Bone marrow transplantation as treatment for X-linked immunodeficiency with hyper-IgM.

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Article

Reference

Bone marrow transplantation as treatment for X-linked immunodeficiency with hyper-IgM.

BORDIGONI, P, et al.

Abstract

We report a 10-year-old boy with a severe form of immunodeficiency with hyper-IgM who underwent successful bone marrow transplantation with his HLA-matched sister as donor.

Busulfan (20 mg/kg) and cyclophosphamide (200 mg/kg) were used as conditioning. The post-transplant course was uneventful. He is alive 25 months later with full hematological and immunological reconstitution.

BORDIGONI, P, et al . Bone marrow transplantation as treatment for X-linked immunodeficiency with hyper-IgM. Bone Marrow Transplantation , 1998, vol. 22, no. 11, p. 1111-4

DOI : 10.1038/sj.bmt.1701497 PMID : 9877275

Available at:

http://archive-ouverte.unige.ch/unige:74619

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http://www.stockton-press.co.uk/bmt

Case report

Bone marrow transplantation as treatment for X-linked immunodeficiency with hyper-IgM

P Bordigoni

¹

, B Auburtin

¹

, A-S Carret

¹

, A Schuhmacher

¹

, J-C Humbert

¹

, F Le Deist

²

and D Sommelet

¹

1Bone Marrow Transplantation Unit, Children’s Hospital, Nancy; and²INSERM U 429, Hoˆpital Necker, Paris, France

Summary:

We report a 10-year-old boy with a severe form of immunodeficiency with hyper-IgM who underwent suc- cessful bone marrow transplantation with his HLA- matched sister as donor. Busulfan (20 mg/kg) and cyclo- phosphamide (200 mg/kg) were used as conditioning.

The post-transplant course was uneventful. He is alive 25 months later with full hematological and immunolog- ical reconstitution.

Keywords: X-linked immunodeficiency with hyper-IgM;

bone marrow transplantation; CD40 ligand

X-linked immunodeficiency with hyper-IgM (X-HIM) is characterized by undetectable serum levels of IgG, IgA and IgE and normal or elevated levels of IgM.¹The underlying defect in these patients is the inability to switch from IgM/IgD secretion to production of the other immunoglobulin isotypes, IgG, IgA and IgE. This rare primary disorder of immunity is caused by mutations affecting the expression of CD40 ligand (CD40 L) on T lymphocytes.^2,3 The gene encoding the CD40 L is located at Xq26 and encompasses 13 kb of genomic DNA.⁴ CD40 L is a type II integral transmembrane glycoprotein expressed primarly by activated CD4^⫹ lymphocytes.³ Interactions between CD40 L^⫹activated CD4^⫹T cells and B lymphocytes (that constitutionally express CD40) serve as a fundamental membrane signal for B cell growth and differentiation.⁵ This interaction normally mediates immunoglobulin class switching by B cells. The consequence of mutations is that CD40 L on T cells cannot interact with the CD40 glycoprotein on the surface of B cells. In addition, interaction between CD40 L activated T cells and antigen presenting cells (which also express CD40) elicits an immune response to intracellular microorganisms. This may explain the sus- ceptibility of a subgroup of patients to severe opportunistic infections particularly those due to Pneumocystis carinii (PC), BCG and cryptosporidium infections.⁶They are also

Correspondence: Dr P Bordigoni, Unite´ de Transplantation Me´dullaire, Hoˆpital d’Enfants, Centre Hospitalier Universitaire de Nancy, rue du Mor- van, 54511 Vandûuvre-les-Nancy, France

Received 24 February 1998; accepted 19 July 1998

prone to autoimmune diseases and neutropenia, and are at increased risk of carcinomas of the liver, pancreas, or biliary tree.^1,6

For this reason, allogeneic bone marrow transplantation (BMT) from HLA-identical siblings, usually beneficial for patients with genetic disorders affecting marrow, could be performed in young patients with defects of CD40 L. We report a successful allogeneic BMT in a child with a severe from of X-HIM.

Materials and methods Case report

A boy born in April 1986, without any family history of immune deficiency, was seen for the first time at the age of 3 months for a localized bacille Calmette–Guerin (BCG) infection (regional adenitis) after vaccine. This episode resolved after surgery. At the age of 5 months, he developed a PC pneumonia cured by trimethoprim-sulfamethoxazole. On the basis of his medical history and low serum concentrations of IgG and IgA with hyper-IgM (Table 1), he was considered to have X-HIM. Treatment with intravenous immune globulins was initiated.

At the age of 6 years, he had recurrent pneumonia due to pyogenic bacteria and persistent diarrhea associated with oral and perianal ulcers, leading to severe failure of thrive (height: 10th percentile; weight: 5th percentile) and requir- ing total parenteral nutrition. He developed a seronegative polyarthritis, successfully treated with nonsteroidal anti- inflammatory agents. A cyclic, chronic neutropenia with defective myeloid differentiation in the bone marrow occurred in February 1991. Lack of sustained efficacy of intravenous immunoglobulin and granulocyte colony-sti- mulating factor (5␮g/kg/day) was recorded. Different treat- ments were begun including corticosteroids and colchicine, without effect and the subject had a poor quality of life. A diagnosis of X-HIM was confirmed by the finding of defective expression of CD40 L on the patient’s activated T lymphocytes (F Le Deist, INSERM U429, Hopital Necker, Paris, France). A mutation in the TNF-homology domain (L 155 P) was found. The mutation was also identified in the patient’s mother, but not in his HLA-identical sister.

Because of the occurrence of opportunistic infections,

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BMT as treatment for X-linked immunodeficiency P Bordigoniet al

1112 Table 1 Serum immunoglobulin concentrations and post immunization antibody responses before and after bone marrow transplantation

Time (months) Diagnosis BMT stop Ig^g immunization^f Normal values

before and after

BMT −1 +3 +9 +12 ⫹15 ⫹23

IgG^a 0.54 4.8 7.2 6.7 7.7 7.1 7.2 11.2⫾3

IgA^a 0 0 0 0.51 0.56 0.7 0.7 1.3⫾0.7

IgM^a 0.7 1.7 0.35 0.57 0.45 0.9 0.6 0.8⫾0.3

IgG1^a NA^b 1.1 4.2 4.5 NA 3.9 4.1 2.8–17.4

IgG2^a NA 1.6 3.4 2.5 NA 2.1 2.4 0.8–5.3

IgG3^a NA 0 0.2 0.2 NA 0.37 0.41 0.2–3.2

IgG4^a NA 0 0.2 0.1 NA 0.02 0.05 0.1–1.7

Isohemagglutinins^g 0 1 NA 4 16 32 32 16–64

(10⁻¹)

Poliovirus (10⁻¹)

1 10 0 NA 40 120 80 128 ⬎40

2 0 0 NA 50 50 80 128 ⬎40

3 10 10 NA 80 120 80 512 ⬎40

Diphteria toxoid 0 0 NA 0.50 NA 0.01 0.6 ⬎0.1

(kUI/l)

Tetanus toxoid 0 0.05 NA 4 3.5 0.4 0.9 ⬎0.1

(UI/ml)

Pneumo^c NA 50 NA 600 NA 50 220 ⬎100

Hib^d(␮^g/ml) ^NA ^5.7 ^NA ⬍0.5 NA 4.3 32.8 ⬎0.5

aMg/dl.

bNot available.

cAntibody to Streptococcus pneumoniae (23 serotypes) expressed as the reciprocal of that serum dilution showing a positive signal compared with a standard serum (the pooled sera of 10 patients who had been successfully immunized) which was used for the calculation of the cutoff.

dAnti-Haemophilus influenzae type b capsular polysaccharide (␮g antibody/ml).

eImmunoglobulins iv.

fImmunization with Hib conjugate vaccines, diphtheria, tetanus toxoids and poliovirus vaccines (1/97, 2/97, 3/97) and 23-valent pneumococcal polysaccharide vaccine (1/97).

gAnti-A isohemagglutinins.

sclerosing cholangitis, severe chronic inflammatory bowel disease and because of the known poor outcome of patients who develop such complications, the parents gave informed consent for BMT with the sister acting as donor. Condition- ing consisted of busulfan (5 mg/kg body weight per day for 4 days) followed by cyclophosphamide (50 mg/kg body weight per day for 4 days). Prophylaxis against graft-ver- sus-host disease consisted of cyclosporine (3 mg/kg/day as a continuous i.v. infusion on days⫺1 to 30 and 6.25 mg/kg twice daily from days 31 to 180 post BMT) and methotrex- ate (15 mg/m²on day 1 and 10 mg/m²on days 3, 6 and 11 after BMT). Prophylaxis against infections included hospi- talization in a laminar air-flow isolation unit, oral adminis- tration of non-absorbable antibiotics and treatment with i.v.

immune globulin for 6 months (200 mg/kg per week for 3 months and 400 mg/kg per month for the 3 following months). Prophylaxis against PC consisted of trimethoprim- sulfamethoxazole administered from day⫺7 to day⫺2 and from day⫹30 to day⫹360. On 3 October 1995, the patient received 2.7 ⫻ 10⁸ nucleated marrow cells/kg from his sister.

Methods

Polymorphonuclear and mononuclear cells were isolated from heparin-treated blood by exposure to dextran followed by Ficoll–Hypaque centrifugation. Flow cytometry was performed according to standard protocols with a FACScan flow cytometer (Becton Dickinson, San Diego, CA, USA).

T and B lymphocyte phenotyping was performed by indirect immunofluorescence using the following specific monoclonal antibodies: anti-CD2, CD3, CD4, CD8, CD16, HLA DR, CD19, CD56 and CD14 (all from Becton Dickinson). Proliferation assays in response to PHA and tetanus toxoid (Pasteur Diagnostic, Marne-la-Coquette, France, final dilution: 1/250) were performed as previously described.⁷ Normal response was determined as an index above 100 for PHA, and as above 15 for tetanus toxoid.

Serum immunoglobulin isotypes and IgG subclass concentrations were measured using nephelometry. Isohemaggluti- nins were determined by an agglutination assay.

The patient was immunized at 12, 13 and 14 months after BMT with a series of three tetanus and diphtheria toxoids, poliovirus and Haemophilus influenzae type B conjugate vaccines (Hib), and a series of two (12 and 13 months post BMT) 23-valent pneumococcal polysaccharide vaccines (Pvax). Antibodies to poliovirus, tetanus and diphtheria toxoids, Hib capsular polysaccharide and to 23-pneumococcal serotypes were detected before and after immunization by enzyme-linked immunosorbent assay tests.

Expression of CD40 L was evaluated with a CD40 immunoglobulin fusion protein (CD40-Fc) as described previously.^3,9Mutations in the gene encoding the CD40 L were assessed by LD Notarangelo (Department of Pedi- atrics, University of Brescia, Brescia, Italy) in the setting of the CD40 L mutation database organized by the European Society for Immune Deficiency. We used polymerase chain reaction amplification of minisatellite sequences and of a

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Y-chromosome-specific sequence to document chimerism 1113

in lymphocytes and polymorphonuclear cells.

Results

The patient’s clinical course after BMT was uneventful. An absolute neutrophil count greater than 500 per cubic milli- meter occurred by day⫹26, and platelet counts were self- sustaining to levels above 50 000/␮l after day⫹34. Neither GVHD nor infectious complications were observed. Of note, clinical manifestations of X-HIM syndrome, particularly chronic inflammatory bowel disease and oral and perianal ulcers, disappeared in our patient within days of BMT, probably as a result of chemotherapy or/and cyclosporine treatment. The patient is currently very well 25 months post BMT, has had no significant infections, is attending school, and he is in the 25th percentile for height and weight. DNA analysis revealed that more than 95% of lymphocytes and polymorphonuclear cells were of donor origin. He had full recovery of immune functions by 18 months after transplantation.

B cell immunity (Table 1)

The percentage of B cells (CD19^⫹cells) and absolute B cell counts reached normal levels by 10 months after BMT.

After cessation of i.v. immune globulin, normal serum IgM, IgA, IgG and subclass IgG (IgG1, IgG2, IgG3) values were achieved respectively 7, 15, 11 and 15 months after transplantation. However, the patient still has subnormal levels of IgG4. Normal isohemagglutinin titers were achieved 11 months after BMT. In response to immunization, he pro- duced normal or borderline levels of specific antibodies to poliovirus, tetanus and diphteria toxoids during the first trimester of the second year post BMT. Immunization with Hib conjugate vaccine and Pvax unconjugated vaccine resulted in protective antibody concentrations 18 months after transplant.

T cell immunity

CD4^⫹, CD8^⫹, CD4^⫹/CD45RA^⫹ and CD4^⫹/CD45RO^⫹ cells reached normal values within the first 8–9 months after BMT. Percentage, but not absolute numbers of CD3^⫹ cells took 8 months to normalize. T cell functions became normal within 18 months post BMT. The time to a normal response to PHA was 9 months. Before BMT, in vitro pro- liferative responses to T cell mitogens were normal, whereas impairment of antigen-specific, T cell proliferation responses (ie tetanus toxoid) was observed.⁸After immunization, the patient had a normal proliferative response to this antigen 17 months post-BMT.

Moreover, expression of the CD40 L by activated T cells from the recipient was equivalent to the expression of the ligand by age-matched control subject T cells (Table 2).

Discussion

We report a successful BMT in a 10-year-old boy with a severe form of X-HIM syndrome. The first and only similar

Table 2 Expression of the CD40 ligand by activated T cells from the patient before and after BMT

Patient Control

Expression of CD40 L^a(%^b) Before After (1 year)

CD69^c 92 96 91⫾5

CD40-Fc^d 0 50 54

aCD40 L expression by activated T cells.³

bPercentage of positive cells.

cControl for cell activation (cells stained with anti-CD69 Moab).

dCD40 immunoglobulin fusion protein.³

published observation was recently reported by the Necker- Enfants Malades team in Paris.⁹The indication was some- what different in that BMT was performed in an infant because of a family history of two fatal cases of X-HIM syndrome and the occurrence in the patient of PC pneumo- nitis at the age of 7 months. Nevertheless, characteristics (preparative regimen and GVHD prophylaxis) and outcome of BMT were similar. Moreover, Levy et al,¹⁰in the context of a European survey, reported three other transplants in children with X-HIM, of whom one died of CMV infection and one is alive and well 3 years after transplantation. Fol- low-up is limited for the third boy. Our patient has required no antibiotic or antifungal agents since transplantation.

Moreover, BMT has markedly improved his quality of life.

Durable and full T and B cell engraftment was achieved within the first 2 months after transplantation. Expression of CD40 L by the activated recipient T cells was equivalent to the expression of the ligand by an age-matched control subject. Most patients with X-HIM syndrome have symp- toms consistent with immunoglobulin deficiency which include recurrent respiratory infections, otitis media, diarrhoea, stomatitis and oral ulcers.^1,6 Nevertheless, an increased incidence of PC pneumonia, particularly as the presenting feature (43% in a recently published cohort¹⁰) in the first year of life, and of chronic, watery diarrhoea with or without cryptosporidium infection has been reported. These features, consistent with cell-mediated immunodeficiency, may be explained by disrupted CD40/CD40L interactions which lead to reduced IL12 production by antigen-presenting cells and a defective immune response to intracellular microorganisms.¹¹

In addition, certain other clinically poor prognostic features deserve emphasis, including sclerosing cholangitis, severe neurological disease and increased incidence of tumors. In the same, recently published cohort of patients with CD40 L deficiency,¹⁰20% of the boys had sclerosing cholangitis, 7% developed hepatic failure necessitating liver transplantation and 10.7% progressed to cirrhosis.

Finally, 23% died, mostly from infections early in life and/or from liver disease after the first decade. The current survival rate at 25 years is no more than 20%.¹⁰

In conclusion, a subgroup of patients with X-HIM syndrome presents with clinical and/or laboratory signs of T cell deficiency with a clinical picture of combined immunodeficiency. It has not been possible to correlate such a severe phenotype with molecular defects of the CD40 L gene.

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BMT as treatment for X-linked immunodeficiency P Bordigoniet al

1114 Nevertheless, establishing a database (CD40 L base) of CD40 L mutations^4,12could perhaps lead to the recognition of a molecular basis for the clinical heterogeneity of X- HIM syndrome and may help to better define the indi- cations for allogeneic BMT.

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