Transcript Value of Bronchoalveolar lavage prior to HSCT for Primary

Emerging indications for HSCT
in primary immunodeficiency
Dr. Andy Gennery,
Newcastle upon Tyne, UK
ESID - Prague May 2007
What Are You Waiting For?
Dr. Andy Gennery,
Newcastle upon Tyne, UK
ESID - Prague May 2007
Overview
• Current Results (SCETIDE)
• Improving parameters
• A new way to think about immunodeficiency
• New indications for HSCT
SCETIDE REGISTRY
STEM CELL TRANSPLANTATION FOR
IMMUNODEFICIENCIES IN EUROPE
Marina Cavazzana-Calvo – Andrew
Cant
Andy Gennery – Mary Slatter
and
the members of the SCETIDE working group
Prepared by Pierre TAUPIN and Paul LANDAIS
Laboratoire de Biostatistique et d’Informatique
Médicale Hôpital Necker. Paris. France.
Primary disease in SCID patients (n=744)
10%
11%
3%
ADA def
B+
BRet. Dysg.
Other SCID
28%
48%
Probability of survival in SCID patients after HSCT
according to period (« before 1995 » versus « after 1995 »)
After 1995 (n=315)
10 years
Survival rate
After 1995 : 70%
Before 1995 : 55%
Before 1995 (n=360)
P=0.0002
SCID and HLA-matching, 1990-2006
Geno (n=73)
Pheno (n=41)
10 years
Survival rate
Geno : 86%
Pheno : 79%
MUD (n=78)
Mismatch (n=262)
MUD : 72%
Mismatch : 59%
P=0.0002
Primary disease in non SCID
patients (n = 828)
6%
21%
19%
WAS
T Ce ll Def
Phagocytic ce ll dis
Hemophagocytic
other inborn
12%
42%
Probability of survival in NON-SCID patients after HSCT
according to period (« before 1995 » versus « after 1995 »)
After 1995 (n=457)
10 years
Survival rate
After 1995 : 61%
Before 1995 : 54%
Before 1995 (n=287)
P=0.007
Probability of survival in NON-SCID patients after HSCT
according to donor-recipient compatibility
10 years
Survival rate
Geno n=250
Pheno n=58
MUD n=213
mmRel n=223
Geno : 72%
MUD : 64%
Pheno : 57%
mmRel : 40%
P<0.0001
CD40 Ligand deficiency
CD40 Ligand deficiency
Observed : expected cases (%)
by age at registration
100%
90%
80%
70%
(%)
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
Age (years)
25
30
35
0.75
1.00
Kaplan-Meier survival estimate
0.25
0
10
20
30
40
50
analysis time
0.00
0.00
0.50
0.25
0.75
0.50
1.00
Kaplan-Meier survival estimates, by sex
0
10
20
30
40
analysis time
F
M
50
HSCT for CGD 1985 - 2000
Well
11 / 11
Inflamed
7/7
Active fungus
5/9
Seger RA, Gungor T, Belohradsky BH, et al. Treatment of chronic granulomatous disease with
myeloablative conditioning and an unmodified hemopoietic allograft: a survey of the European
experience, 1985-2000. Blood 2002;100:4344-50
HSCT for CGD 1985 - 2000
Resolution of inflammatory lung disease
HSCT for CGD 1985 - 2000
HSCT - what’s new?
•
Better HLA typing
•
New stem cell sources
•
New conditioning regimens
•
New viral detection and treatment
•
Better supportive care
•
New approaches to GvHD
HSCT : which donor?


HLA identical sibling
Other family member - match/1Ag
mismatch

Matched unrelated donor

Cord blood

Mismatched - haploidentical parent
Routine:
HLA Class I - low resolution molecular typing
HLA Class II - high resolution molecular typing
Outcome
Overall
79%
Survival post 2000
Cord
72%
Haplo
82%
Overall
88%
B cell function
Cord
92%
Haplo
71%
Reduced Intensity HSCT - GOS
Rao et al, Blood 2004
Reduced Intensity HSCT
•
Prolonged risk of viral re-activation
CMV, EBV, adenovirus
•
Changing chimerism
•
Late aGvHD > 100 days
Rao et al, Blood 2004
Graft versus Host disease
•
•
•
•
Ciclosporine A
Tacrolimus
Steroids
MMF
•
•
Infliximab
Basiliximab/Dacluzimab
•
MSC
Viral infection
•
•
CMV EBV HHV6 Adeno
PCR early detection
•
•
•
Ganciclovir Cidofovir
Rituximab
Specific cytotoxic T cells
•
•
IVIG
 Immunosuppression
Immune system “failure”
Immunodeficiency
Infection
Autoimmunity
Inflammation
Malignancy
New Indications
•
•
•
•
6th child consanguineous Pakistani parents
RSV +ve bronchiolitis aged 2 weeks
Delayed clearance of RSV from respiratory tract (5+ weeks)
Subsequently no significant infection
IMMUNOLOGY
• Lymphopenia
CD3
194
CD19
307
CD56/CD16 480
CD8
30
CD4
149
• impaired PHA
• TCR VB distribution
normal
• Immunoglobulins
IgG 8.41 (on IVIG)
IgA 0.25
IgM 0.35
absence of antibody
response to Tet and HiB
despite 4 vaccinations
• Karyotype normal 46XX
but
5/163 Inv (7) (p13q35)
2/163 t(7:14) (p13:q11)
2/163 t(7:22) (p13:q11)
2/163 break point in chromosome 7
11/163 chromosome 7/14 rearrangements (7%)
• MMC sensitive ( D FA)
• radiosensitive
• NBS - homozygous mutation nbs1 1089C  A resulting in
prematurely truncated protein (nibrin)
•
D NBS
NBS REGISTRY
Hiel JA et al, Nijmegen Breakage Syndrome;
Arch.dis.child 2000
• 55 patients none with 1089C to A
• 19/55 (35%) died at age 0.5-24 years of infection
(5), malignancy (5) and lymphoma (9).
• Life expectancy reduced because of
malignancy/fatal infection.
ICF Syndrome
• Fragility of paracentromeric heterochromatin of Ch 1, 9, 16
• Multibranched chromosomes, triradials
• Facial anomolies
• Hypertelorism, flat nasal bridge, epicanthic folds
• Immunodeficiency
• Agammaglobulinaemia, variable T cell defect
ICF Syndrome
• Variable outcome
• Brown et al 1995 Hum Genet 1995;96:411-6
– 13 patients
– 1 died post BMT
– 4 others died infection (median 10/12)
– 1 A&W, now dead (infection, age 12 yrs)
Clinical Presentation
• First child, no parental consanguinity
• Recurrent chest infection (?PCP) agammaglobulinaemia
• Slightly low set ears – cytogenetics
• Commenced scIg – Co-trimoxazole,
Itraconazole
• Developed persistent diarrhoea (SRSV and
polio 2)
• Failure to thrive (25th
• BMT age 2.25yr
<2nd C)
Table 1. P re- and Post -HSCT immunological parameters in 3 pat ients with ICF
syndrome
Pre HSCT
CD3 (cells/L)
CD19 (cells/L)
CSM B cell (%)
IgM (g/L)
IgA (g/L)
IgG (g/L)
Tetanus/Hib
responses
HSCT
CD34+ dose/kg
GvHD
Follow up
Post BMT
CD3 (cells/L)
CD19 (cells/L)
Pat ient 1
Pat ient 2
Pat ient 3
3031
(1400-8000)
3802
(1400-8000)
2480
(900-4500)
795
(600-3100)
N/A
0.1 (0.43-1.9)
<0.07 (0.43-1.9)
<0.33 (3-10.6)
Absent /absent
725
(100-1400)
0%
0.08 (0.43-1.9)
<0.07 (0.43-1.9)
0.8 (3-10.6)
N/A
950
(200-2100)
N/A
< 0.04
< 0.05
On IVIG
Absent /absent
Bone marrow
(1) 5.2 x 106
(2) 3.43 x 106
nil
46 months
Bone marrow
5.3 x 106
Bone marrow
9.2 x 106
nil
18 months
nil
36 months
950
(700-4500)
311
(200-1600)
8%
0.55 (0.43-1.9)
2.65 (0.40-2.18)
10.10 (3.6-15.2)
normal/normal
1734
(900-4500)
1200
(200-2100)
4%
0.44 (0.43-1.9)
1.22 (0.4-2.18)
4.39 (3.6-15.2)
normal/normal
1994
(700-4200)
886
(200-1600)
20% CD27+
0.73 (0.55-2.32)
1.27 (0.28-2.22)
14.8 (6.5-14.5)
Normal/normal
CSM B cell (%)
IgM (g/L)
IgA (g/L)
IgG (g/L)
Tetanus/Hib
responses
N/A – not available
CSM B cell – Ig class swit ched memory B cell (CD19+CD27+IgM-).
All patients had normal phytohaemagglu t inin-st imulated lymphocyte proliferat ions
and T lymphocyte funct ion after t ransplant.
IPEX syndrome (OMIM 304930)
Immune dysregulation,
polyendocrinopathy,
enteropathy, X-L
• Mutations in FOXP3
• FOXP3 - critical regulator of CD4+CD25+
• Genetic heterogeneity
• cases of late onset with mild clinical features
• male patients w/o FOXP3 mutations
• female patients w. similar features
• “IPEX-like” syndrome? (H. Ochs)
IPEX syndrome - features
•
•
•
•
•
•
•
•
Diarrhoea
Failure to thrive
IDDM/1
Hypothyroidism
Eczema
Haemolytic anaemia
Thrombocytopenia
Recurrent infections
•
•
•
•
•
•
•
•
•
Lymphadenopathy
Hepatosplenomegaly
Polyarticular arthritis
Asthma
Ulcerative colitis
Glomerulonephropathy
Interstitial nephritis
Metabolic acidosis
Hypotonia / muscle atrophy
Wildin, et al. J Med Genet 2002
Gambineri, et al. Curr Opin Rheumatol 2003
• From birth - severe eczema
• 2 / 52 - pneumonia / respiratory distress
- S aureus / sputum
- Pseudomonas, Enterobacter / BAL
• 5 / 52 - episodic secretory diarrhoea
• Failure to thrive [ <0.4th percentile ]
• Small bowel biopsy at 4 mo:
- Villous atrophy, T cell infiltrate
- ‘Autoimmune enteropathy’
Patient 1
Laboratory results
Patient 1
•
•
•
•
•
•
Anti-islet cell Ab’s
Anti-enterocyte Ab’s
Anti-smooth muscle Ab’s
Direct Coombs test
Eosinophilia (2x109/l)
Raised IgE (31720 kU/l)
•
•
•
•
•
•
•
•
•
•
•
•
•
Persistent diarrhoea
DM type 1
Hypothyroidism
Eczema
Failure to thrive
anaemia/DCT
Thrombocytopenia
Lymphadenopathy
Hepatosplenomegaly
Recurrent infections
Eosinophilia
Raised IgE
Typical small bowel bX
Genetic analysis of FOXP3
did not reveal any mutation(s) so far
(H Ochs; T Torgerson)
+
+
+
+
+
+
+
+
+
Patient 1 - BMT
Conditioning
Post-BMT
• Campath 1H 0.2 mg/kg x5
3/52 pre BMT
• Bu 4mg/kg d-10 to d-7
• Cy 50 mg/kg d-5 to d-2
• Ne engraftment
d+15
• Plt engraftment
d+34
• normal stools
d+10
• off TPN
+3/52
• started solids, milk
• normal gut histology
• negative autoab’s / DCT
• Wt 25th / Ht 2nd percentile
• swallowing incoordination
• “slipping” chimerism
• CsA and steroids
• HLA id sister: bone marrow
6.8x108/kg nucl. cells
6x106/kg CD34+ cells
Treg Plots Pt 2
R3
Pre BMT
R3
Post BMT
Newcastle HSCT
April 2005-March 2006
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HIgE
CHARGE
CHH
ICF
CGD (2)
Familial HLH
CD4 lymphopenia
CID
IPEX
CVID
Partial TAP deficiency
ZAP 70 K-like
CD40L deficiency
Griscelli
SLE
Autoimmune enteropathy +
HyperIgD
ALPS
T-B- SCID
RD
April 2006-March 2007
•
•
•
•
•
•
•
•
•
•
•
•
•
RD
CGD (3)
ALPS
JAK3 SCID
Zeta chain deficient SCID
IL7Ra SCID (2)
Osteopetrosis (3, 2 TCIRG1)
CgC SCID
ADA SCID
Undefined SCID with histiocytoma
WAS (2)
Autoimmune enteropathy
JIA (Auto)
Case 1 - Male 14 years
•
•
•
•
•
‘poor wound healing’, from age 5
Warts, from age 7
Repeated styes, from age 7
Abscess drained in 2002, following insect bite, age 10
Discharging ear infections, last few years
Imm Hx
•
•
•
•
Age 12, all up to date
Heaf test was unreactive
BCG given in school: Nov 2004
Immediately after vaccine, local swelling, red, painful
and febrile and heaf site was visible
• Subsequent skin rash
Ix for Lymphoma
• Abscess noted in axillary LN - drained and BCG biopsied BCG seen
• Treatment began with Isoniziad / Rifampicin
• Skin rash reappeared after 10/7 treatment
• Complications of treatment
• Relapse off treatment
• Clinically stable on maintenance therapy, growing and healthy
• On Moxifloxacin, Ethambutol, Clarythromycin, IFNg
Candidate diseases
•
•
•
•
IFNg / IL12 deficiency
CID (T cell deficiency)
CD4 lymphopenia
Myelodysplasia
Blood immunology
Present
• Lymphocytes
• T cells
•
• Phagocytes
•
Absent
B cells
NK cells
Monocytes
Blood counts
Date
7/02
4/05
6/05
10/05
3/06
10/06
3/07
Event
Abscess
BCG
NGH
Hb
13.3
7.8
9.4
12.4
13.3
15.9
14.0
WBC
4.8
1.7
4.7
2.2
1.6
1.6
3.3
Neut
2.4
0.9
4.11
1.52
0.92
0.69
2.1
Lymph
2.1
0.4
0.37
0.35
0.44
0.73
0.93
Mono
0.00
0.00
0.03
0.02
0.01
0.01
0.00
Platelet
439
274
371
319
233
239
297
Subsets
2005
06
07
08
09
CD3+
CD19+
257
4
216
0
89
0
269
0
524
0
CD3+CD4+
147
115
43
155
277
CD3+CD8+
CD4+25+ %
108
35
95
35
44
110
33
235
37
CD3+DR+ %
17
19
9
14
NK
0
0
0
0
0
2006
11
Proliferations
Mitogen
Control
PHA/2
ConA
PMA
PMA/I
Anti-CD3
Anti-CD3 + IL2
IL2
PPD
Patient
43
22816
15945
1774
32326
685
27029
1314
375
Normal
170
124730
193118
132289
169110
173691
232798
90582
80452
Other immunology
•
•
•
•
•
IgG
initially very high, now normal
IgM
low
IgA
low
IgE
29
Neutrophil function burst OK
phagocytosis OK
• Autoantibodies
SM 1:160 only
Other T cell immunology
•
•
•
•
•
•
Normal TCR VB families
Normal ADA/PNP,
CD4+/45RA+/27+ (naïve)
9%
CD4-/45RA+/27+ (naïve)
16%
CD4-/45RA+/27- (effector) 2%
CD40L expression appears normal
Histopathology
April 05
skin
No well-formed granulomata, necrosis +, MFs + (CD68R+),
neutrophils +, sparse lymphocytes, AFB +, few B cells, more
plasma cells, plenty of DCs
axillary node
Definite granulomata, epithelioid cells +, no giant cells
August 05
skin
Neutrophilic adenitis (drug reaction or immunodeficiency)
September 05 LN
Abscess, neutrophils, MFs seen, no granulomata
July 06
skin
Fibrosis, small granulomata seen and many eosinophils. Few T
cells, many plasma cells
Bone Marrows
July 05
Hypocellular, reduced but normal
erythropoiesis and myelopoiesis, no
granulomata
Oct 06
Hypoplastic, reduced granulopoeisis.
Plasma cells and tissue macrophages +
Fanconi, PNH, karyotypic abn: excluded
Imaging
• Leeds
• CT chest & abdo
May 05
– Axillary lymphangitis, HSM, hypodense lesions in spleen, no
mesenteric adenitis
• NGH
• CT
Oct 06
– Lymphadenopathy in chest, with consolidations
• US
– Calcifications in spleen
Imaging
Patel et al.
• 11 patients with late onset, disseminated mycobacterial infection.
• Profound monocytopenia, B cell penia, normal Ig production, variable
T cell penia
• Also severe HPV, EBV, Histoplasma, Cryptococcus
• PAP – independent of marrow failure. Macrophage / Monocytes found
in lung fluid.
• Initially normal marrow became dysplastic in a number, and
transformed to CMMol in one.
• Trisomy 8 found in half.
• Melanoma and squamous carcinomas
•
•
•
•
•
Defects explored:
Normal GM-CSF production, and no antibodies to GM-CSF.
No response to G- or GM-CSF
Recurrence to be expected.
1 BMT, died of lung complications 30 days later
From now…
• Do we put him back on IFNg?
• Do we transplant him?
• Do we transplant him now or leave him?
• Any other ideas to explore the diagnosis
History - 14 year old Male
• May 2003
D
ITP
– Poor response to Ig and prednisolone
• March 2004
splenectomy
• Repeated adenopathy
– Biopsies and BMA/Ts have all been ‘reactive’
• January 2006 proptosis
– Spontaneous partial resolution
Lymphadenopathy
• November 2004 received BCG
• March 2005 presented with painless axillary lymphadenopathy
• Also reported mouth ulcers and earache some cervical LNS
– Mantoux, sputa negative
– CXR non specific
•
•
•
•
•
•
April 2005 returned with ulcers, glands and cough
Neutropenia (0.49)
Raised platelets (964)
ESR 8
BMA - ‘reactive’ with a germinal centre
L axillary LN - ‘reactive’ only
Proptosis
• Jan 2006 admitted with fever, lymphadenopathy, sore
throat, chest pain, proptosis of right eye
• Eczema over head and neck
• MRI identified a 2-3mm rim of abnormal tissue within the
globe, above the superior rectus muscle. ‘Inflammatory’
debris was seen in other sinuses.
•Resolution reported.
•Nov 2006, seen by Mr Neoh (RVI):
only 1mm of proptosis
Recent history / referral trigger
• November 2006
• Bruising and petechiae
• Platelets 5
Investigations
•
•
•
•
•
•
Platelets 3 - 964 - 3 (large volume)
LDH 482 - 791
WBC 2.48 - 14.7
Neutrophils 0.49 - 10.68 (steroid response)
ESR 8 - 11
CRP 20
Summary
• Destructive thrombocytopenia, initially responsive to
splenectomy
• Proptosis (resolving, 1 year duration) seems most likely a
result of inflammatory sinusitis, but ?infective, ?neoplastic,
?vasculitis, ?sarcoidosis
Working differential diagnosis
• Autoimmune disease with additional evidence of immune
dysregulation
– ALPS
– WAS
– XLP
– Lymphoma
Developments since Feb
•
•
•
•
Anterior Uveitis
Recovered on steroid +/- antimicrobials
Chesty cough
Otherwise he had been well
Action
• To come in for antibiotics for chest
• Serious concern re possibility of fungus
• Needs scan of eyes as definitely more proptosis
Imaging
Immunology
Test
Lymphocytes
T cells (CD3+)
NK cells (CD16+/CD56+)
B cells (CD19+)
CD8+ T cells
CD4+ T cells
Activated T cells - %
CD4 / CD25 T cells - %
T Cell Receptor Alpha / Beta
T Cell Receptor Gamma / Delta
CD27-IgM+IgD+ (naive)
CD27+IgM+IgD+ (memory)
CD27+IgM-IgD-(class switched)
CD4-CD45RA+CD27- (effector)
CD4+CD45RA+CD27+ (naive)
CD4-CD45RA+CD27+ (naive)
01/05/07
26/02/07
3787
3802
819
934
86
140
2831
2719
268
371
473
463
46
38
9
11
94
91
6
9
91
81
2 <1
<1
<1
<1
<1
2 <1
9
6
Units
cells/ul
cells/ul
cells/ul
cells/ul
cells/ul
cells/ul
%
%
%
%
%
%
%
%
%
%
Range
(800 to 3500)
(70 to 1200)
(200 to 600)
(200 to 1200)
(400 to 2100)