Non-Helicobacter pylori Helicobacter (NHPH) species are recognized as a cause of chronic systemic infection, cellulitis, and osteomyelitis in patients with X-linked agammaglobulinemia (XLA). Diagnosis and treatment are challenging due to fastidious growth, lack of standardized therapies, and frequent recurrence. We describe two cases of disseminated NHPH infection in XLA, including a patient where allogeneic hematopoietic cell transplant (HCT) was incorporated into management to achieve durable immune reconstitution and cure infection. One patient with disseminated Helicobacter bilis osteomyelitis discontinued antibacterials 14 months post-HCT following immune reconstitution. Another patient with disseminated Helicobacter cinaedi remains on antibacterials and is being evaluated for HCT. In select cases, HCT may represent a potential option to correct the immunodeficiency and enable infection clearance, with antibacterial therapy continued through HCT until systemic immunosuppression is withdrawn, immune reconstitution is documented, and infection resolves.

High-dose post-transplantation cyclophosphamide (HD-PTCy), given at 50 mg/kg/day on days +3/+4, is a standard-of-care graft-versus-host disease (GVHD) prophylaxis for allogeneic hematopoietic cell transplantation (HCT). Our murine MHC-haploidentical HCT studies suggested intermediate-dose PTCy produces superior GVHD control compared with HD-PTCy and PTCy is maximally effective on day +4. We conducted a single-institutional prospective phase I/II trial (NCT03983850) to reduce PTCy dosing to 25 mg/kg/day on days +3/+4 or on day +4 only for myeloablative HLA-haploidentical bone marrow HCT using PTCy, sirolimus, and mycophenolate mofetil. Among 35 patients, 89% were ethnic/racial minorities, 46% had high/very-high-risk disease, and median comorbidity-score was 3. The phase I dose-limiting-toxicity, grade III-IV acute GVHD, was not observed after either reduced-PTCy dose-level. PTCy 25 mg/kg/day on days +3/+4 (intermediate-dose (ID)-PTCy; n=23), the phase II dose, resulted in no grade II-IV acute GVHD; 2-year cumulative incidences of chronic GVHD requiring systemic immunosuppression, non-relapse mortality, and relapse were 13%, 17%, and 22%, and 2-year overall survival, disease-free survival, and GVHD-free/relapse-free survival were 61%, 61%, and 52%. In exploratory analysis compared with HD-PTCy (n=5), ID-PTCy resulted in significantly faster engraftment and T-cell reconstitution, fewer transfusions, less mucositis, and reduced severity of BK-virus-associated cystitis; area-under-the-curve exposure of 4-hydroxycyclophosphamide (4HCY), a key cyclophosphamide metabolite, correlated with these outcomes but not with chronic GVHD occurrence. Ideal-body-weight-based PTCy dosing best approximated 4HCY exposure. Intermediate-dose PTCy is effective and has apparent clinical benefits compared with HD-PTCy. Before broader implementation, further studies are needed to confirm these findings and define optimal PTCy dosing across various donor/graft types. NCT03983850

Introduction Standardly, post-transplantation cyclophosphamide (PTCy) dosing is administered at 50 mg/kg/day on days +3 and +4 (HD-PTCy). Yet, the optimal dosing has not been identified. Our MHC-haploidentical murine hematopoietic cell transplantation (HCT) studies showed that PTCy 25 mg/kg/day on days +3/+4 was more effective in preventing histopathologic and clinical graft-versus-host disease (GVHD) than higher or lower dosing and that the maximal efficacy of PTCy was on day +4. Methods Building on these two findings, at the NIH, we conducted a phase I/II clinical trial reducing PTCy exposure after myeloablative T-cell-replete HLA-haploidentical bone marrow HCT. Patients received myeloablative conditioning with targeted IV busulfan and fludarabine, followed by a fresh bone marrow graft on day 0. The PTCy dose levels were: PTCy 50 mg/kg on days +3/+4 (n=5), 25 mg/kg on days +3/+4, or 25 mg/kg on day +4 only. Additional GVHD prophylaxis included sirolimus from days +5 to +80, and mycophenolate mofetil from days +5 to +35. The primary endpoint used for PTCy dose de-escalation was grade III-IV acute GVHD (aGVHD) by day +60. Secondary endpoints included engraftment; grade II-IV and III-IV aGVHD at day +200; non-relapse mortality (NRM) at 100 days and 1 year; and chronic GVHD (cGVHD), relapse, overall survival (OS), and disease-free survival (DFS) at 1 year. Exploratory endpoints included immune reconstitution, weekly monitoring of BK virus and associated symptoms, and PKs of cyclophosphamide and 4-hydroxycyclophosphamide (4HCY). Patients underwent transplantation from July 2019 to January 2022. Results 35 patients were treated across the three PTCy dose levels. 23 patients received the phase II dose, 25 mg/kg/day PTCy on days +3/+4 (ID-PTCy). For ID-PTCy recipients, median age was 34 years (range 18-57), 87% were racial/ethnic minorities, median HCT-CI was 3 (range: 0-7), 65% underwent HCT for acute leukemia, and 43% were high/very high risk by the revised Disease-Risk Index. Three patients were not evaluable for the primary endpoint: two had primary graft failure (one with primary myelofibrosis and the other with acute myeloid leukemia) and one patient had early relapse. Among evaluable ID-PTCy patients, the median time to engraftment was 14 days for neutrophils (vs. 19 days for HD-PTCy, p=0.0004), and 22 days for platelets (vs. 33 days for HD-PTCy, p=0.0097). The median number of units transfused for RBCs and platelets were 2 and 5 for ID-PTCy compared with 8 and 12 (p=0.015 and p=0.064, respectively) for HD-PTCy. Mixed T-cell chimerism was seen in 4 of 20 evaluable patients treated with ID-PTCy. Grade 3 mucositis was less severe and shorter in duration with ID-PTCy, with a median of 0 days for ID-PTCy and 11 days for HD-PTCy (p=0.0003). CD4+ and CD8+ T-cell reconstitution was markedly faster with ID-PTCy compared with HD-PTCy (median at day +14: CD4+ T cells 11.78 vs. 0.97 cells/µl, p=0.002; CD8+ T cells 4.02 vs. 0.09 cells/µl, p=0.003). BK-virus-associated cystitis symptoms were significantly shorter with ID-PTCy compared with HD-PTCy (hemorrhagic cystitis: median 7 vs 51 days, p=0.006) and this was associated with significantly lower BK viral shedding in blood (p=0.046). No ID-PTCy patient developed grades II-IV acute GVHD and 2-year cumulative incidence of chronic GVHD requiring systemic therapy was 13%. With median follow-up of 2.4 years, 2-year OS, DFS, and GVHD-Free, Relapse-Free Survival (GRFS) were 61%, 61%, and 52%. CI of relapse at 2 years was 22%, and non-relapse mortality at 100 days and 2 years was 0% and 17%. 4HCY, a precursor to phosphoramide mustard, is the principle cytotoxic metabolite of cyclophosphamide. 4HCY area-under-the-curve (AUC) more strongly correlated with PTCy weight-based dosing as calculated by ideal body weight (ρ=0.75, p<0.0001) compared with actual body weight (ρ=0.54, p=0.0011). 4HCY AUC showed significant correlation with the benefits of reduced-dose PTCy, including positive correlation with time to neutrophil engraftment (ρ=0.63, p=0.0013) and duration of mucositis (ρ=0.61, p=0.002) and inverse correlation with CD4+ T-cell recovery on day +14 (ρ=-0.46, p=0.03). Conclusion ID-PTCy maintains efficacy at GVHD prevention. PTCy dose reduction has clinical benefits when compared with HD-PTCy with direct correlation of 4HCY exposure with these clinical benefits. Future comparative studies are needed to assess the relative benefits of ID-PTCy vs. HD-PTCy.

ObjectivePatients with pathogenic variants in the GATA Binding Protein 2 (GATA2), a hematopoietic transcription factor, are at risk for human papillomavirus-related (HPV) anogenital cancer at younger than expected ages. A female cohort with GATA2 haploinsufficiency was systematically assessed by two gynecologists to characterize the extent and severity of anogenital HPV disease, which was also compared with affected males.MethodsA 17-year retrospective review of medical records, including laboratory, histopathology and cytopathology records was performed for patients diagnosed with GATA2 haploinsufficiency followed at the National Institutes of Health. Student’s t-test and Mann-Whitney U test or Fisher’s exact test were used to compare differences in continuous or categorical variables, respectively. Spearman’s rho coefficient was employed for correlations.ResultsOf 68 patients with GATA2 haploinsufficiency, HPV disease was the initial manifestation in 27 (40%). HPV occurred at median 18.9 (15.2-26.2) years in females, and 25.6 (23.4-26.9) years in males. Fifty-two (76%), 27 females and 25 males, developed HPV-related squamous intraepithelial lesions (SIL) including two males with oral cancer. Twenty-one patients developed anogenital high-grade SIL (HSIL) or carcinoma (16 females versus 5 males, (59% versus 20%, respectively, p=0.005) at median 27 (18.6-59.3) years for females and 33 (16.5-40.1) years for males. Females were more likely than males to require >2 surgeries to treat recurrent HSIL (p=0.0009). Of 30 patients undergoing hematopoietic stem cell transplant (HSCT) to manage disease arising from GATA2 haploinsufficiency, 12 (nine females, three males) had persistent HSIL/HPV disease. Of these nine females, eight underwent peri-transplant surgical treatment of HSIL. Five of seven who survived post-HSCT received HPV vaccination and had no or minimal evidence of HPV disease 2 years post-HSCT. HPV disease persisted in two receiving immunosuppression. HPV disease/low SIL (LSIL) resolved in all three males.ConclusionFemales with GATA2 haploinsufficiency exhibit a heightened risk of recurrent, multifocal anogenital HSIL requiring frequent surveillance and multiple treatments. GATA2 haploinsufficiency must be considered in a female with extensive, multifocal genital HSIL unresponsive to multiple surgeries. This population may benefit from early intervention like HSCT accompanied by continued, enhanced surveillance and treatment by gynecologic oncologists and gynecologists in those with anogenital HPV disease.

Background: P47phox (neutrophil cytosolic factor -1) deficiency is the most common cause of autosomal recessive chronic granulomatous disease (CGD) and is considered to be associated with a milder clinical phenotype. Allogeneic hematopoietic cell transplantation (HCT) for p47phox CGD is not well described. Objectives: We sought to study HCT for p47phox CGD in North America. Methods: Thirty patients with p47phox CGD who received allogeneic HCT at Primary Immune Deficiency Treatment Consortium centers since 1995 were included. Results: Residual oxidative activity was present in 66.7% of patients. In the year before HCT, there were 0.38 CGD-related infections per person -years. Inflammatory diseases, predominantly of the lungs and bowel, occurred in 36.7% of the patients. The median age at HCT was 9.1 years (range 1.5-23.6 years). Most HCTs (90%) were performed after using reduced intensity/toxicity conditioning. HCT sources were HLAmatched (40%) and -mismatched (10%) related donors or HLA-matched (36.7%) and -mismatched (13.3%) unrelated donors. CGD-related infections after HCT decreased significantly to 0.06 per person -years ( P 5 .038). The frequency of inflammatory bowel disease and the use of steroids also decreased. The cumulative incidence of graft failure and second HCT was 17.9%. The 2 -year overall and event -free survival were 92.3% and 82.1%, respectively, while at 5 years they were 85.7% and 77.0%, respectively. In the surviving patients evaluated, >= 95% donor myeloid chimerism at 1 and 2 years after HCT was 93.8% and 87.5%, respectively. Conclusions: Patients with p47phox CGD suffer from a significant disease burden that can be effectively alleviated by HCT. Similar to other forms of CGD, HCT should be considered for patients with p47phox CGD.

Chronic granulomatous disease (CGD) is a disorder of immunity characterized by phagocyte dysfunction. Mold infections in patients with CGD are often severe and disseminated. We present patient characteristics, microbiological data, and outcomes for 26 patients with CGD who received hematopoietic cell transplantation (HCT) or gene therapy-modified cells (GT) between 2008 and 2019, with proven fungal infection either before or during their transplant. All patients engrafted, and all but one GT recipient had neutrophil recovery and evidence of functional correction. Eighteen patients (69%) are currently alive and 19 patients (73% of total, 90% of patients with repeat imaging performed) had evidence of radiographic improvement. With 3 exceptions, deaths were not principally related to the fungal infection and duration of antecedent infection did not correlate with death. Aspergillus species accounted for the majority of disease (50%), followed by Phellinus species (18%). Osteomyelitis and disseminated disease were common, as only 11 patients (42%) had disease restricted to pneumonia. Triazole therapy was used in all 26 patients, with combination therapy used in 25 (96%). HCT or gene therapy, with appropriate antifungal therapy, are viable therapies for refractory fungal infections in patients with CGD.

OBJECTIVE:We analyzed events and therapies related to febrile neutropenia in patients receiving hematopoietic cell transplantation (HCT) for chronic granulomatous disease (CGD).METHODS:Three protocols for HCT were used to extract the relation between conditioning and infectious complications during transplantation for CGD, especially the relation of fever and neutropenia to microbiological events and antibiotic therapy.RESULTS:Sixty-nine recipients received either reduced intensity conditioning with matched related or unrelated donors or conditioning specific to haploidentical-related donors utilizing posttransplant cyclophosphamide. Fever prior to neutropenia was common (52) and in eight recipients, Gram negative bacterial infection occurred prior to neutropenia, and in nine during neutropenia. Alemtuzumab as conditioning was associated with preneutropenic infection. Empiric therapy (noncarbapenem) by institutional guideline was given in 40. Carbapenems were given before neutropenia (8) or as empiric therapy in neutropenia (18), or a switch to a carbapenem (n = 22) occurred in 48 cases. No deaths related to infection associated with neutropenia occurred.CONCLUSION:The management of febrile neutropenia in HCT for CGD led to no deaths related to infection associated with neutropenia. Bacteremias occurred both prior to neutropenia and during neutropenia. Bacteria isolated may have represented the recrudescence of prior infection, representing the population transplanted and the platform for HCT. The treatment of prior infections may have had an influence on the necessity of carbapenem use as either empiric or directed therapy for bacterial infections.

Abstract S10.5 Fungal respiratory infections in Cystic Fibrosis, September 24, 2022, 10:30 AM - 12:00 PM Objectives Invasive fungal infections represent one of the major limiting factors for the successful outcome of patients receiving hematopoietic stem cell transplantation (HSCT). The identification and successful treatment of pretransplant fungal colonization/infections may allow for risk modifications before or at the time of HSCT. Here, we report a case of disseminated pulmonary infection due to a hyaline non-septate mold, Mortierella wolfii in an X-linked chronic granulomatous disease (X-linked CGD) patient that was successfully treated with a combination of terbinafine and posaconazole antifungal therapy. Methods A 6-year-old male with X-linked CGD from Sri Lanka was admitted to NIH Clinical Center, Bethesda, MD, USA to receive a matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT). During pre-transplant immunosuppressive conditioning, the patient developed complicated pulmonary signs resulting in diffuse lymphadenitis and meningitis. Upon further radiologic evaluation, a lung biopsy was performed. The lung biopsy sample was submitted to Microbiology Service of Department of Microbiology at NIH Clinical Center for Fungal culture. Antifungal susceptibility testing was conducted in accordance with the Clinical and Laboratory Standards Institute CLSI M38-A3 guidelines. Results A pure heavy growth of white mold grew within 2 days on Sabouraud's Dextrose Agar. Microscopic examination showed hyaline (non-pigmented), non-septate branched hyphae. Sporangiophore-like structures were also present. The species-level identification of the isolate was confirmed as M. wolfii by PCR-sequencing of the internal transcribed spacer (ITS) region of ribosomal DNA. Minimum inhibitory/effective concentrations (μg/ml) were as follows in increasing order: terbinafine = 0.25, amphotericin B = 1, isavuconazole = 4, micafungin >8, itraconazole >16, voriconazole >16, and posaconazole >16. To evaluate the interactions between antifungal drugs, the activity of the posaconazole in combination with terbinafine were also evaluated M. wolfii using agar diffusion test. A combination of posaconazole and terbinafine, significantly inhibited the mycelial growth, which indicates synergism. The patient’s treatment was started on terbinafine in combination with posaconazole. On several follow-up examinations following treatment on day 30, 90 and 120, the infection had not recurred. Conclusion The species of M. wolfii a is an environmental mold belongs to the order Mortierellales within the subphylum Mortierellomycotina of Kingdom Fungi. This fungus has been mostly associated with fungal infections leading to abortion in dairy cows feeding moldy hays and ensilage. Although posaconazole exhibited high MICs against M. wolfii, our in vitro combination study demonstrated that posaconazole and terbinafine combined are significantly more potent than either drug alone. As a suggestion, combination therapy could provide an option for the treatment of severe cases of M. wolfii in patients with underlying primary immunodeficiencies. As molecular identification and sequencing techniques continue to develop and become more available, we will likely see more diverse pathogens emerge in patients with underlying primary immunodeficiencies. In this current case. Additional study is warranted to explore insight into human immunity and the efficacy of combination therapy against rare fungal species in CGD patients.

GATA2 deficiency was described in 2011, and shortly thereafter allogeneic hematopoietic stem cell transplantation (HSCT) was shown to reverse the hematologic disease phenotype. However, there remain major unanswered questions regarding the type of conditioning regimen, type of donors, and graft-versus-host disease (GVHD) prophylaxis. We report 59 patients with GATA2 mutations undergoing HSCT at National Institutes of Health between 2013 and 2020. Primary endpoints were engraftment, reverse of the clinical phenotype, secondary endpoints were overall survival (OS), event-free survival (EFS), and the incidence of acute and chronic GVHD. The OS and EFS at 4 years were 85·1% and 82·1% respectively. Ninety-six percent of surviving patients had reversal of the hematologic disease phenotype by one-year post-transplant. Incidence of grade III-IV aGVHD in matched related donor (MRD) and matched unrelated donor recipients (URD) patients receiving Tacrolimus/Methotrexate for GVHD prophylaxis was 32%. In contrast, in the MRD and URD who received post-transplant cyclophosphamide (PT/Cy), no patient developed grade III-IV aGVHD. Six percent of haploidentical related donor (HRD) recipients developed grade III-IV aGVHD. In summary, a busulfan-based HSCT regimen in GATA2 deficiency reverses the hematologic disease phenotype, and the use of PT/Cy reduced the risk of both aGVHD and cGVHD.

BACKGROUND: GATA2 deficiency is a genetic disorder of hematopoiesis, lymphatics, and immunity caused by autosomal dominant or sporadic mutations in GATA2. The disease has a broad phenotype encompassing immunodeficiency, myelodysplasia, leukemia, and vascular or lymphatic dysfunction as well as prominent pulmonary manifestations. RESEARCH QUESTION: What are the pulmonary manifestations of GATA2 deficiency? STUDY DESIGN AND METHODS: A retrospective review was conducted of clinical medical records, diagnostic imaging, pulmonary pathologic specimens, and tests of pulmonary function. RESULTS: Of 124 patients (95 probands and 29 ascertained), the lung was affected in 56%. In addition to chronic infections, pulmonary alveolar proteinosis (11 probands) and pulmonary arterial hypertension (nine probands) were present. Thoracic CT imaging found small nodules in 54% (54 probands and 12 relatives), reticular infiltrates in 40% (45 probands and four relatives), paraseptal emphysema in 25% (30 probands and one relative), ground-glass opacities in 35% (41 probands and two relatives), consolidation in 21% (23 probands and two relatives), and a typical crazy-paving pattern in 7% (eight probands and no relatives). Nontuberculous mycobacteria were the most frequent organisms associated with chronic infection. Allogeneic hematopoietic stem cell transplantation successfully reversed myelodysplasia and immune deficiency and also improved pulmonary hypertension and pulmonary alveolar proteinosis in most patients. INTERPRETATION: GATA2 deficiency has prominent pulmonary manifestations. These clinical observations confirm the essential role of hematopoietic cells in many aspects of pulmonary function, including infections, alveolar proteinosis, and pulmonary hypertension, many of which precede the formal diagnosis, and many of which respond to stem cell transplantation.

GATA2 deficiency is a bone marrow failure syndrome effectively treated with hematopoietic cell transplantation (HCT), which also addresses the predisposition to many infections (prominently mycobacterial). However, many GATA2-deficient persons who come to HCT also have prevalent and refractory human papilloma virus disease (HPVD), which can be a precursor to cancer. We analyzed 75 HCT recipients for the presence of HPVD to identify patient characteristics and transplantation results that influence HPVD outcomes. We assessed the impact of cellular recovery and iatrogenic post-transplantation immunosuppression, as per protocol (PP) or intensified/prolonged (IP) graft-versus-host disease (GVHD) prophylaxis or treatment, on the persistence or resolution of HPVD. Our experience with 75 HCT recipients showed a prevalence of 49% with anogenital HPVD, which was either a contributing or primary factor in the decision to proceed to HCT. Of 24 recipients with sufficient follow-up, 13 had resolution of HPVD, including 8 with IP and 5 with PP. Eleven recipients had persistent HPVD, including 5 with IP and 6 with PP immunosuppression. No plausible cellular recovery group (natural killer cells or T cells) showed a significant difference in HPV outcomes. One recipient died of metastatic squamous cell carcinoma, presumably of anogenital origin, at 33 months post-transplantation after prolonged immunosuppression for chronic GVHD. Individual cases demonstrate the need for continued aggressive monitoring, especially in the context of disease prevalent at transplantation or prior malignancy. HCT proved curative in many cases in which HPVD was refractory and recurrent prior to transplantation, supporting a recommendation that HPVD should be considered an indication rather than contraindication to HCT, but post-transplantation monitoring should be prolonged with a high level of vigilance for new or recurrent HPVD.

Haploidentical related donor (HRD) transplantation was performed in 7 recipients with chronic granulomatous disease (CGD) who had no matched-related or unrelated donor. Peripheral blood cell (PBC) products were used with a conditioning regimen consisting of low-dose cyclophosphamide, fludarabine, total body irradiation, and busulfan. Graft-versus-host disease (GVHD) prophylaxis consisted of high-dose post-transplant cyclophosphamide and sirolimus. Recipients were ages 14–26 years, and 3 had severe infections active at transplant. All 7 recipients achieved full engraftment with complete donor chimerism early in the post-transplant period. Acute GVHD occurred in all cases and was grade 3 or steroid refractory in 3. Two patients with steroid-refractory GVHD died. Three patients with severe infectious complications active at transplant, 1 Nocardia pneumonia and 2 extensive invasive fungal infections), survived and were cured of their infection at last follow-up. Bacterial disease occurred post-transplant in all recipients, and viral infections/reactivation were common, including 4 cases of BK virus–associated hemorrhagic cystitis. Seven patients with CGD achieved rapid and full-donor engraftment from HRDs utilizing PBCs and a conditioning regimen with PTCy and sirolimus GVHD prophylaxis. However, the incidence of grade 3 and steroid-refractory GVHD was high and led to 2 deaths. Patients with active infections at transplant had successful transplant courses and were cured of their disease. Although there was an initial success with this regimen, the cumulative experience does not support its use in CGD due to an unacceptable rate of severe GVHD.

Allogeneic HCT recipients may develop BK virus (BKV)-associated hemorrhagic cystitis (BKV-HC), typically early after engraftment. Yet, BKV levels in urine and blood are not routinely monitored pre- or post-HCT. Among HCT recipients with primary immunodeficiency diseases (n=40), we prospectively monitored BKV levels by quantitative PCR in blood and urine pre-HCT, as well as weekly post-HCT through day +100 on NCT02579967. Thirty patients were considered at-risk for BKV-HC based on BKV detection in urine/blood at any timepoint. Of these, 22 (73%) developed BKV-HC. Of recipients treated on the reduced-intensity conditioning (RIC) busulfan-containing arms of the trial, 22 of 27 (81%) at-risk patients developed BKV-HC (Fig 1). By contrast, on the non-myeloablative conditioning arms, identical to RIC except for the absence of busulfan (Fig 2), 0 of 3 at-risk patients developed BKV-HC (p=0.01). No patients received antiviral or cellular therapies for BKV-HC, although 3 received cidofovir and/or brincidofovir for adenovirus infection. Three required continuous bladder irrigation; 1 required multiple cystoscopies for clot evacuation but no intravesicular therapy. Disease outside the bladder was rare: 1 patient (Fig 1 - P36, with notably atypical pattern of BKV levels in relation to symptoms) developed tissue-proven BKV nephropathy, along with radiographic and cytopathologic (SV40+ cells on bronchoalveolar lavage) evidence of BKV pneumonitis; thus, further evaluation for extravesicular disease, particularly in those without significant gross hematuria, is under way. Patient discomfort and supportive care needs were significant, especially during gross hematuria (n=19; median duration 21 days, range 2-41; see Fig 1). With neutrophil engraftment at median day +17 (range 13-42), median onset of BKV-HC symptoms was day +22 (range +5-74), with median duration of 26 days (range 6-145 days). Starting on day +21, the trajectory of urine BKV levels diverged between RIC-HCT recipients with or without BKV-HC (Fig 3), with significantly higher BKV in urine at day +28 for BKV-HC patients, median 8.98 log10 IU/mL, compared to those without, median 4.99 log10 IU/mL, Mann-Whitney p=0.02. At BKV-HC onset, median level of BKV in urine was 9.66 log10 IU/mL (range 6.01 to >9.81) and, at full resolution, 8.39 log10 IU/mL (range 2.87 to >9.81). Swimmer's plot (Fig 1) shows the peak in urine BKV to occur soon before or early into symptom onset in most and that blood BKV peak levels vary more in timing. In conclusion, in this cohort, the use of busulfan seems to be an important co-factor in BKV-HC risk, as also noted by others. The trajectory of BKV levels in urine differed between those with and without BKV-HC, although the identification of early BKV-HC predictors is limited by the short interval between divergence in case/control values and symptom onset. Allogeneic HCT recipients may develop BK virus (BKV)-associated hemorrhagic cystitis (BKV-HC), typically early after engraftment. Yet, BKV levels in urine and blood are not routinely monitored pre- or post-HCT. Among HCT recipients with primary immunodeficiency diseases (n=40), we prospectively monitored BKV levels by quantitative PCR in blood and urine pre-HCT, as well as weekly post-HCT through day +100 on NCT02579967. Thirty patients were considered at-risk for BKV-HC based on BKV detection in urine/blood at any timepoint. Of these, 22 (73%) developed BKV-HC. Of recipients treated on the reduced-intensity conditioning (RIC) busulfan-containing arms of the trial, 22 of 27 (81%) at-risk patients developed BKV-HC (Fig 1). By contrast, on the non-myeloablative conditioning arms, identical to RIC except for the absence of busulfan (Fig 2), 0 of 3 at-risk patients developed BKV-HC (p=0.01). No patients received antiviral or cellular therapies for BKV-HC, although 3 received cidofovir and/or brincidofovir for adenovirus infection. Three required continuous bladder irrigation; 1 required multiple cystoscopies for clot evacuation but no intravesicular therapy. Disease outside the bladder was rare: 1 patient (Fig 1 - P36, with notably atypical pattern of BKV levels in relation to symptoms) developed tissue-proven BKV nephropathy, along with radiographic and cytopathologic (SV40+ cells on bronchoalveolar lavage) evidence of BKV pneumonitis; thus, further evaluation for extravesicular disease, particularly in those without significant gross hematuria, is under way. Patient discomfort and supportive care needs were significant, especially during gross hematuria (n=19; median duration 21 days, range 2-41; see Fig 1). With neutrophil engraftment at median day +17 (range 13-42), median onset of BKV-HC symptoms was day +22 (range +5-74), with median duration of 26 days (range 6-145 days). Starting on day +21, the trajectory of urine BKV levels diverged between RIC-HCT recipients with or without BKV-HC (Fig 3), with significantly higher BKV in urine at day +28 for BKV-HC patients, median 8.98 log10 IU/mL, compared to those without, median 4.99 log10 IU/mL, Mann-Whitney p=0.02. At BKV-HC onset, median level of BKV in urine was 9.66 log10 IU/mL (range 6.01 to >9.81) and, at full resolution, 8.39 log10 IU/mL (range 2.87 to >9.81). Swimmer's plot (Fig 1) shows the peak in urine BKV to occur soon before or early into symptom onset in most and that blood BKV peak levels vary more in timing. In conclusion, in this cohort, the use of busulfan seems to be an important co-factor in BKV-HC risk, as also noted by others. The trajectory of BKV levels in urine differed between those with and without BKV-HC, although the identification of early BKV-HC predictors is limited by the short interval between divergence in case/control values and symptom onset. Figure 1, Figure 2, Figure 3.Figure 2Hematopoietic cell transplantation platform arms on NCT02579967. NMA and RIC arms differed in that the RIC arms contained busulfan, while the NMA arms did not. BKV was quantified in all recipients by PCR in blood and urine prior to KT, as well as weekly through day +100.Show full captionPentostatin (P) = 4 mg/m2/day IVCyclophosphamide (C) = 3-5 mg/kg/day orally, with cap of 400 mg/dayBusulfan (Bu) = 3.2 mg/kg/day IV - target daily AUC of 4600 μMol* min (range 3600-5600 0,μmol* min)Posttransplantation cyclophosphamide (PTCy) = 50 mg/kg/day IV (or 25 mg/kg/day IV for select patients with DNA repair defects/telomeropathies/familial cancer syndromes)Mycophenolate mofetil (MMF) = 15 mg/kg orally three times daily, up to 1000 mg/dose from days +5 through +18-35, depending on arm Filgrastim (G-CSF) = 5 μg/kg given daily starting day +5 until neutrophil engraftment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pentostatin (P) = 4 mg/m2/day IV Cyclophosphamide (C) = 3-5 mg/kg/day orally, with cap of 400 mg/day Busulfan (Bu) = 3.2 mg/kg/day IV - target daily AUC of 4600 μMol* min (range 3600-5600 0,μmol* min) Posttransplantation cyclophosphamide (PTCy) = 50 mg/kg/day IV (or 25 mg/kg/day IV for select patients with DNA repair defects/telomeropathies/familial cancer syndromes) Mycophenolate mofetil (MMF) = 15 mg/kg orally three times daily, up to 1000 mg/dose from days +5 through +18-35, depending on arm Filgrastim (G-CSF) = 5 μg/kg given daily starting day +5 until neutrophil engraftment.

BACKGROUND:Patients with GATA2 deficiency present with nontuberculous mycobacterial infections, severe viral infections (particularly refractory human papillomavirus disease), lymphedema, myelodysplastic syndrome (MDS), and acute myeloid leukemia. Patients with GATA2 deficiency who undergo allogeneic hematopoietic stem cell transplantation prior to the development of life-threatening infections or cytogenetic abnormalities may have optimal clinical outcomes.OBJECTIVES:The aim of this article is to determine ways in which oncology nurses can identify GATA2 deficiency in patients early and optimize treatment decisions.METHODS:A case study is presented of a 33-year-old man with recurrent infections and MDS and his two sons, all of whom were found to have the same GATA2 mutation.FINDINGS:Oncology nurses play an important role in early detection and identification by interviewing patients and obtaining a complete and thorough family history.

HCT has been used for decades as a definitive therapy for patients with PIDs. These patients often enter HCT with significant comorbidities and disease sequelae and may have limited donor options if family members are also affected, so the ability to offer HCT to all who require it remains suboptimal.Twenty-nine children and adults with various underlying PIDs received a serotherapy-free, radiation-free reduced intensity conditioning platform designed with the goals of optimizing immune reconstitution, minimizing complications such as graft-versus-host disease (GVHD), and permitting use of alternative donors. Conditioning consisted of pentostatin, low-dose cyclophosphamide and 2 days of busulfan, and GVHD prophylaxis included post-transplantation cyclophosphamide, mycophenolate mofetil, and sirolimus. All received T cell replete bone marrow or peripheral blood stem cell allografts. Patient and donor characteristics are shown in Fig 1a.Neutrophil recovery occurred at median day +17 (range 14-42). With median follow-up of 14 months (range 3-33), graft-failure-free, steroid-refractory grade 3-4 GVHD-free survival was estimated at 82% at 1 year (Fig 2). Two deaths occurred in patients with HCT-CI scores of 6 (bacterial sepsis and invasive Aspergillosis, day +44) and 8 (presumed viral encephalitis, day +110). There were 3 graft failures (1 primary, with autologous recovery on day +14 and 2 secondary on day +34 and +159). Two patients were successfully retransplanted with eventual full donor chimerism, while the third's infection was sufficiently temporized by the first transplant to make an immediate retransplant not necessary. The kinetics of donor chimerism differed between myeloid and lymphoid compartments. Most patients had complete donor myeloid chimerism by day +28 but a slower rise in donor CD3 chimerism (median 77% at day +28 to 94% at day +60) (Fig 3). GVHD rates have been low, with cumulative incidence of steroid-responsive grade 2-4 acute GVHD at 1 year of 14% (death and graft failure as competing risks) and no chronic GVHD to date. HCT-related outcomes and complications are listed in Fig 1b. Of note, BK-associated hemorrhagic cystitis occurred at high rates, but serious viral complications were infrequent. Some degree of phenotype reversal is evident in all evaluable patients. All 10 patients with lymphoma or lymphoproliferative disorder are in remission, and, of 24 engrafted survivors, only two continue to require immunoglobulin replacement beyond 6 months post-HCT. Future directions include reducing the duration of post-HCT immunosuppression to hasten improved viral control and increasing pre-HCT lymphodepletion for selected patients at high risk for graft failure. Continued long term follow up is needed to better characterize phenotype reversal, graft durability, immune reconstitution and late toxicities of the platform. HCT has been used for decades as a definitive therapy for patients with PIDs. These patients often enter HCT with significant comorbidities and disease sequelae and may have limited donor options if family members are also affected, so the ability to offer HCT to all who require it remains suboptimal. Twenty-nine children and adults with various underlying PIDs received a serotherapy-free, radiation-free reduced intensity conditioning platform designed with the goals of optimizing immune reconstitution, minimizing complications such as graft-versus-host disease (GVHD), and permitting use of alternative donors. Conditioning consisted of pentostatin, low-dose cyclophosphamide and 2 days of busulfan, and GVHD prophylaxis included post-transplantation cyclophosphamide, mycophenolate mofetil, and sirolimus. All received T cell replete bone marrow or peripheral blood stem cell allografts. Patient and donor characteristics are shown in Fig 1a. Neutrophil recovery occurred at median day +17 (range 14-42). With median follow-up of 14 months (range 3-33), graft-failure-free, steroid-refractory grade 3-4 GVHD-free survival was estimated at 82% at 1 year (Fig 2). Two deaths occurred in patients with HCT-CI scores of 6 (bacterial sepsis and invasive Aspergillosis, day +44) and 8 (presumed viral encephalitis, day +110). There were 3 graft failures (1 primary, with autologous recovery on day +14 and 2 secondary on day +34 and +159). Two patients were successfully retransplanted with eventual full donor chimerism, while the third's infection was sufficiently temporized by the first transplant to make an immediate retransplant not necessary. The kinetics of donor chimerism differed between myeloid and lymphoid compartments. Most patients had complete donor myeloid chimerism by day +28 but a slower rise in donor CD3 chimerism (median 77% at day +28 to 94% at day +60) (Fig 3). GVHD rates have been low, with cumulative incidence of steroid-responsive grade 2-4 acute GVHD at 1 year of 14% (death and graft failure as competing risks) and no chronic GVHD to date. HCT-related outcomes and complications are listed in Fig 1b. Of note, BK-associated hemorrhagic cystitis occurred at high rates, but serious viral complications were infrequent. Some degree of phenotype reversal is evident in all evaluable patients. All 10 patients with lymphoma or lymphoproliferative disorder are in remission, and, of 24 engrafted survivors, only two continue to require immunoglobulin replacement beyond 6 months post-HCT. Future directions include reducing the duration of post-HCT immunosuppression to hasten improved viral control and increasing pre-HCT lymphodepletion for selected patients at high risk for graft failure. Continued long term follow up is needed to better characterize phenotype reversal, graft durability, immune reconstitution and late toxicities of the platform. Figs. 1, 2 and 3.Figure 2Kaplan-Meier curve for reduced-intensity conditioning recipients with primary endpoint of GVHD-free, graft-failure-free survival. N=29 patients with median follow-up of survivors of 14 months.Show full captionaGVHD-free is defined as absence of grade 3-4 acute GVHD not responsive to 7 days of high-dose steroids and absence of chronic GVHD requiring systemic therapy. Graft-failure-free is defined as maintaining ≥5% myeloid chimerism in blood and/or bone marrow.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Median CD3 and myeloid donor chimerism through the first year post-HCT.View Large Image Figure ViewerDownload Hi-res image Download (PPT) aGVHD-free is defined as absence of grade 3-4 acute GVHD not responsive to 7 days of high-dose steroids and absence of chronic GVHD requiring systemic therapy. Graft-failure-free is defined as maintaining ≥5% myeloid chimerism in blood and/or bone marrow.

Introduction Invasive aspergillosis may complicate up to 23% of HCT. Three patients with predispositions to infection with Aspergillus pre-transplant underwent reduced intensity conditioning HCT for unrelated PIDs: hypomorphic IL2R-γ deficiency (36 y/o man, P1), STAT3 mutated Hyper IgE syndrome (7 y/o girl, P2), and EBV-associated lymphoproliferative disease with mutated IκBα (30 y/o woman, P3). Methods Conditioning consisted of pentostatin/cyclophosphamide (Cy); patients 2 and 3 also received busulfan, with high dose Cy/sirolimus/mycophenolate mofetil for GVHD prophylaxis. P1 and P2 received micafungin prophylaxis and P3 continued pre-HCT posaconazole. Results P1 had preexisting bronchiectasis colonized by Aspergillus fumigatus. The transplant was complicated by fever, mild hemoptysis and new nodular infiltrates during neutropenia. Blood Aspergillus antigen index (AAI) was positive 2 days prior to engraftment and negative day 31. On day 30, peripheral blood eosinophils rose to 4,640/µl (22.9%). Eosinophilia abated with corticosteroids for cutaneous GVHD, but tapering steroids was complicated by increasing eosinophilia and cough. Biopsy (day 59) of the new lung lesions revealed necrotizing inflammation and septate hyphae. P2 had a preexisting large right pneumatocele. Fevers persisted from day 3 post-HCT and beyond engraftment (day 19). Sputum cultures grew A. fumigatus. Eosinophilia on day 35 (560/µl, 12.5%) reached 2640/µl (29.9%) on day 45. Antifungal therapy was continued and corticosteroids and tocilizumab were given, with rapid abatement of fevers, cough and eosinophilia. The blood AAI was positive on day 54 but became negative by day 61. On day 94 a right pneumothorax developed. Resection of the affected lung was performed on day 114. P3 had a left lung cavity aspergilloma and intermittent hemoptysis prior to transplantation. HCT was successfully performed under posaconazole/isavuconazole prophylaxis. Post-HCT, cough was difficult to control, and eosinophilia appeared (460/µl, 13.9%) on day 48 coincident with new diffuse nodular infiltrates, interpreted as bronchial spread of the cavity contents. Right lung lavage revealed numerous neutrophils and eosinophils and grew A. fumigatus. The patient underwent left upper lobectomy on day 83. Symptoms and eosinophilia improved. Conclusion Three patients predisposed to Aspergillus disease underwent successful HCT for different PIDs, but each case was complicated by a mixed picture of invasive Aspergillus infection and eosinophilic inflammation similar to allergic bronchopulmonary aspergillosis. Successful management included aggressive antifungal therapy, but corticosteroids were necessary to manage the allergic symptoms, and lung resection was performed in two cases.

Background. An 11-year-old girl with dedicator of cytokinesis 8 (DOCK8) deficiency was proposed for potentially curative hematopoietic stem cell transplantation (HSCT), the donor being her haploidentical mother. However, end-stage liver disease caused by chronic Cryptosporidium infection required liver transplantation before HSCT. Methods. Consequently, a staged approach of a sequential liver transplant followed by a HSCT was planned with her mother as the donor for both liver and HSCT. Results. The patient successfully underwent a left-lobe orthotopic liver transplant; however, she developed a biliary leak delaying the HSCT. Notably, the recipient demonstrated 3% donor lymphocyte chimerism in her peripheral blood immediately before HSCT. Haploidentical-related donor HSCT performed 2 months after liver transplantation was complicated by the development of acyclovir-resistant herpes simplex virus viremia, primary graft failure, and sinusoidal obstruction syndrome. The patient died from sinusoidal obstruction syndrome-associated multiorgan failure with Candida sepsis on day +40 following HSCT. Conclusions. We discuss the many considerations inherent to planning for HSCT preceded by liver transplant in patients with primary immunodeficiencies, including the role of prolonged immunosuppression and the risk of infection before immune reconstitution. We also discuss the implications of potential recipient sensitization against donor stem cells precipitated by exposure of the recipient to the donor lymphocytes from the transplanted organ.