Primary invasive aspergillosis of the digestive tract: report of two cases and review of the literature.

BACKGROUND: Disseminated aspergillosis is thought to occur as a result of vascular invasion from the lungs with subsequent bloodstream dissemination, and portals of entry other than sinuses and/or the respiratory tract remain speculative. METHODS: We report two cases of primary aspergillosis in the digestive tract and present a detailed review of eight of the 23 previously-published cases for which detailed data are available. RESULTS AND CONCLUSION: These ten cases presented with symptoms suggestive of typhlitis, with further peritonitis requiring laparotomy and small bowel segmental resection. All cases were characterized by the absence of pulmonary disease at the time of histologically-confirmed gastrointestinal involvement with vascular invasion by branched Aspergillus hyphae. These cases suggest that the digestive tract may represent a portal of entry for Aspergillus species in immunocompromised patients.

Fatal myocardial aspergillosis in an immunosuppressed child.

A girl with resistant acute myeloid leukemia (AML) had a stem cell transplantation. Preceding transplantation, she had recurrent pneumonitis. No causative agent was identified. Despite several antibiotics including high-dose liposomal amphotericin-B, pulmonary infection progressed. Aspergillosis, always considered, could not be documented. She died from cardiac arrest on the second day after transplantation, with no forewarning of previous heart disease. Pericardial and myocardial aspergillosis was an autopsy finding. Pericardial and myocardial aspergillosis, rare manifestations of systemic aspergillosis, should be considered in any immunocompromised patient with long-lasting pulmonary infection, even in the absence of specific cardiac findings.

Recovery of immune reactivity after T-cell-depleted bone marrow transplantation depends on thymic activity.

To evaluate the importance of the thymus for the reconstitution of immunity in recipients of a T-cell-depleted bone marrow, we measured the appearance of CD4(+)CD45RA(+)RO(-) naive T cells (thymic rebound), restoration of the diversity of the T-cell-receptor (TCR) repertoire and the response to vaccinations with tetanus toxoid (TT). Repopulation by CD4(+)CD45RA(+)RO(-) thymic emigrants varied among patients, starting at approximately 6 months after transplantation. Young patients reconstituted swiftly, whereas in older patients, the recovery of normal numbers of naive CD4(+) T cells could take several years. Restoration of TCR diversity was correlated with the number of naive CD4(+)CD45RA(+)RO(-) T cells. Moreover, the extent of the thymic rebound correlated with the patient's capacity to respond to vaccinations. Patients without a significant thymic rebound at the moment of vaccination (CD4(+)CD45RA(+)RO(-) T cells less than 30 microL) did not respond, or responded only marginally even after 3 boosts with TT. We conclude that during the first year after transplantation, the absence of an immune response is due mainly to the loss of an adequate T-cell repertoire. Restoration of the repertoire can come only from a thymic rebound that can be monitored by measuring the increase of CD4(+)CD45RA(+)RO(-) naive T cells. This will allow postponing revaccinations to a moment when the patient will be able to respond more effectively. This may be particularly useful in the elderly patient who, owing to low thymic activity, might not yet be able to respond 1 year after transplant when revaccinations are usually scheduled.

CD52 antibodies for prevention of graft-versus-host disease and graft rejection following transplantation of allogeneic peripheral blood stem cells.

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity after allogeneic bone marrow transplantation, but can be avoided by removing T lymphocytes from the donor bone marrow. However, T cell depletion increases the risk of graft rejection. In this study, two strategies are used to overcome rejection: (1) use of high doses of stem cells obtained from peripheral blood (PBSC), (2) admixture with a CD52 monoclonal antibody in order to deplete both donor and residual recipient lymphocytes. Two antibodies are compared: CAMPATH-1G (rat IgG2b) and its humanized equivalent CAMPATH-1H (human IgG1). A total of 187 consecutive patients at six centers received PBSC transplants from HLA-matched siblings between 1997 and 1999. A wide spectrum of diseases, both malignant and non-malignant, was included. The recovery of CD34+ cells after antibody treatment was close to 100%. The risk of acute GVHD (grade 2 to 4) was 11% in the CAMPATH-1G group and 4% in the CAMPATH-1H group (P = NS). The risk of chronic GVHD (any grade) was 11% in the CAMPATH-1G group and 24% in the CAMPATH-1H group (P = 0.03) but the risk of extensive chronic GVHD was only 2%. The overall risk of graft failure/rejection was 2%, not significantly different between the two antibodies. Antibody treatment was equally effective at concentrations between 10 microg/ml and 120 microg/ml and it made no significant difference to the outcome whether the patients received post-transplant immunosuppression or not (87% did not). Transplant-related mortality in this heterogenous group of patients (including high-risk and advanced disease) was 22% at 12 months. It is proposed that treatment of peripheral blood stem cells with CAMPATH-1H is a simple and effective method for depleting T cells which may be applicable to both autologous and allogeneic transplants from related or unrelated donors. Special advantages of this approach are the simultaneous depletion of donor B cells (which reduces the risk of EBV-associated lymphoproliferative disease) and the concomitant infusion of CAMPATH-1H to deplete residual recipient T cells and thus prevent graft rejection.

Reconstitution of the T-cell compartment after bone marrow transplantation: restoration of the repertoire by thymic emigrants.

We have studied the reconstitution of the T-cell compartment after bone marrow transplantation (BMT) in five patients who received a graft-versus-host disease (GVHD) prophylaxis consisting of methotrexate, cyclosporin, and 10 daily injections (day -4 to day +5) of Campath-1G. This treatment eliminated virtually all T cells (7 +/- 8 T cells/microL at day 14) which facilitated the analysis of the thymus-dependent and independent pathways of T-cell regeneration. During the first 6 months, the peripheral T-cell pool was repopulated exclusively through expansion of residual T cells with all CD4(+) T cells expressing the CD45RO-memory marker. In two patients, the expansion was extensive and within 2 months, the total number of T cells (CD8>>CD4) exceeded 1,000/microL. In the other three patients, T cells remained low (87 +/- 64 T cells/microL at 6 months) and remained below normal values during the 2 years of the study. In all patients, the first CD4(+)CD45RA+RO- T cells appeared after 6 months and accumulated thereafter. In the youngest patient (age 13), the increase was relatively fast and naive CD4(+) T cells reached normal levels (600 T cells/microL) 1 year later. In the four adult patients (age 25 +/- 5), the levels reached at that time-point were significantly lower (71 +/- 50 T cells/microL). In all patients, the T-cell repertoire that had been very limited, diversified with the advent of the CD4(+)CD45RA+RO- T cells. Cell sorting experiments showed that this could be attributed to the complexity of the T-cell repertoire of the CD4(+)CD45RA+RO- T cells that was comparable to that of a normal individual and that, therefore, it is likely that these cells are thymic emigrants. We conclude that after BMT, the thymus is essential for the restoration of the T-cell repertoire. Because the thymic activity is restored with a lag time of approximately 6 months, this might explain why, in particular in recipients of a T-cell-depleted graft, immune recovery is delayed.

Clinical consequences of sensitisation to minor histocompatibility antigens before allogeneic bone marrow transplantation.

To study sensitisation to minor histocompatibility antigens (mHag) before and after BMT, we measured antidonor CTL activity in five patients who had rejected their graft, and in a control group of 10 leukemic patients who engrafted without complications. All patients were transplanted with marrow from an HLA-identical sibling. Fourteen patients were conditioned with cyclophosphamide (120 mg/kg) and TBI (1350 cGy) and received a T cell-depleted graft, while one patient with aplastic anaemia received cyclophosphamide alone and unmanipulated marrow. Before transplantation, anti-donor CTL activity was detected in two of the 15 patients. These patients rejected their grafts at days 21 and 58, respectively. In the other three patients who rejected their grafts at days 41, 60 and 250, CTL activity was found only after transplantation. In contrast, no anti-donor CTLs could be detected at any time in the 10 patients who engrafted permanently. We have identified some of the mHags recognised during graft rejection by cloning and subsequent specificity analysis of the recipient CTLs. In the patient who rejected at day 41 without detectable immunisation before BMT, the response was directed against HA-1, a minor antigen known to play a role in GVHD. In the other combinations, a significant part of the CTL activity was directed against the male antigen H-Y. In the patient who rejected the marrow of her HLA-identical brother at day 250, two clones recognised H-Y, while five others recognised at least three distinct autosomal mHags. This patient had an HLA-identical sister who expressed only one autosomal mHag that had been recognised by one single T cell clone. After re-transplantation with the marrow of this second donor, the CTL activity could no longer be detected and the patient engrafted without further complications.

Donor lymphocyte infusion for the treatment of relapse after allogeneic hematopoietic stem cell transplantation.

The results of donor lymphocyte infusion (DLI) for treatment of relapse after bone marrow transplantation (BMT) are reviewed. Durable complete remission can be achieved at the molecular level for a majority (more than 70%) of patients with CML, when treated at early relapse. Results are less favourable for acute leukemias, although useful responses have been reported. Data are scarce though promising for myelodysplastic syndromes and multiple myeloma. Major treatment-associated toxicities are GVHD and bone marrow aplasia. The latter complication can be predicted by evaluating the level of residual donor-derived hematopoiesis. Modification of infused cells (CD8 negative selection or transduction with a suicide gene), addition of peripheral blood stem cells, and early implementation of escalating doses may counteract the complications and increase the response rate. Response rate is variably influenced by the presence of chronic GVHD after initial BMT, T-cell depleted BMT, underlying disease and stage at relapse, and the level of mixed chimerism. DLI is a direct demonstration of the graft-versus-leukemia effect (GVL). Because GVL after BMT is sometimes the predominant cause of cure, it may be advisable in such situations to redirect the conditioning regimens for BMT towards engraftment and less immediate cytotoxicity.

Haploidentical family member transplants for patients with chronic myeloid leukaemia: a report of the Chronic Leukaemia Working Party of off European Group for Blood and Marrow Transplantation (EBMT).

Within the registry of the chronic leukaemia working party of the European Group for Blood and Marrow Transplantation, data were available from 103 patients with chronic myeloid leukaemia who were treated by bone marrow transplantation from haploidentical family members. The patients of median age 30 years were transplanted between 1983 and 1994 in 25 European centres. The overall probabilities of survival and leukaemia-free survival (LFS) at 5 years were 32 and 25%, respectively. In univariate analysis, two factors were identified which affected survival and LFS, ie the state of disease at the time of transplant and the degree of HLA disparity. Fifty-nine patients were transplanted in first chronic phase and the probability of survival at 2 years was 47%. Forty-four patients received their transplants for advanced disease and their probability of survival at 2 years was 25% (P = 0.004). Donor bone marrow was HLA-mismatched for 0-1 antigens in 54 patients (group 1) and for 2-3 antigens in 49 patients (group 2). At 2 years, the probabilities of survival for groups 1 and 2 were 46 and 27% (P < 0.02) and the probabilities of LFS were 43 and 24% (P < 0.03), respectively. Multivariate analysis confirmed the prognostic importance of the disease stage and of the HLA disparity. Patients transplanted in first chronic phase from a donor mismatched for 0-1 HLA antigens had a probability of survival of 52% at 2 years compared with 19% for patients transplanted in advanced disease stage from donors mismatched for 2-3 HLA antigens.

[Bone marrow involvement in Whipple's disease]. / Atteinte de la moelle osseuse en cas de maladie de Whipple.

The authors present the case of a 57 years old woman who had atypical Whipple's disease characterized solely by migratory arthralgia, weight loss and unexplained anemia which had lasted for 5 years. Once the diagnosis of Whipple's disease was established on abdominal lymph node biopsy, the retrospective study of a bone marrow biopsy revealed the presence of PAS-positive sickle-formed particles within medullary macrophages. Review of the literature attests the rarity of ante-mortem diagnosis of Whipple's disease in bone marrow preparations. We suggest that bone marrow biopsies stained with the PAS technique be employed in clinical settings of chronic migratory arthralgia and unexplained anemia.

[Airport malaria: mini-epidemic in Switzerland]. / Paludisme des aéroports: mini-épidémie en Suisse.

Five cases of airport malaria were observed in Geneva in the summer of 1989. All the patients lived within 2 km of Geneva-Cointrin International Airport. They were hospitalized between July 14 and August 2 for high fever. None had received a recent blood transfusion, an i.v. injection or traveled to a tropical country, except for one, a former pilot, whose last brief visit had been a year earlier. High minimum temperatures between July 6 and 10 in all likelihood allowed the survival of infected anopheles introduced by an aircraft. P. falciparum was identified in the blood smears of all the patients. Four had one or more symptoms of serious malaria and received intravenous treatment. In the fifth patient, treatment with cotrimoxazole for suspected acute pyelonephritis made diagnosis particularly difficult because the malaria infection was partially controlled by the antibiotic therapy. The time necessary for diagnosis of malaria varied from 5 to 31 days in the 5 cases. Airport malaria has been observed over the past twenty years in Europe, particularly in the summer, and is often serious because of late diagnosis and the type of plasmodium most frequently involved, P. falciparum. This diagnosis should be considered in patients with high fever of unknown origin, even when they have not travelled to an endemic zone.

Autoantibody repertoire analysis in normal and lupus-prone mice.

We have analyzed at the clonal level (limiting dilution assay) the repertoire of lipopolysaccharide (LPS)-responsive murine B cells committed to the production of autoantibodies characteristic of systemic lupus erythematous (SLE), i.e. anti-single-stranded DNA (ssDNA), anti-double-stranded DNA, anti-Sm and rheumatoid factors (RF). Our results demonstrated that: (1) the frequency of precursor B cells producing each lupus autoantibody (approximately 1 in every 100-400 LPS-responding B cell) was similar in two non-autoimmune (C57BL/6 and BALB/c) and four SLE-prone (NZB, (NZB x NZW)F1, MRL/MpJ and BXSB/MpJ) mice despite the marked differences in autoimmune responses in the different SLE-prone mice, and (2) the relative frequency of autoantibody-secreting precursor B cells was constant throughout life, and equally distributed among activated and resting B-cell populations and among B cells from the peritoneal cavity and spleen. The lack of association of anti-ssDNA secretion with anti-Sm or RF secretion in cultures set up with a smaller number of B cells ruled out the possibility that the similar frequency of different autoantibody-secreting cell precursors is due to the poly-specificity of IgM autoantibodies. Notably, the frequencies of autoantibody-secreting precursor cells were significantly lower, approximately 4 and 10 times, than those of anti-tetanus toxoid and anti-dinitrophenyl antibody-producing precursor B cells, respectively. The similar frequency of precursor B cells producing four different lupus autoantibodies on the one hand and the considerable variation in each autoimmune response among SLE-prone mice on the other, support the hypothesis that specific stimulatory mechanisms may govern each autoimmune response in different SLE strains of mice.

Treatment with high doses of anti-IgM prevents, but with lower doses accelerates autoimmune disease in (NZW x BXSB)F1 hybrid mice.

We have treated autoimmune-prone (NZW x BXSB)F1 hybrid mice with polyclonal rabbit anti-mouse IgM antibodies starting from birth to define conditions leading to quantitative and functional elimination of the B cell compartment and to determine the effect of anti-IgM treatment on the development of autoimmune disease. A maintenance dose of anti-IgM antibodies (600 micrograms/wk), which efficiently induced B cell depletion in various non-autoimmune strains of mice, was not sufficient to deplete B cells from autoimmune-prone (NZW x BXSB)F1 mice. (NZW x BXSB)F1 mice required approximately twice as many anti-IgM antibodies (1200 micrograms/wk) to maintain the suppression of B cell development. Continuous treatment with the sub-suppressive dose of anti-IgM antibodies led to a marked acceleration of autoimmune disease in (NZW x BXSB)F1 mice. In contrast, elimination of B cells in (NZW x BXSB)F1 mice with a higher dose of anti-IgM antibodies (1200 micrograms/wk) completely prevented autoantibody production, immune complex formation, and development of glomerulonephritis and vascular lesions associated with mononuclear cell infiltrations. Our results are a direct demonstration of the primary role of autoantibodies for the development of various tissue lesions seen in systemic lupus erythematosus (SLE) and indicates that autoreactive effector T cells, if they exist, play no major direct role in the pathogenesis of SLE, at least in (NZW x BXSB)F1 hybrid mice.