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Remission and immune reconstitution after T-cell-depleted stem-cell transplantation for rheumatoid arthritis
RESEARCH LETTERS
Remission and immune reconstitution after T-cell-depleted stem-cell transplantation for rheumatoid arthritis Patrick Durez, Michel Toungouz, Liliane Schandené, Micheline Lambermont, Michel Goldman
Transplantation of autologous haemopoietic stem cells (HSC) after myeloablative chemotherapy has been proposed as a potential therapeutic strategy for severe and refractory autoimmune diseases. 1 Disease recurrence has, however, been seen after transplantation of unseparated HSC, presumably because of reinfusion of pathogenic T cells.2 T-cell depletion of the autologous HSC transplant is, therefore, currently recommended for autoimmune disease.3 A major concern with such transplants is the restoration of the immune system, especially in adults. We report on a young woman successfully treated by autologous HSC transplantation for rheumatoid arthritis. A white woman aged 22 years who had intractable rheumatoid arthritis refractory to available antirheumatic agents was selected for autologous HSC transplantation after approval by the ethics committee of the hospital and after she gave informed consent. Mobilisation of peripheral-blood stem cells was achieved with cyclophosphamide (1·5 g/m 2) and etoposide (300 mg/m2), followed by granulocyte colony-stimulating factor administration (5 g/kg). The leukapheresis product was enriched by CD34 stem cells and further depleted of CD4 and CD8 cells by Isolex 300i device (Baxter Immunotherapy Division, Deerfield, USA). The HSC transplant (6·5⫻106 CD34 cells/kg with a purity of 98·4%) was shown to be devoid of T cells by flow cytometry. Transplantation of T-cell-depleted HSC was performed on Aug 28, 1997 (day 0), after administration of busulfan 4 mg daily from day ⫺7 to day ⫺4 and cyclophosphamide 60 mg daily from day ⫺3 to day ⫺2, according to consensus guidelines. 3 10 months after transplantation, the patient was free of arthritis, with a health-assessment questionnaire score of 1 (compared with 13 before transplantation) and a serum concentration of C-reactive protein of less than 2 mg/dL (value before transplantation 12 mg/dL) without any antirheumatic medication. Blood CD4 cell count returned to pretransplantation values (384/mm 3), and CD45 RA naive cells reappeared (6·3% of total CD4 cells). Enumeration of CD4 T cells expressing T-cell receptors of different V families showed a restoration of T-cell diversity, compared with the major skewing seen 3 months after transplantation (table). Similarly, the in-vitro T-cell proliferative responses to candidin which was greatly impaired at 3 months, returned to pretransplantation levels CD4 cell counts/L*
Candidin response†
V2 V5·1 V14 V17 V20 V21·3 V22 Counts Stimulation per index min 103 Before transplanation 61 3 months 6 9 months 31
30 4 23
9 1 8
16 6 19
9 18 46
11 4 14
20 4 20
55·7 7·3 68·0
42 4 37
*CD4 T cells expressing T-cell receptor belonging to indicated V families enumerated by flow cytometry before conditioning chemotherapy and 3 and 9 months after transplantation. †Peripheral blood mononuclear cells (109/mL) cultured with candidin (5 IC/mL) in complete medium for 5 days, and cell proliferation measure by 3H thymidine incorporation.
T-cell repertoire and proliferative responses to candidin after transplantation
THE LANCET • Vol 352 • September 12, 1998
(table). A delayed-type skin hypersensitivity reaction after intradermal injection of candidin confirmed that the patient had recovered immune responsiveness towards this antigen. Immunoglobulin concentrations decreased after HSC transplantation but were within the normal range 9 months later, except for IgG2 and IgA (IgG1 695 mg/dL, IgG2 67 mg/dL, IgG3 84 mg/dL, IgA 41 mg/dL, IgM 53 mg/dl). We conclude that clinical remission of rheumatoid arthritis together with recovery of cell-mediated responses can be achieved after transplantation of T-cell depleted autologous HSC. 1 2
3
Krance R, Brenner MK. Bone marrow transplantation beats autoimmune disease. Nat Med 1998; 4: 153–55. Euler HH, Marmont AM, Bacigalupo A, et al. Early recurrence or persistence of autoimmune diseases after unmanipulated autologous stem cell transplantation. Blood 1996; 88: 3621–25. Tyndall A, Gratwohl A. Blood and marrow stem cell transplants in autoimmune disease: a consensus report written on behalf of the European league against rheumatism (eular) and the European group for blood and marrow transplantation (ebmt). Bone Marrow Transplant 1997; 19: 643–45.
Department of Rheumatology, Laboratory of Immunology (M Goldman), and Cellular and Molecular Therapy Unit, Hôpital Erasme, Université Libre de Bruxelles, B-1070 Brussels, Belgium
Decreased neuronal inhibition in cerebral cortex in obsessivecompulsive disorder on transcranial magnetic stimulation Benjamin D Greenberg, Ulf Ziemann, Ann Harmon, Dennis L Murphy, Eric M Wassermann
Transcranial magnetic stimulation (TMS), initially developed as a non-invasive probe of brain motor physiology, has been applied to research of neuropsychiatric illness. TMS can assess the degree of neuronal inhibition in the cerebral cortex. Cortical motor-output cells are activated with powerful magnetic pulses produced by an electromagnetic coil placed on the scalp. The subsequent motor-evoked potentials (MEPs) are decreased when subthreshold TMS pulses precede by 2–5 ms stimuli above the threshold. This phenomenon of intracortical inhibition is thought to be due to activation of inhibitory interneurons by the subthreshold pulse. One study found that intracortical inhibition was defective in patients with Tourette’s syndrome,2 which suggests an influence on the intrusive motor phenomena characterising that illness. Because obsessive-compulsive disorder and Tourette’s syndrome seem to be related by clinical phenomena and heritability, we used TMS to test for intracortical inhibitory abnormalities in patients with obsessive-compulsive disorder. After we obtained patients’ informed consent, we studied 12 patients (seven on fluoxetine, five on no medication) and 12 healthy volunteers. We determined the change in right abductor pollicis brevis surface MEP amplitude when a suprathreshold stimulus was preceded by a subthreshold pulse. Two magnetic stimulators connected to a single figure-eight shaped coil placed over the hand area of the left primary motor cortex were used to produce single suprathreshold pulses, and pairs of a subthreshold and suprathreshold pulses every 6 s. We took the mean result from ten trials for each type of stimulus. Analysis of variance showed that the patients with obsessivecompulsive disorder had significantly less inhibition of the
881
Remission and immune reconstitution after T-cell-depleted stem-cell transplantation for rheumatoid arthritis Patrick Durez, Michel Toungouz, Liliane Schandené, Micheline Lambermont, Michel Goldman
Transplantation of autologous haemopoietic stem cells (HSC) after myeloablative chemotherapy has been proposed as a potential therapeutic strategy for severe and refractory autoimmune diseases. 1 Disease recurrence has, however, been seen after transplantation of unseparated HSC, presumably because of reinfusion of pathogenic T cells.2 T-cell depletion of the autologous HSC transplant is, therefore, currently recommended for autoimmune disease.3 A major concern with such transplants is the restoration of the immune system, especially in adults. We report on a young woman successfully treated by autologous HSC transplantation for rheumatoid arthritis. A white woman aged 22 years who had intractable rheumatoid arthritis refractory to available antirheumatic agents was selected for autologous HSC transplantation after approval by the ethics committee of the hospital and after she gave informed consent. Mobilisation of peripheral-blood stem cells was achieved with cyclophosphamide (1·5 g/m 2) and etoposide (300 mg/m2), followed by granulocyte colony-stimulating factor administration (5 g/kg). The leukapheresis product was enriched by CD34 stem cells and further depleted of CD4 and CD8 cells by Isolex 300i device (Baxter Immunotherapy Division, Deerfield, USA). The HSC transplant (6·5⫻106 CD34 cells/kg with a purity of 98·4%) was shown to be devoid of T cells by flow cytometry. Transplantation of T-cell-depleted HSC was performed on Aug 28, 1997 (day 0), after administration of busulfan 4 mg daily from day ⫺7 to day ⫺4 and cyclophosphamide 60 mg daily from day ⫺3 to day ⫺2, according to consensus guidelines. 3 10 months after transplantation, the patient was free of arthritis, with a health-assessment questionnaire score of 1 (compared with 13 before transplantation) and a serum concentration of C-reactive protein of less than 2 mg/dL (value before transplantation 12 mg/dL) without any antirheumatic medication. Blood CD4 cell count returned to pretransplantation values (384/mm 3), and CD45 RA naive cells reappeared (6·3% of total CD4 cells). Enumeration of CD4 T cells expressing T-cell receptors of different V families showed a restoration of T-cell diversity, compared with the major skewing seen 3 months after transplantation (table). Similarly, the in-vitro T-cell proliferative responses to candidin which was greatly impaired at 3 months, returned to pretransplantation levels CD4 cell counts/L*
Candidin response†
V2 V5·1 V14 V17 V20 V21·3 V22 Counts Stimulation per index min 103 Before transplanation 61 3 months 6 9 months 31
30 4 23
9 1 8
16 6 19
9 18 46
11 4 14
20 4 20
55·7 7·3 68·0
42 4 37
*CD4 T cells expressing T-cell receptor belonging to indicated V families enumerated by flow cytometry before conditioning chemotherapy and 3 and 9 months after transplantation. †Peripheral blood mononuclear cells (109/mL) cultured with candidin (5 IC/mL) in complete medium for 5 days, and cell proliferation measure by 3H thymidine incorporation.
T-cell repertoire and proliferative responses to candidin after transplantation
THE LANCET • Vol 352 • September 12, 1998
(table). A delayed-type skin hypersensitivity reaction after intradermal injection of candidin confirmed that the patient had recovered immune responsiveness towards this antigen. Immunoglobulin concentrations decreased after HSC transplantation but were within the normal range 9 months later, except for IgG2 and IgA (IgG1 695 mg/dL, IgG2 67 mg/dL, IgG3 84 mg/dL, IgA 41 mg/dL, IgM 53 mg/dl). We conclude that clinical remission of rheumatoid arthritis together with recovery of cell-mediated responses can be achieved after transplantation of T-cell depleted autologous HSC. 1 2
3
Krance R, Brenner MK. Bone marrow transplantation beats autoimmune disease. Nat Med 1998; 4: 153–55. Euler HH, Marmont AM, Bacigalupo A, et al. Early recurrence or persistence of autoimmune diseases after unmanipulated autologous stem cell transplantation. Blood 1996; 88: 3621–25. Tyndall A, Gratwohl A. Blood and marrow stem cell transplants in autoimmune disease: a consensus report written on behalf of the European league against rheumatism (eular) and the European group for blood and marrow transplantation (ebmt). Bone Marrow Transplant 1997; 19: 643–45.
Department of Rheumatology, Laboratory of Immunology (M Goldman), and Cellular and Molecular Therapy Unit, Hôpital Erasme, Université Libre de Bruxelles, B-1070 Brussels, Belgium
Decreased neuronal inhibition in cerebral cortex in obsessivecompulsive disorder on transcranial magnetic stimulation Benjamin D Greenberg, Ulf Ziemann, Ann Harmon, Dennis L Murphy, Eric M Wassermann
Transcranial magnetic stimulation (TMS), initially developed as a non-invasive probe of brain motor physiology, has been applied to research of neuropsychiatric illness. TMS can assess the degree of neuronal inhibition in the cerebral cortex. Cortical motor-output cells are activated with powerful magnetic pulses produced by an electromagnetic coil placed on the scalp. The subsequent motor-evoked potentials (MEPs) are decreased when subthreshold TMS pulses precede by 2–5 ms stimuli above the threshold. This phenomenon of intracortical inhibition is thought to be due to activation of inhibitory interneurons by the subthreshold pulse. One study found that intracortical inhibition was defective in patients with Tourette’s syndrome,2 which suggests an influence on the intrusive motor phenomena characterising that illness. Because obsessive-compulsive disorder and Tourette’s syndrome seem to be related by clinical phenomena and heritability, we used TMS to test for intracortical inhibitory abnormalities in patients with obsessive-compulsive disorder. After we obtained patients’ informed consent, we studied 12 patients (seven on fluoxetine, five on no medication) and 12 healthy volunteers. We determined the change in right abductor pollicis brevis surface MEP amplitude when a suprathreshold stimulus was preceded by a subthreshold pulse. Two magnetic stimulators connected to a single figure-eight shaped coil placed over the hand area of the left primary motor cortex were used to produce single suprathreshold pulses, and pairs of a subthreshold and suprathreshold pulses every 6 s. We took the mean result from ten trials for each type of stimulus. Analysis of variance showed that the patients with obsessivecompulsive disorder had significantly less inhibition of the
881