Value of Bronchoalveolar lavage prior to HSCT for Primary Immunodeficiency

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Emerging indications for HSCT in primary
immunodeficiency
Dr. Andy Gennery, Newcastle upon Tyne, UK
ESID - Prague May 2007
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What Are You Waiting For?
Dr. Andy Gennery, Newcastle upon Tyne, UK
ESID - Prague May 2007
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Overview

• Current Results (SCETIDE)
• Improving parameters
• A new way to think about immunodeficiency
• New indications for HSCT

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SCETIDE REGISTRY
STEM CELL TRANSPLANTATION FOR IMMUNODEFICIENCIES
IN EUROPE
Marina Cavazzana-Calvo Andrew Cant Andy Gennery
Mary Slatter
and the members of the SCETIDE working group
Prepared by Pierre TAUPIN and Paul LANDAIS
Laboratoire de Biostatistique et dInformatique
Médicale Hôpital Necker. Paris. France.
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Primary disease in SCID patients (n744)
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Probability of survival in SCID patients after
HSCT according to period ( before 1995 versus
after 1995 )
After 1995 (n315)
10 years Survival rate
After 1995 70
Before 1995 55
Before 1995 (n360)
P0.0002
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SCID and HLA-matching, 1990-2006
Geno (n73)
10 years Survival rate
Pheno (n41)
Geno 86
Pheno 79
MUD (n78)
MUD 72
Mismatch (n262)
Mismatch 59
P0.0002
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Primary disease in non SCID patients (n 828)
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Probability of survival in NON-SCID patients
after HSCT according to period ( before 1995
versus after 1995 )
10 years Survival rate
After 1995 (n457)
After 1995 61
Before 1995 54
Before 1995 (n287)
P0.007
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Probability of survival in NON-SCID patients
after HSCT according to donor-recipient
compatibility
10 years Survival rate
Geno 72
MUD 64
Pheno 57
Geno n250 Pheno n58 MUD n213 mmRel n223
mmRel 40
Plt0.0001
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CD40 Ligand deficiency
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CD40 Ligand deficiency
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Observed expected cases () by age at
registration
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HSCT for CGD 1985 - 2000

• Well 11 / 11
• Inflamed 7 / 7
• Active fungus 5 / 9
• Seger RA, Gungor T, Belohradsky BH, et al.
  Treatment of chronic granulomatous disease with
  myeloablative conditioning and an unmodified
  hemopoietic allograft a survey of the European
  experience, 1985-2000. Blood 20021004344-50

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HSCT for CGD 1985 - 2000

• Resolution of inflammatory lung disease

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HSCT for CGD 1985 - 2000
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HSCT - whats new?

• Better HLA typing
• New stem cell sources
• New conditioning regimens
• New viral detection and treatment
• Better supportive care
• New approaches to GvHD

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HSCT which donor?

• HLA identical sibling
• Other family member - match/1Ag mismatch
• Matched unrelated donor
• Cord blood
• Mismatched - haploidentical parent
• Routine
• HLA Class I - low resolution molecular typing
• HLA Class II - high resolution molecular typing

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Outcome

• Survival post 2000
• Overall Cord Haplo
• 79 72 82
• B cell function
• Overall Cord Haplo
• 88 92 71

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Reduced Intensity HSCT - GOS
Rao et al, Blood 2004
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Reduced Intensity HSCT

• Prolonged risk of viral re-activation
• CMV, EBV, adenovirus
• Changing chimerism
• Late aGvHD gt 100 days

Rao et al, Blood 2004
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Graft versus Host disease

• Ciclosporine A
• Tacrolimus
• Steroids
• MMF
• Infliximab
• Basiliximab/Dacluzimab
• MSC

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Viral infection

• CMV EBV HHV6 Adeno
• PCR early detection
• Ganciclovir Cidofovir
• Rituximab
• Specific cytotoxic T cells
• IVIG
• ? Immunosuppression

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Immune system failure
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New Indications

• 6th child consanguineous Pakistani parents
• RSV ve bronchiolitis aged 2 weeks
• Delayed clearance of RSV from respiratory tract
  (5 weeks)
• Subsequently no significant infection

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IMMUNOLOGY

• Lymphopenia
• CD3 194
• CD19 307
• CD56/CD16 480
• CD8 30
• CD4 149
• impaired PHA
• TCR VB distribution normal

• Immunoglobulins
• IgG 8.41 (on IVIG)
• IgA 0.25
• IgM 0.35
• absence of antibody response to Tet and HiB
  despite 4 vaccinations

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• Karyotype normal 46XX
• but
• 5/163 Inv (7) (p13q35)
• 2/163 t(714) (p13q11)
• 2/163 t(722) (p13q11)
• 2/163 break point in chromosome 7
• 11/163 chromosome 7/14 rearrangements (7)
• MMC sensitive ( D FA)
• radiosensitive

• NBS - homozygous mutation nbs1 1089C ? A
  resulting in prematurely truncated protein
  (nibrin)
• D NBS

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• NBS REGISTRY
• Hiel JA et al, Nijmegen Breakage Syndrome
  Arch.dis.child 2000
• 55 patients none with 1089C to A
• 19/55 (35) died at age 0.5-24 years of infection
  (5), malignancy (5) and lymphoma (9).
• Life expectancy reduced because of
  malignancy/fatal infection.

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ICF Syndrome

• Fragility of paracentromeric heterochromatin of
  Ch 1, 9, 16
• Multibranched chromosomes, triradials
• Facial anomolies
• Hypertelorism, flat nasal bridge, epicanthic
  folds
• Immunodeficiency
• Agammaglobulinaemia, variable T cell defect

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ICF Syndrome

• Variable outcome
• Brown et al 1995 Hum Genet 199596411-6
• 13 patients
• 1 died post BMT
• 4 others died infection (median 10/12)
• 1 AW, now dead (infection, age 12 yrs)

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Clinical Presentation

• First child, no parental consanguinity
• Recurrent chest infection (?PCP)
  -agammaglobulinaemia
• Slightly low set ears cytogenetics

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• Commenced scIg Co-trimoxazole, Itraconazole
• Developed persistent diarrhoea (SRSV and polio 2)
• Failure to thrive (25th lt2nd C)
• BMT age 2.25yr

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IPEX syndrome (OMIM 304930)Immune dysregulation,
polyendocrinopathy,enteropathy, X-L

• Mutations in FOXP3
• FOXP3 - critical regulator of CD4CD25
• Genetic heterogeneity
• cases of late onset with mild clinical features
• male patients w/o FOXP3 mutations
• female patients w. similar features
• IPEX-like syndrome? (H. Ochs)

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IPEX syndrome - features

• Diarrhoea
• Failure to thrive
• IDDM/1
• Hypothyroidism
• Eczema
• Haemolytic anaemia
• Thrombocytopenia
• Recurrent infections

• Lymphadenopathy
• Hepatosplenomegaly
• Polyarticular arthritis
• Asthma
• Ulcerative colitis
• Glomerulonephropathy
• Interstitial nephritis
• Metabolic acidosis
• Hypotonia / muscle atrophy

Wildin, et al. J Med Genet 2002 Gambineri, et
al. Curr Opin Rheumatol 2003
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Patient 1

• From birth - severe eczema
• 2 / 52 - pneumonia / respiratory distress
• - S aureus / sputum
• - Pseudomonas, Enterobacter / BAL
• 5 / 52 - episodic secretory diarrhoea
• Failure to thrive lt0.4th percentile
• Small bowel biopsy at 4 mo
• - Villous atrophy, T cell infiltrate
• Autoimmune enteropathy

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Laboratory results

• Persistent diarrhoea
• DM type 1 -
• Hypothyroidism -
• Eczema
• Failure to thrive
• anaemia/DCT
• Thrombocytopenia -
• Lymphadenopathy -
• Hepatosplenomegaly
• Recurrent infections
• Eosinophilia
• Raised IgE
• Typical small bowel bX

• Patient 1
• Anti-islet cell Abs
• Anti-enterocyte Abs
• Anti-smooth muscle Abs
• Direct Coombs test
• Eosinophilia (2x109/l)
• Raised IgE (31720 kU/l)

Genetic analysis of FOXP3 did not reveal any
mutation(s) so far (H Ochs T Torgerson)
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Patient 1 - BMT

• Conditioning
• Campath 1H 0.2 mg/kg x5
• 3/52 pre BMT
• Bu 4mg/kg d-10 to d-7
• Cy 50 mg/kg d-5 to d-2
• CsA and steroids
• HLA id sister bone marrow
• 6.8x108/kg nucl. cells
• 6x106/kg CD34 cells

• Post-BMT
• Ne engraftment d15
• Plt engraftment d34
• normal stools d10
• off TPN 3/52
• started solids, milk
• normal gut histology
• negative autoabs / DCT
• Wt 25th / Ht 2nd percentile
• swallowing incoordination
• slipping chimerism

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Treg Plots Pt 2
Pre BMT
Post BMT
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Newcastle HSCT
April 2005-March 2006
April 2006-March 2007

• RD
• CGD (3)
• ALPS
• JAK3 SCID
• Zeta chain deficient SCID
• IL7Ra SCID (2)
• Osteopetrosis (3, 2 TCIRG1)
• CgC SCID
• ADA SCID
• Undefined SCID with histiocytoma
• WAS (2)
• Autoimmune enteropathy
• JIA (Auto)

• HIgE
• CHARGE
• CHH
• ICF
• CGD (2)
• Familial HLH
• CD4 lymphopenia
• CID
• IPEX
• CVID
• Partial TAP deficiency
• ZAP 70 K-like
• CD40L deficiency
• Griscelli
• SLE
• Autoimmune enteropathy
• HyperIgD
• ALPS
• T-B- SCID

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Case 1 - Male 14 years

• poor wound healing, from age 5
• Warts, from age 7
• Repeated styes, from age 7
• Abscess drained in 2002, following insect bite,
  age 10
• Discharging ear infections, last few years

Imm Hx

• Age 12, all up to date
• Heaf test was unreactive
• BCG given in school Nov 2004
• Immediately after vaccine, local swelling, red,
  painful and febrile and heaf site was visible
• Subsequent skin rash

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Ix for Lymphoma

• Abscess noted in axillary LN - drained and BCG
  biopsied - BCG seen
• Treatment began with Isoniziad / Rifampicin
• Skin rash reappeared after 10/7 treatment
• Complications of treatment
• Relapse off treatment
• Clinically stable on maintenance therapy, growing
  and healthy
• On Moxifloxacin, Ethambutol, Clarythromycin, IFNg

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Candidate diseases

• IFNg / IL12 deficiency
• CID (T cell deficiency)
• CD4 lymphopenia
• Myelodysplasia

Blood immunology

• Present Absent
• Lymphocytes
• T cells B cells
• NK cells
• Phagocytes
• Monocytes

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Blood counts
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Subsets
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Proliferations
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Other immunology

• IgG initially very high, now normal
• IgM low
• IgA low
• IgE 29
• Neutrophil function burst OK
• phagocytosis OK
• Autoantibodies SM 1160 only

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Other T cell immunology

• Normal TCR VB families
• Normal ADA/PNP,
• CD4/45RA/27 (naïve) 9
• CD4-/45RA/27 (naïve) 16
• CD4-/45RA/27- (effector) 2
• CD40L expression appears normal

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Histopathology

• April 05 skin
• No well-formed granulomata, necrosis , MFs
  (CD68R), neutrophils , sparse lymphocytes, AFB
  , few B cells, more plasma cells, plenty of DCs
• axillary node
• Definite granulomata, epithelioid cells , no
  giant cells
• August 05 skin
• Neutrophilic adenitis (drug reaction or
  immunodeficiency)
• September 05 LN
• Abscess, neutrophils, MFs seen, no granulomata
• July 06 skin
• Fibrosis, small granulomata seen and many
  eosinophils. Few T cells, many plasma cells

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Bone Marrows

• July 05
• Hypocellular, reduced but normal erythropoiesis
  and myelopoiesis, no granulomata
• Oct 06
• Hypoplastic, reduced granulopoeisis. Plasma
  cells and tissue macrophages
• Fanconi, PNH, karyotypic abn excluded

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Imaging

• Leeds
• CT chest abdo May 05
• Axillary lymphangitis, HSM, hypodense lesions in
  spleen, no mesenteric adenitis
• NGH
• CT Oct 06
• Lymphadenopathy in chest, with consolidations
• US
• Calcifications in spleen

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Imaging
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Patel et al.

• 11 patients with late onset, disseminated
  mycobacterial infection.
• Profound monocytopenia, B cell penia, normal Ig
  production, variable T cell penia
• Also severe HPV, EBV, Histoplasma, Cryptococcus
• PAP independent of marrow failure. Macrophage
  / Monocytes found in lung fluid.
• Initially normal marrow became dysplastic in a
  number, and transformed to CMMol in one.
• Trisomy 8 found in half.
• Melanoma and squamous carcinomas
• Defects explored
• Normal GM-CSF production, and no antibodies to
  GM-CSF.
• No response to G- or GM-CSF
• Recurrence to be expected.
• 1 BMT, died of lung complications 30 days later

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From now

• Do we put him back on IFNg?
• Do we transplant him?
• Do we transplant him now or leave him?
• Any other ideas to explore the diagnosis

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History - 14 year old Male

• May 2003 ? ITP
• Poor response to Ig and prednisolone
• March 2004 splenectomy
• Repeated adenopathy
• Biopsies and BMA/Ts have all been reactive
• January 2006 proptosis
• Spontaneous partial resolution

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Lymphadenopathy

• November 2004 received BCG
• March 2005 presented with painless axillary
  lymphadenopathy
• Also reported mouth ulcers and earache some
  cervical LNS
• Mantoux, sputa negative
• CXR non specific
• April 2005 returned with ulcers, glands and cough
• Neutropenia (0.49)
• Raised platelets (964)
• ESR 8
• BMA - reactive with a germinal centre
• L axillary LN - reactive only

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Proptosis

• Jan 2006 admitted with fever, lymphadenopathy,
  sore throat, chest pain, proptosis of right eye
• Eczema over head and neck
• MRI identified a 2-3mm rim of abnormal tissue
  within the globe, above the superior rectus
  muscle. Inflammatory debris was seen in other
  sinuses.

• Resolution reported.
• Nov 2006, seen by Mr Neoh (RVI) only 1mm of
  proptosis

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Recent history / referral trigger

• November 2006
• Bruising and petechiae
• Platelets 5

Investigations

• Platelets 3 - 964 - 3 (large volume)
• LDH 482 - 791
• WBC 2.48 - 14.7
• Neutrophils 0.49 - 10.68 (steroid response)
• ESR 8 - 11
• CRP 20

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Summary

• Destructive thrombocytopenia, initially
  responsive to splenectomy
• Proptosis (resolving, 1 year duration) seems most
  likely a result of inflammatory sinusitis, but
  ?infective, ?neoplastic, ?vasculitis, ?sarcoidosis

Working differential diagnosis

• Autoimmune disease with additional evidence of
  immune dysregulation
• ALPS
• WAS
• XLP
• Lymphoma

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Developments since Feb

• Anterior Uveitis
• Recovered on steroid /- antimicrobials
• Chesty cough
• Otherwise he had been well

Action

• To come in for antibiotics for chest
• Serious concern re possibility of fungus
• Needs scan of eyes as definitely more proptosis

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Imaging
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Immunology