Summary:Adverse reactions with DMSO-cryopreserved stem cell infusion are well-recognized. However, severe, lifethreatening anaphylactic reactions with DMSO are very rarely described in the literature. We report here a 58-year-old female with AL amyloidosis who developed an unexpected episode of respiratory arrest a few seconds after the beginning of thawed stem cell product infusion. Fortunately, the patient was resuscitated successfully without the need for intubation. The prompt development of the reaction just a few seconds after the stem cell infusion convincingly implicates DMSO as the potential suspect. The presence of amyloid cardiomyopathy might have also contributed to this adverse event. Bone Marrow Transplantation (2000) 25, 1299-1301. Keywords: DMSO; respiratory depression; stem cell transplantation; amyloidosis Amyloid light-chain (AL) amyloidosis is now recognized as a plasma cell dyscrasia resulting from the synthesis and deposition of insoluble immunoglobulin light chains in various organ systems.1 Heart involvement has been associated with increased mortality and poorer prognosis.1,2 The conventional alkylating agent-based therapy of AL amyloidosis has been generally unsuccessful with an average overall survival of 12-20 months, and 6 months in patients with cardiac involvement.1 Dose-intensive melphalan with autologous peripheral blood stem cell rescue (APBSCT) has been recently demonstrated to be an effective treatment modality, 3-6 although follow-up is still short-term. 3 However, the early mortality within the first 100 days can be high (up to an average of 30%) mostly due to heart failure associated with amyloid cardiomyopathy. 4,5 Dimethylsulphoxide (DMSO) prevents damage to hemopoietic stem cells during cryopreservation.7 DMSO-cryopreserved autologous stem cell infusions have been reported to cause a wide variety of toxicities which have been mostly mild. tion is very rare and has been reported only in isolated cases. 10-14We present here a patient with AL amyloidosis and cardiac involvement who developed acute respiratory arrest which was reversed successfully with prompt intervention. Case reportA 58-year-old woman presented to another center with bilateral lower extremity edema and fatigue. She was found to have hypoalbuminemia and a nephrotic range proteinuria. A computerized tomography of the abdomen showed a diffusely enlarged liver and bilaterally enlarged kidneys. An electrocardiogram (EKG) revealed first degree AV block and low voltaged QRS waves in leads II, III and aVF and ST segment elevation in V 1 and V 2 and T inversion in V 3 to V 6 . An echocardiogram was obtained which showed mild left ventricular hypertrophy with a normal ejection fraction of 55%. The patient subsequently underwent a kidney biopsy which revealed sclerosis and obsolescence of several glomeruli with accumulation of Congo-red positive eosinophilic material within the mesangium and the glomerular capillary walls. Lambda light chains were stained only in the glomeruli and blood vessels by immunofluorescence...
Summary:Respiratory syncytial virus (RSV) infection is an important cause of respiratory mortality in immunosuppressed patients, including bone marrow transplant (BMT) recipients. The presence of lower respiratory tract infection and infection in the pre-engraftment phase of BMT is believed to confer a poor prognosis. Three patients who underwent allogeneic BMT at our institution developed RSV pneumonia over 1 year post BMT, with the underlying disease in remission. All three were hypoxic with extensive pulmonary disease at presentation. Treatment consisted of aerosolized ribavirin and intravenous immune globulin with successful clearing of viral shedding and excellent clinical outcomes. RSV infection is probably less severe in the late post-BMT period, but needs to be considered early in the differential diagnosis of pulmonary infiltrates in this patient population. Bone Marrow Transplantation (2001) 27, 1071-1073. Keywords: RSV infection; late; BMT; ribavirin Respiratory syncytial virus (RSV) is a common pediatric pathogen with a predilection for winter outbreaks. In the adult population, RSV infections are increasingly recognized as important causes of respiratory mortality, primarily in immunosuppressed patients, including allogeneic bone marrow transplant (BMT) recipients. The clinical presentation in these sub-groups is frequently as an upper respiratory tract infection (URTI) that can rapidly progress to viral pneumonia if untreated. This progression from URTI to pneumonia is much higher in the immediate posttransplant period.1,2 RSV pneumonia in allogeneic BMT patients has been associated with mortality rates between 60% and 80%, despite aggressive treatment. Negative predictors of outcome following RSV infection in BMT recipients remain ill-defined, but include infection in the pre- There are few data regarding RSV infections in adult BMT recipients 1 year or more after transplant. We report three such cases of RSV infection at the Roswell Park Cancer Institute (Buffalo, NY) treated successfully with aerosolized ribavirin and intravenous immune globulin (IVIG) during the winter of 1999-2000. The absolute neutrophil count was normal and the underlying disease was in complete remission in all three patients. Case reportsPatient 1 is a 24-year-old female, who was 384 days following an allogeneic BMT for chronic myelogenous leukemia from an HLA-matched sibling donor. The conditioning regimen used for BMT was busulfan and cyclophosphamide. The post-BMT course was complicated by acute and chronic graft-versus-host disease (GVHD) requiring methyprednisolone, cyclosporine and tacrolimus therapy. She had completed a course of immunosuppressive therapy 2 weeks prior to detection of RSV infection. The patient was receiving trimethoprim/sulfamethoxazole, penicillin and acyclovir prophylaxis. Presenting symptoms included sinus congestion, cough with mucopurulent expectoration and dyspnea on exertion. Her 15-month-old infant had had symptoms of URTI within the preceding weeks. She was afebrile and hemodynamically sta...
Summary:Several trials have shown the activity of thalidomide (THAL) in relapsed multiple myeloma (MM) patients failing PBSCT or conventional chemotherapy. PBSCT is considered standard treatment for most patients requiring therapy for MM; however, patients with VAD-resistant disease may not be able to receive PBSCT due to rapidly advancing disease. We report four cases of VAD-refractory MM salvaged with THAL ؉ VAD followed by PBSCT. All patients underwent stem cell mobilization with cyclophosphamide (Cy) (4.5 g/m 2 ) and GMCSF. Melphalan (140-200 mg/m 2 ) was given as conditioning. All patients engrafted within 12-16 days after PBSCT. Day ؉100 evaluation showed the following: very good partial response (n ؍ 1) and complete response (n ؍ 3). After a median follow-up to 153 days, two patients continue to take THAL with no signs of disease progression. One patient developed CHF and was taken off THAL while another patient has died of progressive disease while on THAL (MTD 50 mg). In conclusion, VAD-refractory patients were salvaged with the addition of THAL to VAD. They were subsequently able to undergo autologous PBSCT for MM, which will likely improve their overall survival. This suggests that THAL and other related immunomodulatory drugs may prove useful for initial MM therapy in combination with standard chemotherapy followed by PBSCT. Bone Marrow Transplantation (2002) 29, 577-580. DOI: 10.1038/sj/bmt/1703522 Keywords: multiple myeloma; peripheral blood stem cell transplantation; thalidomide VAD (vincristine, adriamycin, dexamethasone) is considered standard, first-line therapy for multiple myeloma (MM). 1,2 Patients who develop VAD-refractory disease are at high risk for mortality due to progressive disease. Single agents such as cytosine arabinoside (Ara-C) have only modest activity against VAD-refractory multiple myeloma. 3 In addition, different combination chemotherapy regimens have limited effect. These include vincristine and etoposide, etoposide, dexamethasone, Ara-C and cisplatin (EDAP) and DAP alone. 4,5 The hyper C-VAD regimen (twice daily cyclophosphamide (Cy) and VAD) produced a 40% response rate and a median remission duration of only 8 months in VAD-refractory MM patients. 6 Thus new approaches are necessary to treat MM refractory to standard treatment.Thalidomide (THAL) is a novel anti-myeloma agent with 25 to 35% response rates in heavily pre-treated patients. 7,8 Singhal et al 7 reported the results of 84 patients with previously treated and progressive MM who were treated with THAL as a single agent. Ten percent of patients had complete or nearly complete remission (CR) and 32% had a reduction in serum or urine paraprotein level of at least 25%. After 12 months of follow-up, 22% of the study patients remained event free and 58% were alive. Juliusson et al 8 reported the results of 23 advanced and heavily pretreated MM patients who were treated with THAL. Ten of 23 (43%) achieved a partial response (PR) and six had minor responses (MR) or stable disease (SD).There is clear evidence suppor...
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