Correspondence

REFERENCES

207

BUCHANAN, G.R., SCHER, C.S., BUTTON, L.N. & NATHAN, D.G. (1977) Use of homologous plate- let survival in the differential diagnosis of chronic thrombocytopenia in childhood. Pedia- trics, 59, 49-54.

FAIRHEAD, S.M., CHIPPING. P.M. & GORDON-SMITH, E.C. (1983) Treatment ofaplastic anaemia with antilymphocyte globulin (ALG). British lournd of’ Haeniutology, 55, 7-16.

HOFFMAN. R., T ~ R U N O , E., ELW-ELL, 1.. MAZUK, E., GEWIRTZ,A.~I..DEKKER,P.&DENES. A.E.(1982) Acquired amegakaryocytic thrombocytnpenic purpura: a syndrome of diverse etiologies.

HOFFMAN, R., ZAKNOEN, S.. YAN. H.H., BRUNO, E., LOBUGLID. A.F., ARROWSMITH, J.R. & PRCHAL. J.T. (1985) An antibody cytotoxic to mega- karyocytic progenitor cells in a patient with immune purpura. New Englund Iuurnal of’ Medi- cine, 312, 1170-1174.

N.A. (1984) Antikorper gegen Megakaryozy- ten bei chronischer idiopatischer thrombozyto- penischer Purpura im Kindersalter. Folia Hue- rriatologica (Leiptig). 111, 350-359.

KRANTZ, S.B. B DESSYPRIS, E.N. (1985) Pure red cell aplasia. Huernutologg (ed. by D. W. Golde and F. Takaku). Marcel Decker, New York.

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SINGER, J.W., BROWN, J.A.. JAMES, M.C., DOONEY. K., WARREN, R.P., STORB. R. B THOMAS. E.D. (1978) Effect of peripheral blood lymphocytes from patients with aplastic anemia on granulo- cyte colony growth from HLA matched and mismatched marrow: effect of transfusion sensitization. Blood, 52, 3 7 4 6 .

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28, 215-219.

SUCCESSFUL TREATMENT OF LATE GRAFT FAILURE FOLLOWING T CELL DEPLETED BONE MARKOW TRANSPLANTATTON

Hows et ul ( l98 5 ) have recently reported that cessation ofcyclosporine therapy preceded four out of five cases of latc graft failure following allogeneic bone marrow transplantation for aplastic anaemia. Treatment with corticosteroids and the reintroduction of cyclosporine resulted usually in autologous recovery rather than graft survival. We have recently observed a case of bone marrow failure following withdrawal of cyclosporine 9 months after allogeneic transplantation with T-cell depleted bone marrow. Treatment with high dose corticosteroids and the reinstitution of cyclosporine led to full allogeneic graft recovery.

A 2 8-year-old male was diagnosed as having Phl-positive chronic granulocytic leukaemia in March 1984 and stable chronic phase was achieved with busulphan. The patient underwent bone marrow transplantation from his HLA and ABO compatible brother in September 1984 with cyclophosphamide (120 mg/kg) and 10 Gy single-fraction total

208 Co rrespo nde nee

body irradiation (6 cGy/min), plus 10 Gy to the splenic area, as conditioning. Graft-versus- host disease prophylaxis was with cyclosporine and pretreatment of the donor marrow with CAMPATH 1 monoclonal antibody. Total mononuclear cells infused were 3.6 x 1OS/kg body weight with 0.3% T-cells (1 .l x lo6 T-cells/kg). Moderately severe acute graft-versus-host disease occurred which was readily controlled with oral corticosteroids, and mild chronic graft-versus-host disease of the skin developed 5 months post transplant. At 7 months post transplantation, cyclosporine was stopped and azathioprine 50 mg/d was added.

Nine months following the transplant the patient became pancytopenic and the azathioprine was stopped. The pancytopenia continued to worsen however, and thcrc was evidence of severe intravascular haemolysis for which no cause was found. Direct Coombs test and Ham’s test were negative. His haemoglobin fell to 5.0 g/dl with absent reticulocytes, and his white count fell to a nadir of 0.2 x 109/1 (all lymphocytes). Platelets, which were previously normal, fell to 50-80 x 109/1. Bone marrow aspirate and trephine biopsy at this time revealed a grossly hypocellular marrow with the majority of cells being lymphocytes and macrophages, some of which were atypical. Occasional erythrocytosis was seen and although there was a relatively normal number of megakaryocytes, they showed qualitative abnormalities. These appearances were not those of transient marrow suppression due to axathioprine, but were considered to be consistent with graft rejection or virally-induced bone marrow failure. Evidence of a viral infection that could have caused the graft failure was sought but viral cultures, antigen and antibody studies for cytomegalovirus were negative. Parvovirus and Epstein-Barr virus serology was also negative, as were cultures and antibody studies for herpes simplex and zoster.

Preparations for re-transplantation were commenced, but since there was to be a delay of 2 weeks, the patient commenced methyl-prednisolone 500 mg daily for 4 d followed by 2 50 mg daily for a further 4 d. A repeat bone marrow after 7 d showed some recovery of myeloid cells although there had been no improvement in the peripheral blood at this time. Transplantation was therefore postponed and cyclosporine added intravenously. Following a further 7 d of prednisolone 120 mg/d, the patient’s white count recovered and he ceased to be transfusion dependent. A bone marrow aspirate and trephne biopsy performed 14 d after the initial one showed good reconstitution with myeloid and erythroid elements and normal megakaryocytes. His marrow recovery was allogeneic rather than autologous, i.e. Philadel- phia chromosome negative and red-cell phenotyping 2 months later was of graft type.

This case illustrates that graft failure may occur as late as 9 months following T-cell depleted bone marrow transplantation, and that this could have been related to stopping cyclosporine. It also emphasizes that although preparations for further transplantation of these patients should be undertaken, a delay of 1 or 2 weeks may be appropriate to allow time for recovery from more conservative management.

Department of’ Haematoloyy, Queen Elizabeth Hospital, Birmingham B15 2TU

N. JACKSON

I. M. FRANKLIN

Correspondence 209

REFERENCE

Hows, I . , PALMER. S. & GORDON-SMITH. E.C. (1985) Cyclosporine and graft failure following bone marrow transplantation for severe aplastic

anaemia. British fourrial of Haematnlngy. 60, 61 1-61 7.

S U C CE S S F U I, A U TO L 0 G O US PERIPHERAL BLOOD MONONUCLEATED CET,LS IN A PATIENT WITH ACUTE PROMYELOCYTIC LEUKAEMIA

HA EM AT 0 P 0 IET I C R E CON STl 'I' U TI ON U S 1 N G

CFU-GM are present in the pcripheral blood of normal subjects but in far lower numbers than in the bone marrow (Verma et al , 1 9 80). Recently in this journal, To Pf a1 (I 984) reported on the very high numbers of UFU-GM rccovered after continuous flow leukapheresis (CFI,) in patients with ANLL during early remission following induction chcmotherapy. Whether these peripheral cells are able to reconstitute normal haematopoietic activity is unknown in man. Autologous reconstitution using peripheral blood cells collected by CPI, has been successful in dogs (Cavins et al, 1981). In two attempts in man, using the same technique, it failed with cells collected from an identical twin (Hershko at al. 19 79; Abrahams et al. 19 80). Successful autotransplantation regularly occurs in patients with chronic myeloid leukaemia after cryopreservation of leukapheresis harvests (Coldman, 1978).

Successful engraftment with cryopreserved leukapheresis cells has been reported previously in a patient with ANTJ, in second remission (Reiffers e t al. 198 5). We report here a case of successful engraftment with cells from cryopreserved leukapheresis. In December 1984 a 19-year-old boy was diagnosed as having a hypercellular variant form of promyelocytic leukaemia with t( 15-1 7) (M3 variant in the FAB classification) (Bennett et al. 1980). Remission induction chcmotherapy included an anthracycline Zorubicine (200 mg/ m'/d x 4 d) (Jacquillat et al, 1976) and continuous infusion of arabinosyl cytosine (200 mg/ m2/d x 7 d). 1 5 d after the onset of therapy, bone marrow aspiration n7as devoid of leukaemia cells. Three CFT, were performed on days 26, 27 and 29 when platelet count began to rise above 50 x 1OY/1 and white blood cells above 1.5 x 109/l. Mononucleated cells of those CFL were cryopreserved with 10% DMSO at 2'C/min freezing rate and stored in liquid nitrogen. Thc number of progenitor cells was evaluated for each leukapheresis, after freezing and thawing. The three CFL provided a total number of 1.9 x 10' mononucleated cells (MNC)/kg body weight, 2 .3 x lo4 CFU/GM/kg and 4.5 x 104 BFU-e/kg.

The paticnt's bone marrow was collected in order to provide rescue if necessary. On day 60, consolidation therapy was administered with Zorubicine and arabinosyl

cytosine. 90 d after initial therapy, the patient received cyclophosphamide 5 0 mg/kg x 2 d i.v.,

followed by a total body irradiation (10 Grays) and the infusion of the three thawed leukapheresis. Bone marrow aspirate 14 d later showed engraftment. Haematological reconstitution is shown in Fig 1. On day 28 haemoglobiri was 10.2 g/dl without need of transfusion, rieutrophils were 1.6 x 109/1, reticulocytes 140 x 109/1, platelets 37 x 109/1 and the patient was discharged from hospital. Platelet recovery was very slow and on day 95,