Familial Mediterranean fever (FMF) is a recessively inherited autoinflammatory disorder characterized by recurrent episodes of fever accompanied by arthritis, peritonitis, pleuritis, pericarditis, or erysipelas-like erythematosus rash (1). The gene responsible for FMF, MEFV, is located on chromosome 16p13 (2) and encodes a 791-amino acid protein, known as pyrin or marenostrin, which is believed to regulate inflammation by modulating the caspase 1 or interleukin (IL)-1β pathway (3). Herein, we report the transmission of FMF mutations in a 22-year-old male patient who underwent bone marrow transplantation (BMT) for idiopathic aplastic anemia in May 2009 from his FMF-affected human leukocyte antigen (HLA)-identical 19-year-old brother. Informed written consent was obtained from the patient, not carrying any FMF mutations pre-BMT, concerning the risk of transmission of FMF. Conditioning regimen consisted of cyclophosphamide 200 mg/kg and antithymocyte globulin 10 mg/kg, each given intravenously in four doses. Graft-versus-host disease prophylaxis-associated cyclosporine 3 mg/kg was initiated intravenously on day 1 and methotrexate intravenously on days 1, 3, and 6. Engraftment was observed on day 19. On day 23, the patient presented fever and abdominal pain, resistant to broad-spectrum antibiotic therapy. C-reactive protein (CRP) was elevated to 229 mg/L. Thoracic and abdominal computed tomography was normal. Resolution of the febrile episode and normalization of CRP were achieved 24 hr after the administration of methylprednisolone at 0.5 mg/kg per day, intravenously. The patient was dismissed from hospital on day 48 under 0.4 mg/kg per day of oral corticosteroids and oral cyclosporine. Donor chimerism 100% was confirmed by amplification of microsatellite markers by polymerase chain reaction. On day 60, the patient presented with fever, abdominal pain, diarrhea, arthritis, erysipelas-like rash, and renal failure. CRP was increased to 150 mg/L. Cyclosporine was interrupted, and antibiotic treatment was administered. The patient was not receiving any corticosteroid treatment. He was dismissed after improvement, 15 days later. He consulted 6 days after dismissal for another similar episode. A treatment with colchicine 1 mg per day was initiated, and the patient was screened for FMF mutations that were positive for homozygous M694V mutation. On day 110, the patient presented one more FMF flare under colchicine treatment, as well as severe neutropenia (<200/mm3), which was attributed to colchicine. Furthermore, an ultrasound echocardiogram revealed a reduction in the ejection fraction from 62% to 30%. Taking into account, the persistent neutropenia (although granulocyte-colony stimulating factor treatment was given at a dose of 48 μg daily), as well as the recurrence of FMF flares, a treatment with anti-IL1 antagonist (anakinra) at a dose of 100 mg per day subcutaneously was initiated on day 120. Neutrophil count and CRP attained normal values 1 week after the cessation of colchicine. Renal function and left ventricular ejection fraction were also normalized 2 weeks after the discontinuation of colchicine. In a 4-month follow-up, neither FMF crisis nor any side effect of anakinra treatment has been observed. The patient continues to receive a daily subcutaneous injection of anakinra at a dose of 100 mg per day. This is to our knowledge, the first report of successful treatment with anakinra in a patient who acquired FMF mutation after allogeneic BMT and who presented intolerance and resistance to colchicine treatment. Transmission of FMF mutations after BMT has rarely been described (4). MEFV is almost exclusively expressed in monocytes and granulocytes. These two cell lineages are of donor origin after successful allogeneic BMT (5). Therefore, FMF mutations are potentially transferred through BMT. Oral daily treatment with colchicine is the most effective therapy for FMF. Nevertheless, bone marrow suppression, especially neutropenia, is a known side effect of colchicine (6,7). Moreover, side effects of colchicine could be reinforced by the concomitant administration of cyclosporine, which suppresses P-glycoprotein; therefore, increasing the intracellular concentration of colchicine and, which interacts with CYP3A4, thus decreasing the hepatic elimination of colchicine (8). Severe neutropenia, cardiomyopathy, and peripheral neuropathy have recently been described in the context of heart transplantation (9). Furthermore, 10% of patients are unresponsive to colchicine (10). Recent short reports demonstrate the efficacy of IL-1 receptor antagonist therapy (anakinra) in colchicine-resistant FMF patients (3, 11–13). Efficacy of anakinra in colchicine-resistant FMF patients after kidney transplantation has been recently reported (14). Moreover, IL-1 receptor antagonist has been evaluated without toxicity in allogeneic BMT in the prevention of graft-versus-host disease (15). Our observation supports the transmission of FMF mutations after allogeneic BMT and demonstrates that anakinra might be an efficacious and safe treatment in allotransplanted FMF patients with severe colchicine-induced neutropenia or intolerance or colchicine resistance. Anna D. Petropoulou1 Marie Robin1 Gérard Socié1 Lionel Galicier2 1Service Hématologie-Greffe Hôpital Saint-Louis Paris, France 2Service Immunologie Clinique Hôpital Saint-Louis Paris, France
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