 1988 and December 2000. Details of pre-existing infection, pretransplantation immunological and infective data, transplant procedure (particularly donor type and HLA match), conditioning regimen, and marrow manipulation were analysed. Post-transplantation data including infective episodes, engraftment details, immune function, complications, and outcome were recorded. RESULTS Eight boys (age 1-14 years, median 5.75) had transplants. Six received T cell depleted unrelated donor marrow. Four survive and have normal immune function. Six had previous Pneumocystis carinii pneumonia and three had histological liver damage. Survival was associated with younger age at transplantation and normal liver histology. CONCLUSIONS Bone marrow transplantation can be curative in CD40L deficiency. Better outcome is associated with younger age at transplantation and normal liver histology.
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Affiliation(s)
- K Khawaja
- Department of Paediatric Immunology, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK
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Crooks BN, Taylor CE, Turner AJ, Osman HK, Abinun M, Flood TJ, Cant AJ. Respiratory viral infections in primary immune deficiencies: significance and relevance to clinical outcome in a single BMT unit. Bone Marrow Transplant 2000; 26:1097-102. [PMID: 11108309 DOI: 10.1038/sj.bmt.1702656] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Respiratory viral infections are major causes of morbidity and mortality in children with SCID and other primary immunodeficiencies who require BMT. Twenty-two of 73 (30%) such children were admitted with respiratory viral infections, of whom 13/22 (59%) died. All viruses were detected in nasopharyngeal aspirate (NPA). Virus was only found in BAL in those with LRTI. Eleven of 22 (50%) had paramyxovirus infections, all with severe viral pneumonitis which worsened post BMT. Five of 11 (45.5%) survived overall. All 11 received aerosolised ribavirin; five of 11 received additional inhaled immunoglobulin and corticosteroid. Three of 5 (60%) survived compared with two of six (33.3%) not thus treated. Three of 22 (13.6%) had adenoviruses; one died of disseminated disease, including pneumonia despite intravenous ribavirin. Eleven patients had rhinovirus detected; nine of 11 (82%) were asymptomatic or coryzal and survived. Two patients with additional severe lung pathologies had LRT rhinovirus and died. All patients received intravenous immunoglobulin. No treatments resulted in viral clearance without successful T cell engraftment. Respiratory viruses, particularly paramyxoviruses and adenoviruses are common, significant pathogens in these patients, significantly worsening outcome of BMT. NPA is an ideal specimen for diagnosis and monitoring of infection. Aggressive treatments may reduce viral replication and damage. Nebulised immunoglobulin and corticosteroid in LRTI may improve respiratory function and outcome.
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Affiliation(s)
- B N Crooks
- Children's BMT Unit, Newcastle General Hospital, Newcastle-upon-Tyne, UK
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Gennery AR, Clark JE, Flood TJ, Abinun M, Cant AJ. T-cell-depleted bone marrow transplantation from unrelated donor for [correction of allogeneic sibling for] X-linked hyperimmunoglobulin M syndrome. J Pediatr 2000; 137:290. [PMID: 10931436 DOI: 10.1067/mpd.2000.106445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Congenital immunodeficiency in hyper IgE syndrome is characterised by a markedly raised IgE level, recurrent staphylococcal skin infection and pneumatoceles. Standard treatments include anti-staphylococcal antibiotics. We report a severely affected patient in whom successful bone marrow transplantation was followed by reappearance of the immunodeficiency. We conclude that bone marrow transplantation does not cure the immunological features of the hyper IgE syndrome. Bone Marrow Transplantation (2000) 25, 1303-1305.
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Affiliation(s)
- A R Gennery
- Department of Paediatric Immunology, Newcastle General Hospital, Newcastle upon Tyne, UK
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Abstract
BACKGROUND Pneumocystis carinii is an important pathogen in immunodeficiency but may be an unrecognised cause of respiratory compromise. OBJECTIVES To ascertain the incidence of P carinii pneumonia (PCP) at presentation of severe combined immunodeficiency (SCID), whether it had been diagnosed, and the effect of treatment on outcome. SETTING The supraregional paediatric bone marrow transplant unit for primary immunodeficiencies at Newcastle General Hospital. METHODS Retrospective case note review of infants referred with a diagnosis of SCID from 1992 to 1998. RESULTS Ten of 50 infants had PCP at presentation; only one was diagnosed before transfer. Eight were diagnosed by bronchoalveolar lavage and two by lung biopsy. In only one was P carinii identified in nasopharyngeal secretions. Five required ventilation for respiratory failure but all were successfully treated with co-trimoxazole and methylprednisolone with or without nebulised budesonide. Nine survived to bone marrow transplantation and four are long term survivors after bone marrow transplantation; no deaths were related to PCP. CONCLUSIONS PCP is a common presenting feature of SCID but is rarely recognised. Bronchoalveolar lavage or lung biopsy are needed for diagnosis. Treatment with co-trimoxazole is highly successful.
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Affiliation(s)
- J E Berrington
- Paediatric Immunology and Infectious Diseases Unit, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK
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Abstract
The Arizona Department of Health Services performed an investigation to determine the health effects associated with the use of a mercury-containing beauty cream. A urine test for mercury was offered to cream users who contacted the Arizona Department of Health Services. Those with urine mercury levels > 20 micrograms/L were offered clinical evaluation. Eighty-nine urine specimens were submitted for testing. Of these, 66 showed an elevated urine mercury level (> 20 micrograms/L), and 55 people were evaluated in clinic. There were no major abnormalities found through physical examination or laboratory testing. Urine mercury levels declined from an initial mean of 170 micrograms/L to 32 micrograms/L at the final test (mean, 139 days later). The high urine mercury levels indicate that the use of this cosmetic cream constitutes a significant exposure. Neuropsychiatric symptoms were frequently reported, but few objective signs were noted.
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Affiliation(s)
- C McRill
- University of Arizona, Tucson, USA.
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Abstract
Neurological complications of malignant infantile osteopetrosis are well recognised; successful bone marrow transplantation, when performed early in life, can prevent or halt some of them. In a subgroup of infants osteopetrosis is associated with primary retinal degeneration and/or generalised neurodegeneration. Bone marrow transplantation, in spite of being successful in correcting the osseous and haematological abnormalities, does not influence the progressive course of the neurodegenerative disorder. Thus, the recognition of this subgroup of infants with a very poor prognosis is essential before deciding on bone marrow transplantation.
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Affiliation(s)
- M Abinun
- Department of Paediatrics, Newcastle General Hospital, Newcastle Upon Tyne, UK.
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Taylor CE, Osman HK, Turner AJ, Flood TJ, Abinun M, Crooks B, Cant AJ. Parainfluenza virus and respiratory syncytial virus infection in infants undergoing bone marrow transplantation for severe combined immunodeficiency. Commun Dis Public Health 1998; 1:202-3. [PMID: 9782636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Respiratory syncytial virus and parainfluenza virus infection carry a poor prognosis in severe combined immunodeficiency (SCID), particularly if the viral load is high. Patients with high viral load develop severe pneumonitis at engraftment which may possibly be modulated by immunotherapy, including high dose nebulised corticosteroids. Further work is required to develop effective treatment for this severe condition.
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Affiliation(s)
- C E Taylor
- Newcastle Public Health Laboratory, Newcastle General Hospital, Newcastle upon Tyne.
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Botto LD, Olney RS, Mastroiacovo P, Khoury MJ, Moore CA, Alo CJ, Costa P, Edmonds LD, Flood TJ, Harris JA, Howe HL, Olsen CL, Panny SR, Shaw GM. Chorionic villus sampling and transverse digital deficiencies: evidence for anatomic and gestational-age specificity of the digital deficiencies in two studies. Am J Med Genet 1996; 62:173-8. [PMID: 8882399 DOI: 10.1002/(sici)1096-8628(19960315)62:2<173::aid-ajmg11>3.0.co;2-l] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Several but not all studies indicate that chorionic villus sampling (CVS) is associated with an increased risk for transverse limb deficiencies, including digital deficiencies. It has been suggested that variations in results regarding the transverse digital deficiencies (TDDs) may be due to the use of different classification criteria. We present the combined analysis of two case-control studies, the U.S. Multistate CVS (US) study and the Italian Multicentric Birth Defects (IP-IMC) study, using two different definitions of TDDs. We compared the frequency of CVS exposure in control infants with that among those infants with any number of affected digits (any TDD), and those with all five digits of at least one limb affected (extensive TDDs). The estimated relative risk (RR) for any TDD following CVS was 10.6 (IPIMC) and 6.6 (US). For the extensive TDDs, the RR was 30.5 (IPIMC) and 10.7 (US). In both studies, extensive TDDs were less than 25% of all TDDs. Compared to all TDDs, extensive TDDs were more likely to occur after CVS performed earlier in the first trimester (before 10-11 weeks' gestation). These findings suggest a relationship between the timing of CVS and the severity of TDDs; indicate that using a restrictive definition of TDDs (all five digits affected) may limit the ability to evaluate the association between CVS and TDDs in populations in whom CVS is usually performed at or after 10 weeks' gestation; and highlight the necessity to consider gestational age in any evaluation of the relative risk for limb deficiencies associated with CVS.
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Affiliation(s)
- L D Botto
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Olney RS, Khoury MJ, Alo CJ, Costa P, Edmonds LD, Flood TJ, Harris JA, Howe HL, Moore CA, Olsen CL. Increased risk for transverse digital deficiency after chorionic villus sampling: results of the United States Multistate Case-Control Study, 1988-1992. Teratology 1995; 51:20-9. [PMID: 7597654 DOI: 10.1002/tera.1420510104] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Although numerous infants have been reported with transverse limb deficiencies after their mothers had undergone chorionic villus sampling (CVS), it has been unclear whether the procedure caused these defects. We report the results of the first multistate case-control study to assess and quantify the risk for specific limb deficiencies associated with CVS. Case subjects were 131 infants with nonsyndromic limb deficiency ascertained from 7 population-based birth defect surveillance programs, and born from 1988-1992 to mothers 34 years of age or older. Control subjects were 131 infants with other birth defects. We ascertained exposure to CVS from medical records and maternal and physician questionnaires. We assessed rates and timing of exposure to CVS, and estimated relative and absolute risks for anatomic subtypes of limb deficiency. The odds ratio for all types of limb deficiency after CVS from 8-12 weeks' gestation was 1.7 (95% confidence interval, 0.4-6.3). For specific anatomic subtypes, the strongest association was for transverse digital deficiency (odds ratio = 6.4; 95% confidence interval, 1.1-38.6). The risk for transverse digital deficiency increased with earlier gestational exposure (P < 0.01 for trend). We estimated that the absolute risk for transverse digital deficiency in infants after CVS was 1 per 2,900 births (0.03%). Exposure to CVS was associated with a sixfold increase in risk for transverse digital deficiency. The causality of this association is supported by its strength, specificity, biologic plausibility, and consistency with the results of previous studies. Although some centers already inform patients about risk for limb deficiency, this study quantifies the magnitude of risk associated with CVS from 8-12 weeks' gestation.
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Affiliation(s)
- R S Olney
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA
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Aickin M, Chapin CA, Flood TJ, Englender SJ, Caldwell GG. Assessment of the spatial occurrence of childhood leukaemia mortality using standardized rate ratios with a simple linear Poisson model. Int J Epidemiol 1992; 21:649-55. [PMID: 1521967 DOI: 10.1093/ije/21.4.649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Reports of a suspected cluster of childhood leukaemia cases in West Central Phoenix have led to a number of epidemiological studies in the geographical area. We report here on a death certificate-based mortality study, which indicated an elevated rate ratio of 1.95 during 1966-1986, using the remainder of the Phoenix standard metropolitan statistical area (SMSA) as a comparison region. In the process of analysing the data from this study, a methodology for dealing with denominator variability in a standardized mortality ratio was developed using a simple linear Poisson model. This new approach is seen as being of general use in the analysis of standardized rate ratios (SRR), as well as being particularly appropriate for cluster investigations.
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Affiliation(s)
- M Aickin
- Department of Family and Community Medicine, University of Arizona, Tucson
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Abstract
In epidemiologic and public health studies of disease incidence in geographic subpopulations, attention is properly directed toward the ascertainment of accurate numerators. Population or person-years denominators are generally given less consideration, under the assumption that estimates produced by sources other than the state health department are sufficiently accurate. Here, we report our experience in estimating person-years denominators in the highly urbanized, rapidly expanding population of Maricopa County, Arizona. The usual sources of population estimates were found to be of little use for public health purposes, and so we report on a method for obtaining smoothed person-years figures that can accurately reflect population acceleration which varies from one time period to another. Our method is to regress the logarithm of census enumerations on quadratic or tertic polynomials in time. We describe how differential reliability of census figures can be incorporated into our procedure, and how the problem of missing census data can be handled by an iterated regression method. Our evidence suggests that the logarithmic regression model works well, even in the face of rapid and erratic population growth or decline.
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Affiliation(s)
- M Aickin
- Arizona Department of Health Services, Division of Disease Prevention, Phoenix
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