Sicca symptoms and their impact on quality of life among very long-term survivors after hematopoietic SCT.

The objective of this prospective cross-sectional case-control study was to examine the prevalence of dryness symptoms and its impact on quality of life (QoL) among very long-term survivors after hematopoietic SCT (HSCT) in comparison with their respective sibling donors. Forty-four allogeneic HSCT recipients with a long-term survival (median: 17.5; range: 11-26 years) were included. Their respective, HLA-identical sibling donors served as controls. Clinical examinations included saliva flow rates (SFR) and the Schirmer's test. The presence of sicca symptoms of mouth, eyes and skin were inquired. The social functioning (SF)-36 questionnaire was applied. Recipients had lower (P<0.01) unstimulated and stimulated mean SFR than donors. Schirmer's test results <5 mm was found in 45% of the recipients in comparison with 27% of the donors (P = 0.07). Xerostomia (34 vs 4 subjects), xerophtalmia (23 vs 3) and dry skin (32 vs 12) were reported more often by the recipients than donors (P<0.001). Sicca symptoms and their objective findings correlated with QoL. The mean SF-36 scores of the donors were significantly higher than those of the recipients for physical component summary. In conclusion, sicca symptoms are common amongst long-term survivors of HSCT and affect remarkably the QoL.

[Stem cell treatment of autoimmune disease]. / Stammzelltherapie bei Autoimmunerkrankungen.

Over 1,500 patients world wide have received a hematopoietic stem cell transplant (HSCT) as treatment for a severe autoimmune disease. Most of these have been autologous and mostly have occurred in the past 15 years. Over 1,000 of these have been registered in the European Group for Bone Marrow Transplantation (EBMT) and European League Against Rheumatism (EULAR) combined data base. A recent retrospective analysis of 900 patients (1) showed that the majority had multiple sclerosis (n = 345) followed by systemic sclerosis (n = 175), systemic lupus erythematosus (n = 85), rheumatoid arthritis (n = 89), juvenile idiopathic arthritis (n = 65) and idiopathic cytopenic purpura (n = 37). An overall 85 % 5-year-survival and 43 % progression-free survival was seen, with 100-day-transplant-related-mortality (TRM) ranging between 1 % (rheumatoid arthritis) and 11 % (systemic lupus erythematosus and juvenile idiopathic arthritis). Around 30 % of patients in all disease subgroups had a complete response, often durable despite full immune reconstitution. In many, e. g. systemic sclerosis, morphological improvement such as reduction of skin collagen and normalisation of microvasculature was documented, beyond any predicted known effects of intense immunosuppression alone. The high TRM was in part related to conditioning intensity, comorbidity and age, and the final risk/benefit assessment will be made after the results of the three randomised propective clinical trials are known. [nl]Recently, multipotent mesenchymal stromal cells have been tested in various autoimmune diseases, exploiting their immune modulating properties and apparent low acute toxicity. Despite encouraging small phase I/II studies, no positive data from randomised, prospective studies are as yet available in the peer reviewed literature.

[Of bugs and joints. Oligoarthritis caused by Tropheryma whipplei]. / Oligoarthritis durch Tropheryma whipplei. "Of bugs and joints".

Whipple's disease is a rare, chronic infection caused by Tropheryma whipplei, an ubiquitary gram positive bacterium. The disease is associated with a high mortality in absence of an antibiotic treatment. The disease can be detected in affected tissues and body fluids by light and electron microscopy, as well as by polymerase chain reaction (PCR). Musculoskeletal symptoms such as arthralgia and arthritis frequently represent the first manifestation of this multi-system disease; typical subsequent symptoms are weight loss, diarrhea, and abdominal pain. Symptoms of central nervous system involvement are present in 10-40% of cases. We report on a 67 year-old male with a history of migratory oligoarthritis over three decades in whom the causative agent was detected by PCR in synovial fluid only. This case illustrates that searches for the characteristic PAS-positive macrophages and PCR in biopsies from the duodenum may be insufficient and that diagnostic efforts should be complemented with PCR assays from affected tissues or body fluids. It is recommended that antibiotic treatment be carried out with an agent that penetrates well into the cerebrospinal fluid, e.g. ceftriaxone, followed by cotrimoxazole. Antibiotics should be maintained over several months to years. It is prudent to document the disappearance of the pathogen in the affected compartments prior to the discontinuation of the antibiotic therapy.

Cellular therapy of systemic lupus erythematosus.

Immunoablation with autologous hematopoietic stem cell rescue has been used in over 1,300 autoimmune disease patients, around 150 with SLE. Some patients have experienced durable remissions with loss of autoantibodies, whereas others either did not respond or died as a result of the treatment. Prospective randomised trials are required and are being planned to establish the place for this potentailly curative strategy. Mesenchymal stem cells are in an exploratory phase for the treatment of acute autoimmune disease including SLE. The principle is that they home to inflammed tissue and exert an antiinflammatory paracrine effect.

Multipotent mesenchymal stromal cells for autoimmune diseases: teaching new dogs old tricks.

MSCs, otherwise known as multipotent mesenchymal stromal cells, are being examined for the treatment of autoimmune disease (AD) on the basis of their in vitro antiproliferative properties, efficacy in animal models, apparent low acute toxicity and the early positive anecdotal outcomes in human acute GVHD. Phase I/II clinical trials are underway in Crohn's disease and multiple sclerosis (MS) and are being planned for systemic lupus erythematosus (SLE), systemic sclerosis (SSc), systemic vasculitis and other AD. Open issues include patient selection, disease stage and activity, MSC source and expansion and long-term safety. Multidisciplinary groups are collaborating to ensure maximal use of available resources to establish the place, if any, of MSC in the treatment of AD.

Allogeneic hematopoietic SCT for patients with autoimmune diseases.

Allogeneic hematopoietic SCT (HSCT) has been used as treatment for single patients with autoimmune diseases (AD). To summarise currently available information, we analyzed all patients who underwent allogeneic HSCT for AD and who reported to the European Group for Blood and Marrow Transplantation (EBMT) database. Thirty-five patients receiving 38 allogeneic transplantations for various hematological and non-hematological AD were identified. Four patients had had an allogeneic HSCT for a conventional hematological indication in the past. Fifty-five per cent of the transplantation procedures led to a complete clinical response of the refractory AD and 23% to at least a partial response. The median duration of response at the last follow-up was 70.7 (15.2-130) months. Three patients relapsed at a median of 12.3 months after HSCT. Treatment-related mortality at 2 years was 22.1% (95% CI: 7.3-36.9%). Two deaths were caused by progression of AD. The probability of survival at 2 years was 70%. No single factor predicting the outcome could be identified. The retrospective nature of this study and the heterogeneous, partly incomplete data are its limitations. However, allogeneic HSCT can induce remission in patients suffering from refractory AD. These data provide the basis for carefully conducted prospective trials.

Tenofovir-induced osteomalacia.

We present an HIV-infected woman in whom antiretroviral treatment with tenofovir disoproxil fumarate (TDF) induced severe skeletal pain, synovial effusions and multiple fractures secondary to a Fanconi syndrome with hypophosphatemia and osteomalacia. TDF interferes with the replication of mitochondrial DNA in the proximal tubules of the kidney, which can explain the delayed onset of this form of renal phosphate loss. Nephrotoxicity had been precipitated by cotreatment with lopinavir/r, an HIV protease inhibitor which increases tenofovir serum levels and inhibits the tubular multidrug resistance protein 4, which is responsible for the efflux of tenofovir from tubular cells.Awareness is needed to link the typically prolonged onset of clinical symptoms with TDF exposure and then establish the correct diagnosis.

Autologous stem cell transplantation improves microcirculation in systemic sclerosis.

BACKGROUND: In systemic sclerosis (SSc) reduced capillary density decreases blood flow and leads to tissue ischaemia and fingertip ulcers. Nail fold videocapillaroscopy (NVC) is a diagnostic and follow-up parameter useful to evaluate the severity, activity and the stage of SSc microvascular damage. Autologous haemopoietic stem cell transplantation (HSCT) is a new treatment for patients with severe diffuse cutaneous systemic sclerosis (dcSSc) refractory to conventional therapies. We aimed to evaluate the improvement of microvasculature after HSCT using NVC. METHODS: A total of 16 patients with severe dcSSc with a "late" videocapillaroscopy pattern underwent an immunesuppressive treatment: 6 were treated with HSCT and 10 with monthly pulse cyclophosphamide (CYC) 1 g for 6 months and then orally with 50 mg/day for further 6 months. NVC was performed before and after 3 months from the beginning of each treatment and then repeated every 3 months. RESULTS: In all patients, before HSCT NVC showed large avascular areas and ramified capillaries and vascular architectural disorganisation ("late" pattern). At 3 months after HSCT, the NVC pattern changed from "late" into "active", showing frequent giant capillaries (>6/mm) and haemorrhages, absence of avascular areas and angiogenesis phenomena; 1 year after HSCT, microvascular abnormalities were still in the "active" pattern. In patients treated with CYC, no NVC modifications were observed during 24 months of follow-up and the pattern always remained "late". CONCLUSIONS: These results indicate that HSCT with a high dose CYC regimen may foster vascular remodelling, while CYC at lower doses and with a chronic regimen does not influence the microvasculature.

Human bone marrow mesenchymal stem cells and chondrocytes promote and/or suppress the in vitro proliferation of lymphocytes stimulated by interleukins 2, 7 and 15.

OBJECTIVES: To investigate whether human bone marrow-derived mesenchymal stem cells (BM-MSCs) and articular chondrocytes (ACs) affect the in vitro proliferation of T lymphocytes and peripheral blood mononuclear cells (PBMCs) driven by the homeostatic interleukin (IL)2, IL7 and IL15 cytokines binding to the common cytokine receptor gamma-chain (gamma(c)) in the absence of T cell receptor (TCR) triggering. METHODS: PBMCs, total T cells and T cell subsets (CD4+ and CD8+) were stimulated with IL2, IL7 or IL15 and exposed to cultured BM-MSCs and ACs at varying cell:cell ratio either in contact or in transwell conditions. Lymphocyte proliferation was measured by (3)H-thymidine uptake or by flow cytometry of carboxyfluorescein succinimidyl ester (CFSE)-labelled lymphocytes. RESULTS: MSCs and ACs enhanced and inhibited lymphocyte proliferation depending on the extent of lymphocyte baseline proliferation and on the MSC/AC to lymphocyte ratio. Enhancement was significant on poorly proliferating lymphocytes and mostly at lower MSC/AC to lymphocyte ratio. Suppression occurred only on actively proliferating lymphocytes and at high MSC/AC to lymphocyte ratio. Neither enhancement nor inhibition required cell-cell contact. CONCLUSIONS: There is a dichotomous effect of MSCs/ACs on lymphocytes proliferating in response to the homeostatic IL2, IL7 and IL15 cytokines likely to be encountered in homeostatic and autoimmune inflammatory conditions. The effect is determined by baseline lymphocyte proliferation, cell:cell ratio and is dependent on soluble factor(s). This should be taken into account when planning cellular therapy for autoimmune disease (AD) using stromal-derived cells such as MSCs.

Stem cell transplantation: a treatment option for severe systemic sclerosis?

High-dose immunosuppressive therapy and autologous stem cell transplantation (commonly referred to as "stem cell transplantation") is an established treatment for a variety of haemato-oncological conditions. Recent studies have confirmed its potent clinical and immunological effects in rheumatic autoimmune diseases, including severe diffuse systemic sclerosis (SSc). With modifications of treatment protocols and more stringent selection of patients, the safety profile of stem cell transplantation has improved as expressed in lower treatment-related morbidity and mortality. Prospective, randomised trials are in progress in Europe and North America to compare the safety and efficacy of stem cell transplantation with conventional chemotherapy in patients with early diffuse SSc, on the premise that induction of remission in early disease can be achieved by stem cell transplantation as a means to interrupt fibrogenesis.

[Spondylodiscitis without fever: a diagnostic challenge]. / Spondylodiszitis ohne Fieber: Eine diagnostische Herausforderung.

HISTORY AND CLINICAL FINDINGS: Three patients with different forms of vertebral osteomyelitis are presented, two with hematogenous infections caused by Streptococcus pneumoniae and Staphylococcus aureus and one with postsurgical infection after excision of a vertebral disc caused by coagulase-negative staphylococci. None of the patients was initially febrile, but all had localized back pain and a restricted range of movement of the vertebral column. EXAMINATIONS, DIAGNOSIS: In all three patients the MRI of the affected vertebral column was consistent with vertebral osteomyelitis. Microbiological diagnosis was made by bone biopsy in all patients and by blood cultures in two of them. TREATMENT AND COURSE: Antibiotics were administered for 4-6 weeks. At follow-up two patients were without symptoms, but the third patient had persistent back pain without radiological signs of vertebral osteomyelitis. CONCLUSION: In patients with localized back pain vertebral osteomyelitis should be included in the differential diagnosis, even if there is no fever and no increase in white cell count, the erythrocyte sedimentation rate or C-reactive protein level and radiography is normal. Specific bacterial diagnosis should be made by multiple bone biopsy or blood cultures, before starting appropriate antibiotics.

Phenotypical and functional characteristics of in vitro expanded bone marrow mesenchymal stem cells from patients with systemic sclerosis.

BACKGROUND: Mesenchymal stem cells (MSCs) have a potential immunomodulatory role in autoimmune disease; however, the qualitative properties and haematopoietic support capacity of MSCs derived from patients with autoimmune disease is unclear. OBJECTIVES: To further characterise phenotypically and functionally bone marrow (BM)-derived MSCs from patients with systemic sclerosis (SSc). METHODS: Key parameters of BM-derived MSC function and phenotype were assessed in 12 patients with SSc and compared with 13 healthy normal controls. The parameters included the ability to: form colony-forming unit fibroblasts (CFU-F), differentiate along the adipogenic and osteogenic lineages, express cell surface antigens defining the MSCs population, support normal haematopoiesis and suppress in vitro lymphocyte proliferation induced by either anti-CD3epsilon plus anti-CD28 monoclonal antibodies or the mixed lymphocyte reaction. RESULTS: SSc MSCs were shown to have a similar characteristic phenotype, capacities to form CFU-F and to differentiate along adipogenic and osteogenic lineages as those of healthy donor MSCs. The ability of SSc MSCs to support long-term haematopoiesis was also identical to that of controls. Both healthy donor and SSc BM MSCs reduced the proliferation of autologous and allogeneic peripheral blood mononuclear cells in a cell number dependent fashion. CONCLUSIONS: These results show that BM-derived MSCs from patients with SSc under the described culture conditions exhibit the same phenotypic, proliferative, differentiation potential and immunosuppressive properties as their healthy counterparts and could therefore be considered in an autologous setting. Further studies are needed to ensure the quality and safety of large-scale expansion of patient MSCs prior to their potential use in clinical trials.

Pregnancy and childbirth after treatment with autologous hematopoietic stem cell transplantation for severe systemic sclerosis requiring parenteral nutrition. Ethical issues.

We report a pregnancy in a patient who had undergone autologous hematopoietic stem cell transplantation (AHSCT) for diffuse cutaneous systemic sclerosis (SSc). SSc onset was at age 25, with Raynaud phenomenon and evolved to include diffuse cutaneous, arthritis, pulmonary fibrosis and extensive gastrointestinal involvement. AHSCT (cyclophosphamide/ATG for conditioning) was performed four years later with improvement of all features apart from the gastrointestinal symptoms requiring parenteral nutrition (PN). Forty months after AHSCT, she had a spontaneous miscarriage necessitating curettage. Despite advice to avoid pregnancy because of poor nutritional status and recurring catheter infections from her PN, she fell pregnant one year later. The pregnancy proceeded normally and she delivered at 34 weeks, under cesarean section. The baby girl, (1990g and 4 APGAR score) after initial respiratory distress, is now 4 years old with normal growth and development. Unfortunately, the patient died early in 2008 due to severe disease progression terminating with gastrointestinal obstruction and pericarditis. This first report of a successful pregnancy in a patient with diffuse SSc treated by AHSCT illustrates that despite the possibility for a normal pregnancy, the decision to do so includes aspects of maternal prognosis.

Impairment of endothelial cell differentiation from bone marrow-derived mesenchymal stem cells: new insight into the pathogenesis of systemic sclerosis.

OBJECTIVE: Systemic sclerosis (SSc) is a disorder characterized by vascular damage and fibrosis of the skin and internal organs. Despite marked tissue hypoxia, there is no evidence of compensatory angiogenesis. The ability of mesenchymal stem cells (MSCs) to differentiate into endothelial cells was recently demonstrated. The aim of this study was to determine whether impaired differentiation of MSCs into endothelial cells in SSc might contribute to disease pathogenesis by decreasing endothelial repair. METHODS: MSCs obtained from 7 SSc patients and 15 healthy controls were characterized. The number of colony-forming unit-fibroblastoid colonies was determined. After culture in endothelial-specific medium, the endothelial-like MSC (EL-MSC) phenotype was assessed according to the surface expression of vascular endothelial growth factor receptors (VEGFRs). Senescence, chemoinvasion, and capillary morphogenesis studies were also performed. RESULTS: MSCs from SSc patients displayed the same phenotype and clonogenic activity as those from controls. In SSc MSCs, a decreased percentage of VEGFR-2+, CXCR4+, VEGFR-2+/CXCR4+ cells and early senescence was detected. After culturing, SSc EL-MSCs showed increased expression of VEGFR-1, VEGFR-2, and CXCR4, did not express CD31 or annexin V, and showed significantly decreased migration after specific stimuli. Moreover, the addition of VEGF and stromal cell-derived factor 1 to cultured SSc EL-MSCs increased their angiogenic potential less than that in controls. CONCLUSION: Our data strongly suggest that endothelial repair may be affected in SSc. The possibility that endothelial progenitor cells could be used to increase vessel growth in chronic ischemic tissues may open up new avenues in the treatment of vascular damage caused by SSc.

Bone marrow mesenchymal stromal cells (BM-MSCs) from healthy donors and auto-immune disease patients reduce the proliferation of autologous- and allogeneic-stimulated lymphocytes in vitro.

OBJECTIVES: To investigate the ability of bone marrow (BM)-derived mesenchymal stromal cells (BM-MSCs) in suppressing the proliferation of stimulated lymphocytes across a range of conditions including autologous BM-MSCs derived from autoimmune disease (AD) patients. METHODS: In vitro cultures of BM-MSCs from healthy donors and AD patients were established and characterized by their differentiation potential into adipocytes and osteoblasts, and their fibroblast-colony-forming unit (CFU-F) ability and phenotype by flow cytometry. BM-MSCs (irradiated and non-irradiated) from healthy and AD patients were tested for their ability to suppress the in vitro proliferation of autologous and allogeneic peripheral blood mononuclear cells (PBMC) (from healthy donors and patients suffering from various ADs) stimulated with anti-CD3epsilon antibody alone or in combination with anti-CD28 antibody. The anti-proliferative effect of the BM-MSCs from healthy donors was tested also on transformed B-cell lines as a model of non-antigen-stimulated lymphocytes. RESULTS: BM-MSCs from healthy donors and AD patients reduced the proliferation of autologous and allogeneic PBMCs by up to 90% in a cell dose-dependent fashion. The immunosuppression was independent of the proliferation of the BM-MSCs and was also effective on already proliferating cells. It was independent also of the clinical activity of AD. An MSC dose-dependent pattern of suppression of proliferation was observed also with transformed B-cell lines, similar to that observed with proliferating PBMC. CONCLUSIONS: The BM-MSCs exhibit extensive anti-proliferative properties against lymphocytes under different conditions. This property might offer a form of immunomodulatory cellular therapy for AD patients if further confirmed in animal models.

Adult stem cells in the treatment of autoimmune diseases.

During the past 10 yrs, over 700 patients suffering from severe autoimmune disease (AD) have received an autologous haematopoietic stem cell transplant as treatment of their disorder with durable remission being obtained in around one-third. The most commonly transplanted ADs have been systemic sclerosis (scleroderma), multiple sclerosis, rheumatoid arthritis, juvenile idiopathic arthritis and systemic lupus erythematosus. A fewer number of patients have received an allogeneic transplant. The initially reported overall treatment-related mortality of 7% has since fallen, with no further cases being reported in systemic sclerosis or multiple sclerosis in the past 3 yrs. This is thought to be due to more careful patient selection. The phase I/II data has led to currently running prospective randomised trials in systemic sclerosis, multiple sclerosis and systemic lupus erythematosus in Europe and North America. Immune reconstitution data suggests a 'resetting' of autoimmunity in those patients achieving stable remission, rather than simply prolonged immunosuppression. Recent results from in vitro experiments, animal models and early human experience in severe acute graft vs host disease suggest that multipotent mesenchymal stromal cells obtained from the bone marrow and expanded ex vivo, may exert a clinically useful immunomodulatory effect. Such cells are immune privileged and apparently of low toxicity. Further characterization of these cells and consideration of their possible clinical application in AD is underway.

Focal myositis of the iliopsoas muscle--a benign pseudotumour: ultrasound appearance in correlation with CT and MRI.

OBJECTIVE: Focal myositis of the iliopsoas muscle is a rare condition. A case is presented, emphasizing the value of ultrasound for detection, localisation, image-guided biopsy and follow-up in correlation with CT and MRI findings. MATERIAL AND METHODS: A 58-year-old woman was referred to our clinic with strong left sided inguinal pain, which radiated to the thigh and had lasted for four days. Ultrasound, CT and MRI were performed. Ultrasound-guided biopsy with histological correlation was obtained and US-follow-ups were available. RESULTS: CT showed an enlarged iliopsoas muscle on the left side without any focal pathology or enhancement. MRI revealed a sharpely delineated lesion, which was hypointense to muscle in fat-suppressed T1 w images with circumferential enhancement and showed a hyperintense appearance in T2 w images. Ultrasound displayed a polylobulated, inhomogeneous and hypoechoic tumour within the iliopsoas muscle. Ultrasound-guided biopsy was found to be compatible with myositis. After oral therapy with steroids, improvement could be documented by serial ultrasound follow-up as the size of the tumour was definitely regressing. CONCLUSION: Focal myositis of the iliopsoas muscle is a rare entity which may mimic a tumoural lesion. Imaging findings may not be conclusive, and US-guided biopsy is recommended to rule out a malignant mass. Ultrasound seems to be the most cost-effective method for diagnosis, image guided biopsy and follow-up.