Allogeneic bone marrow transplantation for chronic granulomatous disease

952

Clinical and laboratory observations

10. Bayley N: Bayley Scales of Infant Development manual. New York, 1969, Psychological Corp. 11. Brown RE, Halperin F: The variable pattern of mental development of rural black children. Clin Pediatr 10:404, 1971. 12. Egeland B, Sroufe LA: Developmental sequelae of maltreatment in infancy. In Rizley R, Cicchetti D, editors: New directions for child development: Developmental perspectives in child maltreatment, San Francisco, 1981, Jossey-Bass.

The Journal of Pediatrics December 1982

13. McCall RB, Hogarty PS, Hurlburt N: Transitions in infant sensorimotor development and the prediction of childhood IQ. Am Psychol 27:728, 1972. 14. lreton H, Thwing E, Gravem H: Infant mental development and neurological status, family socioeconomic status, and intelligence at age four. Child Dev 41:937, 1980.

Allogeneic bone marrow transplantation for chronic granulomatous disease Joel M. Rappeport, M.D., Peter E. Newburger, M.D., Randall M. Goldblum, M.D., Armond S. Goldman, M.D., David G. Nathan, M.D., and Robertson Parkman, M . D . , Boston and Worcester, Mass., and Galveston, T e x a s

CHRONIC GRANULOMATOUS DISEASE is an inherited disorder of phagocytic cells (neutrophils, eosinophils, and monocytes); affected individuals have recurring infections with catalase-positive bacteria. ~.2 The granulocyte colonies from the bone marrow of affected individuals are unable to reduce nitroblue tetrazolium, suggesting that chronic granulomatous disease is a disorder of the hematopoietic stem cell? Based on our previous experience with the use of histocompatible bone marrow transplantation to correct genetic disorders of bone marrow function, we report the transplantation of bone marrow into a 15-year-old boy with severe chronic granulomatous disease.

MATERIALS AND M E T H O D S A 15-year-old white boy with chronic granulomatous disease was referred to the Children's Hospital Medical Center for bone marrow transplantation in an attempt to reverse progressive chronic pulmonary disease and granuloma formation. Repeated infections with Serratia marcescens and Staphylococcus aureus began at 6 weeks of age. 4 The diagnosis of chronic granulomatous disease was made at the age of one year. Thereafter he was hospitalized once or twice yearly with recurrent pneumonia and

From Harvard Medical School, The University of Massachusetts Medical School, and the University of Texas Medical Branch. Supported by United States Public Health grants RR-73, RR128, CA-13472, and AM-31097; by a Basil O'Connor Starter Research Grant from the March of Dimes Birth Defect Foundation; and by the University of Massachusetts CGD Associates. Reprint address: R. Parkman, M.D., Sidney Farber Cancer Institute. 44 Binney St., Boston, MA 02115.

lymphadenitis. During the last year he was treated with antibiotics and surgical drainage for liver abscesses. I

NBT PMA

Nitroblue tetrazolium Phorbol myristate acetate

]

Evaluations performed during his admission to the Children's Hospital Medical Center confirmed the presence of severe obstructive and restrictive lung disease and moderate renal insufficiency, presumably caused by the prolonged use of aminoglycosides. The patient was HLAA, -B, and -C loci identical by standard histocompatibility typing and D locus identical as determined by mutual nonreactivity in one-way mixed lymphocyte culture with his 14-year-old sister, who had no history of recurrent infections and had normal granulocyte function. Despite his poor condition, marrow transplantation was advised and accepted as the only possible curative therapy. The transplantation protocol was approved by the Human Investigations Committee. In vitro studies. A leukocyte-rich peripheral blood cell suspension was prepared from the patient and donor by sedimentation of citrate-anticoagulated peripheral blood in dextran T500 (Pharmacia Fine Chemicals, Piscataway, N.J.). Slides were prepared as previously described, 5 after incubation of the cells with 100/~g/ml phorbol myristate acetate (Consolidated Midland Chemical, Brewster, N.Y.) or zymosan (0.4 mg/ml) (ICN Pharmaceuticals, Plainview, N.Y.) opsonized in fresh human serum. Wrightstained slides were read by light microscopic scoring of consecutive cells for the presence or absence of formazan (reduced NBT).

0022-3476/82/120952+04500.40/0

9 1982 The C. V. Mosbv Co.

Volume 101 Number 6

Clinical and laboratory observations

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POST-TRANSPLANTATION

Figure. Clinical course of a patient after bone marrow transplantation for chronic granulomatons disease. ATS, antithymocyte serum; PC, procarbazine; TBI, total-body irradiation; TX, transplant.

RESULTS Bone marrow transplantation. The patient was prepared

for bone marrow transplantation with procarbazine (12.5 mg/kg/day orally) on days -7, -5, and -3; rabbit antihuman thymocyte serum (0.2 m l / k g / d a y intravenously) on days -6, -4, and -2; and total-body irradiation (800 rad) on day -1. He received 2.8 X 108 nucleated bone marrow cells per kilogram from his HLA-identical sibling. Methotrexate (10 m g / m 2) was given on days I, 3, 6, and 11 as prophylaxis against graft-versus-host disease. No methotrexate was given after day 11. As evidence of engraftment, peripheral blood nucleated red blood cells were detected on day 14, and a bone marrow specimen obtained at that time showed dividing cells of only donor (female) origin. By one month after transplantation the patient's white blood cell count was 1,200/mm 3, with 40% polymorphonuclear neutrophils and no bands (Figure). His reticulocyte count was 2%; he continued to require platelet transfusions for persistent thrombocytopenia. On day 12 the patient developed acute graft-versus-host disease characterized by a cutaneous erythematous rash. One month after transplantation there was a dramatic increase in the rash, particularly on his right arm and leg.

A skin biopsy showed epidermal atrophy and vacuolization of the basal layer, with dyskeratosis and activated lymphocytes, findings consistent with acute graft-versus-host disease. Five weeks after transplantation his skin began to thicken and his serum bilirubin and alkaline phosphatase levels rose. The clinical diagnosis of chronic graft-versushost disease was made, and the patient was given prednisone (1 mg/kg orally) every other day and azathioprine (1.5 mg/kg) daily.6 His skin improved after a period of massive scaling and intense pruritus. The serum bilirubin concentration decreased, but elevation of alkaline phosphatase activity persisted. The patient was discharged from the hospital on day 49 with a leukocyte count of 1,000/ram 3, with 53% neutrophils and 5% bands, a reticulocyte count of 8.9%, and an untransfused platelet count of 35,000/ram 3. Prior to transplantation the patient's arterial blood gas values on room air were Po2 118 mm Hg and Pco2 26 mm Hg, with pH 7.44. The patient was readmitted to the hospital on day 88 with an eight-day history of shortness of breath and with evidence of new pulmonary infiltrates on the chest radiograph. His arterial blood gas values w e r e P o 2 78 mm Hg

954

Clinical and laboratory observations

The Journal of Pediatrics December 1982

Table. NBT reduction by stimulated blood leukocytes

Formazan-positive cells (%) Patient Cells

Stimulant

Pre-Tx

Post-Tx

Donor

Neutrophils

PMA Zymosan PMA PMA

0 0 0 0

99 85 100 100

99 90 99 98

Eosinophils Monocytes

I

Controls 99.5 -+ 0.8 84 _+ 5 99.5 +_ 0.8 99.5 + 0.8

Peripheralbloodleukocytesstimulatedin vitrowithPMA or opsonizedzymosanbeforeand after transplantation(Tx). Resultsare expressedas the percentageof cellscontainingformazandeposits(reducedNBT). For patientand donor,each figurerepresentsthe meanof two determinations;for controls,the mean _+SEM of singledeterminationson each of 10 normaladults. and Pco2 25 mm Hg, with pH 7.45. Therapy with trimethoprim-sulfamethoxazole was begun for possible Pneumocystis carinii pneumonia. His pulmonary status continued to deteriorate despite therapeutic blood concentrations of trimethoprim-sulfamethoxazole; high doses of erythromycin and acyclovir (600 mg/kg every eight hours) were added without improvement. Because of the deterioration in respiratory function, a tracheostomy and pulmonary assistance were required. Uncontrollable gastrointestinal tract bleeding and renal failure developed prior to death. At autopsy, Pseudomonas aeruginosa was cultured from the patient's lungs and blood. Microscopic analysis of the lungs revealed chronic interstitial fibrosis without evidence of viral pneumonitis. His skin revealed epidermal atrophy and minimal dermal fibrosis. Examination of his bone marrow revealed a hypoplasic marrow with erythroid, myeloid, and megakaryoctyic elements present in a normal ratio. In vitro studies. Prior to transplantation, the patient's peripheral blood neutrophils, eosinophils, and monocytes did not reduce NBT after stimulation with either phorbol myristate acetate or opsonized zymosan, whereas the donor cells had normal NBT reduction (Table). E coil were ingested normally by both the donor and patient cells. The patient and donor bone marrow cells were cultured in vitro in agar, and the resultant granulocyte colonies were stimulated with PMA. Before transplantation NBT was not reduced by the patient's stimulated granulocyte colonies, but the donor granulocyte colonies reduced NBT normally. After transplantation the patient's peripheral blood neutrophils, eosinophils, and monocytes reduced NBT normally after both PMA and zymosan stimulation (Table). DISCUSSION The majority of patients with chronic granulomatous disease can be treated successfully with prophylactic antibiotics to control recurrent infections. Nevertheless, some patients develop long-term sequelae, including pulmonary

fibrosis, liver failure, and intestinal adhesions. The basis for the heterogeneity in the severity of chronic granulomatous disease is uncertain. Histocompatiblebone marrow transplantation after preparation with regimens that contain both immunosuppressant and antihematopoietic stern cell activities has permitted the successful donor lymphoid and hematopoietic engraftment of patients with a variety of genetic disorders of bone marrow function, including Wiskott-Aldrich syndrome, infantile agranulocytosis, osteopetrosis, and primary defects of granulocyte function] -9 Because in the majority of cases chronic granulomatous disease is an inherited disease, it affects more than one cell type, and defective oxidative metabolism has been detected in granulocyte colonies derived from progenitor cells obtained from bone marrow cultures, it has been assumed that chronic granulomatous disease is a disorder of the hematopoietic stem cell or its progeny. If so, it may be correctable by bone marrow transplantation. A previous attempt in a patient to correct chronic granulomatous disease was unsuccessful because long-~term hematopoietic engraftment was not achieved? ~ After preparation with rabbit antihuman thymocyte serum, procarbazine, and total-body irradiation, our patient had complete donor and lymphoid hematopoietic engraftment as determined by a change in his red blood cell antigens, chromosomal analysis of spontaneously dividing bone marrow cells, and karyotype analysis of PHA-stimulated peripheral blood lymphocytes. Further in vitro analysis of the capacity of the engrafted recipient cells to reduce NBT demonstrated that his posttransplant neutrophils, eosinophils, and monocytes were capable of normal oxidative metabolism. This evidence demonstrates that after transplantation the recipient's myeloid cells were of donor origin and were capable of normal in vitro function. The patient ultimately died of chronic graft-versus-host disease with pulmonary insufficiency and Pseudomonas sepsis. In our experience, 50% (11 of 22) of long-term survivors of histocompatible bone marrow transplantation

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Clinical and laboratory observations

older than 10 years of age have had chronic graftversus-host disease. Untreated chronic graft-versus-host disease produces severe clinical debilitation related to skin contractures and fibrosis and gastrointestinal tract malabsorption. The routine use of daily azathioprine and alternate-day prednisone therapy has reduced the symptoms of chronic graft-versus-host disease but has accentuated the immunodeficiency of the posttransplant period. Our patient's terminal pulmonary fibrosis and gram-negative sepsis must be considered as a complication of the transplant procedure and its resultant chronic graft-versus-host disease. The degree to which preexisting pulmonary disease may have predisposed the patient to pulmonary fibrosis after transplantation is uncertain. In our experience, chronic graft-versus-host disease continues to be the major limitation to the increased Use of histocompatible bone marrow transplantation for genetic disorders of bone marrow function. If present clinical experiments with in vitro treatment of bone marrow to eliminate donor irnmunoeompetent T lymphoeytes are successful, it may in the future be possible to perform both histocompatible and haploidentical bone marrow transplants without fear of acute or chronic graft-versus-hosp disease. ~, t2 Bone marrow transplantation would then have an increased use in the treatment of pediatric genetic disorders. Choosing the appropriate time to attempt such potentially curative therapy will be difficult, because patients should receive transplants before they develop sequelae that may decrease the likelihood of successful transplantation, but after they have demonstrated a clear clinical need for curative therapy.

REFERENCES 1. Johnston RB Jr, Newman SL: Chronic granulomatous disease. Pediatr Clin North Am 24:365, 1977.

955

2. Babior BM: Oxygen-dependent killing by phagocytes. N Engl J Med 298:659, 1978. 3. Newburger PE, Druskall MS, Rappeport JM, Robinson SH, Chovaniec ME, Cohen H J: Chronic granulomatous disease: Expression of the metabolic defect by in vitro culture of bone marrow progenitors. J Clin Invest 66:599, 1980. 4. Nelms DK, Goldman AS, O'Donnell AA, Henry M J: Serratia marcescens osteomyelitis in an infant. J PED1ATR72:222, 1968. 5. Nathan DG, Baehner RL, Weaver DK: Failure of nitroblue tetrazolium reduction in phagocytic Vacuoles of leukocytes in chronic granulomatous disease. J Clin Invest 48:1895, 1969. 6. Sullivan KM, Shulman HM, Storb R, Weiden PL, Witherspoon RP, McDonald GB, Schubert MM, Atkinson K, Thomas ED: Chronic graft versus host disease in 52 patients: Adverse natural course and successful treatment with combination immunosuppression. Blood 57:267, 1981. 7. Parkman, R, Rappeport J, Geha R, Belli J, Cassady R, Levey R, Nathan DG, Rosen FS: Complete correction of the Wiskott-Aldrich syndrome by allogeneie bone marrow transplantation. N Engl J Med 298:921, 1978. 8. Rappeport JM, Parkman R, Newburger P, Camitta BM, Chusid M J: Correction of infantile agranulocytosis (Kostmann's syndrome) by allogeneic bone marrow transplantation, Am J Med 68:605, 1980. 9. Coccia PF, Drivit W, Cervenka J, Clawson C, Kersey JH, Kim TH, Nesbit ME, Ramsay NKC, Warkentin PI, Teitelbaum SL, Kahn A J, Brown DB: Successful bone marrow transplantation for infantile malignant osteopetrosous. N Engl J Med 302:701, 1980. 10. The Westminster Hospitals Bone Marrow Transplant Team: Bone marrow transplant from an unrelated donor for chronic granulomatous disease. Lancet 1:210, 1977. 11. Reinherz EL, Geha R, Rappeport JM, Wilson M, Schlossman SF, Rosen FS: Immune reconstitution in severe combined immunodefieiency following transplantation with T lymphocyte depleted HLA haplotype mismatched bone marrow. Clin Res 30:515A, 1982. 12. Kapoor N, O'Reilly R J, Kirkpatrick D, Pollack MS, Dupont B, Good RA, Reisner Y. Restoration of immunological function by a histoincompatible, T cell depleted marrow transplant in a child with severe combined immunodeficiency. Pediatr Res 16:874A, 1982.

Congenital permanent diabetes mellitus and celiac disease G. H a t t e v i g , B. K j e i l m a n , and S. P. F[illstr6m, S k O v d e a n d G o t h e n b u r g , S w e d e n

DIABETES MELLITUS is uncommon in the newborn infant. There are two entities--a transient form and a permanent o n e - - a n d differentiation is difficult. 13 W e report a patient with permanent congenital diabetes melliFrom the Department of Pediatrics, K~rn Hospital. Reprint address: B. Kjellman, K~rn Hospital, 54185 Ski~vde, Sweden. " 0022-3476/82/120955+03500.30/0 |

1982 The C. V. Mosby Co.

tus and celiac disease, including the results of genetic investigations, H L A typing, and studies of beta cell function.

METHODS

AND RESULTS

Patient. The patient, a boy, was born after a normal pregnancy and delivery. His birth weight was 3,080 gm,