Addition of doxycycline to ciprofloxacin for infection prophylaxis during autologous stem cell transplants for multiple myeloma.

BACKGROUND: The most commonly used antibacterial prophylaxis during autologous stem cell transplants (ASCT) for multiple myeloma (MM) involves a fluoroquinolone, such as ciprofloxacin or levofloxacin. We assessed the impact of adding doxycycline to ciprofloxacin as routine antibacterial prophylaxis in these patients. METHODS: We retrospectively reviewed electronic medical records and our ASCT database to analyze rates and types of bacterial infections in MM patients who underwent ASCT in our institution. RESULTS: Among 419 patients, 118 received ciprofloxacin alone (cipro group), and 301 ciprofloxacin and doxycycline (cipro-doxy group). Neutropenic fever (NF) developed in 63 (53%) and 108 (36%) patients of the cipro and cipro-doxy groups, respectively (p = 0.010). The number of documented bacteremic episodes was 13 (11%) and 14 (4.7%) in the two groups, respectively (p = 0.017). Antimicrobial resistance and Clostridium difficile infections were uncommon. Transplant-related mortality was 1% in both groups. CONCLUSIONS: The addition of doxycycline to standard prophylaxis with ciprofloxacin seems to reduce the number of NF episodes and documented bacterial infections in patients with MM undergoing ASCT, without increasing rate of serious complications.

BU and CY as conditioning regimen for autologous transplant in patients with multiple myeloma.

High-dose melphalan is considered the current standard of care among the preparative regimens used in peripheral blood autologous SCT (ASCT) for multiple myeloma (MM). We report the results of a single ASCT in 79 MM patients using the BU/CY conditioning regimen, with BU 1 mg/kg p.o. or 0.8 mg/kg i.v. every 6 h x 16 doses, and CY 60 mg/kg per day i.v. for 2 days. ASCT was carried out in first (62%) or subsequent remission/refractory disease (38%). For an overall RR of 86%, 48 and 20 patients achieved PR and CR, respectively. At a median follow-up of 41 months (range 2-132 months), the estimated median OS and PFS were 45 months (95% confidence interval (CI)=38-92) and 20 months (95% CI=15-25), respectively. The BU/CY regimen was well tolerated, and transplant-related mortality was 4%. Clinical outcomes of the BU/CY regimen are not superior to those obtained in historical controls with high-dose melphalan followed by a single ASCT. Therefore, considering even the greater complexity of administration of the BU/CY regimen compared with that of single-agent melphalan, we believe the latter should remain the conditioning regimen of choice for ASCT in MM.

Proinflammatory syndrome mimicking acute rheumatoid arthritis in a patient with Waldenstrom's macroglobulinemia treated with rituximab.

Acute adverse reactions to rituximab treatment have been previously described in association with initiation of therapy. We describe a novel delayed proinflammatory syndrome which occurred at, or near, the completion of a 4-week dose-intense course with rituximab in a 58-year-old man with Waldenstrom's macroglobulinemia, and which mimicked acute rheumatoid arthritis affecting the hands and the knees. This syndrome was associated with an increase in acute phase reactants, and the clinical symptoms were temporally reproducible, although decreased in severity, with subsequent rituximab therapy, and each time responded to prednisone. This is the first report on an acute rheumatoid-like flare occurring in association with rituximab therapy. This phenomenon is all the more intriguing in that rituximab has been used to treat refractory rheumatoid arthritis. Potential etiologic mechanisms and management of this newly described phenomenon are discussed.

Human herpesvirus 8 genome is not found in whole bone marrow core biopsy specimens of patients with plasma cell dyscrasias.

Recently, molecular evidence of the gamma herpesvirus, human herpesvirus 8 (HHV-8), was found in the nonmalignant bone marrow stromal cells of patients with multiple myeloma using a polymerase chain reaction (PCR)-based assay. Other investigators have been unable to confirm either the presence of HHV-8 using molecular techniques or serologic evidence of prior infection with HHV-8. In order to maximize the likelihood of detection of small quantities of the virus and minimize the risk of potential nucleic acid contamination, we used entire bone marrow biopsy core specimens for DNA extraction and amplification. These specimens included both malignant plasma cells and bone marrow stromal cells and were subjected to minimal manipulation prior to DNA extraction and PCR. We tested eight patients with various plasma cell dyscrasias and compared them to negative controls with non-Hodgkin's lymphoma using standard PCR assays utilizing the KS330(233)primers and probe for HHV-8. This assay is reproducibly positive in Kaposi's sarcoma tissue. We found no evidence of HHV-8 DNA in either the lymphoma controls or the samples from patients with the plasma cell dyscrasias using these methods. We conclude that HHV-8 is unlikely to play a major role in the pathogenesis of the plasma cell dyscrasias in the majority of patients with these diseases. This report adds to the body of evidence that HHV-8 is not associated with plasma cell dyscrasias like multiple myeloma.

Concurrent pernicious anemia and myelodysplastic syndrome.

Megaloblastic anemia (MA) due to vitamin B12 deficiency is a reversible form of ineffective hematopoiesis. Myelodysplastic syndrome (MDS) is an acquired, irreversible disorder of ineffective hematopoiesis, characterized by stem cell dysfunction as a consequence of DNA damage manifested in part by karyotype anomalies. Importantly, MA and MDS are generally considered mutually exclusive diagnoses. We report the case of a 73-year-old woman with a profound macrocytic anemia, monocytosis and neurologic symptoms. Low cobalamin levels and the presence of anti-intrinsic-factor antibodies definitively established a diagnosis of pernicious anemia. Replacement therapy resulted in resolution of neurologic findings and macrocytosis; however, the anemia and monocytosis persisted. Bone marrow biopsy revealed trilineage myelodysplasia, which together with the peripheral monocytosis suggested a diagnosis of chronic myelomonocytic leukemia. Karyotype analysis revealed a clone with 45, XX, +der(1;7)(q10;p10)-7 [20]. Eighteen months after documented vitamin B12 replenishment her MDS transformed to terminal acute myeloid leukemia with the same clonal abnormality. Reversible cytogenetic abnormalities have been observed with MA, occasionally including karyotypes typically associated with MDS or myeloid leukemias. These abnormalities, like the anemia, resolve with vitamin replacement. This case suggests that MA and MDS can occur simultaneously; clinicians should be aware that this phenomenon occurs. Whether acquired karyotype abnormalities from the MA were related to the MDS and subsequent myeloid leukemia in this woman is a speculative but intriguing consideration that is discussed.

Cutaneous transfection and immune responses to intradermal nucleic acid vaccination are significantly enhanced by in vivo electropermeabilization.

Naked DNA injection with electropermeabilization (EP) is a promising method for nucleic acid vaccination (NAV) and in vivo gene therapy. Skin is an ideal target for NAV due to ease of administration and the accessibility of large numbers of antigen-presenting cells within the tissue. This study demonstrates that in vivo skin EP may be used to increase transgene expression up to an average of 83-fold relative to naked DNA injection (50 microg DNA per dose, P < 0.005). Transfected cells were principally located in dermis and included adipocytes, fibroblasts, endothelial cells, and numerous mononuclear cells with dendritic processes in a porcine model. Transfected cells were also observed in lymph nodes draining electropermeabilized sites. A HBV sAg-coding plasmid was used to test skin EP-mediated NAV in a murine model. Analysis of humoral immune responses including immunoglobulin subclass profiles revealed strong enhancement of EP-mediated NAV relative to naked DNA injection, with a Th1-dominant, mixed-response pattern compared to immunization with HBV sAg protein that was exclusively Th2 (P = 0.02). Applications for these findings include NAV-based modulation of immune responses to pathogens, allergens, and tumor-associated antigens and the modification of tolerance.

Theory and in vivo application of electroporative gene delivery.

Efficient and safe methods for delivering exogenous genetic material into tissues must be developed before the clinical potential of gene therapy will be realized. Recently, in vivo electroporation has emerged as a leading technology for developing nonviral gene therapies and nucleic acid vaccines (NAV). Electroporation (EP) involves the application of pulsed electric fields to cells to enhance cell permeability, resulting in exogenous polynucleotide transit across the cytoplasmic membrane. Similar pulsed electrical field treatments are employed in a wide range of biotechnological processes including in vitro EP, hybridoma production, development of transgenic animals, and clinical electrochemotherapy. Electroporative gene delivery studies benefit from well-developed literature that may be used to guide experimental design and interpretation. Both theory and experimental analysis predict that the critical parameters governing EP efficacy include cell size and field strength, duration, frequency, and total number of applied pulses. These parameters must be optimized for each tissue in order to maximize gene delivery while minimizing irreversible cell damage. By providing an overview of the theory and practice of electroporative gene transfer, this review intends to aid researchers that wish to employ the method for preclinical and translational gene therapy, NAV, and functional genomic research.

Efficient nonviral cutaneous transfection.

Preclinical in vivo rodent, porcine, and primate experiments aimed at enhancing nonviral transgene delivery to skin have been performed. These investigations have identified a compound (aurintricarboxylic acid or ATA) that enhances transfection activity of "naked" plasmid and pulsed electrical fields (electroporation or EP) that synergistically boosts transgene expression to an average of 115-fold more than that observed with free DNA (P < 0.00009). When plasmid is intradermally injected with or without ATA, the transfected cells are typically restricted to the epidermis. However, when electroporation is added after the same injection, larger numbers of adipocytes and fibroblasts and numerous dendritic-like cells within the dermis and subdermal tissues are transfected. This advance creates new opportunities for cutaneous gene therapy and nucleic acid vaccine development.

Safety and immunogenicity testing of an intranasal group B meningococcal native outer membrane vesicle vaccine in healthy volunteers.

An intranasal vaccine composed of native outer membrane vesicles (NOMV) not exposed to detergent or denaturing agents was prepared from the group B meningococcal strain 9162 SynX(-)(-:15:P1.3:P5.10,11:L3,7,9) and tested in 32 healthy adult volunteers. Four groups of 8 volunteers were vaccinated intranasally with three doses of vaccine. The vaccine was very well tolerated in all dosing groups, despite the presence of lipo-oligosaccharide in the vaccine at a level of 25% relative to protein. The antibody response as measured by ELISA in serum, saliva and nasal wash fluids was relatively low in all 4 groups, but the induced serum antibodies had strong bactericidal activity. Persistent bactericidal antibodies (> or =4-fold increase) were produced in 75% of the recipients. Some of the bactericidal antibodies were cross reactive against divergent group B strains. Most of the bactericidal antibodies appeared to be specific for PorA and L3,7,9 LOS. The vaccine also produced a local antibody response which was detected in the nasal wash fluids of volunteers. These data suggest that nasal immunization with NOMV is a safe and effective approach to induce systemic and local immunity against the group B meningococcus and deserves further study.

Dengue among United Nations mission in Haiti personnel, 1995: implications for preventive medicine.

The incidence of dengue infections has been increasing in the Caribbean, and cases have been identified among successive deployments of multinational peacekeepers to Haiti (1994-1997). In the absence of an effective vaccine or chemoprophylaxis to prevent dengue fever, vector-control operations and use of personal protection measures to prevent arthropod bites are the most effective means of limiting disease transmission. During our 5-month deployment as part of the United Nations Mission in Haiti, 79 cases of recent dengue fever were identified among 249 patients (32%) presenting with febrile illness to the 86th Combat Support Hospital. Further investigation revealed low unit readiness to perform standard vector-control activities and poor individual adherence to measures to prevent arthropod bites. Command enforcement of existing field preventive medicine doctrine is essential to prevent casualties caused by dengue, other arthropod-borne infections, and nuisance arthropod bites during military deployments.

Medical surveillance of multinational peacekeepers deployed in support of the United Nations Mission in Haiti, June-October 1995.

BACKGROUND: Multinational peacekeepers, both military and civilian, often deploy to areas of the world where significant health threats are endemic and host country public health systems are inadequate. Medical surveillance of deployed personnel enables leaders to better direct health care resources to prevent and treat casualties. Over a 5-month period, June to October 1995, a medical surveillance system (MSS) was implemented in support of the United Nations Mission in Haiti (UNMIH). Information obtained from this system as well as lessons learned from its implementation and management may help decrease casualty rates during future multinational missions. METHODS: Over 90% of UNMIH personnel (80% military from over 11 countries and 20% civilian from over 70 countries) stationed throughout Haiti participated in the MSS. A weekly standardized reporting form included the number of new outpatient visits by disease and non-battle injury (DNBI) category and number of personnel supported by each participating UN medical treatment facility (MTF). Previously, medical reporting consisted of simple counts of patient visits without distinguishing between new and follow-up visits. Weekly incidence rates were determined and trends compared within and among reporting sites. The diagnoses and numbers of inpatient cases per week were only monitored at the 86th Combat Support Hospital, the facility with the most sophisticated level of health care available to UN personnel. RESULTS: The overall outpatient DNBI incidence rate ranged from 9.2% to 13% of supported UN personnel/week. Of the 14 outpatient diagnostic categories, the three categories consistently with the highest rates included orthopaedic/injury (1.6-2.5%), dermatology (1.3-2.2%), and respiratory (0.9-2.2%) of supported UN personnel/week. The most common inpatient discharge diagnoses included suspected dengue fever (22.3%), gastro-enteritis (15%), and other febrile illness (13.5%). Of the 249 patients who presented with a febrile illness, 79 (32%) had serological evidence of recent dengue infection. Surveillance results helped lead to interventions that addressed issues related to field sanitation, potable water, food preparation and vector control. CONCLUSIONS: Despite hurdles associated with distance, language, and communications, the MSS was a practical and effective tool for UNMIH force protection. UN requirements for standardized medical surveillance during deployments should be developed and implemented. Furthermore, planners should recognize that if ongoing medical surveillance and related responses are to be effective, personnel should be trained prior to deployment and resources dedicated to a sustained effort in theatre.

Laboratory diagnosis of acute dengue fever during the United Nations Mission in Haiti, 1995-1996.

We evaluated laboratory methods to confirm a clinical diagnosis of dengue. Acute sera were collected from personnel (n = 414) supporting the United Nations Mission in Haiti and presenting with febrile illness consistent with dengue fever or no apparent underlying cause. Dengue virus was recovered from 161 of 379 acute sera by inoculation into C6/36 cell culture. While 93 of 414 acute sera had detectable IgM antibodies, the IgM capture ELISA (MAC ELISA) had a sensitivity of only 13% compared with the virus isolation gold standard. If presumptive dengue fever cases were identified by both virus isolation and the presence of IgM, virus isolation and the MAC ELISA had clinical sensitivities of 69% and 40%, respectively. This study suggests that a combination of laboratory methods that target virus or subviral components as well as anti-viral IgM antibodies may be necessary for sensitive laboratory diagnosis with acute sera.

Seroprevalence of hepatitis E virus among United Nations Mission in Haiti (UNMIH) peacekeepers, 1995.

Information about the prevalence of hepatitis E virus (HEV) infection is sparse in many countries. Following the identification of four cases of acute HEV infection among Bangladeshi soldiers, a serologic survey was conducted to determine the prevalence of HEV infection among other peacekeepers from the United Nations Mission in Haiti (UNMIH) and Haitian civilians. Of the 981 participants in the survey, 876 were soldiers from eight UNMIH-participating countries representing Asia, Africa, and the Americas, and 105 were Haitian civilians. The prevalence of HEV infection by country (from highest to lowest) included Pakistan (62%), India (37%), Nepal (37%), Bangladesh (27%), Djibouti (13%), Honduras (6%), Guatemala (5%), Haiti (3%), and the United States (2%). More than 90% of those surveyed from Guatemala, Haiti, and Honduras, where prevalence data has been scarce, appeared susceptible to HEV infection. Future multinational missions like the UNMIH might also present unique opportunities to study health threats of widespread interest.

Covalent polymyxin B conjugate with human immunoglobulin G as an antiendotoxin reagent.

Polymyxin B (PMB) is a cyclic decapeptide antibiotic which also binds and neutralizes endotoxin. Unfortunately, PMB can be considerably nephrotoxic at clinically utilized doses, thereby limiting its utility as a therapeutic antiendotoxin reagent. We sought to change the pharmacokinetics and toxicity profile of PMB by covalently linking it to a human immunoglobulin G (IgG) carrier. Conjugates of PMB with IgG were prepared by EDAC [1-ethyl-3-(3-dimethylaminopropyl) carbodiimide]-mediated amide formation. Analysis by dot enzyme-linked immunosorbent assay with an anti-PMB monoclonal antibody showed that the purified conjugate contained bound PMB. The IgG-PMB conjugate reacted with lipid A and J5 lipopolysaccharide in Western blot assays in a manner comparable to that of whole antiserum with anti-lipid A reactivity; unconjugated IgG had no reactivity. The PMB bound in the conjugate retained its endotoxin-neutralizing activity compared to that of unbound PMB as evidenced by its dose-dependent inhibition of tumor necrosis factor release by endotoxin-stimulated human monocytes in vitro; unconjugated IgG had no activity. By this assay, the PMB-IgG conjugate was determined to have approximately 3.0 microg of bound functional PMB per 100 microg of total protein of conjugate (five molecules of PMB per IgG molecule). The PMB-IgG conjugate was also bactericidal against clinical strains of Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae relative to unconjugated IgG with MBCs of <4 microg of conjugate per ml for each of the tested strains. The conjugate appeared to be nontoxic at the highest doses deliverable and provided statistically significant protection from death to galactosamine-sensitized, lipopolysaccharide-challenged mice in a dose-dependent fashion when administered prophylactically 2 h before challenge. However, neither free PMB nor the PMB-IgG conjugate could protect mice challenged with endotoxin 2 h after administration. This suggests that these reagents can play a role in prophylaxis but not in therapy of sepsis. These experiments demonstrated that the PMB-IgG conjugate retains bound yet functional PMB as evidenced by its endotoxin-neutralizing activity both in vitro and in vivo. Further work is required to define the role that this or related conjugate compounds may play in the prophylaxis of endotoxin-mediated disease.

A cluster of acute hepatitis E infection in United Nations Bangladeshi peacekeepers in Haiti.

In the fall of 1995, within a month of deployment to Haiti for peacekeeping duty, four Bangladeshi soldiers developed acute icteric hepatitis in rapid succession. Hepatitis E virus (HEV) was found to be the etiology by demonstrating HEV genomic sequences in serum samples by the polymerase chain reaction (PCR) and serologically by the detection of elevated IgM titers to HEV. No case had serologic evidence of acute hepatitis A or C infection. The soldiers had probably acquired their infection while living in a cantonment area outside Dhaka, Bangladesh for one month prior to deployment. Cloning and sequencing of amplified PCR products demonstrated a single strain suggestive of a common source of infection. Furthermore, high genomic identity with Asian strains of HEV and dissimilarity with the Mexican strain was demonstrated, verifying that the strain had indeed been imported. Human waste management from the Bangladesh camp in Haiti was strictly controlled and no secondary cases were observed. A convenience sample of 105 (12%) soldiers from the Bangladesh battalion (850 men) revealed anicteric or asymptomatic HEV infection in seven (7%) of 105. This report contains the first demonstration of acute hepatitis E in natives of Bangladesh and demonstrates the power of the PCR in the rapid diagnosis and epidemiologic analysis of HEV infection. More importantly, this cluster demonstrates the importation of an important infectious disease by multinational peacekeepers to a potentially susceptible host country.

A randomized, placebo-controlled study of oral cimetidine as an immunopotentiator of parenteral immunization with a group B meningococcal vaccine.

Cimetidine (CIM) is an H2-receptor antagonist with a long history of clinical use in peptic ulcer disease. In addition to its inhibitory effect upon gastric acid secretion, CIM can also block histamine-mediated immunosuppression by inhibiting H2 receptors on suppressor T cells. CIM results in immunoaugmentation of both cellular and humoral immunity by this mechanism and has been used clinically in the treatment of chronic infectious and neoplastic diseases. We postulated that orally administered CIM, like an adjuvant, could augment the immunologic response to a parenteral vaccine. To test this hypothesis, a randomized placebo (PLB)-controlled, double-blinded study in 14 healthy volunteers was performed using a Group B meningococcal outer membrane protein (OMP) vaccine administered twice, 6 weeks apart. Volunteers were randomized within pairs defined by their screening OMP antibody titers to receive either CIM or PLB which was administered for 5 days, beginning 2 days before each of the two immunizations. All 14 volunteers completed the study with excellent compliance. Sera were tested for anti-OMP and bactericidal antibodies. The groups were comparable in terms of gender distribution, age and baseline anti-OMP titers. Reactogenicity to the vaccine was mild and comparable between groups. There was little effect of CIM (over PLB) on anti-OMP or functional bactericidal antibody levels over time. Geometric means of maximum OMP antibody increase over baseline was 3.3-fold (95% CI: 1.8-6.3) for CIM and 2.4 for PLB (CI: 1.6-3.7). CIM had a corresponding 3.9-fold increase (CI: 1.9-8.3) in bactericidal antibody level compared to 2.2 for PLB (CI: 1.4-3.4). We conclude that oral CIM was not effective as an immunopotentiator of immunization with this group B meningococcal vaccine.

Prostatodynia in United Nations peacekeeping forces in Haiti.

Prostatodynia is a clinical entity associated with voiding symptoms and pelvic pain suggestive of prostatitis but with a normal prostate examination and without evidence of inflammation or infection in expressed prostatic secretions. The problem tends to be chronic and is vexing in its management. Although thought to be a common condition, prevalence data are generally lacking. From June to October 1995, the U.S. Army's 86th Combat Support Hospital provided medical support to a multinational United Nations peacekeeping force in Haiti. Patients diagnosed with prostatodynia were more common (13 cases) than men with other urologic problems (urolithiasis, 6 cases; urinary tract infection, 6 cases; scrotal abscess/mass, 2 cases; epididymitis, 1 case). Patients tended to be young (mean age 29.8), had multiple visits, failed to respond to multiple courses of antibiotics for presumed "prostatitis," and denied recent sexual relations. Some patients reported having had similar symptoms on prolonged separation from their spouses in the past that resolved with resumption of normal intercourse. Masturbation, however, had no impact on symptoms and was painful in some individuals. Terazosin, an alpha-antagonist, and stress-reduction therapy led to improvement in some patients' symptoms. A discussion of these retrospective findings in light of what is known about the possible etiologies and treatment of prostatodynia is presented. Prostatodynia appears to be a common problem in deployed troops and can lead to frequent use of medical services. Physicians supporting long deployments need to be aware of this entity.

Microbiological laboratory results from Haiti: June-October 1995.

From June to October 1995, the U.S. Army's 86th Combat Support Hospital was deployed in Haiti in support of the United Nations peacekeeping mission. The hospital's mission was to provide comprehensive health care to United Nations military and civilian personnel in Haiti. The hospital's laboratory, with microbiological and parasitological capability, was a critical asset in light of the infectious disease threats in Haiti. A total of 356 microbiological (5.4%) and 887 parasitological (13.4%) tests were performed, out of a total of 6628 laboratory tests. One finding was the discovery of antibiotic-resistant urinary isolates of Escherichia coli. These were from community-acquired infections and included strains resistant to ampicillin (6/15), trimethoprim+sulfamethoxazole (6/15), and ciprofloxacin (2/15). Ampicillin (8/15) and trimethoprim+sulfamethoxazole (3/15) resistance was also noted in Shigella spp. However, no chloroquine-resistant strains of malaria were encountered. Dengue virus, also mosquito borne, was a major pathogen. Antimicrobial-resistant nosocomial pathogens were also encountered. Deployed laboratories should be able to determine antimicrobial susceptibility and perform microbial identification to guide clinical management, conduct medical surveillance, and detect emerging resistance.