Case Series: Bone Marrow Failure in Teen Siblings with Unique RPS19 Variant

Abstract Aplastic anemia occurs when there is a lack of hematopoiesis in the bone marrow leading to peripheral pancytopenia. It is a rare entity and is often idiopathic. However, upon presentation, inherited bone marrow failure syndromes and acquired etiologies must be considered. Investigating causality is particularly important when multiple family members are affected, especially in a short amount of time. It is also essential to identify novel causative genetic variants of bone marrow failure in order to direct treatment in these patients. In our case series, we describe two siblings who presented two weeks apart with severe pancytopenia. The first patient is a 13 year-old non-binary female (prefers pronouns they/them/theirs) who presented from clinic after getting routine labs with white blood cell (WBC) 1.83 x10(3)/mcL, absolute neutrophil count (ANC) 0.16 x10(3)/mcL, hemoglobin (Hgb) 4.8 gm/dL, platelet 13 x10(3)/mcL. Bone marrow biopsy revealed marked hypocellularity (0-10%) with hypoplasia. The second patient is their 16 year-old brother who presented two weeks later with new-onset petechial rash and was found to have WBC 4 x10(3)/mcL, ANC 2.19 x10(3)/mcL, Hgb 6.3 gm/dL, platelet 16 x10(3)/mcL. His bone marrow biopsy demonstrated variable cellularity (10-70%), but after months of transfusion-dependence he met criteria for severe aplastic anemia. Laboratory evaluation for acquired etiologies such as infection was negative. Both patients had a shared medical history of depression briefly treated with fluoxetine, but otherwise no potential medical triggers or environmental exposures were identified. Telomere length analysis was normal and chromosomal breakage analysis was negative. Upon genetic evaluation, both patients were found to have a heterozygous variant of unknown significance of RPS19 (c.-163>T), which substitutes a moderately conserved nucleotide in the noncoding exon 1 in 5' untranslated region of RPS19. Although this variant has not been classified as pathogenic, three other variants in the 5' untranslated region of RPS19 have been reported in patients with Diamond-Blackfan Anemia (DBA). In contrast to classic DBA, these patients did not present in infancy or early childhood. Likewise, they lacked congenital anomalies or other classic phenotypic characteristics of disease. Lab studies showed normal erythrocyte adenosine deaminase levels, though it should be noted that these levels could not be obtained prior to transfusion in both patients. Given lack of other identified etiologies, however, an inherited bone marrow failure syndrome, possibly due to this variant, was presumed. With suspected but potentially unidentifiable genetic predisposition, matched sibling donor transplant was deferred and both patients underwent a matched unrelated donor bone marrow transplant with reduced-intensity conditioning. With these cases, we aim to share a unique presentation of aplastic anemia that reveals a potentially novel pathogenic variant as well as to provide our approach to medical management in pediatric aplastic anemia in the setting of uncertainty. Identification of other patients with bone marrow failure and this genetic variant will be important to determine its pathogenicity. Disclosures No relevant conflicts of interest to declare.

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Unexpected Fanconi Anemia Diagnosis in Patients with Bone Marrow Failure.

Blood ◽

10.1182/blood.v106.11.1056.1056 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1056-1056

Author(s):

Fernando O. Pinto ◽

Thierry Leblanc ◽

Gwenaelle Le Roux ◽

Helene Dastot ◽

Moema Santos ◽

...

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Clinical Features ◽

Fanconi Anemia ◽

Bone Marrow Failure ◽

Somatic Mosaicism ◽

Chromosome Breakage ◽

Large Set ◽

Chromosomal Breakage ◽

Group A

Abstract Early diagnosis of Fanconi Anemia (FA) in patients with bone marrow failure is critical for optimal clinical management. However, the remarkably high clinical variability and the potential emergence of revertant hematopoietic cells (somatic mosaicism) can obscure and delay the diagnosis of FA. Here we addressed FA diagnosis in a prospective series of adult and pediatric patients who presented with bone marrow failure without clear overall clinical picture of FA. Sixty-six patients were classified into three groups: (1) bone marrow failure likely to be congenital, based on dysmorphic features or a family history [n=18], (2) aplastic anemia likely to be idiopathic [n=32], (3) patients with intermediate clinical features not classified into the former groups [n=16]. Of note, FA patients with typical clinical features were not included in the present study. FA diagnosis was evaluated using chromosome breakage test and FANCD2 immunoblot in PHA-stimulated-PBL. In addition, skin primary fibroblasts were analysed in order to overcome potential hematopoietic FA reversion. For that purpose, and considering that chromosome breakage tests are barely efficient in fibroblasts, we used FANCD2 immunoblot and also developped a new flow cytometry test based on MMC-sensitivity in fibroblasts (to detect downstream FA/BRCA groups). Using these approaches, we detected FA in 4 previously undiagnosed patients: a 35-years old patient from the congenital-like group; a 10-years old patient presenting as an idiopathic aplastic anemia without any FA signs; and two patients from the intermediate group: a 10-years old patient with an isolated thrombocytopenia, and a 50-years old patient presenting with pancytopenia/MDS and complete hematopoietic reversion. Importantly, FA diagnosis was definitely excluded in all other patients. In conclusion, we could identify a few unexpected FA cases in a series of patients with bone marrow failure. Therefore, the comprehensive use of a large set of tests is useful for accurate FA diagnosis. Classical chromosomal breakage tests in PBL appeared to be sufficient to exclude FA in idiopathic aplastic anemia, whereas fibroblast analysis can be necessary to definitely diagnose or exclude FA in other patients.

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of the Telomerase RNA (TERC) and Telomerase Reverse Transcriptase (TERT) in Japanese Children with Aplastic Anemia.

Blood ◽

10.1182/blood.v106.11.3750.3750 ◽

2005 ◽

Vol 106 (11) ◽

pp. 3750-3750

Author(s):

Juan Liang ◽

Hirosi Yagasaki ◽

Koji Kato ◽

Kazuko Kudo ◽

Seiji Kojima

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Bone Marrow Failure ◽

Unrelated Donor ◽

Allogeneic Bone ◽

Healthy Controls ◽

Japanese Children ◽

Ribonucleoprotein Complex ◽

Base Substitutions ◽

Tert Gene

Abstract It is well known that the incidence of aplastic anemia (AA) is much higher in Japan than in Western countries. However the reason for this finding is not known. Genetic backgrounds related to AA may be different between populations. Recent studies have shown that some patients with apparently “acquired” AA have mutations in telomerase ribonucleoprotein complex genes such as TERC and TERT. We studied 96 Japanese children with acquired AA (age range, 0–16 years; median, 7 years) and 59 healthy controls for mutations in TERC and TERT genes. Of these children, 35 were classified as having nonsevere AA, 39 as having severe AA, and 22 as having very severe AA. In 7 patients, AA was secondary to acute hepatitis. We extracted DNA samples from peripheral blood and all exons and flanking introns of TERT and TERC were amplified by PCR using 19 primer pairs (1 TERC, 18 TERT). To determine the sequence, the PCR products were analyzed by ABI/PRISM 3100 automated sequencer. Telomere lengths of leukocytes were assessed by flow-FISH. For the TERC gene, no mutation was found. One polymorphism (n514 G>A) was observed in 57/96 (59.4%) of patients. The same substitutions were detected in 31/59 (52.5%) healthy controls. For the TERT gene, two novel heterozygous, nonsynonymous mutations were identified (exon5; n2045 G>A, exon6; n2177 C>T). These base substitutions introduce an amino acid change-G682D and T726M, respectively. Neither patient had any clinical characteristics suggesting constitutional bone marrow failure syndrome. The n2177C>T substitution was identified in a 9-year-old girl with very severe AA who failed to respond to immunosuppressive therapy. She received an allogeneic bone marrow transplant (BMT) from an unrelated donor, but did not engraft. She was then treated by a second BMT from an HLA haploidentical her mother. Her blood cells had a very short telomere compared with that of age-matched controls. Another patient carrying the n2045G>A substitution had nonsevere AA and did not require any specific medication for 8 years. Six polymorphisms in exons of the TERT gene were identified in 102 unrelated patients (n915 G>A, n2097 C>T, n2520 G>A, n2946 T>C, n3039 C>T, and n3366 G>A). The allele frequencies of these silent base substitutions were 38/192 (19.8%), 3/192 (1.6%), 1/192 (0.5%), 1/192 (0.5%), 57/192 (29.7%), 2/192 (1.0%), respectively. Additionally, we identified 5 polymorphisms in introns of the TERT genes in 64 patients (IVS4+143 A>G, IVS9+11 C>T, IVS13+45 C>T, IVS15+136 G>A, and IVS16+81 C>T). The frequencies were 52/192 (27.1%), 3/192 (1.6%), 7/192 (3.6%), 1/192 (0.5%), and 1/192 (0.5%), respectively. Except for two substitutions (n915G>A and IVS4+143A>G), the other 9 were not listed in the SNP database. We found a few patients with AA carrying mutations of telomerase ribonucleoprotein complex genes. Because the incidence of these mutations is not higher than that in Western populations, this genetic difference does not explain the higher incidence of AA in Japanese children.

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23 Years of Management: A Retrospective Review of Treatment for Aplastic Anemia.

Blood ◽

10.1182/blood.v114.22.1091.1091 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1091-1091

Author(s):

Connie M Piccone ◽

Marie Boorman Martin ◽

Zung Vu Tran ◽

Kim Smith-Whitley

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Retrospective Review ◽

Pediatric Patients ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Complete Response ◽

Primary Objective ◽

Hematopoietic Stem ◽

Transfusion Independence

Abstract Abstract 1091 Poster Board I-113 Introduction Aplastic anemia (AA) is a syndrome of bone marrow failure characterized by peripheral pancytopenia and marrow hypoplasia. In the past, AA was considered to be a fatal disease; however, current therapies, including bone marrow transplantation or immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporine (CSA), are curative in the majority of patients. IST is effective at restoring hematopoietic stem cell production, but relapse and evolution to myelodysplastic syndromes remain clinical challenges. Additionally, there is no real consensus regarding optimal CSA levels, duration of CSA treatment, or the optimal use of growth factors and their relationship to the development of clonal disease. Objectives The primary objective was to review treatment management for severe AA in pediatric patients in order to elucidate treatment differences and review morbidity and mortality as they relate to treatment variation. Study Design/Methods A retrospective review of pediatric patients treated at the Children's Hospital of Philadelphia for AA (both severe and moderate) over a 23 year period was performed. Results A total of 70 patients with AA were treated at our institution from 1985 to July 2008. Exclusions included: 6 patients who received some type of initial treatment at outside institutions, 4 patients who had missing records, and 2 patients who had a diagnosis of moderate AA. Thus, a total of 58 patient records were included in the analysis. Of the total patients reviewed, 60% were male and 40% were female. 34.5% of patients were African-American, and 57% were diagnosed in 2000 or later. The mean age at diagnosis was 9.5±5.8 years. 52% fell into the category of very severe AA based on published diagnostic criteria, 45% had severe AA, and 2 patients (3%) had moderate AA. 15.5% of patients developed AA in the setting of acute hepatitis. More than half of the patients treated with IST had a complete response (CR). The average time to CR was 15±15 months. Average duration of CSA treatment was 15±13 months and 8.6±10.7 months for growth factor. Two patients (3.5%) died, one from complications unrelated to AA and one from infectious complications post-BMT after initial IST failure. Average time to transfusion independence for all patients was 8±11 months (with a range of 0-54 months). Not surprisingly, the time to transfusion independence was significantly associated with IST failure (p=0.010). Patients who failed treatment had an average time to transfusion independence of 17±16 months as compared to those who were complete responders who had an average time to transfusion independence of 3±3 months. Additionally, there was a significant association between IST failure and CSA levels (p=0.014). Patients who had nontherapeutic CSA levels overall had an increased rate of treatment failure. Of those patients who were nontherapeutic, 56% were noncompliant with CSA administration. There was no significant association between IST failure and bone marrow cellularity (p=0.251). PNH was diagnosed in 5% of patients; there were no patients with evidence of myelodysplastic syndrome (MDS). Two of the 3 patients with PNH failed initial IST. Another 2 patients had evidence of a cytogenetic abnormality (16q deletion), but never progressed to MDS. (Note: averages presented as mean±SD) Conclusions/Methods With current IST regimens, AA is curative in the majority of pediatric patients. IST failure was associated with nonadherence to CSA treatment. For patients with confirmed clonal disease, it is possible that IST failure and the ultimate development of clonal disease are related. Disclosures No relevant conflicts of interest to declare.

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High Incidence of Fanconi Anemia in Patients with a Morphological Picture Consistent with Refractory Cytopenia of Childhood

Blood ◽

10.1182/blood.v118.21.2780.2780 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2780-2780

Author(s):

Ayami Yoshimi ◽

Charlotte M. Niemeyer ◽

Irith Baumann ◽

Stephan Schwarz-Furlan ◽

Detlev Schindler ◽

...

Keyword(s):

Bone Marrow ◽

Fanconi Anemia ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Test Group ◽

Clinical Feature ◽

Chromosomal Breakage ◽

Mild Phenotype ◽

European Working ◽

Chromosome Breaking

Abstract Abstract 2780 Introduction: Refractory cytopenia in childhood (RCC) is the most common subtype of myelodysplastic syndrome (MDS) in children. Differential diagnosis from inherited bone marrow failure (IBMF) such as Fanconi anemia (FA) remains an intriguing challenge, because most patients with RCC have a hypocellular bone marrow (BM) and dysplastic features in haematopoiesis are observed in both RCC and IBMF. Moreover the spectrum of phenotypic findings in FA is extremely wide. Some FA patients have a mild phenotype without malformation. The purpose of this study is to estimate the incidence of FA in an RCC cohort without a full clinical feature of FA, but subsequently diagnosed by chromosome breaking test. Patients and Methods: Between 01/2007 and 12/2010 reference pathologists of the European Working Group of MDS in Childhood (EWOG-MDS) provided a morphological report consistent with RCC in 137 children studied in Germany. Seventeen patients with hypercellular BM or abnormal karyotype, 2 patients, in whom dyskeratosis congenital was diagnosed after initial inclusion and one patient, in whom chromosome breaking test was not performed, were excluded. Results: Seven of remaining 117 patients had facial and/or skeletal anomalies typically noted in FA and one patient had a brother with FA. In these 8 patients, FA had been suspected by their local physicians (group FA-1). Nine patients (8.3%) without these typical anomalies were subsequently diagnosed of FA by chromosome breakage test (group FA-2). The diagnosis of RCC was finally made in the remaining 100 patients with negative chromosomal breakage test (group RCC). The clinical features of patients in each group are summarized in the Table. The mean corpuscular volume of red cells (MCV) was elevated (> +2SD) for ages in all patients with FA, but only 42 % in patient with RCC. In some children of group FA-2 additional non-haematological abnormalities were also observed. However, they were not evident and or typical to prompt the treating physicians to suspect FA. A few patients in the group RCC also had some physical anomalies, not specific for any of the known IBMF disorders. Possibly that other known or not yet described IBMF disorders remain uncovered in children with “de novo” RCC. Conclusion: Our results illustrate that the same haematological features and congenital anomalies can be noted in FA and RCC. More importantly, they indicate that the exclusion of FA by a chromosomal breakage test or other methods is mandatory in all patients prior to diagnosis RCC. Chromosomal breakage analysis may identify patients with FA in 8% of patients with a morphological description of RCC without a full clinical picture of FA. Disclosures: No relevant conflicts of interest to declare.

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Genetics in Inherited Bone Marrow Failure Disorders

Blood ◽

10.1182/blood.v126.23.sci-1.sci-1 ◽

2015 ◽

Vol 126 (23) ◽

pp. SCI-1-SCI-1

Author(s):

Sioban Keel

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Accurate Diagnosis ◽

Cell Transplant ◽

Medical Monitoring ◽

Hematopoietic Stem ◽

New Genes ◽

Increased Risk

The classical Inherited Bone Marrow Failure Syndromes (IBMFS) such as Fanconi anemia, Dyskeratosis Congenita, Shwachman-Diamond syndrome, and Diamond-Blackfan anemia are a heterogeneous group of disorders, all of which are characterized by impaired hematopoiesis, varying degrees of peripheral cytopenias and marrow hypoplasia and dysplasia. Many of these are associated with an increased risk of clonal dominance and evolution to myelodyplastic syndrome (MDS) and acute myeloid leukemia (AML). For the purposes of this talk, the familial MDS and acute leukemia predisposition syndromes are also included in the broad term IBMFS. The genes responsible for a subset of IBMFS have been identified and will be reviewed. However, the causative mutations in many patients presenting with seemingly inherited marrow failure remain unknown. Gene discovery in IBMFS has been difficult in large part due to the phenotypic heterogeneity of these syndromes. Some patients with IBMFS display a distinct clinical phenotype with associated syndromic abnormalities, others are variable and overlap with one another or with acquired MDS or idiopathic acquired aplastic anemia, and additional cases are more obscure and have evaded classification altogether. Accurate diagnosis of IBMFS inform patient care as it allows appropriate screening of siblings to avoid choosing an affected donor if marrow transplant is indicated and the selection of an appropriate transplant conditioning regiment to avoid undue toxicity. Additionally, accurate diagnosis allows appropriate medical monitoring and early intervention to successfully treat disease-specific non-hematologic medical complications. The application of next generation sequencing approaches for comprehensive genetic screening of IBMFS, including these cryptic or atypical presentations will be reviewed. In addition to providing accurate diagnoses in a subset of patients, genetic characterization in small family kindreds or even in single individuals presents unique opportunities to discover new genes and pathways contributing to dysfunctional hematopoiesis and clonal progression. The frequency of inherited mutations in known IBMFS genes among seemingly idiopathic acquired aplastic anemia patients or pediatric and younger adults with MDS referred for hematopoietic stem cell transplant will be reviewed. Future genetic studies are needed to characterize the secondary genetic events that lead to disease progression in IBMFS. Disclosures No relevant conflicts of interest to declare.

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Chronic Pancytopenia and Increased Bone Density Due to TBXAS1 Deficiency

Blood ◽

10.1182/blood.v128.22.1503.1503 ◽

2016 ◽

Vol 128 (22) ◽

pp. 1503-1503

Author(s):

Richa Sharma ◽

Jennifer E. Schwartz ◽

Grzegorz Nalepa

Keyword(s):

Bone Marrow ◽

Bone Density ◽

Bone Marrow Biopsy ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Long Bone ◽

Surgical Biopsy ◽

Hematopoietic Stem ◽

Thromboxane Synthase ◽

Marrow Cavity

Abstract Non-dysmorphic 32-year old Caucasian female developed malaise, fluctuating body aches and progressive transfusion-dependent pancytopenia with peripheral blood morphology consistent with myelodysplastic syndrome (MDS). Reportedly, she had an episode of "low blood counts" of unclear etiology 23 years prior. Multiple attempts at bone marrow biopsy were unsuccessful due to technical difficulties with penetrating the bone, necessitating surgical biopsy by an orthopedic surgeon. Bone densitometry revealed increased bone density with Z-score of 4.5, consistent with mild thickening of long bone diaphysis noted via x-ray. Strikingly, the bone marrow biopsy revealed haphazard ossification, immature cartilage formation and thickened trabeculae replacing hematopoiesis within the marrow cavity. Next-generation sequencing revealed two novel biallelic mutations within the thromboxane synthase gene TBXAS1 (c.266T>C; c.989T>C). Both mutations affected conserved amino acid residues and were predicted to be disruptive to the protein function by two independent bioinformatics algorithms (Provean and PolyPhen-2). Thromboxane cascade regulates pathways of inflammation, coagulation and osteoclast activation, suggesting a mechanistic explanation of how thromboxane synthase malfunction causes abnormal bone remodeling and bone marrow failure. TBXAS1 disruption had been described in a rare autosomal recessive syndrome Ghosal hematodiaphyseal dysplasia (GHDD) associated with increased bone density and bone marrow failure. GHDD due to TBXAS1 mutations was genetically confirmed only in four families of Northern African and Middle Eastern descent (Nat Genet 2008; 40: 284-286). To our knowledge, this is the first genetically validated case of TBXAS1-/- Ghosal syndrome in the Caucasian population. Consistent with the well-established role of thromboxane in platelet function, our patient's platelets displayed impaired aggregation in response to arachidonic acid and structural abnormalities by transmission electron microscopy, revealing a functional platelet defect. Steroid therapy rendered the patient transfusion-independent and alleviated chronic pain and inflammation. A long-term follow-up will be needed to determine whether steroid treatment will result in stable improvement in hematopoiesis and decreased bone density, similar to other GHDD patients. This case illustrates how establishing the diagnosis of an underlying rare inherited bone marrow failure syndrome allows personalized, evidence-based treatment with lower risk of morbidity compared to cytotoxic chemotherapy and hematopoietic stem cell transplantation. Figure Figure. Disclosures No relevant conflicts of interest to declare.

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Sars-Cov-2 Infection Associated with Aplastic Anemia and Pure Red Cell Aplasia

Blood ◽

10.1182/blood-2021-145139 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2195-2195

Author(s):

Nicholas C.J. Lee ◽

Bhavisha A. Patel ◽

Taha Bat ◽

Ibrahim F. Ibrahim ◽

Madhuri Vusirikala ◽

...

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Bone Marrow Biopsy ◽

Bone Marrow Failure ◽

Pure Red Cell Aplasia ◽

Cell Transplant ◽

Red Cell ◽

Red Cell Aplasia ◽

Immune Mediated ◽

Work Up

Abstract Introduction: Aplastic anemia (AA) is a life-threatening disorder characterized by pancytopenia and a hypocellular bone marrow. Pure red cell aplasia (PRCA) is a similar disorder with primary reduction in the red blood cell population and virtual absence of erythroid precursors in the bone marrow. While the etiology of immune mediated marrow failure is multifactorial, preceding viral infections have been associated with the disease; these include parvovirus B19, cytomegalovirus, and Epstein-Barr virus. We present four cases of immune mediated marrow failure with either preceding or simultaneous SARS-CoV-2 infection. Methods: The medical records of patients treated for AA or PRCA at the University of Texas Southwestern Medical Center, Parkland Hospital, and the National Institutes of Health (NIH) were reviewed for SARS-CoV-2 infection. Four patients without prior hematological diseases were identified who had SARS-CoV-2 infection prior to or with simultaneous the diagnosis of AA or PRCA. Results: Patient #1 was a 22-year-old white female who was diagnosed with asymptomatic COVID-19 10 days prior to her pancytopenia and AA diagnosis was confirmed by bone marrow biopsy (5% cellularity; Table 1). Her extensive work-up including HIV, hepatitis panel, immunoglobulins, B12 and folate was negative, and she underwent HLA-matched family donor hematopoietic stem cell transplant. Patient #2 was a 69-year-old Asian female who presented to her primary care physician with symptoms of fatigue and was found to be pancytopenic. CBC from a few months prior was completely normal. Further work-up was positive for COVID-19 and negative for HIV, nutritional deficiency, or hemolysis. She did not have respiratory symptoms, was eventually diagnosed with pRBC and platelet transfusion-dependent severe AA (5-10% cellularity on bone marrow), and underwent treatment with cyclosporine, equine antithymocyte globulin, and eltrombopag. She has had a partial response to this therapy. Both patients had bone marrow specimens stained for SARS-CoV-2 by immunohistochemistry that were negative. Patient #3 was a 76-year-old white male who was diagnosed with COVID-19 4 months prior to presenting with a non-ST segment myocardial infarction and found to be profoundly anemic, requiring pRBC transfusion. He re-presented with chest pain one week later and was found to be anemic again, and required transfusion. A trial of darbepoetin alfa was unsuccessful. Extensive work-up for malignancy, infection, and autoimmune etiologies were negative. He was diagnosed with PRCA based on the bone marrow biopsy and initiated treatment with cyclosporine. Patient # 4 was diagnosed with severe AA (presenting as pancytopenia) and COVID-19 infection. He had fatigue for one month and fever, chills and sore throat one-week prior seeking medical care. Testing for hepatitis, HIV, EBV, and CMV was negative. He was treated on a clinical trial (NCT04304820) at NIH with cyclosporine and eltrombopag until SARS-CoV-2 PCR was negative then received equine anti-thymocyte globulin. He has achieved a complete hematologic response at 6 months and remains well at last follow-up. Conclusion: The four patients described had minimal respiratory COVID-19 symptoms, but they presented with cytopenia and were eventually diagnosed with bone marrow failure. It is possible that this is co-incidental due to the high prevalence of SARS-CoV-2. However, there is emerging evidence that COVID-19 pneumonia is a hyperinflammatory and immune dysregulated state improved by dexamethasone therapy. Other immune mediated hematologic conditions, such as autoimmune hemolytic anemia and immune thrombocytopenia, have been reported. The onset from infection to cytopenia appears rapid, although patients often presented with symptoms for many days prior to diagnosis and thus testing may have been delayed from the onset of infection. This case series does not provide a mechanistic link between SARS-CoV-2 infection and bone marrow failure, but it raises the possibility that SARS-CoV-2 may mediate an immunologic response that contributes to marrow failure. Patients appear to respond well to standard immunosuppressive treatment. Further cases and studies are needed to determine if this is directly linked to SARS-CoV-2 and whether the natural history and response to standard therapy is different than idiopathic cases. Figure 1 Figure 1. Disclosures Young: Novartis: Research Funding.

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Regulatory Mutations in GATA2 Associated with Aplastic Anemia

Blood ◽

10.1182/blood.v120.21.3488.3488 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3488-3488 ◽

Cited By ~ 6

Author(s):

Danielle M. Townsley ◽

Amy Hsu ◽

Bogdan Dumitriu ◽

Steven M. Holland ◽

Neal S. Young

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Immunosuppressive Therapy ◽

Nk Cell ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Early Adulthood ◽

Mycobacterial Disease ◽

Regulatory Regions ◽

Exon 2

Abstract Abstract 3488 Germline heterozygous mutations in GATA2 have been reported to cause familial myelodysplasia–acute myeloid leukemia (MDS/AML), monocytopenia and mycobacterial infection (monoMAC syndrome), dendritic cell, myeloid and NK cell lymphopenia (DCML), and Emberger syndrome (lymphedema and MDS). GATA2 is a zinc finger transcription factor that plays a crucial role in regulating growth of hematopoietic progenitors. In some pedigrees, patients or family members have manifestations of bone marrow failure. We hypothesized that patients with aplastic anemia (AA) may harbor mutations in GATA2. The coding regions and regulatory regions of GATA2 were sequenced in 99 patients with confirmed AA. Sequences from 100 normal individuals as well as published human genomes from unaffected individuals (dbSNP build 135 and 1000 Genomes Project) were used as controls. Genetic variants were confirmed in hematopoietic and somatic tissues. We identified 4 heterozygous mutations in regulatory regions of GATA2 in 5 patients. In two patients, a mutation at nucleotide 59T>G in exon 1 of isoform 2 was identified; both had severe AA in early adulthood refractory to immunosuppressive therapy. We noted this 59T>G mutation in two unrelated individuals with severe disseminated mycobacterial disease. We identified a mutation at nucleotide 20G>A in exon 2 of isoform 1, in a 3 year-old male with hepatitis-associated severe AA whose disease was refractory to multiple rounds of immunosuppressive therapy. Another mutation was present in 38G>A in exon 2 of isoform 1 in a 32 year old male with moderate AA and paroxysmal nocturnal hemoglobinuria (PNH). We also identified the exon 2 38G>A mutation in a patient with disseminated mycobacterial disease where reduced transcription of the mutant 38G>A allele was noted on RT-PCR. Finally, an intron 5, c.512+573 G>A variant was identified in an 18 year old male with severe AA who progressed after immunosuppressive therapy to MDS/AML. This variant, which causes a disruption of the FLI1 binding site, has also been found to be pathogenic in monoMAC syndrome. In summary, a subset of patients with AA were found to have mutations in GATA2 suggesting a role for the gene in the pathogenesis of bone marrow failure. It also may identify patients at higher risk of infectious complications, those who may have less advantageous responses to immune suppression, and command earlier bone marrow transplantation. Disclosures: No relevant conflicts of interest to declare.

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Telomerase Enzyme Activity In Egyptian Children With Bone Marrow Failure

Blood ◽

10.1182/blood.v122.21.4662.4662 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4662-4662

Author(s):

Amal M. El-Beshlawy ◽

Mona Mohamed Hamdy ◽

Amina Abd El Salam ◽

Mervet El Ansary ◽

Nelly Abulata ◽

...

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Immunosuppressive Therapy ◽

Mononuclear Cells ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Telomerase Activity ◽

Telomere Maintenance ◽

Control Group ◽

Egyptian Children

Background Telomeres are structural elements that seal the ends of chromosomes protecting them from recombination and end to end fusion. Maintenance of the integrity of telomeres requires the telomerase ribonucleoprotein complex. Abnormal telomere maintenance is a feature of a variety of human diseases including constitutional aplastic anemia. Predisposition to the development of marrow failure has been conferred by genetic alternations results in low telomerase activity. Short telomeres in leukocytes and reduced hematopoietic function. Aim To evaluate the telomerase functional activity in Egyptian children with inherited and acquired bone marrow failure and its relation to the phenotypic features of the acquired disease and its response to immunosuppressive therapy. Patients and Methods This was a case-control study conducted on unrelated children (n=40) with bone marrow failure syndromes and forty healthy subjects age and sex-matched as controls. The diagnosis of bone marrow failure was based on the bone marrow biopsy and blood-count results. Patients with acquired aplastic anemia (AAA) were considered severe if at least 2 of the following were noted: neutrophil count < 0.5×109/L; platelet count < 20×109/L with hypocellular marrow. Response to immunosuppressive therapy (IST) was evaluated after 6 months of initiation of therapy. Assessment of Telomerase Activity Telomerase activity was measured in mononuclear cells utilizing the Telomeric Repeat Amplification Protocol (TRAP )using the TeloTAGGG Telomerase PCR ELISA. Results Forty patients were included in the study (30 AAA , 6 Fanconi Anemia (FA), 2 Pure Red Cell Aplasia (PRCA), one case with Dyskeratosis Congenita (DCK) and one case with constitutional aplastic anemia. The Mean age was 11.1±4.9 years (range 3.5 to 18 years, median 11 years ) and the duration of follow-up mean; 5.14 (±3.84) years (range 1-13 years). Patients with AAA (n=30) received treatment with cyclosporine A( n =27) and ATG( n=3). Telomerase level The median telomerase level was significantly lower in inherited BMF syndromes when compared to controls [5.05 (4.60 – 8.70 IQR) Vs 11.15 (5.90-16.60 IQR), p=0.04]. In AAA the median telomerase level was insignificantly lower than controls [5.4 (2.3 – 21.0 IQR) Vs 11.15 (5.90-16.60 IQR), p=0.228]. A good inverse correlation was detected between the telomerase level and age of the patients (r=-0.39, p=0.026). No correlation was found between the telomerase level and disease duration in hereditary or AAA (r= -0.303, p=0.111 and r=0.305, p=0.156 respectively). Telomerase activity and clinical variables We classified our cases into two groups according to the median value of the control group (11.5): Low telomerase level group: (n=27): included 18 AAA (66.7%) and 9 hereditary aplastic Anemia (33.3%). Cases with AAA 14/18 (77.8%) with low telomerase activity were severe cases with bone marrow cellularity less than 10 % Vs 6/12 (50%) with normal telomerase. Fifty per cent of cases (9/18) with low telomerase responded partially or completely to IST Vs. 83.4% of the normal telomerase (10/12) group. Patients of AAA who received cyclosporine therapy (n=27), 19 cases (70.4%) were responders versus zero % of patients who received ATG (n=3). The median telomerase of responders was 16.5 + 4.7 Vs 11.6 + 3.8 of none responders. Conclusion • Telomerase activity was affected in hereditary and acquired bone marrow failure. • Evaluation of telomerase activity is essential for therapeutic and prognostic aspects of these diseases. Cyclosporin A can be used as a monotherapy in the treatment of acquired aplastic anemia even in the presence of decreased telomerase activity Disclosures: No relevant conflicts of interest to declare.

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Telomere Length Changes of Lymphocytes in Aplastic Anemia

Blood ◽

10.1182/blood.v124.21.5160.5160 ◽

2014 ◽

Vol 124 (21) ◽

pp. 5160-5160

Author(s):

Rong Fu ◽

Jiangbo Zhang ◽

Zonghong Shao

Keyword(s):

Bone Marrow ◽

Aplastic Anemia ◽

Telomere Length ◽

Mononuclear Cells ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Predictive Biomarker ◽

Cd34 Cells ◽

Primary Disorder ◽

Length Changes

Abstract Aplastic anemia (AA) is a primary disorder of severe bone marrow failure characterized by pancytopenia. The pathogenesis of AA is closely related to T cell hyperfunction. Abnormal telomere shortening of bone marrow mononuclear cells which has been reported in AA not only lead to genomic instability and apoptosis but also regulate T cells immunity to antigen. Interestingly,lymphocytes with shorter telomere length have undergone apoptosis escape in autoimmune disease. In our study, the relative telomere length (RTLs) of CD3+, CD3+CD4+, CD3+CD8+, CD19+ and CD34+ cells were investigated in 14 untreated AA patients and 32 controls. The RTLs of CD3+,CD3+CD4+ and CD3+CD8+T lymphocytes were shorter than those of the controls. Meanwhile, no differences in CD19+B and CD34+ cells were found between AA and controls. A change in telomere length may be involved in the pathogenesis of AA and could be considered as a predictive biomarker for the diagnose of AA. Disclosures No relevant conflicts of interest to declare.

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