Bone Marrow Transplantation for Hepatitis-associated Aplastic Anaemia: Case Reports and a Review of the Literature
Hepatitis-associated aplastic anaemia is a rare cause of bone marrow aplasia. The exact aetiology and the pathogenetic mechanisms involved are largely unknown. The marrow aplasia is usually progressive and severe. Mortality is high without treatment. We report two cases of severe hepatitis-associated aplastic anaemia treated successfully with matched sibling allogeneic bone marrow transplantation, followed by a brief review of the major case series in the literature. Immunosuppressive conditioning regimen usually results in rapid resolution of hepatitis without concomitant liver injury. Bone marrow transplantation for the treatment of hepatitis-associated aplastic anaemia appears to result in good recovery of blood counts with favourable outcome similar to other causes of severe aplastic anaemia. Allogeneic bone marrow transplantation should be considered a preferred option for treatment of severe hepatitis-associated aplastic anaemia when a matched sibling donor is available.
Keyword : Aplastic anaemia; Bone marrow transplantation; Hepatitis
Hepatitis-associated aplastic anaemia (HAAA) is a rare cause of marrow aplasia and is usually progressive and severe. Mortality is high without treatment. Allogeneic bone marrow transplantation (BMT) was reported to be effective in a few case series.1-4 We report two cases of severe HAAA treated with matched sibling allogeneic BMT and present a brief review of the literature.
Patient 1 was a 6.5-year-old boy presented with pallor, jaundice and easy bruising for one week. He had no history of drug intake and his family history was unremarkable.
He had pancytopenia (Hb 8.8 g/dL, WBC 2.2 x 109/L, Neutrophil 1.5 x 109/L, Platelet 13 x 109/L, Reticulocyte 1.0%). Bone marrow examination confirmed severe hypocellularity. Liver transaminases were increased with ALT 3040 U/L and AST 2840 U/L. Total bilirubin was 394 umol/L. Virology screening including HAV IgM, HBsAg, HCV Ab, parvovirus IgM, CMV and EBV serology were all negative. His blood counts deteriorated in the following weeks with neutrophil progressively falling to 0 and platelet declined to 4 x 109/L. Total bilirubin rose to a peak of 474 umol/L without improvement in ALT and AST.
He underwent bone marrow transplantation about eight weeks after the onset of the disease. His 11-year-old HLA-matched elder sister was the donor. He received a total of seven units of packed red cells and 72 units of random donor platelets before BMT. He did not receive any immuno-suppressive therapy before conditioning for BMT. Conditioning regimen consisted of cyclophosphamide at a total dose of 200 mg/Kg and anti-thymocyte globulin (ATG) 120 mg/Kg. Graft-versus-host disease (GVHD) prophylaxis employed methotrexate and cyclosporin A. The donor nucleated cell dose was 3.37 x 108/Kg. The liver enzymes improved dramatically one day after initiation of the conditioning immunosuppressive drugs and were completely normalised on Day +12 post-BMT (ALT 43 U/L, AST 44 U/L). Neutrophil engraftment (>0.5 x 109/L) occurred on Day +13 and platelet engraftment (>50 x 109/L) on Day +18. The temporal profiles of blood counts and liver function in relation to BMT are shown in Figure 1.
He developed transient febrile illness and mild respiratory distress at around ten days post-BMT. Chest X-ray revealed interstitial pneumonitis involving both lungs. He was initially treated as Pneumocystis pneumonia with intravenous pentamidine and subsequently high dose septrin. He was also given multiple antibiotics including clarithromycin, and put on prednisolone 2 mg/Kg/day. Since he had no definite response, he was subsequently put on ribavirin (inhalation and intravenous) empirically to cover for possible viral infection after consultation with microbiologist. Microbiological studies failed to identify any infectious agents. Sputum samples for bacterial, viral and fungal cultures were all negative. He became more dyspnoeic and hypoxic in the following few weeks and his chest X-ray worsened with increased hazziness. CT scan of the thorax showed changes consistent with interstitial pneumonitis and mild pneumomediastinum. He was then given a trial of high dose methylprednisolone for the possibility of GVHD though he showed no sign of skin, liver or gut involvement. Because he was too ill and tissue diagnosis was probably not revealing, bronchoscopic examination was not performed. He ran downhill and finally succumbed on Day +54 post-BMT. Paramortem lung biopsy revealed interstitial pneumonitis with focal hyaline membrane formation. There was no fungus, acid-fast bacilli, Pneumocystis jiroveci or viral inclusion body. CMV immunostain was negative.
Patient 2 was a 13.5-year-old boy presented to our hospital with one week's history of repeated vomiting, progressive jaundice and malaise. There was no significant drug or family history. Fever was noticed on admission with pancytopenia and hepatitis (WBC 1 x 109/L, Hb 9.8 g/dL, Platelet 8 x 109/L, Reticulocyte 0.8%, ALT 532 U/L, AST 358 U/L, Total bilirubin 213 umol/L). Bone marrow biopsy showed severe hypocellularity without evidence of malignancy. Extensive investigation was performed to search for an aetiology of hepatitis, including hepatitis A-E serology, parvovirus IgM, CMV and EBV serology, mycoplasma antibody, brucella and leptospirosis antibody, anti-nuclear antibody, anti-smooth muscle antibody and anti-LKM antibody, which were all negative. Liver biopsy revealed cholestatic hepatitis with mild necrosis, but the aetiology was not revealing. Liver function worsened progressively with ALT and AST >3000 U/L and the total bilirubin peaked at 341 umol/L. Neutrophil fell to 0 and platelet declined to 7 x 109/L. There was no sign of recovery of both the marrow and the liver in the subsequent five weeks.
Bone marrow transplantation from his 8-year-old HLA-matched younger sister was performed eight weeks after the onset of the disease. He received four units of packed red cells and 65 units of platelets before BMT. He did not receive any immunosuppressive therapy before BMT. Conditioning and GVHD prophylaxis were the same as those of patient 1. The donor nucleated cell dose was 1.47 x 108/kg. Again liver function tests showed marked improvement shortly after the initiation of immuno-suppressive regimen. ALT and AST were normalised on Day +16 post-BMT (ALT51 U/L, AST 26 U/L). Neutrophil and platelet engrafted on Day +23 and Day +32 (Platelet > 20 x 109/L), respectively. The temporal profiles of blood counts and liver function in relation to BMT are shown in Figure 2. BMT proceeded smoothly without complications. Full donor chimerism was documented on bone marrow examination on Day +30 post-BMT. He had no acute GVHD and the patient was discharged on Day +45. Hepatitis had not recurred on follow-up to 3.5 years post-BMT.
Aplastic anaemia is known to be associated with hepatitis, with variable time of onset of marrow aplasia following acute hepatitis. Hepatitis-associated aplastic anaemia represents approximately 0.3-5% of all cases of severe aplastic anaemia.5 In more than 80% of cases, the aetiology of hepatitis is often obscured. Many viruses have been implicated including Hepatitis A-C,6-8 Hepatitis G,9,10 CMV, EBV, transfusion transmissible virus (TTV) and parvovirus B19.11 The mechanism by which hepatitis leads to aplastic anaemia is still unclear. The pathogenesis may involve direct invasion or suppression of haematopoietic progenitor cells by hepatitis viruses, as well as immune-mediated suppression,12 possibly as a response to infected marrow cells that display viral antigens on their surface.7,12 The marrow aplasia associated with hepatitis is usually severe and non-remitting. If untreated, its mortality can exceed 85%.13 The median survival is barely three to six months, with only 20% individuals surviving beyond one year.14,15 Even if survived, about 10-15% of the survivors would develop myelodysplastic syndrome or acute myeloid leukaemia 6-60 months after the initial diagnosis of HAAA, similar to that of idiopathic severe aplastic anaemia patients.16
Currently there is no consensus on the best treatment for HAAA. A few patients have shown response to immunosuppressive treatment, usually involving anti-thymocyte globulin, anti-lymphocyte globulin, high dose methylprednisolone17 or cyclosporin A.18 However, anti-lymphocyte globulin and methylprednisolone have been reported to result in exacerbation of viral replication of hepatitis B, leading to worsening of the hepatitis.19 Liver transplantation with or without subsequent high doses of cytokine therapy such as granulocyte-colony stimulating factor, monocyte-colony stimulating factor and recombinant human erythropoietin is also found to be effective in some patients.20
On the other hand, bone marrow transplantation has been explored as another therapeutic option for HAAA and long-term survivor was first reported by Storb and colleagues in 1974.21 Thereafter, a few series of patients treated with allogeneic BMT were reported.1-4,22,23 Larger series of HAAA with five or more patients were reviewed. The patients' characteristics in the four series1-4 selected are summarised in Table 1.
A total of 58 patients were reported in the four series. The median age at presentation of HAAA was 17.5 years, ranging from 3 to 53 years. Thirty-two of 41 patients (78%) for which the gender was reported were male. The onset of aplastic anaemia ranged from 0 to 240 days after hepatitis, with a median of 35 days. BMT was performed at a median of 101 days (range, 15 to 750 days) after the onset of hepatitis. Thirty-four out of 41 patients (82.9%) received multiple transfusions before BMT. The liver parenchymal enzymes (ALT or AST) were completely normalised in 28 patients (48%) before the day of transplant. Fifty-six patients (96.6%) received bone marrow from HLA-matched siblings, while one patient (1.7%) received bone marrow from mismatched sibling and one (1.7%) from matched unrelated donor. Conditioning regimen employed cyclophosphamide alone in 31 patients (53.4%), cyclophosphamide plus either total lymphoid irradiaton or anti-thymocyte globulin in 23 patients (39.7%), total body irradiation alone in two patients (3.4%), and other regimen in two patients (3.4%). Thirty-three patients (56.9%) were given methotrexate alone as GVHD prophylaxis while five patients (8.6%) used methotrexate plus cyclosporin A, and three patients (5.2%) used cyclosporin A alone. Lymphocyte depleted bone marrow was used in the remaining 17 patients as GVHD prophylaxis4 (29.3%). The donor nucleated cell dose ranged from 1.57 x 108/Kg to 9.9 x 108/Kg. Fifty-two patients (89.7%) engrafted but six (10.3%) did not. Acute GVHD occurred in 15 of 41 patients (36.6%) and chronic GVHD in 16 out of 58 (27.6%). The incidence of graft rejection, acute and chronic GVHD after BMT for HAAA appeared similar to those in patients transplanted for aplastic anaemia of other aetiologies. Forty-one patients (70.7%) had long-term survival on follow-up while 17 patients (29.3%) died. The survival rate was similar to that reported for aplastic anaemia from other aetiologies. Among the long-term survivors, the Karnofsky performance score was 100% in 29 patients, and 40-95% in five patients. Only one patient had hepatic veno-occlusive disease (VOD) and none had recurrence of marrow aplasia or idiopathic hepatitis.
These reports and other studies demonstrated that previous hepatic damage from viral hepatitis and existing liver function abnormalities at the time of grafting do not appear to increase the risk of post-transplant morbidity and mortality from hepatocellular damage or hepatic VOD in cyclophosphamide-conditioned patients. In contrast, immunosuppressive conditioning frequently results in improvement of liver function, suggesting that the hepatitis component in HAAA most likely represents immune mediated liver cell damage rather than direct cellular invasion and lysis. However, Shulman and colleagues24 found that conditioning regimes that contained irradiation was associated with VOD and Storb and coworkers25 reported that irradiation tended to increase the risk of late malignancies.
Our two patients shared many similarities with those reported in the literature. Both are boys with idiopathic hepatitis-associated severe aplastic anaemia. Both received multiple transfusions before undergoing HLA-matched sibling BMT. Both patients had rapid resolution of hepatitis soon after initiation of cyclophosphamide and ATG. There was no added liver toxicity. Although the second patient received a lowish cell dose, he successfully engrafted, albeit a little delay in platelet engraftment. Both patients had not developed GVHD. Aplastic anaemia resolved and there was no recurrence of hepatitis or marrow aplasia.
Patient 1 was unfortunate that his post-transplant course was complicated by fatal interstitial pneumonitis of unknown aetiology, which showed no response to all therapeutic efforts. Although atypical pneumonia cannot be completely excluded, he most probably suffered from idiopathic pneumonia syndrome, which occurs in about 10-17% of post-BMT patients,26,27 usually within the first few weeks, and has a mortality up to 70-90%.28,29 Other non-infectious causes of pneumonitis that needs to be considered are drug toxicities and engraftment syndrome, which may occur after neutrophil engraftment, especially in the presence of prior administration of G-CSF. However, these are less likely in our case.
Hepatitis-associated aplastic anaemia is a rare, yet important cause of severe marrow aplasia. Its aetiology and pathogenesis are not completely understood. Matched sibling allogeneic bone marrow transplantation results in reasonable long-term survival. Immunosuppressive conditioning regimen usually leads to rapid resolution of hepatitis without increased toxicity despite compromised liver function. The response of aplastic anaemia to BMT is as good as that of other causes of aplastic anaemia. Allogeneic BMT should be considered a preferred option for treatment of severe HAAA when a matched sibling donor is available.
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