Graft-Versus-Host
Disease
Following
ECMO
By R.M. Hatley, M. Reynolds, AS. Paller, and P. Chou Augusta, Georgia and Chicago, Illinois l Since 1973, over 3,990 newborns have been treated worldwide for respiratory failure with extracorporeal membrane oxygenation (ECMO). ECMO requires transfusion of numerous blood products including platelets and packed red blood cells. Transfusion-associated graft-versus-host disease (GVHD) developed in one of the authors’ patients following treatment with ECMO. ECMO exposes newborn infants to a large number of blood components. Although a rare complication, GVHD can be prevented by irradiating blood products prior to transfusion. We now irradiate all blood products prior to use during ECMO and recommend that other institutions do the same.
Copyright o 799 7 by W.B. Saunders Company INDEX WORDS: Extracorporeal membrane (ECMO); graft-versus-host disease.
oxygenation
T
RANSFUSION-associated graft-versus-host disease (TA-GVHD) is a rare disease first described in 1965 in two children with vaccinia necrosis after receiving leukocyte-rich fresh whole blood.’ TA-GVHD has since been described in infants receiving nonirradiated blood product&’ in the form of plasma transfusions, exchange transfusions,1-3 intrauterine maternal-fetal transfusions,’ and after single blood transfusions.4 TA-GVHD mortality is greater than 90%5 and most patients die of infection.6 We report the first case of fatal TA-GVHD in an infant after extracorporeal membrane oxygenation (ECMO). CASE REPORT A 2,980-g full-term 0’ baby was delivered by cesarean section for fetal distress. Meconium staining was noted. The baby was intubated and meconium suctioned from below the vocal cords. The child developed respiratory distress at 4 hours of age. A septic workup was performed and the child was started on ampicillin and gentamicin. The chest x-ray showed bilateral infiltrates. Respiratory failure was demonstrated with an arterial blood gas showing pH 7.21, PCO, 60 mm Hg, PO, 26 mm Hg on F,O, lOO%, rate 80 breaths/min, PIP 35 cm, and a PEEP 5 cm. The child was transferred to the Children’s Memorial Hospital at 20 hours of age. Initial examination showed coarse bilateral breath sounds. Chest x-ray demonstrated normal thymic shadow with bilateral pulmonary infiltrates consistent with meconium aspiration syndrome. Relevant admission laboratory results included white blood cell count 17.8, hemoglobin 15.6, and hemocrit 45.8. The differential included 54 polymorpholeukocytes, 36 bands, 1 eosinophils, 0 basophil, 4 lymphocytes, 3 atypical lymphocytes, and 1 monocyte. The child met ECMO criteria and was placed on ECMO 1 day after birth. The ECMO run was 80 hours and uneventful. During the ECMO run the child received 19 separate blood components. On day 17 he developed a temperature of 38.9”C with an initial maculopapular rash on the ears, upper trunk, back, and extremities, including the palms and soles. The rash spread to the entire body. A septic workup was negative. The following day he
Journa/ofPediatric
Surgery,
Vol26, No
3
(March). 1991: pp 317-319
developed diarrhea. His liver edge was 4 cm below the right costal margin. Pertinent laboratory findings included aspartate aminotransferase 898 U/L (normal, 8 to 42), alanine aminotransferase 261 U/L (normal, 8 to 78), alkaline phosphatase 13.8 U/L. (normal, 7.8 to 26.4), albumin 1.9 g/dL, white blood cell count 13.8 U/L, hematocrit 41.0, hemoglobin 14.0, platelets 156,000, polys 20, bands 9, eosinophils 8, basophil 0, lymphocytes 58, atypical lymphocytes 5, total bilirubin 12.4, and direct bilirubin 5.2. The child initially was thought to have either a fulminant viral infection, drug eruption, erythema multiforme, or GVHD. Histopathologic examination of a skin biopsy specimen done on day 18 was characteristic of GVHD, with basal cell liquification degeneration. There were abundant lymphocytes in the dermis and epidermis, with lymphocytes surrounding the necrotic keratinocytes (“satellite cell necrosis”) (Fig 1). The diarrhea continued, hepatomegaly increased, and the liver enzyme levels remained elevated. Protective isolation was instituted and the baby was continued on antibiotics. High-dose methylprednisolone (2 mg/ kg/d) and cyclosporine (1 mg/kg every 12 hours) were instituted and resulted in partial resolution of the cutaneous eruptions. Neutropenia developed with a white blood cell count of 700/L, of which 99% were lymphocytes and 1% were atypical lymphocytes. An extensive evaluation for sepsis disclosed disseminated Candida parapsilosis involving the urine, blood, lungs, and gut. Ampoterin B was administered. Studies to identify an immunologic defect demonstrated no T-lymphocyte abnormality with a normal supply of T cells and normal in vitro mitogen stimulation studies. Despite hypoimmunoglobulinemia (IgG of 133 mg/dL, normal, 251 to 906 mg/dL), other immunoglobulin levels were normal and B cells had surface immunoglobulins. The child began to have seizures and demonstrated multiple organ failure. He had a progressive downhill course and died of respiratory arrest on day 36. An autopsy showed fungal infiltration of the gastrointestinal tract, lungs, heart, kidneys, thyroid, pancreas, central nervous system, and the spinal cord. A skin biopsy showed fewer lymphocytes and less keratinocyte necrosis than was observed on the initial biopsy. The bone marrow was hypocellular and there was marked lymphoid depletion of the thymus, spleen. and lymph nodes, suggesting a primary immune deficiency, GVHD, or septicemia. GVHD reaction was also found in tissue sections from the gastrointestinal tract, liver, and pancreas. DISCUSSION The diagnosis of TA-GVHD is often delayed because its signs are similar to those seen in viral infecFrom the Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia Hospital and Clinics, Augusta, GA, and the Sections of Pediarric Surgery, Dermatology, and Pathology, The Children S Memorial Hospital, Chicago, IL. Presented at the 21st Annual Meeting of the American Pediatric Surgical Association, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to R.M. Hat& MD, Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia, Augusta, GA 30912-4010. Copyright D 1991 by WB. Saunders Company 0022-3468/91/2603-0014$03.00l0 317
318
HATLEY ET AL
Fig 1. Liquification degeneration of the basal cell layer is seen. Lymphocytes surround the necrotic keratinocytes (satellite cell necrosis) (arrow).
tions, drug reactions, and erythema multiforme.4’5 The diagnosis in this patient was suggested by the clinical picture of fever, diarrhea, and generalized maculopapular rash with involvement of the soles and palms and progressive liver failure. Skin biopsy findings were diagnostic of GVHD. The primary organs involved in TA-GVHD are the skin, gastrointestinal tract, liver, bone marrow, spleen, and thymus.i’6 Clinical manifestations of TA-GVHD resemble those of bone marrow transplantation GVHD (BMT-GVHD)? There are several important differences between TA- and BMT-GVHD. The bone marrow in TA-GVHD is hypoplastic or aplastic and has erythrolymphophagocytosis.“6 The bone marrow usually does not recover and the patient usualIy dies of overwhelming infection.“4’6 TA-GVHD occurs 2 to 30 days after blood product infusion, often during the first 2 weeks after transfusion in contrast to BMT-GVHD, which occurs at 5 to 10 weeks.1T2,4,6 The most important differences in the two disorders are noted in incidence and mortality. Acute TA-GVHD has an incidence of 0.1% to 1% and a mortaIity of 95% to 100% in reported cases.*-4’6About 70% of
bone marrow transplant patients develop evidence of GVHD but only 10% to 15% die of the disease.‘z4 Although TA-GVHD usually occurs in severely immunodeficient patients, normal neonates are immunocompromised and are susceptible to TA-GVHD. Recent reports describe 7 neonates (6 premature and 1 full-term) who developed TA-GVHD after an. exchange transfusion.2 A 6-month-old infant who developed TA-GVHD after cardiac surgery has also been described.2 TA-GVHD have been reported after transfusion of whole blood, packed red cells, platelets, and granulocytes.‘.2,7One times 10’ lymphocytes per kilogram of body weight are necessary to establish a GVH reaction.1,2 Whole blood and packed cells contain from 1 to 2 x 10’ lymphocytes.* TA-GVHD occurs in patients incapable of rejecting immunocompetent transfused lymphocytes.‘~2~7The T lymphocytes are histoincompatible with the host but the difference may involve non-HLA antigens6 The diagnosis of TA-GVHD can be difficult. The onset of high fever, maculopapular rash, and profuse diarrhea in neonates or immunocompromised infants and young children 2 to 30 days following a transfusion should alert the physician to the possibility of TA-GVHD. More cases will be recognized through physician awareness. Exclusion of an ongoing viral infection is an obvious important consideration. Treatment of TA-GVHD has been unsuccessful in 100% of affected infants despite the administration of systemic corticosteroids and cyslosporine.1*2,4,h.7 Because treatment of TA-GVHD is unsuccessful, the emphasis should be placed on prevention by irradiation of blood products.‘” The recommended dose of radiation is 1,500 to 7,500 rads’s2 because the radiation dose needed to ablate the mitotic potential of lymphocytes is 500 rads. There have been no documented cases of TA-GVHD in patients given blood products irradiated with greater than 1,500 rads.’ A case of fatal TA-GVHD following ECMO is presented. ECMO is a therapeutic modality that has significant life-saving potential. During ECMO the babies are exposed to large numbers of different blood products and are therefore susceptible to TA-GVHD. There is no adequate treatment of TAGVHD. Therefore, we recommend irradiation of all blood products used prior to and during ECMO.
REFERENCES 1. Berger RS, Dixon SL: Fulminant transfusion-associated graftversus-host disease in a premature infant. J Am Acad Dermatol Z&945-950,1989
2. Holland PV: Prevention of transfusion-associated graft-vshost disease. Arch Path01 Lab Med 113:285-291,1989 3. Laver BA, Githens JH, Hayward AT, et al: Probable graft-vs-
GRAFT-VERSUS-HOST
DISEASE FOLLOWING
ECMO
319
graft reaction in an infant after exchange transfusion and marrow transplantation. Pediatrics 70:43-47,1982 4. Arsura EL, Bertelle A, Minkowitz S, et al: Transfusionassociated graft-vs-host disease in a presumed immunocompetent patient. Arch Intern Med 148:1941-1944,198s 5. Thaler M, Shamiss A, Orgad S: The role of blood from HLA homozygous donors in fatal transfusion-associated graft-versus-
host disease after open-heart surgery. N Engl J Med 321:2.5-28, 1989 6. Brubaker DB: Transfusion-associated graft-versus-host disease. Hum Path01 17:1085-1088,1986 7. Editorial: Transfusion and graft-versus-host disease. Lancet 1:529-530,1989
Discussion S. ildsrad (Pittsburgh, PA): This is a fascinating report and I applaud the authors on their high index of suspicion to include GVHD in the differential diagnosis. As you mentioned, GVHD is mediated by transfusion of competent donor T lymphocytes that attack the host and in effect attempt to reject the host. It is a reaction of the donor against the host. These cells can be transfused in separated blood products. The target organs that you describe for your patient are the classic ones for GVHD--the liver, the spleen, the thymus, and especially the skin. There is a generalized rash that appears and skin biopsy is usually diagnostic. There have been a number of case reports recently of transfusion-induced GVHD in patients who are not recipients of bone marrow transplants. This has been true for both adults and for neonates. It includes the transplant patient population recipients of solid organ grafts and even critically ill patients who have undergone major stress and been transfused multiple blood products. Further studies are required to determine the incidence of
this problem. Perhaps some of the generalized exanthema we attribute to viral infection in critically ill patients is actually GVHD. I would like to ask two questions. First, do you think that we should be irradiating blood products for critically ill patients? Second, did you look at the phenotype of the T cells that were present in your patient to see if they were of host or donor type? R Hatley (response): I think we should consider irradiating all blood products in the critically ill infant and young child. It only costs $35.00. Although transfusion-induced GVHD is a rare complication, once it surfaces the money invested in trying to treat the child will go into the hundreds of thousands of dollars. I think that $35.00 to irradiate the blood for 6 or 7 minutes is a minimal price to pay for the life of the child because GVHD is not a treatable problem. However, further studies are required to determine when and if blood products should be in activated. To answer your second question, we did not get the T subsets on the blood.
Disease
Following
ECMO
By R.M. Hatley, M. Reynolds, AS. Paller, and P. Chou Augusta, Georgia and Chicago, Illinois l Since 1973, over 3,990 newborns have been treated worldwide for respiratory failure with extracorporeal membrane oxygenation (ECMO). ECMO requires transfusion of numerous blood products including platelets and packed red blood cells. Transfusion-associated graft-versus-host disease (GVHD) developed in one of the authors’ patients following treatment with ECMO. ECMO exposes newborn infants to a large number of blood components. Although a rare complication, GVHD can be prevented by irradiating blood products prior to transfusion. We now irradiate all blood products prior to use during ECMO and recommend that other institutions do the same.
Copyright o 799 7 by W.B. Saunders Company INDEX WORDS: Extracorporeal membrane (ECMO); graft-versus-host disease.
oxygenation
T
RANSFUSION-associated graft-versus-host disease (TA-GVHD) is a rare disease first described in 1965 in two children with vaccinia necrosis after receiving leukocyte-rich fresh whole blood.’ TA-GVHD has since been described in infants receiving nonirradiated blood product&’ in the form of plasma transfusions, exchange transfusions,1-3 intrauterine maternal-fetal transfusions,’ and after single blood transfusions.4 TA-GVHD mortality is greater than 90%5 and most patients die of infection.6 We report the first case of fatal TA-GVHD in an infant after extracorporeal membrane oxygenation (ECMO). CASE REPORT A 2,980-g full-term 0’ baby was delivered by cesarean section for fetal distress. Meconium staining was noted. The baby was intubated and meconium suctioned from below the vocal cords. The child developed respiratory distress at 4 hours of age. A septic workup was performed and the child was started on ampicillin and gentamicin. The chest x-ray showed bilateral infiltrates. Respiratory failure was demonstrated with an arterial blood gas showing pH 7.21, PCO, 60 mm Hg, PO, 26 mm Hg on F,O, lOO%, rate 80 breaths/min, PIP 35 cm, and a PEEP 5 cm. The child was transferred to the Children’s Memorial Hospital at 20 hours of age. Initial examination showed coarse bilateral breath sounds. Chest x-ray demonstrated normal thymic shadow with bilateral pulmonary infiltrates consistent with meconium aspiration syndrome. Relevant admission laboratory results included white blood cell count 17.8, hemoglobin 15.6, and hemocrit 45.8. The differential included 54 polymorpholeukocytes, 36 bands, 1 eosinophils, 0 basophil, 4 lymphocytes, 3 atypical lymphocytes, and 1 monocyte. The child met ECMO criteria and was placed on ECMO 1 day after birth. The ECMO run was 80 hours and uneventful. During the ECMO run the child received 19 separate blood components. On day 17 he developed a temperature of 38.9”C with an initial maculopapular rash on the ears, upper trunk, back, and extremities, including the palms and soles. The rash spread to the entire body. A septic workup was negative. The following day he
Journa/ofPediatric
Surgery,
Vol26, No
3
(March). 1991: pp 317-319
developed diarrhea. His liver edge was 4 cm below the right costal margin. Pertinent laboratory findings included aspartate aminotransferase 898 U/L (normal, 8 to 42), alanine aminotransferase 261 U/L (normal, 8 to 78), alkaline phosphatase 13.8 U/L. (normal, 7.8 to 26.4), albumin 1.9 g/dL, white blood cell count 13.8 U/L, hematocrit 41.0, hemoglobin 14.0, platelets 156,000, polys 20, bands 9, eosinophils 8, basophil 0, lymphocytes 58, atypical lymphocytes 5, total bilirubin 12.4, and direct bilirubin 5.2. The child initially was thought to have either a fulminant viral infection, drug eruption, erythema multiforme, or GVHD. Histopathologic examination of a skin biopsy specimen done on day 18 was characteristic of GVHD, with basal cell liquification degeneration. There were abundant lymphocytes in the dermis and epidermis, with lymphocytes surrounding the necrotic keratinocytes (“satellite cell necrosis”) (Fig 1). The diarrhea continued, hepatomegaly increased, and the liver enzyme levels remained elevated. Protective isolation was instituted and the baby was continued on antibiotics. High-dose methylprednisolone (2 mg/ kg/d) and cyclosporine (1 mg/kg every 12 hours) were instituted and resulted in partial resolution of the cutaneous eruptions. Neutropenia developed with a white blood cell count of 700/L, of which 99% were lymphocytes and 1% were atypical lymphocytes. An extensive evaluation for sepsis disclosed disseminated Candida parapsilosis involving the urine, blood, lungs, and gut. Ampoterin B was administered. Studies to identify an immunologic defect demonstrated no T-lymphocyte abnormality with a normal supply of T cells and normal in vitro mitogen stimulation studies. Despite hypoimmunoglobulinemia (IgG of 133 mg/dL, normal, 251 to 906 mg/dL), other immunoglobulin levels were normal and B cells had surface immunoglobulins. The child began to have seizures and demonstrated multiple organ failure. He had a progressive downhill course and died of respiratory arrest on day 36. An autopsy showed fungal infiltration of the gastrointestinal tract, lungs, heart, kidneys, thyroid, pancreas, central nervous system, and the spinal cord. A skin biopsy showed fewer lymphocytes and less keratinocyte necrosis than was observed on the initial biopsy. The bone marrow was hypocellular and there was marked lymphoid depletion of the thymus, spleen. and lymph nodes, suggesting a primary immune deficiency, GVHD, or septicemia. GVHD reaction was also found in tissue sections from the gastrointestinal tract, liver, and pancreas. DISCUSSION The diagnosis of TA-GVHD is often delayed because its signs are similar to those seen in viral infecFrom the Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia Hospital and Clinics, Augusta, GA, and the Sections of Pediarric Surgery, Dermatology, and Pathology, The Children S Memorial Hospital, Chicago, IL. Presented at the 21st Annual Meeting of the American Pediatric Surgical Association, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to R.M. Hat& MD, Section of Pediatric Surgery, Department of Surgery, Medical College of Georgia, Augusta, GA 30912-4010. Copyright D 1991 by WB. Saunders Company 0022-3468/91/2603-0014$03.00l0 317
318
HATLEY ET AL
Fig 1. Liquification degeneration of the basal cell layer is seen. Lymphocytes surround the necrotic keratinocytes (satellite cell necrosis) (arrow).
tions, drug reactions, and erythema multiforme.4’5 The diagnosis in this patient was suggested by the clinical picture of fever, diarrhea, and generalized maculopapular rash with involvement of the soles and palms and progressive liver failure. Skin biopsy findings were diagnostic of GVHD. The primary organs involved in TA-GVHD are the skin, gastrointestinal tract, liver, bone marrow, spleen, and thymus.i’6 Clinical manifestations of TA-GVHD resemble those of bone marrow transplantation GVHD (BMT-GVHD)? There are several important differences between TA- and BMT-GVHD. The bone marrow in TA-GVHD is hypoplastic or aplastic and has erythrolymphophagocytosis.“6 The bone marrow usually does not recover and the patient usualIy dies of overwhelming infection.“4’6 TA-GVHD occurs 2 to 30 days after blood product infusion, often during the first 2 weeks after transfusion in contrast to BMT-GVHD, which occurs at 5 to 10 weeks.1T2,4,6 The most important differences in the two disorders are noted in incidence and mortality. Acute TA-GVHD has an incidence of 0.1% to 1% and a mortaIity of 95% to 100% in reported cases.*-4’6About 70% of
bone marrow transplant patients develop evidence of GVHD but only 10% to 15% die of the disease.‘z4 Although TA-GVHD usually occurs in severely immunodeficient patients, normal neonates are immunocompromised and are susceptible to TA-GVHD. Recent reports describe 7 neonates (6 premature and 1 full-term) who developed TA-GVHD after an. exchange transfusion.2 A 6-month-old infant who developed TA-GVHD after cardiac surgery has also been described.2 TA-GVHD have been reported after transfusion of whole blood, packed red cells, platelets, and granulocytes.‘.2,7One times 10’ lymphocytes per kilogram of body weight are necessary to establish a GVH reaction.1,2 Whole blood and packed cells contain from 1 to 2 x 10’ lymphocytes.* TA-GVHD occurs in patients incapable of rejecting immunocompetent transfused lymphocytes.‘~2~7The T lymphocytes are histoincompatible with the host but the difference may involve non-HLA antigens6 The diagnosis of TA-GVHD can be difficult. The onset of high fever, maculopapular rash, and profuse diarrhea in neonates or immunocompromised infants and young children 2 to 30 days following a transfusion should alert the physician to the possibility of TA-GVHD. More cases will be recognized through physician awareness. Exclusion of an ongoing viral infection is an obvious important consideration. Treatment of TA-GVHD has been unsuccessful in 100% of affected infants despite the administration of systemic corticosteroids and cyslosporine.1*2,4,h.7 Because treatment of TA-GVHD is unsuccessful, the emphasis should be placed on prevention by irradiation of blood products.‘” The recommended dose of radiation is 1,500 to 7,500 rads’s2 because the radiation dose needed to ablate the mitotic potential of lymphocytes is 500 rads. There have been no documented cases of TA-GVHD in patients given blood products irradiated with greater than 1,500 rads.’ A case of fatal TA-GVHD following ECMO is presented. ECMO is a therapeutic modality that has significant life-saving potential. During ECMO the babies are exposed to large numbers of different blood products and are therefore susceptible to TA-GVHD. There is no adequate treatment of TAGVHD. Therefore, we recommend irradiation of all blood products used prior to and during ECMO.
REFERENCES 1. Berger RS, Dixon SL: Fulminant transfusion-associated graftversus-host disease in a premature infant. J Am Acad Dermatol Z&945-950,1989
2. Holland PV: Prevention of transfusion-associated graft-vshost disease. Arch Path01 Lab Med 113:285-291,1989 3. Laver BA, Githens JH, Hayward AT, et al: Probable graft-vs-
GRAFT-VERSUS-HOST
DISEASE FOLLOWING
ECMO
319
graft reaction in an infant after exchange transfusion and marrow transplantation. Pediatrics 70:43-47,1982 4. Arsura EL, Bertelle A, Minkowitz S, et al: Transfusionassociated graft-vs-host disease in a presumed immunocompetent patient. Arch Intern Med 148:1941-1944,198s 5. Thaler M, Shamiss A, Orgad S: The role of blood from HLA homozygous donors in fatal transfusion-associated graft-versus-
host disease after open-heart surgery. N Engl J Med 321:2.5-28, 1989 6. Brubaker DB: Transfusion-associated graft-versus-host disease. Hum Path01 17:1085-1088,1986 7. Editorial: Transfusion and graft-versus-host disease. Lancet 1:529-530,1989
Discussion S. ildsrad (Pittsburgh, PA): This is a fascinating report and I applaud the authors on their high index of suspicion to include GVHD in the differential diagnosis. As you mentioned, GVHD is mediated by transfusion of competent donor T lymphocytes that attack the host and in effect attempt to reject the host. It is a reaction of the donor against the host. These cells can be transfused in separated blood products. The target organs that you describe for your patient are the classic ones for GVHD--the liver, the spleen, the thymus, and especially the skin. There is a generalized rash that appears and skin biopsy is usually diagnostic. There have been a number of case reports recently of transfusion-induced GVHD in patients who are not recipients of bone marrow transplants. This has been true for both adults and for neonates. It includes the transplant patient population recipients of solid organ grafts and even critically ill patients who have undergone major stress and been transfused multiple blood products. Further studies are required to determine the incidence of
this problem. Perhaps some of the generalized exanthema we attribute to viral infection in critically ill patients is actually GVHD. I would like to ask two questions. First, do you think that we should be irradiating blood products for critically ill patients? Second, did you look at the phenotype of the T cells that were present in your patient to see if they were of host or donor type? R Hatley (response): I think we should consider irradiating all blood products in the critically ill infant and young child. It only costs $35.00. Although transfusion-induced GVHD is a rare complication, once it surfaces the money invested in trying to treat the child will go into the hundreds of thousands of dollars. I think that $35.00 to irradiate the blood for 6 or 7 minutes is a minimal price to pay for the life of the child because GVHD is not a treatable problem. However, further studies are required to determine when and if blood products should be in activated. To answer your second question, we did not get the T subsets on the blood.
