Case Report

Bone Marrow Transplantation (2003) 31, 403–405. doi:10.1038/sj.bmt.1703863

Successful umbilical cord blood stem cell transplantation for chronic granulomatous disease

A Bhattacharya1, M Slatter1, A Curtis2, C E Chapman3, D Barge4, A Jackson2, T J Flood1, M Abinun1, A J Cant1 and A R Gennery1

  1. 1Newcastle upon Tyne Hospitals NHS Trust, University of Newcastle upon Tyne, UK
  2. 2Institute of Human Genetics, University of Newcastle upon Tyne, UK
  3. 3Newcastle Blood Transfusion Service, University of Newcastle upon Tyne, UK
  4. 4Department of Immunology, University of Newcastle upon Tyne, UK

Correspondence: Dr AR Gennery, Ward 23, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, NE4 6BE, UK

Received 16 July 2002; Accepted 3 October 2002.

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Abstract

Chronic granulomatous disease (CGD) causes growth failure, inflammatory lung damage and often early death. Prophylactic cotrimoxazole improves medium-term survival, but cannot prevent inflammatory sequelae. We report the first patient with CGD who underwent successful HLA identical sibling umbilical cord stem cell transplantation (UCSCT) after myeloablative conditioning. The patient presented with colitis, confirmed as CGD at 2 years of age. Following BU16/CY200 conditioning, he had UCSCT from his unaffected HLA identical sister. A year post-transplant, his colitis had resolved clinically and on radioisotope scan growth has improved. Neutrophil oxidative burst was 92% normal with full donor lymphocyte reconstitution.

Keywords:

chronic granulomatous disease, umbilical cord blood, allogeneic transplantation

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency, characterised by impaired intracellular microbial killing by phagocytes and consequent susceptibility to bacterial and fungal infections. Mutations in the genes coding for the NADPH oxidase complex lead to defective-free oxygen radical production and failure to kill organisms ingested into the phagolysosomes of neutrophils and monocyte-derived cells. Patients suffer from recurrent infections, particularly with catalase-positive organisms such as Aspergillus species, Staphylococcus aureus and Burkholderi cepacia. Contiguous and haematogenous spread of infection explains the wide range of organs that may be affected, including liver, bone and brain. About 60% of patients are symptomatic in the first year of life, and those with X-linked disease generally present earlier and with more severe symptoms (reviewed by Roos and Curnutte1). Repeated episodes of infection and chronic inflammation lead to an impaired quality of life with recurrent diarrhoea, growth failure, inflammatory lung damage leading to frequent hospitalisation, end-organ damage and often death by the end of the third decade of life.

Conventional treatment with prophylactic cotrimoxazole to prevent bacterial infection and antifungal prophylaxis has lead to improved survival in the short to medium term.2 Prophylactic recombinant human interferon gamma has been advocated and reduces the risk of infection in patients with CGD.3 However, many fungi are resistant to the current antifungals, and inflammatory sequelae such as colitis, gastrointestinal strictures and inflammatory lung disease cannot be prevented by these agents. Moreover, the annual mortality remains between 2 and 4% and invasive aspergillosis accounts for more than 30% of deaths.4 Matched sibling bone marrow transplantation (BMT) has been advocated as a cure for patients with CGD, although the recently reported results from the US with a low-intensity conditioning regimen were disappointing.5 Conventional myeloablative conditioning regimens have resulted in more promising results even in those with active fungal infection at the time of transplant.6

Umbilical cord blood has been recognised as a good source of haemopoietic stem cells since 1988. Theoretical advantages of umbilical cord stem cells include reduction of risk to donor, reduction of rate of viral transmission and availability of donation at the convenience of recipient. The major disadvantage is low stem cell dose for larger patients.7

Cure of CGD can be achieved by stem cell transplantation, and the best results are achieved when this is performed early in the course of the disease before serious infections and inflammatory sequelae have developed. We report a patient with X-linked CGD, who underwent a successful HLA-identical sibling umbilical cord stem cell transplant (UCSCT) after myeloablative conditioning.

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Case report

The child was referred at the age of 2.5 years. He was born vaginally at 37 weeks. He had a chicken-pox-like rash at 5 months and a cervical abscess drained at 10 months from which methicillin-resistant S. aureus was grown. At the age of 6 months, he developed persistent diarrhoea with mucus, which became haemorrhagic by the age of 2 years. Upper gastrointestinal endoscopy and a small bowel barium meal were normal. Colonoscopy showed pan colitis extending to the caecum with epitheloid granulomas on histology. Neutrophil oxidative burst was absent on two occasions when tested by FACS and confirmed the diagnosis of CGD.8 A mutation analysis on the patient showed a C271T mutation in CYBB encoding gp91phox, the commonest mutation in the X-linked form of the disease.

Cotrimoxazole antibacterial prophylaxis and itraconazole antifungal prophylaxis were commenced along with mesalazine for colitis. The patient subsequently had an episode of radiologically proven left lower lobe pneumonia, which resolved with antibiotics.

He was the elder child of unrelated Caucasian parents. There was no family history of CGD. His mother's neutrophil respiratory burst test showed a dual population with 56% of neutrophils showing normal respiratory burst confirming a carrier state. The mother was pregnant at the time of diagnosis of the patient and cord blood donation was thus arranged. She delivered an unaffected female infant, who was HLA identical to her affected sibling.

Owing to early disease presentation and severe ongoing CGD-associated colitis, UCSCT was considered as a curative treatment. The cell dose from the cord blood donation was 2.1 times 107 nucleated cells/kg, slightly less than the ideal dose of 3.7 times 107 nucleated cells/kg, thus giving a 75% predicted chance of engraftment rather than 85–90% as reported from published series.9 The parents wished to proceed with cord stem cell transplantation after consideration of the risks and possible benefits.

The patient received standard myeloablative conditioning according to guidelines from the Inborn Errors Working Party of the European Blood and Marrow Transplantation Group with Busulphan 4 mg/kg/day from day -10 to day -7 and cyclophosphamide 50 mg/kg/day from day -5 to day -2. Cyclosporin was commenced on day -1 for graft-versus-host disease (GvHD) prophylaxis. The stored cord blood stem cells were thawed and washed as per published protocol.10 In total, 35 ml of cord blood was infused, which contained 1.6 times 107 white cells/kg and 0.7 times 105 CD34+ cells/kg. Overall, 70% of white cells and 100% of CD34 cells were viable.

G-CSF 5 mug/kg/day was commenced on day 5 post-transplant. The post-transplant course was uneventful. There was no GvHD or infective complications.

Neutrophil oxidative burst test performed on day +33 post-transplant showed a donor population with 87% of neutrophils demonstrating normal oxidative burst (Figure 1). Separated myeloid and lymphoid genetics on day +57 showed full donor chimerism of all cell lines including neutrophils and T and B lymphocytes. A neutrophil count consistently greater than 1 times 109/l was achieved by day +108. The patient has been erythrocyte transfusion independent since day +45 and platelet independent since day +65. G-CSF was stopped on day +106. Cyclosporin and replacement intravenous immunoglobulin were stopped 6 months post-transplant.

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Neutrophil oxidative burst test post-UCSCT showing a predominant donor population with positive oxidative burst and small residual recipient population with negative oxidative burst.

Full figure and legend (15K)

A year post-transplant, the patient is clinically improved with normal stools. A radioisotope-labelled white cell scan was normal with no abnormal focal areas of uptake within the gut, indicating resolution of colitis. There have been no bacterial- or fungal-infective episodes. A repeat neutrophil oxidative burst showed 92% neutrophils with normal oxidative burst. T and B lymphocytes confirmed as of donor origin were of normal number. His serum isohaemaggluttinin, IgM, IgA and IgG levels are normal and he has made normal antibody responses to Tetanus and Haemophilus influenzae B vaccinations.

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Discussion

CGD is still a life-threatening condition. Antibacterial and antifungal prophylaxis and possibly interferon gamma therapy have reduced the incidence of serious infections, lengthened infection-free intervals, reduced hospital stay and mortality.3 However, in the US the annual death rate remains between 2 and 5% in these patients despite aggressive conservative treatment.4 Therefore, more definite therapy has been advocated.

Gene therapy has recently been advocated as a curative treatment for CGD.11 Although animal mouse models have shown promise of long-term cure using retroviral vectors, phase 1 clinical studies have yet to produce a sufficient number of functioning neutrophils for an extended period of time.12

Allogeneic BMT from an HLA-matched related donor remains the only curative treatment for CGD. The emerging evidence from patients with other forms of primary immune deficiency suggests this is most successful when done early, as younger patients have less end-organ damage and a lower risk of GVHD.

In recent years, cord blood banks have increased the use of UCSCT to treat a variety of haematological and immunological disorders.13 Best results are seen with cord blood donations from HLA-matched siblings, with 63% of recipients alive at 1 year.9 More rapid neutrophil engraftment was associated with an age less than 6 years and a weight less than 20 kg and occurred in 85% of patients receiving 37 million or more nucleated cells per kilogram of body weight. Engraftment occurred in related pairs in 73% receiving less than 37 million nucleated cells per kilogram. The advantages of cord blood compared with other stem cell sources include ready availability, no risk to the donor , low rate of viral contamination and reduction in GvHD.9

Our patient had successful full neutrophil and lymphocyte engraftment after his HLA-matched related UCSCT in spite of the nucleated cell dose being less than 3.7 times 107/kg. However, engraftment was slow and he was GCSF dependent until day +106. A year post-transplant neutrophil burst tests showed 92% of neutrophils expressing normal respiratory burst, well in excess of the 10% level needed for normal host defence. The complete resolution of severe inflammatory complications is particularly noteworthy as is the dramatic improvement in growth, with his height and weight going up from the ninth percentile to the 50th percentile. This is the first reported case of CGD successfully transplanted using umbilical cord stem cells. This case highlights the option of using cord blood stem cell transplantation as a curative treatment for CGD particularly in the younger patient in whom end-organ damage has not occurred.

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References

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