Bone Marrow Transplantation (2001) 27, 337–340  2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Case report Successful treatment of thrombocytopenia and hemolytic anemia with IvIG in a patient with lupus-like syndrome after mismatched related PBSCT

A Hartert, W Willenbacher, S Gu¨nzelmann, E Roemer, N Basara, AA Fauser and MG Kiehl

Clinic of Bone Marrow Transplantation and Haematology/Oncology, Idar-Oberstein Germany

Summary: weakness, edema, anemia, thrombocytopenia, and erosive cutaneous lesions. He had received a conditioning regimen Hematopoietic stem cell transplantation (HSCT) is a consisting of busulfan (4 mg/kg bw × day on days −7to treatment option for autoimmune diseases but can also −4) and cyclophosphamide (60 mg/kg bw × day on day −3 cause clinical features similar to those of autoimmune and day −2) before PBSCT. The donor was the patient’s diseases. In some of these cases the autoimmune-like sister. The patient’s blood group was A Rh positive, CMV- condition is associated with autoimmune cytopenia, a IgG seropositive and HLA-typing demonstrated HLA- complication that can be unresponsive to established A01/01, B 8/35, Cw 040/0701, DR 12/11, DRB1 120/110, treatment strategies and which may be fatal. The and DQB1 0301/0603. He received peripheral blood stem majority of cases reported on immune hemolytic anemia cells form his A Rh positive, CMV seronegative and HLA have been of alloimmune origin due to ABO red blood partially mismatched (DRB1 010×/110×; DQB1: cell antigen incompatibilities between donor and recipi- 0501/0603) sister. The graft contained 2.28 × 106 CD34+ ent. We now report a patient with a lupus-like syn- cells/kg/bw. drome, presenting with severe thrombocytopenia and GvHD prophylaxis consisted of cyclosporine (CYA) hemolytic anemia 9 months after HLA-mismatch, ABO starting on day −3, prednisolone starting on day +7 after compatible-related PBSCT who experienced no transplantation and MTX given as a short course on days response to high-dose steroids, but who had a sustained +1, +3 and +6 at a dose of 15 mg/m2 and twice at 10 mg/m2, response to repeated IvIG therapy. Bone Marrow Trans- respectively. Engraftment (leukocyte count Ͼ1000 × 109/l, plantation (2001) 27, 337–340. neutrophil count Ͼ0.5 × 109/l) occurred on day +21 after Keywords: autoimmune cytopenia; hematopoietic stem PBSCT. He developed slight cutaneous GVHD grade I–II cell transplantation; lupus-like syndrome; alloimmunity; which responded promptly to increased immunosuppres- IvIG sion with prednisolone (0.7 mg/kg bw × day) for 1 week, then tapered, and mycophenolate-mofetil (MMF) (2 g/day) for 3 months. CMV reactivation, as diagnosed by CMV-PCR, occurred Hematopoietic stem cell transplantation (HSCT) can cause 2 months after PBSCT (recipient CMV IgG positive, donor clinical symptoms characteristic of autoimmune diseases CMV IgG negative). This was successfully treated with like myasthenia gravis, immune thyroiditis, as well as ganciclovir, but the PCR became positive again shortly 1–11 immune cytopenia. Especially, autoimmune cytopenia is after cessation of therapy. He therefore received cidofovir 2,3 mostly refractory to standard therapeutic approaches. We as maintenance for 2 months. herein report a patient with a lupus-like syndrome associa- Immunosuppressive therapy on admission consisted of ted with hemolytic anemia and severe thrombocytopenia prednisolone 5 mg/day and CYA 150 mg/day given orally after HSCT. (blood level 284 ng/ml).

Patient characteristics Clinical findings + Nine months (day 277) after a mismatched related allo- As papular cutaneous lesions were the main clinical finding geneic stem cell transplant (PBSCT) for CML in first CP, a viral infection was suspected, possibly herpes virus or a 38-year-old patient presented with weight gain, general VZV reactivation. CMV testing had been negative for the last 4 months. However, the CMV-PCR was positive at the time of admission. He was treated with foscarnet to avoid Correspondence: Dr MG Kiehl, Clinic of Bone Marrow Transplan- tation and Oncology/Oncology, Dr Ottmar-Kohler-Str. 2, 55743 Idar- further myelosuppression in a graft which was already Oberstein, Germany suboptimal. Testing for VZV and HSV was negative. Received 31 May 2000; accepted 4 October 2000 Within a few days of admission the patient developed Successful treatment of thrombocytopenia after PBSCT with IvIG A Hartert et al 338 fever, arthralgia, severe pancytopenia, generalized edema, resolved slowly. Colonoscopy demonstrated discrete polyserositis with pericardial and pleural effusions, and changes compatible with intestinal GVHD grade I. Thus, nephrotic syndrome. Creatinine levels increased to the prednisolone dose was increased from 5 mg/day to 176.8 ␮mol/l and creatinine clearance decreased to 12.5 mg/day, whereas the other immunosuppressive medi- 83 ml/min, with a mixed glomerular/tubular proteinuria of cation remained unchanged for the first days of inpatient 4.5 g/l. He had oliguria with a further weight gain of nearly treatment. Intestinal symptoms improved within 1 week. A 7 kg, and for 1 week he experienced diarrhea which com- few days after admission the patient developed a tempera- menced shortly after the onset of these symptoms. A bone ture up to 38.8°C. No infection focus was found. Testing marrow biopsy showed mild hypoplasia, incompatible with for other herpes viruses including VZV and EBV was nega- the severe peripheral cytopenia. Folic acid, vitamin B12 tive. With the onset of fever the hemoglobin and platelet and iron levels were within normal ranges; the ferritin level levels dropped to 4 g/dl and 6000/␮l, respectively, without was increased to 774 ng/ml. The hemoglobin decreased to increment after transfusion. Direct Coombs testing was 40 g/l, leukocyte count to 1.5 × 109/l from 3.1 × 109/l, and positive and blood smears showed fragmented cells due to platelet count to 6 × 109/l from 66 × 109/l (Figure 1). The hemolysis. The edema worsened with a further increase in reticulocyte count was 4.2%. Coagulation parameters were body weight up to 96.2 kg. Ultrasound and CT scan within the normal ranges. Endoscopy revealed no gastro- revealed a polyserositis. CYA medication for GVHD intestinal bleeding, but GVHD grade 2 of the bowel was prophylaxis was immediately stopped and replaced by diagnosed histologically. The pancytopenia was refractory MMF because of a possible CYA-induced microangiopa- to platelet and red cell transfusion. We observed a slight thy. Autoantibody screening was performed and findings increase in bilirubin levels to 27.36 ␮mol/l, but hapoglobins corresponded to an autoreactive process after allogeneic remained within the normal range (53 mg/dl). Blood smears PBSCT, comparable to a lupus-like syndrome that met six showed fragmented cells indicating severe haemolysis and of the ARC criteria for SLE (serositis, arthralgia, ANA, the direct Coombs test was positive. Further analysis Anti-ds-DNA, Coombs positive anemia, thrombocytopenia, revealed polyspecific antibodies and ANA titers which proteinuria, discoid skin lesions). We did not perform a increased from 1:20 000 to 1:40 000 within 3 weeks with kidney biopsy to assess the grade of renal involvement homogenous a IF-pattern, and concomitant slightly elevated because of the refractory thrombocytopenia. Neither patient anti ds-DNA antibodies (25 U/l and 30 U/l). Anti Scl 70, nor donor had a history of rheumatic disease. No other rela- Ro/SS-A, c-ANCA, p-ANCA, MPO, C3 nephritis factor, tive had suffered from autoimmune disease. anti-tubular and anti-glomerular basal membrane antibodies Treatment consisted of prednisolone 75 mg for 8 days, were negative. C3 complement was decreased to 68 mg/dl then reduced to 50 mg/day, and MMF 2 g/day. Intravenous (normal range 90–180 mg/dl) and C4 complement factor immunoglobulin (IvIG) treatment was started at a dose of was reduced to levels below 11 mg/dl (10–40 mg/dl). 0.4 mg/kg bw on 5 consecutive days. A total of four cycles Lupus-anticoagulant was negative. was given. Oliguria and edema were treated with furose- mide and xipermide. Renal function subsequently improved markedly. On day +329, 2 months after symptom onset, the Clinical course and therapy serum creatinine was within the normal range and pro- teinuria decreased from 4.5 g/l to 0.8 g/l. The patient’s body On admission (day +277 after PBSCT) skin rash, diarrhea weight declined from 96 kg (maximum) to his regular body three to four times a day, and pancytopenia were observed weight of 72 kg and he no longer required diuretics. Hemo- and interpreted as GVHD of the skin and bowel, associated globin level (50 g/l) and platelet count (23 × 109/l) were with graft dysfunction, possibly CMV associated. Joint still low at the time of discharge on day +368 and there pains were interpreted as symptoms of CMV disease. PCR were no clinical signs of anemia or bleeding. Hb and plate- testing was positive, but pp65 Ag was negative. Adminis- lets increased during the following 2 weeks to levels of tration of foscarnet, twice a day (90 mg/kg) improved the 70 g/l and 50 × 109/l, respectively. Three weeks later (day clinical symptoms of CMV disease and the cytopenia +398) the patient was readmitted with new self-limiting

Platelet counts 140

120 IvIG /l)

9 100

80

60

40 Platelets (x10 20

0 270 275 279 283 291 297 305 335 341 370 400 421 447 533 590 751 Days post HSCT

Figure 1 Response of platelet counts to IvIG treatment. ↓, IvIG treatment.

Bone Marrow Transplantation Successful treatment of thrombocytopenia after PBSCT with IvIG A Hartert et al 339 episodes of arthralgia, decrease in platelet count Various drugs can induce an SLE-like syndrome. One (39 × 109/l) and Hb (37 g/l) associated with a slight of these is cyclosporine. It has been reported to possibly reduction (35 to 30 mg/day) in steroid therapy. Serum-PCR cause a comparable autoimmune disease associated with testing for CMV was again positive. There was no renal microangiopathy, cytopenia, and positive ANA titers.11 involvement. The patient received a course of foscarnet for However, detection of anti-ds DNA as was the case in 5 days, followed by ganciclovir p.o. for 4 weeks at a dose our patient, is rare. As our patient had only one episode of 3 g/day. IvIG was given at a dose of 0.4 mg/kg bw for of hemolysis and acute thrombocytopenia after cessation 5 days and resulted in a marked increase in the platelet of CYA therapy, a drug-related effect might have contrib- count to 84 × 109/l. Hb increased slowly to 51 g/l at dis- uted to his lupus-like syndrome. In addition, it is unclear charge after IvIG therapy. IvIG was repeated 2 weeks later whether this syndrome is a real autoimmune phenomenon at a reduced dose of 5 g/day for 5 days, repeated 4 weeks or a symptom of chronic GVHD. Previous case reports later. The Hb was stable above 90 g/l and the platelet count about cytopenia and especially severe thrombocytopenia remained above 40 × 109/l from approximately day +400. after SCT have demonstrated that thrombocytopenia is ANA titers were still high at 1:20 000–40 000, anti-ds- associated with IgG or IgM platelet-specific antibodies.1,2 DNA dropped to levels below 8 U/ml. CMV testing was Therapy consisted of prednisolone given at a dose of 1– negative from October 1999. IvIG was given every 4 weeks 2mg/kg× day and/or high-dose IvIG and/or anti-D from October 1999. The patient has been very well mean- immunoglobulin, and even plasma exchange.1,2,10 In while and there have been no similar episodes since August some cases complete recovery has been reported after 1999. The platelet count has been Ͼ80 × 109/l since Nov- IvIG. On the other hand, several of these cases proved ember 1999, Hb has remained Ͼ90 g/l. There are no signs to be therapy refractory and the clinical course was of GVHD. Day +769 blood counts are Hb 141 g/l, platelets fatal.2,3 The causes of failure or success of therapeutic 144 × 109/l, leukocytes 4.5 × 109/l. GVHD prophylaxis/ modalities in severe autoimmune cytopenia/ immunosuppressive therapy consists of 3 mg predni- thrombocytopenia are still unknown. solone/day and MMF 750 mg/day. In our patient, no anti-platelet antibodies were detected, but we observed an auto-antibody pattern resembling SLE Discussion with a poor response to steroid therapy. Nevertheless, a sustained response to IvIG therapy was observed. Whether Autoimmune-like conditions such as immune thyroiditis, further escalation of the steroid dose (dexamethasone) cytopenia, myasthenia gravis, and polymyositis have been would have led to the same result is an open question, but reported after allogeneic, syngeneic and even autologous as our patient had CMV reactivation at the same time, more hematopoietic stem cell transplantation (SCT).4–10 Cyto- aggressive steroid therapy was avoided. In conclusion, use penia after allogeneic SCT is a common phenomenon and of high-dose IvIG is a good treatment option for patients can occur secondary to various immune or non-immune with autoimmune thrombocytopenia after SCT. mechanisms. In this case a non-immune mechanism such as graft failure, peripheral consumption due to bleeding, sepsis or relapse of the underlying disease could be References excluded. As demonstrated by Sherer and Shoenfeld1 the prevalence of autoantibodies in long-term survivors of allo- 1 Sherer Y, Shoenfeld Y. Autoimmune diseases and auto- geneic SCT is increased. These autoantibodies are not immunity post bone-marrow transplantation. Bone Marrow necessarily associated with clinical symptoms.1 Transplant 1998; 22: 873–881. Chronic GVHD occurs in 25–70% of patients after allo- 2 Kottaridis PD, Rees H, Smith G et al. A fatal case of auto- geneic SCT and can cause symptoms resembling auto- immune thrombocytopenia with an IgM anti-GPIb/IX follow- immune-disease such as Sjo¨gren’s syndrome, scleroderma, ing one antigen mismatched unrelated donor bone marrow and autoimmune hepatitis. However, it is unclear how transplantation. Bone Marrow Transplant 1999; 23: 739–741. GVHD can be distinguished from these clinical syndromes. 3 Ting SS, Ziegler JB, Vowels MR. Acquired autoimmune Possibly such diseases depend on an underlying auto- thrombocytopenia post-bone marrow transplantation for sev- 9 ere combined immunodeficiency. Bone Marrow Transplant immune disease in the donor or recipient. In our case 1998; 21: 841–843. neither patient nor donor had a history of autoimmune 4 Lambertenghi Deliliers GL, Amnaloro C, Della Volpe A et symptoms and therefore the revelation of a pre-existing al. Multiple autoimmune events after autologous bone marrow autoimmune syndrome or transfer of an autoimmune dis- transplantation. Bone Marrow Transplant 1997; 19: 745–747. ease seems unlikely. Immune cytopenia post-allogeneic 5 Berisso GA, von Lint MT, Bacigalupo A, Marmont AM. SCT may be explained by recipient-versus-donor (HVG) Adoptive autoimmune hyperthyreoidism following allogeneic reactions as a result of alloantibodies of host origin, or stem cell transplantation from an HLA-identical sibling with otherwise donor-versus-donor reactions due to loss of auto- Grave’s disease. Bone Marrow Transplant 1999; 23: 1091– regulative T cells and consecutive loss of tolerance against 1092. 6 Karthaus M, Gabrysiak T, Brabant G et al. Immune thyroiditis autoantigens. These effects may contribute to autoimmune- + after transplantation of allogeneic CD34 selected peripheral like syndromes. Infections are another important cause of blood cells. Bone Marrow Transplant 1997; 20: 697–699. allo or autoimmune phenomena induced by antigenic cross- 7 Tse S, Saunders EF, Silvermann E et al. Myasthenia gravis reactivity. It should be noted that our patient developed and polymyositis as manifestations of chronic graft-versus- lupus-like symptoms during CMV reactivation, indicating host disease. Bone Marrow Transplant 1999; 23: 397–399. infection as a possible trigger of these immune phenomena. 8 Muro Y, Kamimoto T, Hagiwara M. Anti-myosin antibodies

Bone Marrow Transplantation Successful treatment of thrombocytopenia after PBSCT with IvIG A Hartert et al 340 in a patient with chronic graft-versus-host disease after allog- bocytopenic purpura following allogeneic bone marrow trans- eneic bone marrow transplantation. Bone Marrow Transplant plantation treated with anti-D immunoglobulin. Bone Marrow 1997; 19: 951–953. Transplant 1997; 19: 173–174. 9 Nelson JL, Torres R, Louie FM et al. Pre-existing autoimmune 11 Damoiseaux JG, van Breda Vriesman PJ. Pathogenesis of disease in patients with long-term survival after allogeneic cyclosproin A-induced autoimmunity: absence of T-cell reac- bone marrow transplantation. J Rheumatol 1997; 48: 23–29. tivity towards syngeneic antigen presenting cells. Autoimmun- 10 Lee SJ, Churchill WH, Konugres A et al. Idiopathic throm- ity 1998; 27: 45–56.

Bone Marrow Transplantation