Pure Red Cell Aplasia After a Major ABO-Mismatched Bone Marrow

Correspondence

Pure red cell aplasia after a major ABO- probes was negative for the t(9;22) translocation. Through- mismatched bone marrow transplant for chronic out this period, there was no evidence of blood loss. Haemolytic screens were carried out on days 93 and 226. myeloid leukaemia: response to re-introduction The reticulocyte count on day 226 was 0.4%, the direct of cyclosporin antiglobulin test was repeatedly negative and haptoglobins were in the normal range. Erythropoietin levels were Bone Marrow Transplantation (2004) 33, 459–461. elevated at 275 and 565, respectively (normal range – 6– doi:10.1038/sj.bmt.1704366 25 units). Serology for parvovirus was IgG þ ve and IgM Published online 15 December 2003 Àve. On day 197, no donor erythropoiesis was yet evident, although assessment of peripheral blood nucleated cell Bone marrow transplantation in the setting of incompa- chimeric status using short-tandem repeat profiling by a tibility between donor ABO antigens and the recipient fluorescent PCR-based technique indicated a predomi- immune system (major ABO incompatibility) is associated nantly donor profile (see Figure 1).4 with specific immunohaematological complications.1 These On day 295, the patient was still Group O Rh –ve by include acute and delayed haemolysis and delayed onset of forward typing with no reduction in transfusion require- donor erythropoiesis. Pure red cell aplasia (PRCA) has ments. The anti-A isohaemagglutinin titres were 1:4 (IgG) been reported to occur in about 15% of HLA-matched and undetectable (IgM). A bone marrow biopsy confirmed major ABO-incompatible pairs.2 Most cases are felt to be persistent erythroid hypoplasia. Profuse growth of BM- due to the persistence of high-titre host antidonor derived BFU-e colonies was seen in culture medium isohaemagglutinins inhibiting donor erythropoiesis. A role containing erythropoietin. It should be noted, however, for cell-mediated immune mechanisms has been suggested, that growth was not assessed in the context of either a where titres are low or absent.3 reduced concentration of patient serum (10%) or auto- We report a case of PRCA following a major ABO- logous T lymphocytes. Although FISH analysis of bone incompatible BMT, where the aplasia persisted after the marrow aspirate with a dual-labelled XY probe confirmed withdrawal of cyclosporin employed for graft-versus-host- complete donor chimerism (XX 0, XY 100), the more disease prophylaxis. On the basis of persistent mixed sensitive PCR-based technique indicated 99% donor cells chimaerism and minimal isohaemagglutinin titres, cyclo- in a mixed chimaeric profile. Cyclosporin (5 mg/kg) was sporin was re-introduced in order to treat a presumed T- introduced on day 295 at a haemoglobin concentration of cell-mediated inhibition of donor erythropoiesis. Erythroid 6.9 g/dl. On day 302, the reticulocyte count was 1.2%. This engraftment rapidly ensued and was promptly followed by increased to 2.1% on day 316. Standard serological testing the switch to a complete donor chimeric state. of the blood group revealed a mixed field reaction from day A 40-year-old woman was diagnosed with chronic 316 until day 332. By day 339, the patient had converted to myeloid leukaemia in first chronic phase in March 2001. donor erythropoiesis by blood group and to full donor She proceeded to sibling allogeneic bone marrow transplant chimerism by molecular analysis of both total nucleated using a HLA-matched brother as the donor in November marrow cells and BFU-e colonies. Aspirate morphology 2001. Donor and recipient were CMV negative. There was revealed trilineage haemopoiesis. The cyclosporin was a major ABO incompatibility between the donor (A Rh slowly tapered from day 371 and stopped on day 445. No þ ve) and recipient (O Rh Àve). The anti-A isohaemagglu- red cell transfusions were required subsequent to the re- tinin titres prior to transplant were 1:64 (IgG) and 1:64 introduction of cyclosporin. (IgM). The conditioning regimen consisted of busulphan The initial management of delayed erythropoiesis is 4 mg/kg p.o. in divided doses daily for 4 days (total dose the regular transfusion of red cell concentrates while 16 mg/kg) and cyclophosphamide 60 mg/kg i.v. once daily awaiting engraftment. Prolonged PRCA, however, requires for 2 days (total dose 120 mg/kg). The total number of treatment to prevent transfusion-associated complications, mononuclear cells infused was 1.95 Â 108/kg and the primarily iron overload. Numerous therapeutic approaches CD34 þ cell count was 2.29 Â 106/kg. The cells were have been reported. Plasmapheresis, rituximab and infused after red cell depletion, using the COBE 2991 the rapid withdrawal of immunosuppression to deliberately blood cell processor. induce a graft-versus-plasma cell effect have each Short-course methotrexate and cyclosporin were used for been successfully employed in cases where persistent prophylaxis against graft-versus-host disease. Engraftment for host isohaemagglutinins have been present.5–7 Erythropoie- neutrophils (40.5 Â 109/l) and platelets (4100 Â 109/l) both tin has proved of benefit not only in the induction took place on day 21. Erythroid engraftment, however, was of delayed donor erythroid engraftment, but also in delayed and the patient remained transfusion-dependent, establishing erythropoiesis when the donor ABO group is requiring approximately 4 U of red cells each month. No acute already present and isohaemagglutinins absent.3,8 More or chronic graft-versus-host disease was seen and the radically, PRCA has responded to donor lymphocyte cyclosporin was tapered from day 155 and stopped on day 239. infusions (DLI), used either as part of a routine relapse A bone marrow aspirate on day 106 revealed erythroid prophylaxis protocol or in the context of late graft aplasia. FISH analysis using dual-labelled ABL and BCR failure.9,10 Correspondence 460

Donor Chimerism +197 +295 +339 (PCR of STRs) 97% (PB) 99% 100% (both BM)

0 +155 +239 +295 +371 +445

CSA CSA

ABO GroupCyclosporin O (CSA) CSA Group A

70 /L)

9 RCC transfusion

10 Absolute Reticulocyte Count (x10

0 0 100 200 300 400 500 Days after BMT

Absolute Reticulocyte Count (x109/L)

Figure 1 Correlation of donor chimerism, use of cyclosporin, ABO group, red cell concentrate transfusion requirement and absolute reticulocyte count during the ﬁrst 500 days post BMT. PB ¼ peripheral blood; BM ¼ bone marrow; CSA ¼ cyclosporin; RCC ¼ red cell concentrate.

Importantly, several reported cases of PRCA have been firmed the presence of low-level host haematopoiesis on characterised by low or absent isohaemagglutinin titres, days þ 197 and þ 295. Although lineage-specific chimae- suggesting a role for cell-mediated immune mechanisms.3 rism was not performed, a role for host alloreactive T cells The inhibition of erythropoiesis may relate to alloreactive is supported by the response to a specific inhibitor of T-cell immunocompetent host T-cell clones. The use of anti- function, that is, cyclosporin. Additionally, IgG antibody thymocyte globulin (ATG) in the presence of low isohaem- titres at the time of introduction of cyclosporin were 1:4, a agglutinin titres led to the rapid resolution of PRCA in an level below the threshold at which other authors have noted ABO-mismatched transplant, supporting the potential role the onset of donor erythropoiesis.13 of T cells in BMT-associated PRCA.11 In vitro erythroid The rational choice of therapy for BMT-associated colony studies documented evidence for T-cell-mediated PRCA in the setting of major ABO incompatibility may suppression of erythropoiesis in PRCA, which occurred benefit from knowledge of chimeric status as well as the after chemotherapy for Hodgkin’s lymphoma.12 The residual titre of host antidonor isohaemagglutinins. The use aplasia responded to a combination of cyclosporin and of ATG was considered but, in view of the need for erythropoietin. inpatient treatment and high-dose corticosteroids, cyclo- Cyclosporin may have played a role in the resolution of sporin was felt to be preferable. We conclude that this case of PRCA. Molecular chimaerism studies con- cyclosporin may have a role in the treatment of

Bone Marrow Transplantation Correspondence 461 BMT-associated PRCA in the context of absent or low-titre 6 Maschan AA, Skorobogatova EV, Balashov DN et al. host antidonor isohaemagglutinins. Successful treatment of pure red cell aplasia with a single dose of rituximab in a child after major ABO incompatible 1,2 1 PJ Hayden Department of Haematology, peripheral blood allogeneic stem cell transplantation for N Gardiner1 St. James’s Hospital, Dublin acquired aplastic anaemia. Bone Marrow Transplant 2002; K Molloy1 8, Ireland;and 30: 405–407. J Ryan2 2University of Dublin, Trinity 7 Yamaguchi M, Sakai K, Murata R et al. Treatment of pure red M Lawler1,2 College, Dublin 1, Ireland cell aplasia after major ABO-incompatible peripheral blood SR McCann1,2 stem cell transplantation by induction of chronic graft-versus- host disease. Bone Marrow Transplant 2002; 30: 539–541. 8 Paltiel O, Cournoyer D, Rybka W. Pure red cell aplasia following ABO-incompatible bone marrow transplantation: response to erythropoietin. Transfusion 1993; 33: 418–421. References 9 Bavaro P, Di Girolamo G, Olioso P et al. Donor lymphocyte infusion as therapy for pure red cell aplasia following bone 1 Sniecinski IJ, Oien L, Petz LD, Blume KG. Immunohaema- marrow transplantation. Br J Haematol 1999; 104: 930–931, tologic consequences of major ABO-mismatched bone marrow (letter). transplantation. Transplantation 1988; 45: 530–534. 10 Selleri C, Raiola A, De Rosa G et al. CD34+-enriched donor 2 Worel N, Greinix HT, Schneider B et al. Regeneration of lymphocyte infusions in a case of pure red cell aplasia and late erythropoiesis after related- and unrelated-donor BMT or graft failure after major ABO-incompatible bone marrow peripheral blood HPC transplantation: a major ABO mis- transplantation. Bone Marrow Transplant 1998; 22: 605–607. match means problems. Transfusion 2000; 40: 543–550. 11 Bierman PJ, Warkentin P, Hutchins MR, Klassen LW. Pure 3 Santamaria A, Sureda A, Martino R et al. Successful treatment red cell aplasia following ABO mismatched marrow trans- of pure red cell aplasia after major ABO-incompatible T-cell- plantation for chronic lymphocytic leukaemia: response to depleted bone marrow transplantation with erythropoietin. antithymocyte globulin. Leuk Lymphoma 1993; 9: 169–171. Bone Marrow Transplant 1997; 20: 1105–1107. 12 Reid III TJ, Mullaney M, Burrell LM et al. Pure red cell 4 Hancock JP, Goulden NJ, Oakhill A et al. Quantitative aplasia after chemotherapy for Hodgkin’s lymphoma: in vitro analysis of chimerism after allogeneic bone marrow transplan- evidence for T cell mediated suppression of erythropoiesis and tation using immunomagnetic selection and ﬂuorescent micro- response to sequential cyclosporin and erythropoietin. Am J satellite PCR. Leukaemia 2003; 17: 247–251. Haematol 1994; 46: 48–53. 5 Ohta S, Yokoyama H, Ise T et al. Apheresis therapy for 13 Gmur JP, Burger J, Schaffner A et al. Pure red cell aplasia of prolonged red cell aplasia after major ABO-mismatched bone long duration complicating major ABO-incompatible bone marrow transplantation. Intern Med 1997; 36: 487–491. marrow transplantation. Blood 1990; 75: 290–295.

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