Hookworm infection of sigmoid colon masquerading as graft-versus-host disease in an allogeneic stem cell transplant recipient after donor lymphocyte infusion for refractory acute promyelocytic leukemia

Abstract Objective: Little information exists regarding pregnancy after allogeneic stem cell transplantation. Pregnancy in the setting of active graft-versus-host disease (GVHD) is even less common. We report an interesting case of a patient with active GVHD who had a spontaneous pregnancy four years after allogeneic stem cell transplant and whose GVHD remained stable during her pregnancy. Patient information: Our patient is a 27 year-old African-American female who was diagnosed with aplastic anemia in January 2002. She was initially treated with anti-thymocyte gamma globulin (ATG) and cyclosporine with minimal response. She was red blood cell and platelet transfusion dependent during this time. She was referred to the UAB Bone Marrow Transplant Center for evaluation for allogeneic stem cell transplant in June 2002. Her conditioning regimen included cyclophosphamide and ATG. She received her stem cell transplant on July 30, 2002 and was no longer transfusion dependent seven months after her transplant. In January 2003, the patient was diagnosed with GVHD of her oropharynx and skin. She was treated with cyclosporine and oral solumedrol initially. By February 2003, mycophenolate mofetil was added to her regimen. She was tapered off of the solumedrol by day +366 and maintained on cyclosporine and mycophenolate. Tapering of her immunosuppressive medication was attempted multiple times unsuccessfully. Unfortunately, she progressed to sclerodermatous changes of the skin that were confirmed as GVHD by biopsy. She started psoralen and UVA light therapy (PUVA) in August 2004. Subsequently, she was treated with topical hydroquinone and FK-506 along with photopheresis and physical and occupational therapy. Pentoxifylline and vitamin E were added in August 2005. By August 2006, photopheresis had been decreased to every month and she was controlled on mycophenolate and photopheresis. Planned immunosuppressant taper at four years post-transplant was complicated by an unplanned pregnancy at that time. The patient’s photopheresis was discontinued because of concerns for teratogenicity with psoralens. During her pregnancy, the patient was maintained on full dose mycophenolate and low dose oral FK-506. Of note, the patient was not on any estrogen supplementation at the time of conception. The patient was monitored by the transplant team serially throughout her pregnancy. Her GVHD did not progress objectively, and the patient reported subjective improvement. The patient went on to deliver a healthy female infant at term via C-section. Conclusions: Ours is the first reported case of pregnancy and successful delivery of a healthy infant in a patient with active extensive chronic GVHD. On review of the literature, only a few cases of spontaneous pregnancies after allogeneic stem cell transplant have been reported, and they typically involve reduced dose intensity chemoradiotherapy or occur in premenarchal patients. There are twenty unconfirmed cases of pregnancy in the transplant registry. More cases have been reported in solid organ transplant patients on immunosuppressive medications. As transplants for non-malignant disorders and the use of nonmyeloablative transplants increase, we expect to see more cases of pregnancy after transplant. Attention to fertility issues and monitoring for pregnancy in potentially fertile patients needs to be considered. Also, further research into the altered immune state during pregnancy may lead to further understanding of the mechanism of GVHD and possibly novel treatments.

Download Full-text

Conditioning with Fludarabine, Busulfan, and ATG Prior to Reduced-Intensity Allogeneic Stem Cell Transplant for CLL Is Associated with a Low Incidence of Acute Graft-Versus-Host Disease.

Blood ◽

10.1182/blood.v116.21.4568.4568 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4568-4568

Author(s):

Samantha M. Jaglowski ◽

Diane Scholl ◽

Patrick Elder ◽

Thomas S. Lin ◽

John C. Byrd ◽

...

Keyword(s):

Stem Cell ◽

Graft Versus Host Disease ◽

Stem Cell Transplant ◽

Chronic Gvhd ◽

Cell Transplant ◽

Allogeneic Stem Cell Transplant ◽

Graft Versus Host ◽

Significant Difference ◽

Reduced Intensity ◽

Count Recovery

Abstract Abstract 4568 Introduction: Allogeneic stem cell transplant (SCT) is the only potentially curative treatment available for CLL. While transplant-related mortality has decreased with use of reduced-intensity conditioning (RIC) regimens, acute and chronic graft-versus-host-disease (GVHD) remain important causes of morbidity and mortality, with up to 50% of patients developing chronic GVHD (cGVHD). While the optimal way to combat this has not been established, in vitro T cell depletion with ATG or alemtuzumab has been employed to attempt to lessen its incidence. Herein, we report our institutional experience with each of these agents. Patients and methods: Information on all patients who underwent RIC allogeneic SCT at Ohio State from January 1, 2002 to June 29, 2010 was obtained following approval from the ORRP. Data collected by the transplant coordinators was correlated with data in our electronic databases. Comparative statistics were performed using the Fisher exact test and all p-values are two-sided. Results: Between January 1, 2002 and June 29, 2010, 50 patients with CLL/SLL underwent RIC allogeneic SCT at Ohio State. Pretransplant characteristics are listed in Table 1. Thirty patients received fludarabine, busulfan, and ATG (FBA) as a preparative regimen, and 8 patients received alemtuzumab, fludarabine, and TBI (Cam/Flu/TBI). Another 6 patients received fludarabine and busulfan, 4 received fludarabine and cyclophosphamide, one received pentostatin, fludarabine, and ATG, and the patient who had a cord blood transplant received fludarabine, cyclophosphamide, TBI, and ATG. The breakdown of characteristics between patients who received FBA and Cam/Flu/TBI is also provided in Table 1. None of the characteristics were statistically different. Time to count recovery is provided in Table 2. There was not a statistically significant difference in the time to count recovery between FBA and Cam/Flu/TBI. Patients who received Cam/Flu/TBI received significantly more DLIs; patients who received FBA have not required any DLIs. Incidence of acute and chronic GVHD is provided in Table 3. There was not a statistically significant difference in rates or grades of aGVHD, but patients who received Cam/Flu/TBI were more likely to develop extensive cGVHD. Conclusions: While patients who received Cam/Flu/TBI were more likely to receive DLI, these were all done to treat disease recurrence, reflecting changes in group practice over time. There were no failures to engraft with FBA, and while not statistically significant in comparison to Cam/Flu/TBI, only 10% of patients developed grade 3 or 4 aGVHD. All of the patients who received Cam/Flu/TBI and developed cGVHD developed extensive disease. While the Cam/Flu/TBI sample is small, the FBA patients appear to fare no worse in terms of count recovery and development of GVHD without exposure to TBI, and this has become our institutional practice for patients with CLL. Disclosures: Lin: GlaxoSmithKline: Consultancy, Employment.

Download Full-text