Case Report Successful Hematopoietic Reconstitution by Transplantation of Umbilical Cord Blood Cells in a Transfusion-Dependent Child with Diamond– Blackfan Anemia

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Case report Successful hematopoietic reconstitution by transplantation of umbilical cord blood cells in a transfusion-dependent child with Diamond– Blackfan anemia

M Bonno1, E Azuma1,2, T Nakano1, M Higashikawa1, H Kawaski1, H Nishihara1, M Obata1, M Umemoto1, H Sakatoku1, Y Komada1, M Ito1, M Nagai1,2 and M Sakurai1

1Department of Pediatrics and 2Department of Clinical Immunology, Mie University School of Medicine, Mie, Japan

Summary: Case report

A 4-year-old boy with Diamond–Blackfan anemia and A 4-year-old boy was first noted to have severe anemia at a history of multiple transfusions underwent umbilical 1 month of age. An evaluation showed hemoglobin 50 g/l, cord blood transplantation from his HLA-identical white blood cell count 5.5 × 109/l with normal distribution, female sibling born by vaginal delivery at 38 weeks. The platelet count 385 × 109/l, and 0% reticulocyte. The bone patient was prepared with busulfan, cyclophosphamide marrow showed marked erythroid hypoplasia with no and antilymphocyte globulin. Methotrexate and cyclo- abnormal cells and a diagnosis of Diamond–Blackfan ane- sporin A were given for the prophylaxis of GVHD. Regi- mia was confirmed. He was 2680 g at birth, the product men-related toxicity was not observed and successful of a full-term, uncomplicated gestation. The parents were engraftment occurred, including the erythroid series. healthy and there was no consanguinity or family history No evidence of acute or chronic GVHD has been of hematological disorders. Several therapeutic approaches observed for 14 months after transplantation. This is including intravenous high-dose methylprednisolone and the first case of successful umbilical cord blood trans- oral corticosteroids had been tried. However, they had only plantation to a patient with Diamond–Blackfan anemia. a transient effect on the progressive anemia, and the patient Keywords: cord blood transplantation; Diamond– became steroid-resistant and transfusion-dependent. He Blackfan anemia; childhood; hemosiderosis received 60 units of filtered and irradiated packed red cells before transplantation without any iron-chelating therapy. His HLA-type was A24, 31; B51, 52; DR15(2), 4; DQ1, 4, and not identical to the parents and a sibling (father: Diamond–Blackfan anemia is a disorder of childhood A31, 33; B44, 52; DR15(2), 8; DQ1, mother: A24, 33; B44, characterized by normochromic–macrocytic anemia, reti- 51; DR4, 13; DQ1, 4, brother: A31, 33; B44, 52). culocytopenia and a normocellular marrow with a selective At 3 years of age, he displayed signs of iron overload deficiency of erythroid progenitors. Most patients respond including elevations of serum transaminase, iron and ferri- to corticosteroids initially. However, about 60% require tin. CT scan showed a marked increase in the density of chronic red cell transfusion and die in the second and third the liver parenchyma, which was consistent with liver 1 decade of life as a result of hemosiderosis. Allogeneic hemosiderosis. Echocardiography revealed mild left ven- BMT is already accepted as effective therapy for steroid- tricular dilatation and grade II mitral regurgitation with nor- resistant, transfusion-dependent patients with Diamond– mal wall mobility. His mother became pregnant and a girl 2–5 Blackfan anemia. However, the limited availability of was delivered vaginally at 38 weeks without any compli- suitable donors remains a problem. Recently, unbilical cord cations. At the time of delivery, 70 ml of cord blood was blood has been postulated to be an alternative and effi- collected from the umbilical cord and purified with 3% gel- cacious source of hematopoietic stem cells for allogeneic atin as previously described.7 HLA typing was identical to reconstitution and successful cord blood transplantation has the patient and the MLC was negative. The ABO group of been reported in patients with a variety of hematological the donor and the recipient was O Rh+. Differential WBC 6 and immunological disorders. We report a steroid-resist- count in the cord blood was normal. Cell recovery rate was ant, transfusion-dependent patient with Diamond–Blackfan 96.2% and 4.3 × 107/kg cord blood cells were cryo- anemia, who was successfully transplanted with umbilical preserved at −180°C. Serological tests on the mother were cord blood cells from his newborn sibling. negative for hepatitis B, C, HIV, and human T cell leukemia virus type I. No external anomalies were found on the baby. Correspondence: Dr E Azuma, Department of Clinical Immunology, Mie In June 1995, at 4 years of age, the patient underwent University School of Medicine, 2-174 Edobashi, Tsu, Mie 514, Japan cord blood transplantation. His body weight was 12 kg. Received 4 March 1996; accepted 16 August 1996 Laboratory investigations showed: hemoglobin 55 g/l, CBSCT for Diamond–Blackfan anemia M Bonno et al 84 WBC 3.3 × 109/l with 57% neutrophils, 1% eosinophils, 2% cord blood and for the transplantation procedure. The donor basophils, 4% monocytes, 35% lymphocytes, platelet count is healthy and no signs of anemia or developmental delay 335 × 109/l, 0% reticulocyte, asparate aminotransferase have been observed on medical examination at 6 months, 478 IU/l (normal 0–40 IU/l), alanine aminotransferase which was just before the patient received transplantation, 272 IU/l (0–35 IU/l), serum iron 318 × 10−5 g/l (85– and 14 months of age. 135 × 10−5 g/l), serum ferritin 932 × 10−5 g/l (5.5– 18.5 × 10−5 g/l). The bone marrow showed total absence of erythroid precursors with 70% myeloid cells, 27% lympho- Discussion cytes and 4.7 × 107/l megakaryocytes. His karyotype was 46, XY without any abnormalities, and he was positive for We report a boy with Diamond–Blackfan anemia in whom CMV IgG. normal erythroid hematopoiesis was restored after trans- The patient was isolated in a room with laminar airflow plantation of cord blood stem cells. To our knowledge, this and received nonabsorbable oral antibiotics, inhalations is the first successful case of umbilical cord blood trans- with tobramycin and amphotericin B, sulfamethoxazole/ plantation in a patient with Diamond–Blackfan anemia. trimethoprim, and acyclovir. CMV high-titer immunoglob- Umbilical cord blood has been utilized as an alternative ulin was administered weekly from day −7 to day 180. Con- source for hematopoietic reconstitution in patients with ditioning was busulfan 3.5 mg/kg/day on days −9to−6, hematological and immunologic diseases since the first suc- equine anti-human thymocyte globulin (Lymphoglobuline, cessful report in Fanconi’s anemia in 1988.8 In view of the Pasteur Me´rieux, Lyon, France) 13 mg/kg/day on days −5 rapid progression of iron overload and lack of an HLA- to −1, and cyclophosphamide 50 mg/kg/day on days −4 to matched elder sibling, our patient was transplanted with −1. On day 0, cryopreserved umbilical cord blood was cord blood rather than bone marrow. thawed and 3.8 × 107/kg of nucleated cells containing Previously, allogeneic bone marrow transplantation has 8.7 × 105 CD34+ cells/kg, 3.6 × 104 CFU-GM/kg and been considered as a primarily curative procedure for 2.1 × 104 BFU-E/kg, were transplanted. For GVHD patients with transfusion-dependent Diamond–Blackfan prophylaxis CsA was started intravenously from day −1 and anemia. However, complications resulting from previous tapered off from 3 to 12 months. MTX 15 mg/m2 was given sensitization of patients and iron overload has been reported on day 1 and 10 mg/m2 on days 3, 6, 11 and 18. For prophy- in transfusion-dependent children.4 In 16 cases of reported laxis of veno-occlusive disease (VOD), prostaglandin E1 Diamond–Blackfan anemia who received bone marrow 0.3 ␮g/kg/h and heparin 100 U/kg were given intravenously transplantation,2–5 four patients died (two, interstitial pneu- with oral pentoxifylline 10 mg/kg from day −10 to day 9. monia, one, cardiac failure; one, chronic GVHD-related), G-CSF 5 ␮g/kg/day was given intravenously from day 1 to graft rejection occurred in one patient, and acute and day 50. The patient had taken low-dose prednisolone for 2 chronic GVHD was observed in nine and seven patients, years before transplantation. Prednisolone was maintained respectively. Because our patient was heavily transfused at 10 mg on alternate days during transplantation and tap- and liver hemosiderosis was present, antilymphocyte globu- ered off on day 59. lin was added to busulfan and cyclophosphamide for The clinical course of the patient was uneventful. A total immunosuppression and heparin and prostaglandin E1 was leukocyte count of 1.0 × 109/l and an absolute neutrophil administered for prophylaxis of VOD. No regimen-related count 0.5 × 109/l were achieved on day 29, and a reticulo- toxicity was observed and engraftment occurred success- cyte count of 100 × 109/l on day 55. The platelet count fully with no signs of rejection. Successful engraftment exceeded 20 × 109/l unsupported on day 72 and was without regimen-related toxicity in this patient may suggest 50 × 109/l on day 96. Red blood cells were last transfused that our preparative regimen is sufficient and tolerable for on day 40 and platelets on day 64. Bone marrow examin- transfusion-dependent patients. ation on day 40 showed that the total nucleated cells were GVHD is another major issue affecting not only the 81.5 × 109/l, with 23% erythroid cells and 56% myeloid transplant course but also quality of life after transplan- cells; chromosomes were of a normal female karyotype in tation. It has been reported that life-threatening GVHD 20 of 20 cells. Complete chimerism was confirmed with occurs less frequently in patients transplanted with umbili- karyotyping in the peripheral blood on day 373. At 12 cal cord blood compared with bone marrow.6 In this case, months, laboratory findings were as follows: hemoglobin no signs of acute and chronic GVHD were observed for 141 g/l, WBC 8.5 × 109/l with 40% neutrophils; IgG 14 months. 8.24 g/l, IgA 0.48 g/l, IgM 1.98 g/l, and IgE 1.7 × 104 IU/l. It has been reported that the median number of nucleated Examinations on the subsets, and PHA-induced prolifer- cells and CFU-GM obtained from cord blood after red cell ation of lymphocytes were normal. CT still showed a high depletion is 5.2 × 107/kg (range 1–33) and 2.4 × 104/kg but slightly decreased density of the liver parenchyma com- (range 0.01–100), respectively, and it has also been shown pared with previously, and serum transaminase, iron and that to neutrophil recovery does not correlate with the num- ferritin had slightly decreased: aspartate aminotransferase ber of nucleated cells or CFU-GM infused.6 The number 61 IU/l, alanine aminotransferase 59 IU/l, serum iron of CFU-GM infused into our patient, 3.6 × 104/kg, is aver- 212 × 10−5 g/l, and serum ferritin 680 × 10−5 g/l. No abnor- age and the slow hematopoietic recovery observed in this mal findings were observed on echocardiography. No signs patient is therefore not due to the low number of progenitor of acute or chronic GVHD have developed up to 14 cells infused. months, and performance status is 100%. Informed consent In conclusion, this is the first case of successful umbilical was obtained from the parents for collecting the umbilical cord blood transplantation to a patient with transfusion- CBSCT for Diamond–Blackfan anemia M Bonno et al 85 dependent Diamond–Blackfan anemia to be reported. We 4 Saunders EF, Olivieri N, Freedman MH. Unexpected compli- demonstrated that umbilical cord blood can be an effective cations after bone marrow transplantation in transfusion-depen- source of cells for hematopoietic reconstitution and that dent children. Bone Marrow Transplant 1993; 12 (Suppl. 1): they can be safely transplanted even in heavily transfused 88–90. patients. 5 Greinix HT, Storb R, Sanders JE et al. Long-term survival and cure after marrow transplantation for congenital hypoplastic anaemia (Diamond–Blackfan syndrome). Br J Haematol 1993; References 84: 515–520. 1 Halperin DS, Freedman MH. Diamond–Blackfan anemia: etiol- 6 Wagner JE, Kernan NA, Steinbuch M et al. Allogeneic sibling ogy, pathophysiology, and treatment. Am J Pediatr Hematol umbilical-cord-blood transplantation in children with malignant Oncol 1989; 11: 380–394. and non-malignant disease. Lancet 1995; 346: 214–219. 2 August CS, King E, Githens JH et al. Establishment of erythro- 7 Pahwa RN, Fleischer A, Than S, Good RA. Successful hematopoiesis following bone marrow transplantation in a patient with poietic reconstitution with transplantation of erythrocyte- congenital hypoplastic anemia (Diamond–Blackfan syndrome). depleted allogeneic human umbilical cord blood cells in a child Blood 1976; 48: 491–498. with leukemia. Proc Natl Acad Sci USA 1994; 91: 4485–4488. 3 Iriondo A, Garijo J, Baro J et al. Complete recovery of hemopo- 8 Gluckman E, Broxmeyer HE, Auerbach AD et al. Hematopo- iesis following bone marrow transplant in a patient with unre- ietic reconstitution in a patient with Fanconi’s anemia by means sponsive congenital hypoplastic anemia (Diamond–Blackfan of umbilical cord blood from an HLA-identical sibling. New syndrome). Blood 1984; 64: 348–351. Engl J Med 1989; 321: 1174–1178.