Case Report
The First Allogeneic Bone Marrow Transplantation in the Armed Forces for Thalassemia Col Velu Nair, VSM*, Col SK Nema+, Col GS Chopra#, Lt Col (Mrs) J Kotwal**, Col PS Dhot##, Lt Col Rajat Kumar (Retd)++ MJAFI 2005; 61 : 190-191 Key Words : Beta thalassemia; Allogenic bone marrow transplantation
Introduction eta Thalassemia major is a form of haemoglobinopathy where the Beta-globulin chains of the haemoglobin molecule are not found due to an inherited defect. The disease is manifest in first few months of life in the form of severe anaemia necessitating life long RBC transfusions. Till the advent of bone marrow transplantation (BMT), which is the only curative treatment, patients with thalessemia major were kept alive with supportive care (RBC transfusions + Iron chelation therapy) only [1]. We report the first allogeneic bone marrow transplant performed successfully in a patient of Beta Thalessemia major in an Armed Forces Hospital.
B
Case Report 5-1/2 years old male child, born of parents from a nonconsanguinous marriage was diagnosed to have Beta Thalessemia major in September 1997 at age of 4 months. Thereafter, he was on transfusion support and 64 units of red blood cells (RBC’s) were transfused till August 2002. He was also on iron chelation with subcutaneous desferal infusions, (50 mg/kg body wt) plus vitamin C, six days a week along with daily folic acid. He was vaccinated against Hepatitis B successfully 2 years back. On examination, the patient had haemolytic facies with pallor. There was no icterus, lymphadenopathy or purpura. He had no hepatomegaly and spleen tip was palpable. Other systems were normal. Investigation Hb was kept > 8 gm/dl by regular RBC transfusions. TLC, DLC and platelets were within normal limits. His LFT, RFT, calcium, phosphorus and electrolytes were within normal limits. HbsAg, Anti HCV and HIV were negative. Serum Ferritin pre-transplant was 1200 ng/ml. He was seropositive for CMV by ELISA. PCR for CMV was negative. *
The patient had a sibling brother 1 year of age who had a six antigen HLA match with the patient, done by DNA technique. His cord blood was cryopreserved at birth for subsequent use. There was a blood group mismatch with patient being AB +ve and donor A +ve who was CMV positive by ELISA and negative by PCR. Hemoglobin electrophoresis of the donor was normal. Patient was planned for allogeneic BMT and a double lumen Hickman catheter was inserted into right internal jugular vein on 09 July 2002. He was conditioned with chemotherapy protocol using oral Busulphan (Bu) on day minus 10 to minus 7 at a dose of 4 mg per kg body weight daily (in four divided doses) for four days, followed by injection cyclophosphamide (cy) 60 mg/kg body weight daily for two days (Day minus 6 and minus 5) along with injection Mesna for protection of bladder uroepithelium from developing hemorrhagic cystitis. Anti-lymphocytic Globulin of equine origin from Pharmacia Upjohn (ATGAM) was administered on day minus 4, minus 3 and minus 2 in a dose of 30 mg/kg body weight per day as per protocol. However, on the first day of ATGAM infusion, patient developed anaphylactic reaction and ATGAM was discontinued. There was no past history of allergic diathesis or exposure to any equine anti sera. On day zero (01 August 2002), he was transfused 200 ml of bone marrow which was harvested from his sibling brother (blood group A +ve) aged 1 year, under GA from both posterior superior iliac spines (130 ml) and anterior superior iliac spines (70 ml). The marrow dose was 3 X 108 mononuclear cells (MNC) with a CD 34 count of 0.56%. The marrow was infused uneventfully after pre-medication with hydrocortisone and injection chlopheniramine maleate using a normal blood giving set. In addition, he was also transfused cryopreserved cord blood. A total of 116 ml of cord blood cryopreserved with anticoagulant and DMSO (Cryoprotectant) was infused and the viability on thawing was 75,94 and 90% in bag 1,2
Senior Adviser (Medicine & Hematology), #Senior Adviser (Pathology & Transplant Immunology), **Classified Specialist (Pathology & Haematopathology), Army Hospital (R&R), Delhi Cantt, ##Senior Adviser (Pathology & Haematopathology), AFTC, Delhi Cantt-10, + Professor & Head, Department of Pathology, Armed Forces Medical College, Pune-40, ++Professor & Head, Department of Clinical Haematology, AIIMS, New Delhi. Received : 19.06.2003; Accepted : 19.04.2004
Allogeneic Bone Marrow Transplantation
and 3 respectively. Patient was started on Injection G-CSF (Neupogen), 150 g subcutaneously once a day wef day +1. Graft Versus Host Disease (GVHD) prophylaxis was given with injection cyclosporine starting on day zero (01 August 2002) at a dose of 5 mg/kg body weight in two divided doses to achieve blood cyclosporine levels of 250 to 350 ng/ml and continued till day +14 and changed to oral cyclosporine (Neoral of Novartis) thereafter. Inj methrotoxate (10mg / m2) was also given for GVHD prophylaxis on Day +1 and then in reduced dose (7 mg/ m2) on Day +3, +6 and +11 with folinic acid (Leucovorin) rescue 24 hours after administration of each dose of methotrexate. The patient engrafted on day 13. He was supported with a total of 09 donor group specific (A +ve) RBC and 06 single donor platelet transfusions after conditioning. All blood components were irradiated prior to transfusion as prophylaxis against development of transfusion related GVHD. Injection G-CSF was given for a total of 16 days at a dose of 150 g, subcutaneously daily. He was on total parenteral nutritional support during the post transplant period till oral feeds were started. Complications 1. Developed febrile neutropenia on day +5. Blood culture was sterile. No clinical focus of infection was identifiable and defeverscence was achieved with broad-spectrum antibiotics. 2. Developed delayed haemorrhagic cystitis on D+35, which was treated conservatively with hydration and saline flushing of bladder. On D+38 he also developed a productive cough with low-grade fever and a rise in liver enzymes (AST 108 iu/l and ALT 104 iu/l). Sputum culture was sterile and no AFB was seen on ZN stain. Chest Xray and ultrasound of abdomen were found to be normal. CMV-DNA by PCR was positive however no inclusion bodies were seen in urine. He was started on Inj Ganciclovir (10 mg/kg body weight in two divided doses). Patient responded and haematuria gradually subsided over a period of 04 weeks and the liver transminases also settled to normal levels. Ganciclovir was given daily for 15 days. 3. Grade II mucositis developed on day +4 which settled with supportive care. There was no evidence of any venoocclusive disease or GVHD during the post transplant period. Further course The patient was discharged from hospital on day 75 after removal of the Hickman Catheter. He has been free of transfusion support since day 60 and has been followed up on immunosuppressive therapy with cyclosporine and other supportive care for 180 days post transplant. His blood group has converted from AB positive (pre transplant) to the donor blood group i.e. A positive on day 108 post transplant. There has been no features of chronic GVHD on follow up.
Discussion BMT is the only curative form of treatment for this MJAFI, Vol. 61, No. 2, 2005
191
hereditary disorder. In BMT, conditioning destroys the defective marrow, which is followed by infusion of the bone marrow (graft) from a HLA matched sibling or unrelated donor. In recent times cord blood has also been used as a source of stem cells for transplantation [2]. However the largest number of transplants have been done from HLA matched sibling donors to patients where the results have been most rewarding. The chances of finding a HLA matched sibling donor is only 25%. BMT today offers an alternative to life long transfusion with iron chelation. It is the only curative treatment available for Thalessemia major. The first BMT in a thalessemic patient was done successfully in Seattle in December 1981 [3]. The Lucarelli group in Pesaro, Italy have performed more than 800 transplants for Thalessemia patients and have demonstrated excellent results in well chelated patients with no hepatomegaly or hepatic fibrosis secondary to iron overload [4]. Christian Medical College and Hospital in Vellore have performed the largest number of BMTs in Thalessemia patients in India [5,6] with results comparable to the west. The approximate cost for transfusion and iron chelation with desferrioxamine in a 30 kg child in India is approximately US $5000 whereas the cost of a BMT in the civil centers in India is in the range of US $15,000 (Indian Rs. 6.5 to 7.0 lakhs) [6]. In our patient the cost worked out to Rs. 2.5 lakhs excluding the cost for the BMT unit and hospital stay (being a government hospital). Hence BMT offers a cost effective alternative to life long transfusion for Thalessemia patients and if done early in a well chelated patient with no hepatomegaly or hepatic fibrosis the success rate of BMT could well be upwards of ninety percent. References 1. Weatherall J David. Genetic disorders of haemoglobin. In: Hoffbrand, Lewis, Tuddenham, editors. Postgraduate Haematology. 4th ed. Butterworth-Heinemann 1999;91-119. 2. Issaragrisil S, Suvatte V, Visnthisakchai S, et al. Bone marrow and cord blood stem cell transplantation for Thalassemia in Thailand. Bone marrow transplantation 1997;19:54-6. 3. Thomas ED, Buckner CD, Sanders JE, et al. Marrow transplantation for Thalessemia. Lancet 1982;2:227-9. 4. Lucarelli G, Clift RA, Galimberti M, et al. Marrow transplantation for patients with Thalassemia. Results in class 3 patients. Blood 1996;87:2082-8. 5. Dennison D, Srivastava A and Chandy M. Bone marrow transplantation for Thalassemia in India. Bone marrow transplantation 1997;19:70-4. 6. Chandy M, Srivastava, Dennison D, Mathews V and George B. Allogeneic bone marrow transplantation in the developing world: experience from a center in India. Bone marrow transplantation 2001;27:785-90.
The First Allogeneic Bone Marrow Transplantation in the Armed Forces for Thalassemia Col Velu Nair, VSM*, Col SK Nema+, Col GS Chopra#, Lt Col (Mrs) J Kotwal**, Col PS Dhot##, Lt Col Rajat Kumar (Retd)++ MJAFI 2005; 61 : 190-191 Key Words : Beta thalassemia; Allogenic bone marrow transplantation
Introduction eta Thalassemia major is a form of haemoglobinopathy where the Beta-globulin chains of the haemoglobin molecule are not found due to an inherited defect. The disease is manifest in first few months of life in the form of severe anaemia necessitating life long RBC transfusions. Till the advent of bone marrow transplantation (BMT), which is the only curative treatment, patients with thalessemia major were kept alive with supportive care (RBC transfusions + Iron chelation therapy) only [1]. We report the first allogeneic bone marrow transplant performed successfully in a patient of Beta Thalessemia major in an Armed Forces Hospital.
B
Case Report 5-1/2 years old male child, born of parents from a nonconsanguinous marriage was diagnosed to have Beta Thalessemia major in September 1997 at age of 4 months. Thereafter, he was on transfusion support and 64 units of red blood cells (RBC’s) were transfused till August 2002. He was also on iron chelation with subcutaneous desferal infusions, (50 mg/kg body wt) plus vitamin C, six days a week along with daily folic acid. He was vaccinated against Hepatitis B successfully 2 years back. On examination, the patient had haemolytic facies with pallor. There was no icterus, lymphadenopathy or purpura. He had no hepatomegaly and spleen tip was palpable. Other systems were normal. Investigation Hb was kept > 8 gm/dl by regular RBC transfusions. TLC, DLC and platelets were within normal limits. His LFT, RFT, calcium, phosphorus and electrolytes were within normal limits. HbsAg, Anti HCV and HIV were negative. Serum Ferritin pre-transplant was 1200 ng/ml. He was seropositive for CMV by ELISA. PCR for CMV was negative. *
The patient had a sibling brother 1 year of age who had a six antigen HLA match with the patient, done by DNA technique. His cord blood was cryopreserved at birth for subsequent use. There was a blood group mismatch with patient being AB +ve and donor A +ve who was CMV positive by ELISA and negative by PCR. Hemoglobin electrophoresis of the donor was normal. Patient was planned for allogeneic BMT and a double lumen Hickman catheter was inserted into right internal jugular vein on 09 July 2002. He was conditioned with chemotherapy protocol using oral Busulphan (Bu) on day minus 10 to minus 7 at a dose of 4 mg per kg body weight daily (in four divided doses) for four days, followed by injection cyclophosphamide (cy) 60 mg/kg body weight daily for two days (Day minus 6 and minus 5) along with injection Mesna for protection of bladder uroepithelium from developing hemorrhagic cystitis. Anti-lymphocytic Globulin of equine origin from Pharmacia Upjohn (ATGAM) was administered on day minus 4, minus 3 and minus 2 in a dose of 30 mg/kg body weight per day as per protocol. However, on the first day of ATGAM infusion, patient developed anaphylactic reaction and ATGAM was discontinued. There was no past history of allergic diathesis or exposure to any equine anti sera. On day zero (01 August 2002), he was transfused 200 ml of bone marrow which was harvested from his sibling brother (blood group A +ve) aged 1 year, under GA from both posterior superior iliac spines (130 ml) and anterior superior iliac spines (70 ml). The marrow dose was 3 X 108 mononuclear cells (MNC) with a CD 34 count of 0.56%. The marrow was infused uneventfully after pre-medication with hydrocortisone and injection chlopheniramine maleate using a normal blood giving set. In addition, he was also transfused cryopreserved cord blood. A total of 116 ml of cord blood cryopreserved with anticoagulant and DMSO (Cryoprotectant) was infused and the viability on thawing was 75,94 and 90% in bag 1,2
Senior Adviser (Medicine & Hematology), #Senior Adviser (Pathology & Transplant Immunology), **Classified Specialist (Pathology & Haematopathology), Army Hospital (R&R), Delhi Cantt, ##Senior Adviser (Pathology & Haematopathology), AFTC, Delhi Cantt-10, + Professor & Head, Department of Pathology, Armed Forces Medical College, Pune-40, ++Professor & Head, Department of Clinical Haematology, AIIMS, New Delhi. Received : 19.06.2003; Accepted : 19.04.2004
Allogeneic Bone Marrow Transplantation
and 3 respectively. Patient was started on Injection G-CSF (Neupogen), 150 g subcutaneously once a day wef day +1. Graft Versus Host Disease (GVHD) prophylaxis was given with injection cyclosporine starting on day zero (01 August 2002) at a dose of 5 mg/kg body weight in two divided doses to achieve blood cyclosporine levels of 250 to 350 ng/ml and continued till day +14 and changed to oral cyclosporine (Neoral of Novartis) thereafter. Inj methrotoxate (10mg / m2) was also given for GVHD prophylaxis on Day +1 and then in reduced dose (7 mg/ m2) on Day +3, +6 and +11 with folinic acid (Leucovorin) rescue 24 hours after administration of each dose of methotrexate. The patient engrafted on day 13. He was supported with a total of 09 donor group specific (A +ve) RBC and 06 single donor platelet transfusions after conditioning. All blood components were irradiated prior to transfusion as prophylaxis against development of transfusion related GVHD. Injection G-CSF was given for a total of 16 days at a dose of 150 g, subcutaneously daily. He was on total parenteral nutritional support during the post transplant period till oral feeds were started. Complications 1. Developed febrile neutropenia on day +5. Blood culture was sterile. No clinical focus of infection was identifiable and defeverscence was achieved with broad-spectrum antibiotics. 2. Developed delayed haemorrhagic cystitis on D+35, which was treated conservatively with hydration and saline flushing of bladder. On D+38 he also developed a productive cough with low-grade fever and a rise in liver enzymes (AST 108 iu/l and ALT 104 iu/l). Sputum culture was sterile and no AFB was seen on ZN stain. Chest Xray and ultrasound of abdomen were found to be normal. CMV-DNA by PCR was positive however no inclusion bodies were seen in urine. He was started on Inj Ganciclovir (10 mg/kg body weight in two divided doses). Patient responded and haematuria gradually subsided over a period of 04 weeks and the liver transminases also settled to normal levels. Ganciclovir was given daily for 15 days. 3. Grade II mucositis developed on day +4 which settled with supportive care. There was no evidence of any venoocclusive disease or GVHD during the post transplant period. Further course The patient was discharged from hospital on day 75 after removal of the Hickman Catheter. He has been free of transfusion support since day 60 and has been followed up on immunosuppressive therapy with cyclosporine and other supportive care for 180 days post transplant. His blood group has converted from AB positive (pre transplant) to the donor blood group i.e. A positive on day 108 post transplant. There has been no features of chronic GVHD on follow up.
Discussion BMT is the only curative form of treatment for this MJAFI, Vol. 61, No. 2, 2005
191
hereditary disorder. In BMT, conditioning destroys the defective marrow, which is followed by infusion of the bone marrow (graft) from a HLA matched sibling or unrelated donor. In recent times cord blood has also been used as a source of stem cells for transplantation [2]. However the largest number of transplants have been done from HLA matched sibling donors to patients where the results have been most rewarding. The chances of finding a HLA matched sibling donor is only 25%. BMT today offers an alternative to life long transfusion with iron chelation. It is the only curative treatment available for Thalessemia major. The first BMT in a thalessemic patient was done successfully in Seattle in December 1981 [3]. The Lucarelli group in Pesaro, Italy have performed more than 800 transplants for Thalessemia patients and have demonstrated excellent results in well chelated patients with no hepatomegaly or hepatic fibrosis secondary to iron overload [4]. Christian Medical College and Hospital in Vellore have performed the largest number of BMTs in Thalessemia patients in India [5,6] with results comparable to the west. The approximate cost for transfusion and iron chelation with desferrioxamine in a 30 kg child in India is approximately US $5000 whereas the cost of a BMT in the civil centers in India is in the range of US $15,000 (Indian Rs. 6.5 to 7.0 lakhs) [6]. In our patient the cost worked out to Rs. 2.5 lakhs excluding the cost for the BMT unit and hospital stay (being a government hospital). Hence BMT offers a cost effective alternative to life long transfusion for Thalessemia patients and if done early in a well chelated patient with no hepatomegaly or hepatic fibrosis the success rate of BMT could well be upwards of ninety percent. References 1. Weatherall J David. Genetic disorders of haemoglobin. In: Hoffbrand, Lewis, Tuddenham, editors. Postgraduate Haematology. 4th ed. Butterworth-Heinemann 1999;91-119. 2. Issaragrisil S, Suvatte V, Visnthisakchai S, et al. Bone marrow and cord blood stem cell transplantation for Thalassemia in Thailand. Bone marrow transplantation 1997;19:54-6. 3. Thomas ED, Buckner CD, Sanders JE, et al. Marrow transplantation for Thalessemia. Lancet 1982;2:227-9. 4. Lucarelli G, Clift RA, Galimberti M, et al. Marrow transplantation for patients with Thalassemia. Results in class 3 patients. Blood 1996;87:2082-8. 5. Dennison D, Srivastava A and Chandy M. Bone marrow transplantation for Thalassemia in India. Bone marrow transplantation 1997;19:70-4. 6. Chandy M, Srivastava, Dennison D, Mathews V and George B. Allogeneic bone marrow transplantation in the developing world: experience from a center in India. Bone marrow transplantation 2001;27:785-90.
