Donor lymphocyte Donor lymphocyte infusion as a treatment infusion as a treatment of a complete DiGeorge of a complete DiGeorge
syndromesyndromeK.ZdráhalováK.Zdráhalová22, E.Mejstříková, E.Mejstříková1,21,2,T.Kalina,T.Kalina1,21,2,P.Sedláček,P.Sedláček22, ,
A. Janda A. Janda11, H.Žižková, H.Žižková33, Z.Sieglová, Z.Sieglová33,A.Šedivá,A.Šedivá11, , J.BartůňkováJ.Bartůňková11, J.Starý, J.Starý22, P.Kobylka, P.Kobylka33 , P.Hubáček , P.Hubáček 2,42,4, ,
O.HrušákO.Hrušák1,21,2
22Department of Pediatric Hematology and Oncology, Department of Pediatric Hematology and Oncology, 11Department of Immunology, Department of Immunology,
33Institute of Hematology and Blood Transfusion,Institute of Hematology and Blood Transfusion,44Department of Pediatrics,Department of Pediatrics,Prague, Czech RepublicPrague, Czech Republic
Introduction - DiGeorge syndromeIntroduction - DiGeorge syndrome• the most common deletion syndrome in humans – the most common deletion syndrome in humans – • monoallelic microdeletion of monoallelic microdeletion of 22q11.222q11.2 (DiGeorge (DiGeorge and velo-cardio-facial sy, conotruncal anomaly)and velo-cardio-facial sy, conotruncal anomaly)
• variable phenotype even in pts with the same deletionvariable phenotype even in pts with the same deletion
• manifestation:manifestation: ("CATCH22")("CATCH22")• mainly heart defects; mainly heart defects; hypoparathyroidismhypoparathyroidism• thymic hypoplasia thymic hypoplasia immunodeficiency, facial immunodeficiency, facial dysmodysmorrphism, developmental and behavioral problemsphism, developmental and behavioral problems
• Deletion or interstiDeletion or interstittial deletion ial deletion of of 10p13 10p13 - - other rare cause of DiGeorge sy other rare cause of DiGeorge sy (type II)(type II)
Patient:Patient: male, born June 18 male, born June 18thth 2004, now 10 months 2004, now 10 months
Family history:Family history: healthy parents, 0 siblings healthy parents, 0 siblings
Personal history:Personal history: 1 1stst pregnancy, polyhydramnios pregnancy, polyhydramnios amniocentesis amniocentesis normal karyotype 46, XY normal karyotype 46, XY
term delivery, fetal hypoxia term delivery, fetal hypoxia Cesarian section, Cesarian section, resuscitation, intubation, artificial ventilationresuscitation, intubation, artificial ventilation
• esophageal atresia + tracheoesophageal fistula:esophageal atresia + tracheoesophageal fistula: D+2 operationD+2 operation• bilateral choanal atresia:bilateral choanal atresia: D+5 operation D+5 operation • congenital heart defects:congenital heart defects: D+13 operation D+13 operation
• Stigmatisation:Stigmatisation:* faceface* genitalsgenitals* eyeseyes* CNSCNS
• CHARGE associationCHARGE association ((CColoboma, oloboma, HHeart disease, eart disease, AAtresia choanae, tresia choanae, RRetarded growth + etarded growth + development and/or CNS anomalies, development and/or CNS anomalies, GGenital anomalies and/or enital anomalies and/or hypogonadism, hypogonadism, EEar anomalies and/or deafness)ar anomalies and/or deafness)
Problems:Problems:• recurrent infections, septicemiasrecurrent infections, septicemias• recurrent respiratory distress recurrent respiratory distress ventilation ventilation • apneas, irritability, states of altered consciousnessapneas, irritability, states of altered consciousness
Immunology:Immunology:• lymphocyte subsets in 2 months of age: lymphocyte subsets in 2 months of age: CD3+ 0%CD3+ 0% NK 40% NK 40% CD4+ 0% CD4+ 0% CD8+ 0% CD8+ 0% CD19+ 58%CD19+ 58%
absent T absent T cellscells
• response to mitogens: absentresponse to mitogens: absent
• MRI -MRI - absent thymusabsent thymus
0,0001
0,001
0,01
0,1
1
10
CD4 (10^9/L)CD8 (10^9/L)CD3 (10^9/L)CD19 (10^9/L)NK (10^9/L)
prior DLI 16.12.05prior DLI 16.12.05at 12.8.04at 12.8.04
Complete DiGeorge SyndromeComplete DiGeorge Syndrome
(diagnosis at 2 months)(diagnosis at 2 months)
• microdeletion 22q11 not foundmicrodeletion 22q11 not found
• prophylaxis started : prophylaxis started : cotrimoxazole + itraconazole + IVIGcotrimoxazole + itraconazole + IVIG
2 months of age2 months of age
1st donor lymphocyte infusion1st donor lymphocyte infusion
age 6 monthsage 6 months
unrelated donor from register, 8/10 unrelated donor from register, 8/10 (B, Cw)(B, Cw)
no conditioningno conditioning
no GVHD preventionno GVHD prevention
1x 101x 1066/kg CD3+; 0.2x 10/kg CD3+; 0.2x 1066/kg CD34+/kg CD34+
due to mistake non irradiated blood products due to mistake non irradiated blood products administered (administered (7 times prior 17 times prior 1stst DLI, 1 time after DLI, 1 time after 11stst DLI DLI))
1st donor1st donor lymphocytelymphocyte infusioninfusion (cont.)(cont.)
Complications:Complications: D+10:D+10:• isolated skin isolated skin aGVHD aGVHD ((stage 3, grade II)stage 3, grade II)• sepsis sepsis • cardiopulmonary cardiopulmonary instability instability • capillary leak sycapillary leak sy
Chimerism:Chimerism: D+10 donorD+10 donor detected detected
0,00010,0001
0,0010,001
0,010,01
0,10,1
11
1010
CD4 (10^9/L)CD4 (10^9/L)
CD8 (10^9/L)CD8 (10^9/L)
CD3 (10^9/L)CD3 (10^9/L)
Between 1st and 2nd DLI
after ATGafter ATG
00 1010 days post 1days post 1stst DLI DLI 88
after ATGafter ATG
aGVHDaGVHD, Capillary leak sy
Immunosupressive therapy:Immunosupressive therapy:• rATG FreseniusrATG Fresenius (25mg/kg 3x D+10, D+12, D+14)(25mg/kg 3x D+10, D+12, D+14)• CsACsA• corticosteroidscorticosteroids - MP (2mg/kg)- MP (2mg/kg)
• GVHD resolvedGVHD resolved
• corticosteroids corticosteroids - - 2 weeks 2 mg/kg, 1 week 1 mg/kg, 2 weeks 2 mg/kg, 1 week 1 mg/kg, 1 week 0.5 mg/kg, then tapered (D+35)1 week 0.5 mg/kg, then tapered (D+35)
• CsA continuedCsA continued
**********• D+33 last extubation!D+33 last extubation! - aged 7 months- aged 7 months
2nd donor lymphocyte infusion2nd donor lymphocyte infusion
age 7 months, D+36 after 1age 7 months, D+36 after 1stst DLI DLI
the same donorthe same donor
no conditioningno conditioning
prevention of GVHD: CsA (continued)prevention of GVHD: CsA (continued)
0.89x 100.89x 1066/kg CD3+/kg CD3+
2nd donor lymphocyte infusion2nd donor lymphocyte infusion (cont.) (cont.)
Complications:• D+27 EBV infection: (B cell proliferation, oligoclonality, IgM; no clinical manifestation)
• withdrawal of CsA
• Rituximab (375 mg/m2)
• proliferation of CD8+ activated T cells started
CD19CD1900
0,0010,001
0,010,01
0,10,1
11
1010
CD4CD4
CD8CD8
EBVEBVrituximabrituximab
00 days post days post 22ndnd DLI DLI
2727
10^
9/L
10^
9/L CD3CD3
1st DLI1st DLIacute GVHDacute GVHD
d 0
d 8
d 10
d 19
d 34
2nd DLI2nd DLI
d 1
0d
10
d 2
5d
25
EBV infection and prior rituximab EBV infection and prior rituximab
d 4
1d
41
d 5
5d
55
proliferation of activated T cells, proliferation of activated T cells, severe liver GVHDsevere liver GVHD
last non last non irradiated irradiated trftrf
NNo proof of engraftment of non irradiated blood transfusionso proof of engraftment of non irradiated blood transfusions
chimerism in non separated chimerism in non separated blood: recipient mainly, donor blood: recipient mainly, donor detecteddetected
chimerism in FACSorted chimerism in FACSorted T lymphocytes CD3+ T lymphocytes CD3+ (D+41 and D+55 CD4+ (D+41 and D+55 CD4+ and CD8+): mainly donorand CD8+): mainly donor
Chimerism after 1st and 2nd DLIChimerism after 1st and 2nd DLI
D+34:D+34: jaundice jaundice - bilirubin 4 mg/dL- bilirubin 4 mg/dL
dif.dg.:dif.dg.: • hepatic GVHDhepatic GVHD • EBV lymphoproliferationEBV lymphoproliferation (EBV in blood 0; in organs?)(EBV in blood 0; in organs?)
• hepatic infectionhepatic infection - not found- not found
******************
D+35D+35 2nd Rituximab2nd Rituximab (375 mg/m(375 mg/m22))
D+41 D+41 corticosteroidscorticosteroids (MP 1 mg/kg) hepatic aGVHD(MP 1 mg/kg) hepatic aGVHD
neutropenia - granulo 215!neutropenia - granulo 215!
D+55 D+55 preventive ATB, antimycoticspreventive ATB, antimycotics
D+45 - D+49: D+45 - D+49: agranulocytosisagranulocytosis (0 granulo) (0 granulo)
• corticosteroidscorticosteroids (MP 2 mg/kg)(MP 2 mg/kg)• CsACsA• G-CSFG-CSF 5x5x
D+52: granulo 3000D+52: granulo 3000 bilirubin 13.7 mg/dLbilirubin 13.7 mg/dL
isolated liver GVHD stage 3, grade IIIisolated liver GVHD stage 3, grade III
D+56: D+56: rATG FreseniusrATG Fresenius 1 1 dose, 25mg/kgdose, 25mg/kg
D+57: D+57: bilirubin 23.8 mg/dL bilirubin 23.8 mg/dL
isolated liver GVHD stage 4, grade IVisolated liver GVHD stage 4, grade IV
******************• corticosteroids corticosteroids (D+63 1.5 mg/kg, D+83 1 mg/kg)(D+63 1.5 mg/kg, D+83 1 mg/kg)• CsA continues CsA continues
Current status:Current status: • D+108 after 2nd DLI, age 10 months• bilirubin 7.6 mg/dL• CD8 activated T cells absolutely decreased• slight gradual psychomotor development
Patient aged 10 months
Thank you.