RESUMEN
This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.
Asunto(s)
Cuidados Críticos/normas , Neoplasias/terapia , Aloinjertos , Cuidados Críticos/métodos , Enfermedad Crítica , Manejo de la Enfermedad , Educación Médica Continua , Trasplante de Células Madre Hematopoyéticas , Humanos , Control de Infecciones/métodos , Control de Infecciones/normas , Oncología Médica/educación , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/etiología , Neoplasias/complicaciones , Puntuaciones en la Disfunción de Órganos , Cuidados Paliativos/normas , Admisión del Paciente/normas , Grupo de Atención al Paciente , Pronóstico , Respiración Artificial , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Índice de Severidad de la Enfermedad , Cuidado Terminal/normasAsunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Leucemia Linfocítica Crónica de Células B/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Ensayos Clínicos Fase II como Asunto , Ensayos Clínicos Fase III como Asunto , Femenino , Identidad de Género , Humanos , Inmunoterapia/métodos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
High mortality rates of invasive fungal disease (IFD), especially invasive aspergillosis (IA), in immunocompromised haematological patients and current diagnostic limitations require improvement of detection of fungal pathogens by defining the optimal use of biomarkers and clinical samples. Concurrent bronchoalveolar lavage (BAL) and peripheral blood samples of 99 haematological patients with suspected IFD were investigated within a multicentre prospective study. Diagnostic performance of a galactomannan (GM) enzyme immune assay (EIA), a 1,3-ß-D-glucan assay (BDG), an Aspergillus PCR, and a multifungal DNA-microarray (Chip) alone or in combination were calculated. IFD were classified as proven (n=3), probable (n=34), possible (n=33), and no IFD (n=29) according to EORTC/MSG criteria. GM, PCR, and Chip showed superior diagnostic performance in BAL than in blood, whereas specificity of BDG in BAL was poor (48% (14/29)). The combination of GM (BAL) with BDG (blood) showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and DOR (diagnostic odds ratio) of 92% (34/37), 93% (27/29), 94%, 90%, and 153.0, respectively. Combining GM (BAL) with PCR (BAL) showed convincing diagnostic potential for diagnosing IA with sensitivity, specificity, PPV, NPV, and DOR of 85% (17/20), 97% (28/29), 94%, 90%, and 158.7. Addition of the DNA-microarray resulted in further detection of two mucormycetes infections. In 1 out of 15 Aspergillus DNA-positive samples a triazole resistance-mediating Cyp51A mutation was found. Combination of biomarkers is superior to their sole use in diagnosing IFD, particularly IA. Integrating blood and BAL samples into a diagnostic algorithm is an advantageous approach.
Asunto(s)
Aspergilosis/diagnóstico , Líquido del Lavado Bronquioalveolar/microbiología , Infecciones Fúngicas Invasoras/diagnóstico , Técnicas Microbiológicas/métodos , Técnicas de Diagnóstico Molecular/métodos , Aspergilosis/sangre , Aspergillus/efectos de los fármacos , Aspergillus/genética , Azoles/farmacología , Galactosa/análogos & derivados , Humanos , Infecciones Fúngicas Invasoras/sangre , Mananos/análisis , Reacción en Cadena de la Polimerasa Multiplex/métodos , Análisis de Secuencia por Matrices de Oligonucleótidos/métodos , Estudios Prospectivos , Sensibilidad y Especificidad , beta-Glucanos/análisisRESUMEN
Hypercalcemia is in many cases a symptom of advanced stage malignant diseases due to increased resorption and reduced secretion. A slightly increased hypercalcemia is mostly asymptomatic but high calcium levels are associated with neurological, gastrointestinal, cardiac and renal symptoms. Important diagnostic tools are the determination of serum albumin and ionized calcium levels. Therapeutic intervention depends on the clinical symptoms as well as calcium levels. Furthermore, increase over time and duration of hypercalcemia has to be taken into account. The principles of treatment are sufficient fluid replacement and maintaining adequate diuresis. In addition, calcitonin, bisphosphonates and steroids are effective and widely used to decrease plasma calcium levels.
Asunto(s)
Calcio/sangre , Diuréticos/uso terapéutico , Fluidoterapia , Hipercalcemia/diagnóstico , Hipercalcemia/terapia , Neoplasias/complicaciones , Albúmina Sérica/análisis , Biomarcadores/sangre , Humanos , Hipercalcemia/etiología , Neoplasias/diagnóstico , Neoplasias/terapiaRESUMEN
Allogeneic stem cell transplantation (SCT) is best performed with an HLA-identical sibling donor (matched related donor, MRD) to reduce the risk of early complications such as acute graft-vs.-host disease (aGvHD). However, as only about 30% of recipients have an MRD for this potentially curative approach, the use of family donors with one or two mismatches in the HLA-antigens (mismatch related donor, MMRD) or fully matched unrelated donors (MUD) (''alternative donors'') has been introduced in the allogeneic SCT setting in recent years. To evaluate the feasibility of allogeneic SCT from alternative donors by using peripheral blood stem cells (PBSC) we initiated a prospective, phase II study in 1996. From April 1996 to July 1998, 18 patients with various hematological malignancies underwent allogeneic SCT from alternative donors (two patients with MUD and 16 patients with MMRD). All patients received stable engraftment and none of the patients had graft rejection. The rate of aGvHD (grades II-IV) and the relapse rate at last follow-up (seven to nine yr after SCT) were with 40% and 24%, respectively, comparable with those found in patients receiving allogeneic SCT from MRD. However, five yr after allogeneic SCT only 17% were alive, which was mainly due to the treatment-related mortality (TRM) rate of 59%. We conclude that allogeneic PBSC transplantation by using alternative donors is associated with an unsatisfying long-term TRM rate. The significance of TRM and particular late deaths has to be evaluated further in this transplantation setting.
Asunto(s)
Leucemia/terapia , Trasplante de Células Madre , Donantes de Tejidos , Antígenos CD/sangre , Familia , Femenino , Filgrastim , Estudios de Seguimiento , Factor Estimulante de Colonias de Granulocitos/uso terapéutico , Prueba de Histocompatibilidad , Humanos , Leucemia/mortalidad , Masculino , Síndromes Mielodisplásicos/mortalidad , Síndromes Mielodisplásicos/terapia , Proteínas Recombinantes , Análisis de Supervivencia , Factores de Tiempo , Trasplante HomólogoRESUMEN
According to recent reports, fast engraftment with minimal transplant-related toxicity and mortality (TRT, TRM) can be achieved by using reduced-intensity preparative regimens in allogeneic hematopoietic stem cell transplantation (HSCT). We report our experience with related (39%) and unrelated (61%) HSCT in 44 high risk patients (AML, ALL, CML, CLL) receiving either busulfan/fludarabine or busulfane/fludarabine/ATG or TBI/fludarabine as reduced-intensity preparative regimens. Organ toxicity was minimal with mild mucositis and no major bleeding. Acute GVHD was recorded in 64% of the patients. Twenty-three patients achieved complete remission after transplantation, and complete chimerism was obtained in all patients with stable engraftment (35 patients). Twenty-nine patients died: 15 due to relapse/progression, 14 due to TRM. Survival with median follow-up of 18.5 months was significantly better in patients with matched related transplants compared to patients with other transplants. However, there was no difference between related and unrelated transplants with regard to engraftment, TRM and GVHD. In conclusion, our results in high-risk patients transplanted in CR or with smoldering leukemia from a related donor are encouraging, although a longer follow-up and a larger group of patients is needed in order to evaluate the role of different reduced-intensity preparative regimens in unrelated and related HSCT.
Asunto(s)
Trasplante de Células Madre Hematopoyéticas/métodos , Acondicionamiento Pretrasplante/métodos , Vidarabina/análogos & derivados , Adulto , Anciano , Suero Antilinfocítico/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/toxicidad , Busulfano/administración & dosificación , Terapia Combinada , Femenino , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Trasplante de Células Madre Hematopoyéticas/mortalidad , Humanos , Leucemia/complicaciones , Leucemia/mortalidad , Leucemia/terapia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Acondicionamiento Pretrasplante/efectos adversos , Acondicionamiento Pretrasplante/mortalidad , Trasplante Homólogo , Resultado del Tratamiento , Vidarabina/administración & dosificación , Irradiación Corporal TotalAsunto(s)
Enfermedad Injerto contra Huésped/prevención & control , Inmunosupresores/uso terapéutico , Ácido Micofenólico/uso terapéutico , Trasplante de Células Madre/efectos adversos , Enfermedad Aguda , Prueba de Histocompatibilidad , Humanos , Ácido Micofenólico/análogos & derivados , Factores de TiempoAsunto(s)
Antiinfecciosos/uso terapéutico , Infecciones Bacterianas/epidemiología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Micosis/epidemiología , Complicaciones Posoperatorias , Virosis/epidemiología , Antibacterianos/uso terapéutico , Antifúngicos/uso terapéutico , Antivirales/uso terapéutico , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/tratamiento farmacológico , Fiebre/etiología , Humanos , Recuento de Leucocitos , Persona de Mediana Edad , Micosis/diagnóstico , Micosis/tratamiento farmacológico , Neutropenia/complicaciones , Neutrófilos , Neumonía por Pneumocystis/diagnóstico , Neumonía por Pneumocystis/tratamiento farmacológico , Complicaciones Posoperatorias/tratamiento farmacológico , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Toxoplasmosis/diagnóstico , Toxoplasmosis/terapia , Trasplante Homólogo , Virosis/diagnóstico , Virosis/tratamiento farmacológicoRESUMEN
BACKGROUND: Severe acute graft-versus-host disease (aGVHD) of the gut is a serious and frequent posttransplantation event associated with a high mortality rate. We report on our experience with factor XIII replacement in patients with severe aGVHD of the bowel after allogeneic hematopoietic stem cell transplantation. METHODS: Twenty-seven patients after allogeneic stem cell transplantation and severe aGVHD of the gut were enrolled. All patients suffered from bloody diarrhea that required packed red blood cell infusions. All patients received high-dose immunosuppression in combination with coagulation factor XIII (5,000 units initially, followed by 20 IU/kg body weight three times a day) for up to 3 weeks. RESULTS: After 8 days of factor XIII replacement and unchanged high-dose immunosuppression, we observed a significant reduction in the red blood cell requirement of 21 patients. CONCLUSION: We conclude that factor XIII replacement might be a useful supplementation in the treatment of aGVHD of the bowel.
Asunto(s)
Factor XIII/uso terapéutico , Enfermedad Injerto contra Huésped/terapia , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Enfermedades Intestinales/terapia , Enfermedad Aguda , Adolescente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trasplante HomólogoAsunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/tratamiento farmacológico , Citosina/uso terapéutico , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Organofosfonatos , Compuestos Organofosforados/uso terapéutico , Trasplante Homólogo/efectos adversos , Antivirales/administración & dosificación , Antivirales/farmacología , Cidofovir , Citomegalovirus/efectos de los fármacos , Citomegalovirus/aislamiento & purificación , Citomegalovirus/fisiología , Infecciones por Citomegalovirus/etiología , Infecciones por Citomegalovirus/transmisión , Citosina/administración & dosificación , Citosina/análogos & derivados , Citosina/farmacología , Farmacorresistencia Microbiana , Quimioterapia Combinada , Foscarnet/uso terapéutico , Ganciclovir/administración & dosificación , Ganciclovir/uso terapéutico , Neoplasias Hematológicas/terapia , Humanos , Síndromes Mielodisplásicos/terapia , Compuestos Organofosforados/administración & dosificación , Compuestos Organofosforados/farmacología , Estudios Prospectivos , Insuficiencia del Tratamiento , Viremia/tratamiento farmacológico , Viremia/etiología , Activación ViralRESUMEN
The clinical results in 107 patients receiving a peripheral blood stem cell (PBSC) graft mobilized by granulocyte colony-stimulating factor (G-CSF) from HLA-A, -B, and -DR-compatible unrelated donors were compared to 107 matched controls receiving unrelated bone marrow (BM) transplants. Engraftment was achieved in 94% of the patients in both groups. The PBSC graft contained significantly more nucleated cells, CD34(+), CD3(+), and CD56(+) cells (P <.001), and resulted in a significantly shorter time-to-neutrophil (15 versus 19 days) and platelet engraftment (20 versus 27 days), compared to the BM control group (P <.001). Probabilities of acute graft-versus-host disease (GVHD) grades II to IV were 35% and 32% (not significant [NS]) and of chronic GVHD 61% and 76% (NS) in the PBSC and BM groups, respectively. There was no difference between the 2 groups in bacteremia, cytomegalovirus reactivation or disease, and fungal infection. The 3-year transplant-related mortality (TRM) rates were 42% in the PBSC group and 31% in the BM controls (P =.7) and the survival rates were 46% and 51%, respectively. The probability of relapse was 25% and 31% in both groups (NS), resulting in disease-free survival rates of 43% in the PBSC group and 46% in the BM controls (NS). In the multivariate analysis, early disease, acute GVHD grade 0 to I, and presence of chronic GVHD were independent factors associated with a better disease-free survival in this study. PBSC from HLA-compatible unrelated donors can be used safely as an alternative to BM for stem cell transplantation.
Asunto(s)
Donantes de Sangre , Trasplante de Médula Ósea/efectos adversos , Trasplante de Médula Ósea/mortalidad , Enfermedad Injerto contra Huésped/etiología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Trasplante de Células Madre Hematopoyéticas/mortalidad , Adolescente , Adulto , Infecciones Bacterianas/etiología , Transfusión Sanguínea , Niño , Preescolar , Supervivencia sin Enfermedad , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Micosis/etiología , Recurrencia , Análisis de SupervivenciaAsunto(s)
Inmunosupresores/sangre , Ácido Micofenólico/sangre , Profármacos/metabolismo , Trasplante de Médula Ósea , Cromatografía Líquida de Alta Presión , Estabilidad de Medicamentos , Trasplante de Corazón , Humanos , Hidrólisis , Inmunosupresores/administración & dosificación , Infusiones Intravenosas , Ácido Micofenólico/administración & dosificación , Ácido Micofenólico/análogos & derivados , Profármacos/administración & dosificaciónAsunto(s)
Trasplante de Médula Ósea/inmunología , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Trasplante de Células Madre Hematopoyéticas , Inmunosupresores/uso terapéutico , Leucemia/terapia , Ácido Micofenólico/uso terapéutico , Enfermedad Aguda , Adulto , Enfermedad Crónica , Ciclosporina/uso terapéutico , Femenino , Enfermedad Injerto contra Huésped/prevención & control , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Prueba de Histocompatibilidad , Humanos , Terapia de Inmunosupresión/métodos , Inmunosupresores/efectos adversos , Leucemia/mortalidad , Masculino , Metotrexato/uso terapéutico , Persona de Mediana Edad , Ácido Micofenólico/efectos adversos , Ácido Micofenólico/análogos & derivados , Núcleo Familiar , Recurrencia , Estudios Retrospectivos , Tasa de Supervivencia , Irradiación Corporal TotalAsunto(s)
Anticuerpos Monoclonales/uso terapéutico , Trasplante de Médula Ósea/inmunología , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Enfermedad Injerto contra Huésped/prevención & control , Trasplante de Células Madre Hematopoyéticas , Inmunoglobulina G/uso terapéutico , Inmunosupresores/uso terapéutico , Ácido Micofenólico/uso terapéutico , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales Humanizados , Citomegalovirus/fisiología , Infecciones por Citomegalovirus/fisiopatología , Daclizumab , Quimioterapia Combinada , Humanos , Inmunoglobulina G/efectos adversos , Inmunosupresores/efectos adversos , Ácido Micofenólico/análogos & derivados , Activación ViralRESUMEN
Acute and chronic GvHD are still a major concern in allogeneic hematopoietic stem cell transplantation, still contributing substantially to morbidity and mortality in this therapeutic procedure. Over the past decade, many advances have been made with regard to the prevention and treatment of GvHD using various drugs such as cyclosporine A, FK506, mycophenolate mofetil and/or monoclonal IL-2 receptor antagonists. Despite these measurements with regard to the prevention of acute GvHD, it is very difficult to treat these clinical conditions successfully. However, if patients do not experience any GvHD often the desired effect of graft versus leukemia (GvL) remains absent increasing the probability of a relapse, in particular, in patients transplanted, which are considered at higher risk for relapse. At the present time, new strategies in the prevention of acute GvHD are in progress in particular the use of genetic manipulated donor T cells expressing suicide genes. Further clinical and laboratory studies are required in order to improve the prevention and, in particular, the therapy of established GvHD.
Asunto(s)
Enfermedad Injerto contra Huésped/terapia , Terapia Combinada , Enfermedad Injerto contra Huésped/diagnóstico , Enfermedad Injerto contra Huésped/epidemiología , Trasplante de Células Madre Hematopoyéticas , Humanos , Índice de Severidad de la EnfermedadRESUMEN
Hematopoietic stem cell transplantation (HSCT) is a treatment option for autoimmune diseases but can also cause clinical features similar to those of autoimmune diseases. In some of these cases the autoimmune-like condition is associated with autoimmune cytopenia, a complication that can be unresponsive to established treatment strategies and which may be fatal. The majority of cases reported on immune hemolytic anemia have been of alloimmune origin due to ABO red blood cell antigen incompatibilities between donor and recipient. We now report a patient with a lupus-like syndrome, presenting with severe thrombocytopenia and hemolytic anemia 9 months after HLA-mismatch, ABO compatible-related PBSCT who experienced no response to high-dose steroids, but who had a sustained response to repeated IvIG therapy.
Asunto(s)
Anemia Hemolítica/tratamiento farmacológico , Enfermedad Injerto contra Huésped/diagnóstico , Trombocitopenia/tratamiento farmacológico , Trasplante Homólogo/efectos adversos , Adulto , Anemia Hemolítica/diagnóstico , Anemia Hemolítica/etiología , Enfermedades Autoinmunes/diagnóstico , Enfermedades Autoinmunes/etiología , Diagnóstico Diferencial , Supervivencia sin Enfermedad , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Enfermedad Injerto contra Huésped/etiología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Prueba de Histocompatibilidad/efectos adversos , Humanos , Inmunoglobulinas Intravenosas/administración & dosificación , Lupus Vulgar/diagnóstico , Masculino , Recuento de Plaquetas , Trombocitopenia/diagnóstico , Trombocitopenia/etiologíaRESUMEN
Competitive inhibition of interleukin 2-dependent lymphocytes by daclizumab demonstrates some beneficial effects in the treatment of graft-versus-host disease (GVHD). Sixteen patients with steroid refractory GVHD received daclizumab (1 mg/kg BW) on d 1, 2 (-5), 7, 14 and 21. Twelve patients suffered from grade III-IV acute GVHD and four patients from extensive chronic GVHD. Responses were observed in nine patients (six acute, three chronic GVHD). Fourteen out of 16 patients acquired infections during daclizumab treatment and three deaths were infection related. Daclizumab demonstrates limited activity and is associated with an increased incidence of infectious complications.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Inmunoglobulina G/uso terapéutico , Inmunosupresores/uso terapéutico , Receptores de Interleucina-2/inmunología , Enfermedad Aguda , Adulto , Anticuerpos Monoclonales Humanizados , Enfermedad Crónica , Daclizumab , Femenino , Trasplante de Células Madre Hematopoyéticas , Humanos , Hepatopatías/tratamiento farmacológico , Hepatopatías/inmunología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Enfermedades de la Piel/tratamiento farmacológico , Enfermedades de la Piel/inmunología , Insuficiencia del TratamientoRESUMEN
We compared the outcomes in patients receiving unrelated peripheral blood stem cell transplants (PBSCT) with those receiving bone marrow transplants (BMT) in a matched pair analysis. Seventy-four patients with hematological malignancies with HLA-matched (77%) and mismatched (23%) donors were analyzed in this study. Thirty-four patients (45%) were considered as high risk patients. Sixty-eight patients received standard conditioning regimens with Bu/Cy or TBI/Cy. Six patients received an intensified conditioning regimen with the addition of etoposide, thiotepa or melphalan. GVHD prophylaxis consisted of prednisolone, cyclosporine and methotrexate. Groups were matched for patient, donor, transplant characteristics and HLA compatibility. Peripheral blood stem cell collection led to the collection of a higher number of CD34+ and CD3+ cells in comparison to bone marrow collection. Leukocyte engraftment in the PBSCT group occurred in 14 days (median; range 6-26 days) and in the BMT group in 19 days (range 9-29 days; P < 0.02). The time of platelet engraftment did not differ significantly. The incidence of grades II-lV acute GVHD in the group of HLA-identical patients was 35% in the PBSCT group and 25% in the BMT group (P < 0.33, log-rank). However, there was a significant difference (P < 0.05, log-rank) in incidence and time to onset of acute GVHD II-IV comparing all patients, including the 17 mismatched transplants. Disease-free survival was 51% (19 patients) with a median of 352 days and 59% (21 patients) with a median of 760 days for PBSC and BMT transplants, respectively. In conclusion, our results indicate that allogeneic PBSCT led to significantly faster leukocyte engraftment but is associated with a higher incidence and more rapid onset of severe acute GVHD comparing all patients, including the 17 mismatched transplants. However, the incidence of severe acute GVHD in HLA-identical patients was not different between the PBSCT and BMT groups.
Asunto(s)
Trasplante de Células Madre Hematopoyéticas/normas , Adolescente , Adulto , Donantes de Sangre , Trasplante de Médula Ósea/efectos adversos , Trasplante de Médula Ósea/mortalidad , Trasplante de Médula Ósea/normas , Supervivencia sin Enfermedad , Estudios de Factibilidad , Femenino , Supervivencia de Injerto , Enfermedad Injerto contra Huésped , Neoplasias Hematológicas/complicaciones , Neoplasias Hematológicas/terapia , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Trasplante de Células Madre Hematopoyéticas/mortalidad , Prueba de Histocompatibilidad , Humanos , Infecciones/etiología , Infecciones/microbiología , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Recurrencia , Resultado del TratamientoRESUMEN
Toxoplasmosis is a rare but often fatal complication that occurs after patients undergo allogeneic hematopoietic stem cell transplant. At our institution, toxoplasmosis was diagnosed in 8 of 301 patients who received stem cell transplants. Disseminated toxoplasmosis with a rapid fatal course was observed in 2 patients. Six patients had cerebral toxoplasmosis diagnosed on the basis of neurological signs and observation of the patients' mental confusion, seizures, and typical lesions (which were assessed by computed tomography, magnetic resonance imaging, or both). Seroconversion of antitoxoplasma immunoglobulin and a discovery of toxoplasma deoxyribonucleic acid in the cerebrospinal fluid (confirmed by use of polymerase chain reaction) were documented in all patients. Treatment consisted of clindamycin therapy (for 2 patients) and of pyrimethamine-clindamycin therapy, sulfadiazine therapy, or both (for 5 patients). Patients showed improvement after therapy, as assessed by clinical and radiological means. Three of 8 patients survive-1 without any residual neurological symptoms and 2 with minimal neurological symptoms.
Asunto(s)
Clindamicina/uso terapéutico , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Pirimetamina/uso terapéutico , Sulfadiazina/uso terapéutico , Toxoplasmosis Cerebral/tratamiento farmacológico , Toxoplasmosis Cerebral/etiología , Adulto , Animales , Anticuerpos Antiprotozoarios/inmunología , Quimioterapia Combinada , Femenino , Humanos , Inmunoglobulina M/inmunología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Toxoplasma/aislamiento & purificación , Toxoplasmosis Cerebral/diagnóstico , Trasplante HomólogoRESUMEN
GVHD continues to be a major complication after allogeneic hematopoietic stem cell transplantation even when the recipient is given immunosuppression for the prophylaxis of this severe disease. There have been many advances in the prevention and treatment of GVHD, using compounds such as cyclosporine, FK506, mycophenolate mofetil or monoclonal IL-2 receptor antagonist. New strategies seem to include sequential therapy involving the blocking of both endogenous cytokines and alloreactive donor cells. However, further clinical and laboratory studies are needed in order to improve the therapy of established GVHD.