[CIS-PAGID] looking for transplant advice

[Donald Cuong Vinh, Dr]

In response to Dr. Bleesing's question: BCG and MAI are quite distinct. Yes, both belong to the genus Mycobacteria, but BCG is part of the M. tuberculosis complex (BCG being a variant of M. bovis). MAI is an older taxonomic group that encompasses the M. avium complex and M. intracellulare (and related organisms that have yet to be defined into a complex); these are phylogenetically related to each other but as a whole (microbiologically and disease-wise) are distinct from the M.tb complex -- hence, they fall under the "Non-tuberculous mycobacteria" (NTM) classification. BCG and MAI are also distinct in terms of environmental distributions and anti-mycobacterial therapy.


Donald C. Vinh, MD
Assistant Professor
Division of Infectious Diseases,
Division of Allergy & Clinical Immunology
Dept of Medicine; Dept of Medical Microbiology
McGill University Health Centre - Montreal General Hospital
1650 Cedar Ave, Rm A5-156
Montreal, Quebec,  Canada H3G 1A4
Ph: 514-934-1934 x42419 (office); x42811 (admin assist)
Fax: 514-934-8423
e-mail: donald.vinh at mcgill.ca

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________________________________
From: pagid-bounces at list.clinimmsoc.org [pagid-bounces at list.clinimmsoc.org] On Behalf Of Jack Bleesing [Jack.Bleesing at cchmc.org]
Sent: Thursday, June 23, 2011 5:05 PM
To: Luigi.Notarangelo at childrens.harvard.edu; pagid at list.clinimmsoc.org; sullivak at mail.med.upenn.edu
Subject: Re: [CIS-PAGID] looking for transplant advice

Just for my education:

BCG / MAI: same thing? Or asked in a different way; can you actually clear MAI versus BCG post-BMT?

In cases, donors were used that had received BCG themselves (perhaps too rare an occurrence): does it speed-up or improve BCG control post BMT (agreeing with Gigi that using a TCD graft would not make sense to me)

Would it be possible (perhaps in the case of a matched sibling or single-allele mismatched family donor - theorizing of course) that BCG is given to the donor before donating? In other words, just like in other BMT scenarios in which an infectious agent is giving lots of trouble (for example EBV in XLP), I would consider a not-fully matched donor, over a fully matched donor if the former is EBV+ and the latter is EBV-, if I really need adoptive transfer of EBV-specific T-cells.

jb



---------------------------------------------------------------------------
Jack J.H. Bleesing, M.D., Ph.D.
Associate Professor of Pediatrics
Cincinnati Children's Hospital Medical Center
Division of Bone Marrow Transplantation & Immune Deficiency
3333 Burnet Avenue, MLC 7015
Cincinnati, OH 45229
513-636-4266 (phone)
513-636-3549 (fax)
Jack.Bleesing at CCHMC.org
http://www.cincinnatichildrens.org/immunodeficiencies/


>>> "Notarangelo, Luigi" <Luigi.Notarangelo at childrens.harvard.edu> 06/23/11 4:08 PM >>>

I agree with Antonio that this patient needs multi-drug treatment of BCG and that this needs to be continued across transplant, including engraftment (because this is the time when inflammatory complications would otherwise develop). I would start treatment now but I would try to perform the transplant within the next month or so. This is the only way to save the patient. Who will be the donor? I would personally favor an unmanipulated MUD (as long as full match)vs. a T-cell depleted haplo.

Gigi

Luigi D. Notarangelo
Division of Immunology
Children's Hospital boston
Sent from my Verizon Wireless BlackBerry

-----Original Message-----
From: "Prof. Dr. Antonio Condino Neto" <condino at icb.usp.br>
Sender: "pagid-bounces at list.clinimmsoc.org"
    <pagid-bounces at list.clinimmsoc.org>
Date: Thu, 23 Jun 2011 15:52:44
To: pagid at list.clinimmsoc.org<pagid at list.clinimmsoc.org>; Sullivan,Kathleen<sullivak at mail.med.upenn.edu>
Reply-To: "pagid at list.clinimmsoc.org" <pagid at list.clinimmsoc.org>
Subject: Re: [CIS-PAGID] looking for transplant advice

Dear Kate

All of my CGD cases that underwent BMT started receiving drugs for BCG
at least 6 weeks before the BMT or even earlier if they developed
complications with BCG (25% of them complicate with BCG). The drugs
against BCG were given continuously, before and after the BMT
procedure and ALL of them worsened during BMT procedure, bringing it
to real risk that has to explained to the family. As the BMT engrafted
the BCG was brought to control.

In your case I would try to have it as more stable as possible before
BMT and do it as quick as possible, the patient?s only chance to cure
it.

Hope this helps your decision

All best

Condino
--
Antonio Condino-Neto
Professor of Experimental Medicine
Institute of Biomedical Sciences, University of São Paulo
1730 Lineu Prestes Avenue, São Paulo - SP. ZIP 05508-000. Brazil
Tel (55) (11) 3091-7387 / Fax (55) (11) 3091-7224



Citando "Sullivan, Kathleen" <sullivak at mail.med.upenn.edu>:


> I am posting this question on behalf of others but the big question is:

>

> Does it make more sense to transplant now or to try to achieve some

> clearance of mycobacteria prior to BMT?

>

> The patient is a two year old with very low T cell numbers (CD3

> about 100-200) and no TRECS. Her mitogens are not completely flat

> but about 2-4% of the control. She has immunoglobulin and B cells

> and has had some responses to vaccines. She had PCP and now

> presents with MAI and huge nodes. She was treated with triple

> therapy for about three weeks for her MAI and the nodes enlarged.

> We have increased her MAI coverage to 5 drugs and are thinking about

> adding gamma-interferon. We do not have a genetic type of SCID

> identified although she has a mutation of uncertain significance in

> the IL-7Ra gene and she has uniparental isodisomy of that chromosome.

>

> Given this picture, what do other people think about hurrying to do

> a transplant on the theory that this is the only curative maneuver

> that can clear her MAI vs waiting to achieve some level of control

> and then transplanting?

>

>

> Kate

>

> Kate Sullivan, MD PhD

> Professor of Pediatrics

> ARC 1216 Immunology CHOP

> 3615 Civic Center Blvd.

> Philadelphia, PA 19104

> (p) 215-590-1697

> (f) 267-426-0363

>

>

>




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