- Email: [email protected]
Autoimmune Neutropenia in Multiple Myeloma and the Role of Clonal T-Cell Expansion: Evidence of Cross-Talk Between B-Cell and T-Cell Lineages?
Case Report
Autoimmune Neutropenia in Multiple Myeloma and the Role of Clonal T-Cell Expansion: Evidence of Cross-Talk Between B-Cell and T-Cell Lineages? Madan Raj Aryal,1 Vijaya Raj Bhatt,2 Pavankumar Tandra,2 Jairam Krishnamurthy,2 Ji Yuan,3 Timothy C. Greiner,3 Mojtaba Akhtari2 Clinical Practice Points Autoimmune neutropenia (AIN), characterized by an
absolute neutrophil count below 1500 cells/mL in the presence of autoantibodies directed against neutrophil antigens, can be secondary to a variety of underlying diseases, such as connective tissue diseases, infections, and malignancies. However, it has not been reported in association with multiple myeloma (MM). We report a case of AIN in a patient with MM who also had a population of small lymphocytes with
T-cell receptor gamma chain gene rearrangements. We also review other autoimmune manifestations of MM, the role of T-cell receptor gene rearrangement in AIN, and the implications of AIN in the management of MM. AIN can develop as a consequence of MM, and it is likely underdiagnosed because of the diagnostic difficulties. AIN can increase the risk of recurrent or serious infections in patients undergoing chemotherapy.
Clinical Lymphoma, Myeloma & Leukemia, Vol. 14, No. 1, e19-23 ª 2014 Elsevier Inc. All rights reserved. Keywords: Anti-neutrophil antibody, Filgrastim, T-cell receptor gene rearrangement, T-lymphocyte
Introduction Autoimmune neutropenia (AIN), defined by the presence of an absolute neutrophil count (ANC) less than 1500 cells/mL, can be of 2 types: primary, in which there is no underlying disorder, and secondary. Secondary AIN has been associated with a variety of underlying diseases, including infection (hepatitis B viral infection and mycoplasma pneumonia), connective tissue disease, primary immunodeficiency, autoimmune hemolytic anemia, idiopathic thrombocytopenia purpura, and malignancy.1,2 Medications such as penicillin, phenytoin, metformin, and antineoplastic drugs (eg, fludarabine and rituximab) have also been associated with AIN.2 *M.R.A. and V.R.B. contributed equally to this work as first authors. 1
Department of Medicine, Reading Health System, West Reading, PA 2 Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE 3 Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE Submitted: Jun 21, 2013; Revised: Aug 21, 2013; Accepted: Aug 28, 2013; Epub: Oct 30, 2013 Address for correspondence: Mojtaba Akhtari, MD, Division of HematologyOncology, Department of Internal Medicine, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198 E-mail contact: [email protected]
2152-2650/$ - see frontmatter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clml.2013.08.002
We report a case of AIN in association with multiple myeloma (MM), a combination that, to our knowledge, has not been reported previously.
Case Report A 54-year-old man with a history of persistent neutropenia despite the use of filgrastim was referred to our hematologyoncology clinic. He had been admitted to an outside facility with a perirectal abscess 3 months before, which is when he was first noted to be leukopenic. Repeat counts since then had shown persistent neutropenia with a lowest ANC of 600 cells/mL (Table 1). The patient underwent bone marrow biopsy and was subsequently started on filgrastim. His medical history was notable for heterozygous factor V Leiden, multiple superficial venous thrombosis, and peripheral vascular disease. Medications included filgrastim, warfarin, and hydrocodone/acetaminophen. The patient’s physical exam was unremarkable, and his laboratory findings included a white count of 2200 cells/mL with ANC of 1100 cells/mL, a hemoglobin level of 13.4 gm/dL, and a platelet count of 231,000 cells/mL. The patient’s hepatitis and HIV serologic tests, antineutrophil cytoplasmic antibody screen, and antinuclear antibody panel returned negative results. Neutrophil reactive antibodies (immunoglobulin [Ig]M), antibodies against neutrophil-specific
Clinical Lymphoma, Myeloma & Leukemia February 2014
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Autoimmune Neutropenia in Myeloma Table 1 Changes in Different Parameters With Time in a Patient With AIN and MM Time (mos) Antibody ANC (cells/mL) Monoclonal protein level (g/dL)
0 600
Chemotherapy use Filgrastim use
e20
-
3 Positive 1100 1.36 No
10
1.59
17
4200 0.67
2300 0.92
Yes
No
antigens, were detected, whereas human leukocyte antigen class I and II antibodies were not detected. A bone marrow analysis that was performed at the outside facility revealed a hypocellular bone marrow with panhypoplasia and plasma cell dyscrasia. Filgrastim was discontinued for 1 week, and a repeat bone marrow biopsy was performed. The repeat bone marrow analysis found that the marrow was hypocellular given the patient’s age (30%) (Fig. 1a), with panhypoplasia and plasma cell dyscrasia. Myeloid, erythroid, and megakaryocytic lineages were all decreased, but they displayed orderly maturation without significant dysplasia. Plasma cells were increased to 26% with clustering and appeared abnormal morphologically (Fig. 1b). Immunostaining results showed that the plasma cells were positive for CD20, CD117, Cyclin-D1, and IgG, in addition to CD138 (Fig. 1c). In situ hybridization showed kappa light chain restriction with lambda negativity (Figs. 1e and 1f). Several interstitial lymphoid aggregates, composed mostly of small CD3-positive T-cells, were present in the core biopsy. (Figs. 1a and 1d). Immunostain analysis revelaed that the T cells expressed normal antigen profiles with a CD4-to-CD8 ratio of 1:1. A plasma cell population expressing CD20, CD23, CD38, CD117, CD138, and monotypic cytoplasmic and surface kappa light chains was identified, by flow cytometry, at 3% of ficolled cells, and mature Bcells were polyclonal by light chain distribution. T cells appeared normal by antigen profile. Interestingly, clonal biallelic T-cell receptor (TCR) gamma chain gene rearrangements were detected by DNA amplification (Fig. 2). Only rare plasma cells were positive for IgM, and the presence of a monoclonal IgG kappa serum paraprotein suggested that the myeloma cells may not be the source of the antineutrophil IgM antibody. Cytogenetic analysis showed a normal male karyosome; FISH results were positive for trisomy 11 in 8% of the interphase cells. Serum protein electrophoresis and immunofixation showed an IgG kappa monoclonal protein level of 1.36 g/dL. Further testing showed a kappa-to-lambda free light chain ratio of 1.48 and a beta-2 microglobulin level of 2.2 mg/L. A skeletal survey was negative for abnormalities. Because there was no end-organ damage, the patient was diagnosed with smoldering myeloma with autoimmune neutropenia. He was restarted on filgrastim at a dosage of 480 mg subcutaneously, twice weekly. The patient did well for approximately 6 months, and then he developed symptomatic myeloma. The patient was then started on bortezomib, thalidomide, and dexamethasone therapy for MM. During the second cycle of therapy, the patient developed a skin rash (from a superficial fungal infection), oral thrush, dysphagia, and peripheral neuropathy. The fungal infection was treated with oral fluconazole, and the filgrastim dosage was increased to 480 mg every 48 hours. The patient’s therapy was changed to bortezomib and
Clinical Lymphoma, Myeloma & Leukemia February 2014
16
18 Negative
20 2000 1.52
Held Continued
21
25 6100 1.5
1.6
Restarted Stopped
dexamethasone because of the suspicion that the rash and dysphagia were related to thalidomide. Despite stopping the thalidomide, the dysphagia persisted; hence, bortezomib was discontinued and the patient’s regimen was changed to thalidomide and dexamethasone. In 2 months, the patient achieved a partial response. His white blood cell count continued to improve; hence, the filgrastim frequency was decreased to once every 4 days. The thalidomide and dexamethasone dosage remained constant and further chemotherapy was discontinued. Cyclophosphamide- and filgrastimassisted mobilization and collection of stem cells over 9 days yielded only 2.107 million CD34þ stem cells per kilogram. The neutrophil IgM antibody that was identified in prior testing was not detected on this evaluation, after which filgrastim was stopped. The patient was then started on weekly bortezomib and prednisone therapy for progressive disease. After 3 months, the therapy was switched to carfilzomib, secondary to disease progression. Four months after starting carfilzomib, the patient has achieved a partial response, and he remains off filgrastim with the highest white blood cell count of 7300 cells/mL and ANC of 6100 cells/mL in between chemotherapy cycles.
Discussion Neutropenia in MM is most often the result of therapy. Lenalidomide-induced neutropenia (grades 3 and 4) occurs in as much as 35% of patients.3 In our patient, the presence of neutrophil antibodies, the absence of alternate causes, the diagnosis of AIN around the same time as that of MM but prior to chemotherapy, and the resolution of AIN with the control of MM suggest that the likely underlying reason for AIN was MM. Viral infections (such as those from HIV and hepatitis viruses), connective tissue diseases (such as systemic lupus erythematosus [SLE], rheumatoid arthritis, and Sjögren syndrome) and Graves disease were also ruled out. Thus, our case illustrates that neutropenia in MM can be due to AIN, which might be underreported because of the difficulty in establishing the diagnosis. AIN has been reported, although infrequently, in association with other hematological malignancies, such as chronic lymphocytic leukemia,4-6 other leukemias, and lymphoma, as well as solid tumors, such as thymoma and melanoma.2 Although the cause of AIN in MM remains unclear, there is an association between immune dysregulation and MM. AIN may be the result of immune dysregulation in MM, or immune dysregulation may result in MM. The fact that MM is associated with other autoimmune diseases, such as autoimmune thyroid disease,7 pernicious anemia, rheumatoid arthritis, and polymyalgia rheumatica,8 supports the possibility that AIN is the result of immune dysregulation in MM. Conversely, it has also been suggested that
Madan Raj Aryal et al Figure 1 A Bone Marrow Biopsy Shows (a) a Variably Hypocellular Bone Marrow (30%) With Small Clusters of Plasma Cells and Several Interstitial Lymphoid Aggregates (Arrow). The Plasma Cells are Increased With Clustering as Shown (b) in Aspirate Smear and (c) by CD138 Immunostain, and They are Kappa Light Chain Restricted by (e) Kappa and (f) Lambda in Situ Hybridization. Plasma Cells Appear Morphologically Atypical, With Scant Cytoplasm and Prominent Nucleoli. (d)The Lymphoid Aggregates are Composed of Mainly Small Lymphocytes With Prominent T Cells, as Highlighted by CD3 Immunostain
autoimmune disease can be a risk factor for MM.9 Patients with SLE have been reported to be at increased risk for various plasma cell dyscrasias.10 It has been hypothesized that the hyperactivity of B cells in SLE favors the escape of abnormal B-cell clones from the normal regulatory mechanisms. An alternative hypothesis is that defective immunological surveillance in SLE patients predisposes them to malignancies in general, including MM.11 A large study of U.S. veterans showed that varieties of immune-mediated conditions, including autoimmune, infectious, and inflammatory disorders, can predispose patients to the development of MM.12 This predisposition could be the result of chronic immune stimulation, treatment used for autoimmune diseases, or shared risk factors.13 The underlying molecular pathogenesis of autoimmune disease in MM is not clear. However, in our patient, we speculate that the clonal T-cell expansion and TCR gene rearrangement may have played a role in the development of AIN. Despite being a B-cell disorder, MM has been shown to harbor clonal expansion of CD4þ and CD8þ T cells14,15 as well as clonal TCR gene
rearrangement,16,17 thus indicating the possibility of the cross-talk between B- and T-cell lineages. In fact, immunodominant CD8þ T-cell clones are detected in some patients with chronic idiopathic neutropenia, thus indicating their possible role in autoimmune phenomena.18 In addition, in 1 study, the presence of TCR gene rearrangement correlated to the presence of idiotype-reactive T cells and better outcome from MM compared with that of patients without such rearrangement.16 More important, TCR gene rearrangement has been shown to result in aberrant TCR signaling 19 and is associated with neutropenia in patients with benign neutropenia 20,21 as well as neutropenia in association with large granular leukemia.22 CD8þ T cells can result in AIN through an increased serum level of Fas ligand and neutrophil apoptosis through Fas-Fas ligand interaction.23 Taken together, these findings lead us to speculate that there is a possibility of the cross-talk between B-cells and T-cells in MM, resulting in TCR gene rearrangement with aberrant TCR signaling and ultimately AIN. Myeloma cells in our patient were positive for IgG but rarely for
Clinical Lymphoma, Myeloma & Leukemia February 2014
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Autoimmune Neutropenia in Myeloma Figure 2 Clonal Biallelic T-Cell Receptor Gamma Chain Gene Rearrangements are Detected by Polymerase Chain Reaction in a One-Tube T-Gamma Assay Using Primers to the J Gamma 1 and 2 Gene Segments (Black). The Peaks are at 178 and 191 Nucelotides
e22
-
IgM. Therefore, the myeloma cells were unlikely to be the source of antineutrophil IgM antibody. Finally, our patient had CD20þ MM, which has been reported in 7.5% to 18% of MM.24,25 In 1 study, the expression of CD20 was associated with small mature plasma cell morphology and the presence of translocation t(11;14). MM with t(11;14) expressed CD20 more frequently than those without the translocation. About 7% of MM expressed CD20 in 100% of the tumor cells.24 In another study, many patients with CD20þ MM had neutropenia (4%), anemia (32%), or thrombocytopenia (8%) at diagnosis25; however, it remains unclear whether the neutropenia seen in these patients had an autoimmune cause. The management of secondary AIN should be aimed at treating the underlying disease. If the underlying disease cannot be treated successfully or AIN does not resolve spontaneously, filgastrim may be considered. Most patients show response to filgrastim with a fall in ANC after the discontinuation of filgrastim. Filgrastim reduces neutrophil apoptosis and increases the release of soluble FCɣRIIIb, possibly clearing the antibodies against FCɣRIIIb (transmembrane protein on neutrophils)23 Cyclosporin A and sirolimus have also been used to treat secondary AIN with some success.2 Treatment with rituximab and alemtuzumab for severe AIN that does not respon to conventional treatment or for relapses of AIN with life threatening infections have been reported.2 Although long-lasting remissions have been reported following the administration of alemtuzumab, results with rituximab therapy have not been encouraging.2 The association of AIN with MM can have challenging implications. Although lenalidomide therapy was considered in our patient, we decided against it because of the presence of AIN and concern for worsening neutropenia. Even though our patient fortunately had no serious infectious complications, AIN can increase the risk of recurrent or serious infections in patients undergoing chemotherapy.
Clinical Lymphoma, Myeloma & Leukemia February 2014
The patient experienced a resolution of AIN and a disappearance of neutrophil antibodies with the treatment of his MM; whether this was related to the control of MM or the nonspecific immunosuppression from chemotherapeutic agents remains unclear.
Conclusion As illustrated by our case report, AIN can develop as a consequence of MM, and we argue that it is likely underdiagnosed because of the diagnostic difficulties. We believe that clonal T-cell expansion and TCR gene rearrangement may have played an important role in the development of AIN in our patient, indicating cross-talk between B-cell and T-cell lineages. Understanding the pathophysiology of AIN can help us better understand the immune alteration in MM; this can provide useful insights for developing targeted agents.
Disclosure The authors have stated that they have no conflicts of interest.
References 1. Bux J, Kissel K, Nowak K, et al. Autoimmune neutropenia: clinical and laboratory studies in 143 patients. Ann Hematol 1991; 63:249-52. 2. Akhtari M, Curtis B, Waller EK. Autoimmune neutropenia in adults. Autoimmun Rev 2009; 9:62-6. 3. Palumbo A, Bladé J, Boccadoro M, et al. How to manage neutropenia in multiple myeloma. Clin Lymphoma Myeloma Leuk 2012; 12:5-11. 4. Stern SC, Shah S, Costello C. Probable autoimmune neutropenia induced by fludarabine treatment for chronic lymphocytic leukaemia. Br J Haematol 1999; 106:836-7. 5. Roberts L, Lucas G, Green L, et al. Autoimmune neutropenia following therapy for chronic lymphocytic leukaemia: a report of three cases. Br J Haematol 2007; 136:348-9. http://dx.doi.org/10.1111/j.1365-2141.2006.06436.x. 6. Zent CS, Ding W, Reinalda MS, et al. Autoimmune cytopenia in chronic lymphocytic leukemia/small lymphocytic lymphoma: changes in clinical presentation and prognosis. Leuk Lymphoma 2009; 50:1261-8. 7. Dalamaga M, Karmaniolas K, Papadavid E, et al. Association of thyroid disease and thyroid autoimmunity with multiple myeloma risk: a case-control study. Leuk Lymphoma 2008; 49:1545-52. 8. Thomas E, Brewster DH, Black RJ, et al. Risk of malignancy among patients with rheumatic conditions. Int J Cancer 2000; 88:497-502.
Madan Raj Aryal et al 9. Owlia MB, Distler O, Foratyazdi M, et al. Low back pain as initial manifestation of multiple myeloma complicating a man with preexisting systemic sclerosis. J Coll Physicians Surg Pak 2013. 10. Choi JW, Han SW, Kwon KT, et al. Early onset multiple myeloma in a patient with systemic lupus erythematosus: a case report and literature review. Clin Rheumatol 2010; 29:1323-6. 11. Afeltra A, Amoroso A, Garzia P, et al. Systemic lupus erythematosus and multiple myeloma: a rare association. Semin Arthritis Rheum 1997; 26:845-9. 12. Brown LM, Gridley G, Check D, et al. Risk of multiple myeloma and monoclonal gammopathy of undetermined significance among white and black male United States veterans with prior autoimmune, infectious, inflammatory, and allergic disorders. Blood 2008; 111:3388-94. 13. Goldin LR, Landgren O. Autoimmunity and lymphomagenesis. Int J Cancer 2009; 12:1497-502. 14. Moss P, Gillespie G, Frodsham P, et al. Clonal populations of CD4þ and CD8þ T cells in patients with multiple myeloma and paraproteinemia. Blood 1996; 87: 3297-306. 15. Sze DMY, Brown RD, Yuen E, et al. Clonal cytotoxic T cells in myeloma. Leuk Lymphoma 2003; 44:1667-74. 16. Brown RD, Yuen E, Nelson M, et al. The prognostic significance of T cell receptor beta gene rearrangements and idiotype-reactive T cells in multiple myeloma. Leukemia 1997; 11:1312-7. 17. Berenson J, Lichtenstein A. Clonal rearrangement of the beta-T cell receptor gene in multiple myeloma. Leukemia 1989; 3:133-6.
18. Wlodarski MW, Nearman Z, Jiang Y, et al. Clonal predominance of CD8(þ) T cells in patients with unexplained neutropenia. Exp Hematol 2008; 36:293-300. 19. Bank I, Cohen L, Kneller A, et al. Aberrant T-cell receptor signalling of interferongamma- and tumour necrosis factor-alpha-producing cytotoxic CD8þ Vdelta1/ Vbeta16 T cells in a patient with chronic neutropenia. Scand J Immunol 2003; 58: 89-98. 20. Van Oostveen JW, Breit TM, de Wolf JT, et al. Polyclonal expansion of T-cell receptor-gamma deltaþ T lymphocytes associated with neutropenia and thrombocytopenia. Leukemia 1992; 6:410-8. 21. Bank I, Book M, Cohen L, et al. Expansion of a unique subpopulation of cytotoxic T cells that express a C alpha V delta 1 T-cell receptor gene in a patient with severe persistent neutropenia. Blood 1992; 80:3157-63. 22. Kasten-Sportès C, Zaknoen S, Steis RG, et al. T-cell receptor gene rearrangement in T-cell large granular leukocyte leukemia: preferential V alpha but diverse J alpha usage in one of five patients. Blood 1994; 83:767-75. 23. Smith MA, Smith JG. The use of granulocyte colony-stimulating factor for treatment of autoimmune neutropenia. Curr Opin Hematol 2001; 8:165-9. 24. Robillard N, Avet-Loiseau H, Garand R, et al. CD20 is associated with a small mature plasma cell morphology and t(11;14) in multiple myeloma. Blood 2003; 102(3):1070-1. 25. Grigoriadis G, Gilbertson M, Came N, et al. Is CD20 positive plasma cell myeloma a unique clinicopathological entity? A study of 40 cases and review of the literature. Pathology 2012; 44:552-6.
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Autoimmune Neutropenia in Multiple Myeloma and the Role of Clonal T-Cell Expansion: Evidence of Cross-Talk Between B-Cell and T-Cell Lineages? Madan Raj Aryal,1 Vijaya Raj Bhatt,2 Pavankumar Tandra,2 Jairam Krishnamurthy,2 Ji Yuan,3 Timothy C. Greiner,3 Mojtaba Akhtari2 Clinical Practice Points Autoimmune neutropenia (AIN), characterized by an
absolute neutrophil count below 1500 cells/mL in the presence of autoantibodies directed against neutrophil antigens, can be secondary to a variety of underlying diseases, such as connective tissue diseases, infections, and malignancies. However, it has not been reported in association with multiple myeloma (MM). We report a case of AIN in a patient with MM who also had a population of small lymphocytes with
T-cell receptor gamma chain gene rearrangements. We also review other autoimmune manifestations of MM, the role of T-cell receptor gene rearrangement in AIN, and the implications of AIN in the management of MM. AIN can develop as a consequence of MM, and it is likely underdiagnosed because of the diagnostic difficulties. AIN can increase the risk of recurrent or serious infections in patients undergoing chemotherapy.
Clinical Lymphoma, Myeloma & Leukemia, Vol. 14, No. 1, e19-23 ª 2014 Elsevier Inc. All rights reserved. Keywords: Anti-neutrophil antibody, Filgrastim, T-cell receptor gene rearrangement, T-lymphocyte
Introduction Autoimmune neutropenia (AIN), defined by the presence of an absolute neutrophil count (ANC) less than 1500 cells/mL, can be of 2 types: primary, in which there is no underlying disorder, and secondary. Secondary AIN has been associated with a variety of underlying diseases, including infection (hepatitis B viral infection and mycoplasma pneumonia), connective tissue disease, primary immunodeficiency, autoimmune hemolytic anemia, idiopathic thrombocytopenia purpura, and malignancy.1,2 Medications such as penicillin, phenytoin, metformin, and antineoplastic drugs (eg, fludarabine and rituximab) have also been associated with AIN.2 *M.R.A. and V.R.B. contributed equally to this work as first authors. 1
Department of Medicine, Reading Health System, West Reading, PA 2 Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE 3 Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE Submitted: Jun 21, 2013; Revised: Aug 21, 2013; Accepted: Aug 28, 2013; Epub: Oct 30, 2013 Address for correspondence: Mojtaba Akhtari, MD, Division of HematologyOncology, Department of Internal Medicine, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198 E-mail contact: [email protected]
2152-2650/$ - see frontmatter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clml.2013.08.002
We report a case of AIN in association with multiple myeloma (MM), a combination that, to our knowledge, has not been reported previously.
Case Report A 54-year-old man with a history of persistent neutropenia despite the use of filgrastim was referred to our hematologyoncology clinic. He had been admitted to an outside facility with a perirectal abscess 3 months before, which is when he was first noted to be leukopenic. Repeat counts since then had shown persistent neutropenia with a lowest ANC of 600 cells/mL (Table 1). The patient underwent bone marrow biopsy and was subsequently started on filgrastim. His medical history was notable for heterozygous factor V Leiden, multiple superficial venous thrombosis, and peripheral vascular disease. Medications included filgrastim, warfarin, and hydrocodone/acetaminophen. The patient’s physical exam was unremarkable, and his laboratory findings included a white count of 2200 cells/mL with ANC of 1100 cells/mL, a hemoglobin level of 13.4 gm/dL, and a platelet count of 231,000 cells/mL. The patient’s hepatitis and HIV serologic tests, antineutrophil cytoplasmic antibody screen, and antinuclear antibody panel returned negative results. Neutrophil reactive antibodies (immunoglobulin [Ig]M), antibodies against neutrophil-specific
Clinical Lymphoma, Myeloma & Leukemia February 2014
- e19
Autoimmune Neutropenia in Myeloma Table 1 Changes in Different Parameters With Time in a Patient With AIN and MM Time (mos) Antibody ANC (cells/mL) Monoclonal protein level (g/dL)
0 600
Chemotherapy use Filgrastim use
e20
-
3 Positive 1100 1.36 No
10
1.59
17
4200 0.67
2300 0.92
Yes
No
antigens, were detected, whereas human leukocyte antigen class I and II antibodies were not detected. A bone marrow analysis that was performed at the outside facility revealed a hypocellular bone marrow with panhypoplasia and plasma cell dyscrasia. Filgrastim was discontinued for 1 week, and a repeat bone marrow biopsy was performed. The repeat bone marrow analysis found that the marrow was hypocellular given the patient’s age (30%) (Fig. 1a), with panhypoplasia and plasma cell dyscrasia. Myeloid, erythroid, and megakaryocytic lineages were all decreased, but they displayed orderly maturation without significant dysplasia. Plasma cells were increased to 26% with clustering and appeared abnormal morphologically (Fig. 1b). Immunostaining results showed that the plasma cells were positive for CD20, CD117, Cyclin-D1, and IgG, in addition to CD138 (Fig. 1c). In situ hybridization showed kappa light chain restriction with lambda negativity (Figs. 1e and 1f). Several interstitial lymphoid aggregates, composed mostly of small CD3-positive T-cells, were present in the core biopsy. (Figs. 1a and 1d). Immunostain analysis revelaed that the T cells expressed normal antigen profiles with a CD4-to-CD8 ratio of 1:1. A plasma cell population expressing CD20, CD23, CD38, CD117, CD138, and monotypic cytoplasmic and surface kappa light chains was identified, by flow cytometry, at 3% of ficolled cells, and mature Bcells were polyclonal by light chain distribution. T cells appeared normal by antigen profile. Interestingly, clonal biallelic T-cell receptor (TCR) gamma chain gene rearrangements were detected by DNA amplification (Fig. 2). Only rare plasma cells were positive for IgM, and the presence of a monoclonal IgG kappa serum paraprotein suggested that the myeloma cells may not be the source of the antineutrophil IgM antibody. Cytogenetic analysis showed a normal male karyosome; FISH results were positive for trisomy 11 in 8% of the interphase cells. Serum protein electrophoresis and immunofixation showed an IgG kappa monoclonal protein level of 1.36 g/dL. Further testing showed a kappa-to-lambda free light chain ratio of 1.48 and a beta-2 microglobulin level of 2.2 mg/L. A skeletal survey was negative for abnormalities. Because there was no end-organ damage, the patient was diagnosed with smoldering myeloma with autoimmune neutropenia. He was restarted on filgrastim at a dosage of 480 mg subcutaneously, twice weekly. The patient did well for approximately 6 months, and then he developed symptomatic myeloma. The patient was then started on bortezomib, thalidomide, and dexamethasone therapy for MM. During the second cycle of therapy, the patient developed a skin rash (from a superficial fungal infection), oral thrush, dysphagia, and peripheral neuropathy. The fungal infection was treated with oral fluconazole, and the filgrastim dosage was increased to 480 mg every 48 hours. The patient’s therapy was changed to bortezomib and
Clinical Lymphoma, Myeloma & Leukemia February 2014
16
18 Negative
20 2000 1.52
Held Continued
21
25 6100 1.5
1.6
Restarted Stopped
dexamethasone because of the suspicion that the rash and dysphagia were related to thalidomide. Despite stopping the thalidomide, the dysphagia persisted; hence, bortezomib was discontinued and the patient’s regimen was changed to thalidomide and dexamethasone. In 2 months, the patient achieved a partial response. His white blood cell count continued to improve; hence, the filgrastim frequency was decreased to once every 4 days. The thalidomide and dexamethasone dosage remained constant and further chemotherapy was discontinued. Cyclophosphamide- and filgrastimassisted mobilization and collection of stem cells over 9 days yielded only 2.107 million CD34þ stem cells per kilogram. The neutrophil IgM antibody that was identified in prior testing was not detected on this evaluation, after which filgrastim was stopped. The patient was then started on weekly bortezomib and prednisone therapy for progressive disease. After 3 months, the therapy was switched to carfilzomib, secondary to disease progression. Four months after starting carfilzomib, the patient has achieved a partial response, and he remains off filgrastim with the highest white blood cell count of 7300 cells/mL and ANC of 6100 cells/mL in between chemotherapy cycles.
Discussion Neutropenia in MM is most often the result of therapy. Lenalidomide-induced neutropenia (grades 3 and 4) occurs in as much as 35% of patients.3 In our patient, the presence of neutrophil antibodies, the absence of alternate causes, the diagnosis of AIN around the same time as that of MM but prior to chemotherapy, and the resolution of AIN with the control of MM suggest that the likely underlying reason for AIN was MM. Viral infections (such as those from HIV and hepatitis viruses), connective tissue diseases (such as systemic lupus erythematosus [SLE], rheumatoid arthritis, and Sjögren syndrome) and Graves disease were also ruled out. Thus, our case illustrates that neutropenia in MM can be due to AIN, which might be underreported because of the difficulty in establishing the diagnosis. AIN has been reported, although infrequently, in association with other hematological malignancies, such as chronic lymphocytic leukemia,4-6 other leukemias, and lymphoma, as well as solid tumors, such as thymoma and melanoma.2 Although the cause of AIN in MM remains unclear, there is an association between immune dysregulation and MM. AIN may be the result of immune dysregulation in MM, or immune dysregulation may result in MM. The fact that MM is associated with other autoimmune diseases, such as autoimmune thyroid disease,7 pernicious anemia, rheumatoid arthritis, and polymyalgia rheumatica,8 supports the possibility that AIN is the result of immune dysregulation in MM. Conversely, it has also been suggested that
Madan Raj Aryal et al Figure 1 A Bone Marrow Biopsy Shows (a) a Variably Hypocellular Bone Marrow (30%) With Small Clusters of Plasma Cells and Several Interstitial Lymphoid Aggregates (Arrow). The Plasma Cells are Increased With Clustering as Shown (b) in Aspirate Smear and (c) by CD138 Immunostain, and They are Kappa Light Chain Restricted by (e) Kappa and (f) Lambda in Situ Hybridization. Plasma Cells Appear Morphologically Atypical, With Scant Cytoplasm and Prominent Nucleoli. (d)The Lymphoid Aggregates are Composed of Mainly Small Lymphocytes With Prominent T Cells, as Highlighted by CD3 Immunostain
autoimmune disease can be a risk factor for MM.9 Patients with SLE have been reported to be at increased risk for various plasma cell dyscrasias.10 It has been hypothesized that the hyperactivity of B cells in SLE favors the escape of abnormal B-cell clones from the normal regulatory mechanisms. An alternative hypothesis is that defective immunological surveillance in SLE patients predisposes them to malignancies in general, including MM.11 A large study of U.S. veterans showed that varieties of immune-mediated conditions, including autoimmune, infectious, and inflammatory disorders, can predispose patients to the development of MM.12 This predisposition could be the result of chronic immune stimulation, treatment used for autoimmune diseases, or shared risk factors.13 The underlying molecular pathogenesis of autoimmune disease in MM is not clear. However, in our patient, we speculate that the clonal T-cell expansion and TCR gene rearrangement may have played a role in the development of AIN. Despite being a B-cell disorder, MM has been shown to harbor clonal expansion of CD4þ and CD8þ T cells14,15 as well as clonal TCR gene
rearrangement,16,17 thus indicating the possibility of the cross-talk between B- and T-cell lineages. In fact, immunodominant CD8þ T-cell clones are detected in some patients with chronic idiopathic neutropenia, thus indicating their possible role in autoimmune phenomena.18 In addition, in 1 study, the presence of TCR gene rearrangement correlated to the presence of idiotype-reactive T cells and better outcome from MM compared with that of patients without such rearrangement.16 More important, TCR gene rearrangement has been shown to result in aberrant TCR signaling 19 and is associated with neutropenia in patients with benign neutropenia 20,21 as well as neutropenia in association with large granular leukemia.22 CD8þ T cells can result in AIN through an increased serum level of Fas ligand and neutrophil apoptosis through Fas-Fas ligand interaction.23 Taken together, these findings lead us to speculate that there is a possibility of the cross-talk between B-cells and T-cells in MM, resulting in TCR gene rearrangement with aberrant TCR signaling and ultimately AIN. Myeloma cells in our patient were positive for IgG but rarely for
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Autoimmune Neutropenia in Myeloma Figure 2 Clonal Biallelic T-Cell Receptor Gamma Chain Gene Rearrangements are Detected by Polymerase Chain Reaction in a One-Tube T-Gamma Assay Using Primers to the J Gamma 1 and 2 Gene Segments (Black). The Peaks are at 178 and 191 Nucelotides
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IgM. Therefore, the myeloma cells were unlikely to be the source of antineutrophil IgM antibody. Finally, our patient had CD20þ MM, which has been reported in 7.5% to 18% of MM.24,25 In 1 study, the expression of CD20 was associated with small mature plasma cell morphology and the presence of translocation t(11;14). MM with t(11;14) expressed CD20 more frequently than those without the translocation. About 7% of MM expressed CD20 in 100% of the tumor cells.24 In another study, many patients with CD20þ MM had neutropenia (4%), anemia (32%), or thrombocytopenia (8%) at diagnosis25; however, it remains unclear whether the neutropenia seen in these patients had an autoimmune cause. The management of secondary AIN should be aimed at treating the underlying disease. If the underlying disease cannot be treated successfully or AIN does not resolve spontaneously, filgastrim may be considered. Most patients show response to filgrastim with a fall in ANC after the discontinuation of filgrastim. Filgrastim reduces neutrophil apoptosis and increases the release of soluble FCɣRIIIb, possibly clearing the antibodies against FCɣRIIIb (transmembrane protein on neutrophils)23 Cyclosporin A and sirolimus have also been used to treat secondary AIN with some success.2 Treatment with rituximab and alemtuzumab for severe AIN that does not respon to conventional treatment or for relapses of AIN with life threatening infections have been reported.2 Although long-lasting remissions have been reported following the administration of alemtuzumab, results with rituximab therapy have not been encouraging.2 The association of AIN with MM can have challenging implications. Although lenalidomide therapy was considered in our patient, we decided against it because of the presence of AIN and concern for worsening neutropenia. Even though our patient fortunately had no serious infectious complications, AIN can increase the risk of recurrent or serious infections in patients undergoing chemotherapy.
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The patient experienced a resolution of AIN and a disappearance of neutrophil antibodies with the treatment of his MM; whether this was related to the control of MM or the nonspecific immunosuppression from chemotherapeutic agents remains unclear.
Conclusion As illustrated by our case report, AIN can develop as a consequence of MM, and we argue that it is likely underdiagnosed because of the diagnostic difficulties. We believe that clonal T-cell expansion and TCR gene rearrangement may have played an important role in the development of AIN in our patient, indicating cross-talk between B-cell and T-cell lineages. Understanding the pathophysiology of AIN can help us better understand the immune alteration in MM; this can provide useful insights for developing targeted agents.
Disclosure The authors have stated that they have no conflicts of interest.
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