Bone Marrow Transplantation (2002) 29, 995–998  2002 Nature Publishing Group All rights reserved 0268–3369/02 $25.00 www.nature.com/bmt Case report Successful treatment of Griscelli syndrome with unrelated donor allogeneic hematopoietic stem cell transplantation

M Arico`1, M Zecca2, N Santoro3, D Caselli2, R Maccario2, C Danesino4, G de Saint Basile5 and F Locatelli2

1Onco Ematologia Pediatrica, Ospedale dei Bambini ‘G Di Cristina’, Palermo, Italy; 2Oncoematologia Pediatrica, IRCCS Policlinico San Matteo, Universita` di Pavia, Italy; 3Clinica Pediatrica, Universita` di Bari, Italy; 4Biologia Generale e Genetica Medica, Universita` di Pavia, Italy; and 5Institut National de la Sante et de la Recherche Medicale (INSERM) U429, Hopital Necker Enfants Malades, Paris, France

Summary: show severe neurologic impairment, without apparent immune abnormalities.4 Griscelli syndrome (GS) is a rare autosomal recessive First reports of this new clinical entity, distinct from disorder, characterized by pigmentary dilution of the Chediak–Higashi syndrome (OMIM 214500) (CHS), were skin and hair and in most patients by abnormal regu- provided simultaneously in 1978 by Griscelli et al1 and by lation of the immune system, which results in a syn- Siccardi et al.2 drome of macrophage hyperactivation, known as hemo- In 1997 Pastural et al5 found a homozygous C2332T phagocytic lymophohistiocytosis (HLH). Allogeneic truncating mutation of the gene encoding myosin VA hematopoietic stem cell transplantation (HSCT) is the (MYO5A) in a Turkish girl with GS. Other mutations of the only curative treatment available for genetically same gene were reported in other cases. Recently, Pastural induced HLH. Few cases of successful HSCT from a et al6 presented evidence suggesting the existence of a compatible donor have been reported in children with second locus associated with Griscelli syndrome in the GS. We describe the first patient with GS cured with 15q21 region, which is located less than 7.3 cm from the an allograft from a compatible unrelated bone marrow MYO5A gene. Mutations in RAB27A were found in 16 donor. We used a novel preparative regimen consisting patients with GS.3 Unlike MYO5A, the GTP-binding pro- of busulfan, thiotepa and fludarabine. The demon- tein RAB27A is involved in the control of immune regu- strated curative effect of HSCT from an unrelated lation, and it seems to be a key effector of cytotoxic granule donor in a patient with genetically determined HLH exocytosis, a pathway essential for immune homeostasis. also supports the use of a systematic diagnostic All patients with RAB27A mutations, but none with the approach in these patients, in order to identify those MYO5A mutation, developed HLH. In addition, RAB27A- with a worse prognosis and needing an urgent allograft deficient T cells exhibited reduced cytotoxicity and cyto- in a timely manner. lytic granule exocytosis, whereas MYO5A-defective T cells Bone Marrow Transplantation (2002) 29, 995–998. DOI: did not. 10.1038/sj/bmt/1703567 As mentioned above, GS is a very rare disease, with Keywords: Griscelli syndrome; hemophagocytic lym- about 30 cases reported over the past 20 years;1–4,7–11 it is phohistiocytosis usually fatal within the first few years of life, due to HLH, which in most cases is triggered by common infections. We report a new case of GS in an Italian child cured after HSCT from a matched unrelated donor. Griscelli syndrome (GS) (OMIM 214450) is a rare autoso- mal recessive disorder that results in pigmentary dilution of the skin and hair, in the presence of large clumps of Case report pigment in hair shafts and an accumulation of melanosomes 1,2 in melanocytes. Most patients with this disorder also A male child was the only child born to healthy first cousins develop an uncontrolled T lymphocyte and macrophage from Southern Italy. The pregnancy was uneventful. Family activation syndrome, known as hemophagocytic syndrome, history failed to disclose any relevant medical problem. At or hemophagocytic lymophohistiocytosis (HLH), leading to the age of 5.5 months, the boy developed persistent fever. death in the absence of allogeneic hematopoietic stem cell When first seen at the age of 7 months, he had fever, 3 transplantation (HSCT). Early in life, some GS patients edema, hepatosplenomegaly and skin rash. His hairs and eyebrows were silvery-gray. Blood count showed leuko- 3 3 Correspondence: M Arico`, Onco Ematologia Pediatrica, Ospedale dei penia (2100/mm , neutrophils 260/mm ), anemia (8.5 g/dl), 3 Bambini ‘G Di Cristina’, Palermo, Italy thrombocytopenia (14 000/mm ); triglycerides were Received 5 November 2001; accepted 18 February 2002 363 mg/dl, fibrinogen 130 mg/dl, and ferritin 1040 ng/ml. MUD-BMT for Griscelli syndrome M Arico` et al 996 Serum immunoglobulins were as follows: IgG 480 mg/dl days and teicoplanin (10 mg/kg/day) for 12 days led to res- (n.v. 351–919), IgA 7 mg/dl (n.v. 10–85), IgM 50 mg/dl olution of the clinical symptoms and disappearance of the (n.v. 38–204). Bone marrow aspiration showed increased organism from blood and stool. numbers of monocytes with active erythrophagocytosis and Thirty months after HSCT, the patient is well, with com- no blast cells. Examination of the cerebro-spinal fluid plete donor chimerism and normal full blood cell counts; he (CSF) showed 17 cells/mm3 with no evidence of hemo- is not receiving any immune suppression and has recovered phagocytosis. On the basis of these findings, HLH was normal function of the immune system (see also Table 1 diagnosed. Natural killer (NK) activity was tested and for further details). found to be impaired, with 2%, 3% and 15% of lysis at the effector:target ratios of 10:1, 30:1, 100:1, respectively. The child was treated with dexamethasone, etoposide and Discussion cyclosporine, according to the HLH–94 study,12 with immediate response and stable disease control. A search for Differential diagnosis between the different subtypes of a suitable unrelated donor was started in the international HLH is crucial for appropriate and successful therapy. In registries of both bone marrow and cord blood donors. particular, prompt identification of genetic disorders lead- The possibilities of CHS and GS were considered. ing to HLH may confirm the indication for allogeneic Microscopic examination of the hairs showed unevenly HSCT as the only curative tool, while other less severe clustered pigment in the medulla, characteristic of GS. conditions should be identified as soon as possible in order Mutation analysis of the RAB27A gene showed a homo- to avoid potentially unnecessary and life-threatening treat- zygous six base pair deletion (del 510 AAGCC) confirming ments.13 Presence of silvery-gray hairs in patients with the diagnosis of GS. HLH should be considered a strong hallmark of CHS or At the age of 16 months, treatment according to HLH– GS. 94 was withdrawn and the child underwent HSCT from an Allogeneic HSCT is the only treatment proved to be unrelated bone marrow donor. Donor and recipient were potentially curative in genetically based HLH. We have found to be completely identical using a high-resolution been able to identify only five cases of GS in the literature allelic technique for both HLA class I and class II antigens. treated with allogeneic HSCT, all from a family donor Conditioning regimen before the allograft comprised busul- (Table 2).7,9,14 In 1990 Schneider et al9 reported one con- fan (16 mg/kg) from days Ϫ9toϪ6, thiotepa (10 mg/kg) sanguinous family in which four of seven children had GS. on day Ϫ5, and fludarabine (40 mg/m2/day) i.v. from days Three patients died before 20 months of age; in the fourth Ϫ4toϪ2. Graft-versus-host disease prophylaxis consisted sibling, allogeneic HSCT was performed at 4 months of of cyclosporine A, short-term methotrexate and anti-lym- age. Two years later, the patient remained in excellent phocyte globulin (ALG, 10 mg/kg/day from days Ϫ4to health. Ϫ2). The number of nucleated cells infused was 7.8 ϫ In their report in 1994, Klein et al7 included three chil- 108/kg of recipient body weight. Hematopoietic and lymph- dren with GS who were allografted. Two patients died dur- oid engraftment were documented by studying the genetic ing the immediate post-transplantation period of infectious polymorphism of variable number of tandem repeat short complications, but one patient was cured and at the time DNA sequences (VNTRs). of the report, the follow-up was 5 years. In 1999, Tezcan et Engraftment of donor cells was prompt. The child reco- al14 carried out an allogeneic HSCT from an HLA-identical vered an absolute neutrophil count more than 0.5 ϫ 109/l on sibling donor on a 4-year-old girl with GS who presented day +14 after transplantation, whereas platelet engraftment in accelerated phase with neurological manifestations. She (у20 ϫ 109/l) was observed on day +21. The post-trans- was treated with etoposide, methylprednisolone and intra- plant course was complicated by an episode of sepsis from thecal methotrexate for 8 weeks and underwent BMT after vancomycin-resistant Enterococcus faecium. Treatment receiving a conditioning regimen including ALG (rabbit, with quinupristin/dalfopristin (7.5 mg/kg every 8 h) for 22 10 mg/kg ϫ 5 days), busulfan and cyclophosphamide.

Table 1 Natural killer cell activity and immunological evaluation of the patient before and after allografting

Pre-transplant 6 months after 12 months after transplantation transplantation

NK activity at a 10:1 2% 15% 16% effector:target ratio NK activity at a 30:1 3% 23% 22% effector:target ratio NK activity at a 100:1 15% 42% 48% effector:target ratio CD3+ cells (/␮l) 2870 680 3900 CD4+ cells (/␮l) 1500 280 1870 CD8+ cells (/␮l) 1300 420 2100 CD19+ cells (/␮l) 390 480 270 CD56+ cells (/␮l) 180 500 330

Bone Marrow Transplantation MUD-BMT for Griscelli syndrome M Arico` et al 997 Table 2 Reported cases of Griscelli syndrome treated with allogeneic HSCT

Case Source Origin Consanguinity Sex/Age at onset Donor Outcome

1 Schneider et al9 1990 Arabian + F/3 months HLA-identical sibling Alive 22+ months 2 Klein et al7 1994 Italian unknown M/4 months HLA-identical sibling Early death 3 Klein et al7 1994 French unknown F/3 years HLA-identical sibling Early death 4 Klein et al7 1994 North-African unknown M/3 years and 7 months HLA-identical sibling Well 5+ years 5 Tezcan et al141999 Arabian − F/4 y HLA-identical sibling Well 18+ months 6 Present case Italian + M/7 m MUD Well 30+ months

Engraftment occurred early and the post-transplant period with genetically determined HLH supports the need for a was uneventful. Eighteen months after the allograft, she standardized diagnostic approach to HLH. was well, with sustained engraftment and normal neurologi- cal examination except for minimal clonus. To our knowledge, this is the first case of a successful Acknowledgements allograft of haematopoietic progenitors from an unrelated HLA-matched donor reported in a patient with GS. Regis- This work was partly supported by grants from: AIRC tries of unrelated donors have widened the possibility of (Associazione Italiana Ricerca sul Cancro) (FL); CNR (Consiglio performing allogeneic HSCT in these patients. However, Nazionale delle Ricerche) (FL); MURST (Ministero dell’Univer- the period of time needed for locating an unrelated stem sita` e della Ricerca Scientifica e Tecnologica) (FL); IRCCS cell donor can still unfavorably prejudice use of this treat- (Istituto di Ricovero e Cura a Carattere Scientifico) Policlinico ment in children with GS. In this regard, stable disease con- S Matteo (FL and MA); Telethon (MA); ‘Vaincre les maladies trol achieved with chemo-immunotherapy, can be lysosomales (VML)’ (GDSB). extremely helpful in gaining the time needed to identify a suitable donor. Chemo-immunotherapy with dexame- thasone, etoposide and cyclosporine according to the HLH– References 94 study12 proved to be very effective in achieving disease control in our patient, as is the case in children with other 1 Griscelli C, Durandy A, Guy-Grand D et al. A syndrome forms of HLH. ATG has also been utilized successfully to associating partial albinism and immunodeficiency. Am J Med induce remission of HLH in patients with GS.7,15,16 Unre- 1978; 65: 691–702. lated donor cord blood transplantation can represent a valid 2 Siccardi AG, Bianchi E, Calligari A et al. A new familial alternative option in offering a rapid allograft to patients defect in neutrophil bactericidal activity. Helv Paediatr Acta with HLH, due to the more prompt availability of hemato- 1978; 33: 401–412. poietic stem cells.17 3 Menasche G, Pastural E, Feldmann J et al. Mutations in RAB27A cause Griscelli syndrome associated with haemo- Since graft rejection has been reported to be frequent phagocytic syndrome. Nat Genet 2000; 25: 173–176. in patients with HLH given a mismatched family donor 4 Hurvitz H, Gillis R, Klaus S et al. A kindred with Griscelli 18 allograft and the use of an unrelated donor per se can disease: spectrum of neurological involvement. Eur J Pediat increase the risk of graft failure although it has also been 1993; 152: 402–405. successfully reported, we had concerns about the chances 5 Pastural E, Barrat FJ, Dufourcq-Lagelouse R et al. Griscelli of obtaining sustained engraftment of donor cells. Thus, disease maps to chromosome 15q21 and is associated with we decided to use a novel preparative regimen containing mutations in the myosin-Va gene. Nat Genet 1997; 16: 289– fludarabine and thiotepa instead of cyclophosphamide as 292. the immunosuppressive agent.19–25 Terenzi et al have both 6 Pastural E, Ersoy F, Yalman N et al. Two genes are respon- documented that fludarabine can replace cyclophosphamide sible for Griscelli syndrome at the same 15q21 locus. Genom- 19 ics 2000; 63: 299–306. in pre-transplant conditioning therapy and that, in an 7 Klein C, Phillipe, N Le Deist F et al. Partial albinism with experimental model of a fully mismatched transplant, immunodeficiency (Griscelli syndrome). J Pediat 1994; 125: enhanced engraftment of donor stem cells is achieved when 886–895. thiotepa is added to the preparative regimen.20 Moreover, 8 Mancini AJ, Chan LS, Paller AS. Partial albinism with previous clinical studies have shown that both thiotepa- and immunodeficiency: Griscelli syndrome: report of a case and fludarabine-based preparative regimens are well tolerated, review of the literature. J Am Acad Derm 1998; 38: 295–300. have limited extra-medullary toxicity and are currently used 9 Schneider LC, Berman RS, Shea CR et al. Bone marrow trans- in patients who are not eligible for conventional myelo- plantation (BMT) for the syndrome of pigmentary dilution and ablative conditioning because of advanced age and/or lymphohistiocytosis (Griscelli’s syndrome). J Clin Immunol poor performance status.21–25 1990; 10: 146–153. 10 Kurugol Z, Ozkinay F, Vardar F et al. Griscelli syndrome: In conclusion, available data suggest that an HLH is report of a case and review of the literature. Pediatr Int 2001; likely to occur in GS patients with RAB27A mutations, 43: 298–301. making affected children candidates for an early allograft, 11 Kumar M, Sackey K, Schmalstieg F et al. Griscelli syndrome: even from an alternative donor. The demonstrated curative a rare neonatal syndrome of recurrent hemophagocytosis. J effect of HSCT even from alternative donors in patients Pediatr Hematol Oncol 2001; 23: 464–468.

Bone Marrow Transplantation MUD-BMT for Griscelli syndrome M Arico` et al 998 12 Henter J-I, Samuelsson AC, Arico` M et al for the Histiocyte as immunosuppressor for bone marrow transplantation con- Society. Treatment of hemophagocytic lymphohistiocytosis ditioning. Blood 1996; 88 (Suppl. 1): 596a. with HLH–94 immuno-chemotherapy and bone marrow trans- 20 Terenzi A, Lubin I, Lapidot T et al. Enhancement of T cell- plantation. Blood (in press). depleted bone marrow allografts in mice by thiotepa. Trans- 13 Arico` M, Allen M, Brusa S et al. Hemophagocytic lymphohis- plantation 1990; 50: 717–720. tiocytosis: proposal of a flow-chart for the differential diag- 21 Zecca M, Pession A, Messina C et al. Total body irradiation, nosis of the different subtypes. Br J Haematol (in press). thiotepa, and cyclophosphamide as a conditioning regimen for 14 Tezcan I, Sanal O, Ersoy F et al. Successful bone marrow children with acute lymphoblastic leukemia in first or second transplantation in a case of Griscelli disease which presented remission undergoing bone marrow transplantation with HLA- in accelerated phase with neurological involvement. Bone identical siblings. J Clin Oncol 1999; 17: 1838–1846. Marrow Transplant 1999; 24: 931–933. 22 Grigg A, Bardy P, Byron K et al. Fludarabine-based non-mye- 15 Schuster F, Stachel DK, Schmid I et al. Griscelli syndrome: loablative chemotherapy followed by infusion of HLA-ident- report of the first peripheral blood stem cell transplant and the ical stem cells for relapsed leukaemia and lymphoma. Bone role of mutations in the RAB27A gene as an indication for Marrow Transplant 1999; 23: 107–110. BMT. Bone Marrow Transplant 2001; 28: 409–412. 23 Giralt S, Estey E, Albitar M et al. Engraftment of allogeneic 16 Arico` M, Danesino C, Pende D, Moretta L. Pathogenesis of hematopoietic progenitor cells with purine analog-containing haemophagocytic lymphohistiocytosis. Br J Haematol 2001; chemotherapy: harnessing graft-versus-host leukemia without 114: 761–769. myeloablative therapy. Blood 1997; 89: 4531–4536. 17 Gluckman E, Locatelli F. Umbilical cord blood transplants. 24 Chan KW, Bekassy AN, Ha CS et al. Fludarabine-based pre- Curr Opin Haematol 2000; 7: 353–357. parative protocol for unrelated cord blood transplantation in 18 Jabado N, de-Graeff-Meeder ER, Cavazzana-Calvo M et al. children: successful engraftment with minimal toxicity. Bone Treatment of familial hemophagocytic lymphohistiocytosis Marrow Transplant 1999; 23: 849–851. with bone marrow transplantation from HLA genetically non- 25 Amrolia P, Gaspar HB, Hassan A et al. Nonmyeloablative identical donors. Blood 1997; 90: 4743–4748. stem cell transplantation for congenital immunodeficiencies. 19 Terenzi A, Aversa F, Perruccio K et al.Efficacy of fludarabine Blood 2000; 96: 1239–1246.

Bone Marrow Transplantation