Juan Gea-Banacloche | Mayo Clinic Graduate School (original) (raw)

Papers by Juan Gea-Banacloche

British Journal of Haematology, Aug 16, 2004

Mixed chimaerism and graft rejection are higher after reduced-intensity allogeneic stem cell tran... more Mixed chimaerism and graft rejection are higher after reduced-intensity allogeneic stem cell transplantation (RIST) with T-cell depleted (TCD) allografts. As host immune status before RIST affects engraftment, we hypothesized that targeted depletion of host lymphocytes prior to RIST would abrogate graft rejection and promote donor chimaerism. Lymphocyte-depleting chemotherapy was administered at conventional doses to subjects prior to RIST with the intent of decreasing CD4(+) counts to <0.05 x 10(9)cells/l. Subjects (n = 18) then received reduced-intensity conditioning followed by ex vivo TCD human leucocyte antigen-matched sibling allografts. All evaluable patients (n = 17) were engrafted; there were no late graft failures. At day +28 post-RIST, 12 patients showed complete donor chimaerism. Mixed chimaerism in the remaining five patients was associated with higher numbers of circulating host CD3(+) cells (P = 0.0032) after lymphocyte-depleting chemotherapy and was preferentially observed in T lymphoid rather than myeloid cells. Full donor chimaerism was achieved in all patients after planned donor lymphocyte infusions. These data reflect the importance of host immune status prior to RIST and suggest that targeted host lymphocyte depletion facilitates the engraftment of TCD allografts. Targeted lymphocyte depletion may permit an individualized approach to conditioning based on host immune status prior to RIST.

Emerging Infectious Diseases, Jul 1, 2012

We report a case of disseminated microsporidiosis in a patient with multiple myeloma who had rece... more We report a case of disseminated microsporidiosis in a patient with multiple myeloma who had received an allogeneic stem cell transplant requiring substantial immunosuppression. The causative organism was identifi ed as Tubulinosema acridophagus, confi rming this genus of microsporidia as a novel human pathogen.

Social Science Research Network, 2021

Acta Oto-laryngologica, 1994

Page 1. Acta Otolaryngol (Stockh) 1994; 114: 663-668 Functional and Phenotypic Analysis of T-lymp... more Page 1. Acta Otolaryngol (Stockh) 1994; 114: 663-668 Functional and Phenotypic Analysis of T-lymphocytes in Laryngeal Carcinoma FRANCISCO M. GONZALEZ,' JUAN ANTONIO VARGAS,2 JUAN C. GEA-BANACLOCHE,' JOSE ...

Transplant Infectious Disease, Nov 9, 2022

Biology of Blood and Marrow Transplantation, Mar 1, 2018

Open Forum Infectious Diseases, 2015

Journal of Clinical Immunology, Jul 21, 2020

This is a report of a successful bone marrow transplant in an IFN-γR1 patient with progressive my... more This is a report of a successful bone marrow transplant in an IFN-γR1 patient with progressive mycobacterial infection. Purpose Hematopoietic cell transplant in patients with interferon gamma receptor deficiencies has been fraught with challenges, not the least of which is failure of engraftment and infectious complications. Methods This is a report of a successful hematopoietic cell transplant in an actively infected patient of advanced age. Results This case report shows successful engraftment and resolution of infection posttransplant using a matched related donor in a single institution. Conclusion A successful curative HCT despite persistent, disseminated, nontuberculous mycobacterial infection in a patient with AD-IFNγR1 suggests that this approach, while difficult, may be useful in other patients with otherwise refractory disease.

Case reports in critical care, Jan 22, 2021

Background. Hemophagocytic lymphohistiocytosis (HLH) was originally described in pediatric patien... more Background. Hemophagocytic lymphohistiocytosis (HLH) was originally described in pediatric patients presenting with fever, hepatosplenomegaly, and blood cell abnormalities. Later, HLH was recognized to occur in adults, often associated with hematologic malignancies or serious infections. Conclusion. Patients presenting with HLH are critically ill, and rapid diagnosis is key. In adults, the search for the trigger must begin promptly as time to diagnosis effects survival. The underlying trigger in our patients was Histoplasma capsulatum infection, which is rare in the southwestern United States. Prompt diagnosis led to recovery in one patient, while the other did not survive.

Transplant Infectious Disease, Feb 21, 2022

We analyzed events and therapies related to febrile neutropenia in patients receiving hematopoiet... more We analyzed events and therapies related to febrile neutropenia in patients receiving hematopoietic cell transplantation (HCT) for chronic granulomatous disease (CGD).

Biology of Blood and Marrow Transplantation, Feb 1, 2014

This "first-in-man" study demonstrated the safety and feasibility of manufacturing both CD34-TK75... more This "first-in-man" study demonstrated the safety and feasibility of manufacturing both CD34-TK75+ T cells and [ 18 F]FHBG onsite for administration to patients. A future upfront haploidentical transplant study will employ 100-fold more CD34-TK75 modified T cells.

MBio, Oct 29, 2019

Strains of Pseudomonas aeruginosa with deficiencies in DNA mismatch repair have been studied in t... more Strains of Pseudomonas aeruginosa with deficiencies in DNA mismatch repair have been studied in the context of chronic infection, where elevated mutational rates ("hypermutation") may facilitate the acquisition of antimicrobial resistance. Whether P. aeruginosa hypermutation can also play an adaptive role in the more dynamic context of acute infection remains unclear. In this work, we demonstrate that evolved mismatch repair deficiencies may be exploited by P. aeruginosa to facilitate rapid acquisition of antimicrobial resistance in acute infection, and we directly document rapid clonal succession by such a hypermutating lineage in a patient. Whole-genome sequencing (WGS) was performed on nine serially cultured blood and respiratory isolates from a patient in whom ceftazidime-avibactam (CZA) resistance emerged in vivo over the course of days. The CZA-resistant clone was differentiated by 14 mutations, including a gain-of-function G183D substitution in the PDC-5 chromosomal AmpC cephalosporinase conferring CZA resistance. This lineage also contained a substitution (R656H) at a conserved position in the ATPase domain of the MutS mismatch repair (MMR) protein, and elevated mutational rates were confirmed by mutational accumulation experiments with WGS of evolved lineages in conjunction with rifampin resistance assays. To test whether MMR-deficient hypermutation could facilitate rapid acquisition of CZA resistance, in vitro adaptive evolution experiments were performed with a mutS-deficient strain. These experiments demonstrated rapid hypermutation-facilitated acquisition of CZA resistance compared with the isogenic wild-type strain. Our results suggest a possibly underappreciated role for evolved MMR deficiency in facilitating rapid adaptive evolution of P. aeruginosa in the context of acute infection. IMPORTANCE Antimicrobial resistance in bacteria represents one of the most consequential problems in modern medicine, and its emergence and spread threaten to compromise central advances in the treatment of infectious diseases. Ceftazidime-avibactam (CZA) belongs to a new class of broad-spectrum betalactam/beta-lactamase inhibitor combinations designed to treat infections caused

Biology of Blood and Marrow Transplantation, 2020

Allogeneic blood or marrow transplantation (BMT) is a potentially curative therapy for patients w... more Allogeneic blood or marrow transplantation (BMT) is a potentially curative therapy for patients with primary immunodeficiency (PID). Safe and effective reduced-intensity conditioning (RIC) approaches that are associated with low toxicity, use alternative donors, and afford good immune reconstitution are needed to advance the field. Twenty PID patients, ranging in age from 4 to 58 years, were treated on a prospective clinical trial of a novel, radiation-free and serotherapy-free RIC, T-cell-replete BMT approach using pentostatin, low-dose cyclophosphamide, and busulfan for conditioning with post-transplantation cyclophosphamide-based graft-versus-host-disease (GVHD) prophylaxis. This was a high-risk cohort with a median hematopoietic cell transplantation comorbidity index of 3. With median follow-up of survivors of 1.9 years, 1-year overall survival was 90% and grade III to IV acute GVHD-free, graft-failure-free survival was 80% at day +180. Graft failure incidence was 10%. Split chimerism was frequently observed at early post-BMT timepoints, with a lower percentage of donor T cells, which gradually increased by day +60. The cumulative incidences of grade II to IV and grade III to IV acute GVHD (aGVHD) were 15% and 5%, respectively. All aGVHD was steroid responsive. No patients developed chronic GVHD. Few significant organ toxicities were observed. Evidence of phenotype reversal was observed for all engrafted patients, even those with significantly mixed chimerism (n = 2) or with unknown underlying genetic defect (n = 3). All 6 patients with pre-BMT malignancies or lymphoproliferative disorders remain in remission. Most patients have discontinued immunoglobulin replacement. All survivors are off immunosuppression for GVHD prophylaxis or treatment. This novel RIC BMT approach for patients with PID has yielded promising results, even for high-risk patients. Published by Elsevier Inc. on behalf of the American Society for Transplantation and Cellular Therapy.

Biology of Blood and Marrow Transplantation, Feb 1, 2013

Blood, Nov 13, 2019

Background: Early data from anti-CD19 chimeric antigen receptor (CAR) T-cell trials suggest that ... more Background: Early data from anti-CD19 chimeric antigen receptor (CAR) T-cell trials suggest that concurrent infection can lead to poor outcomes. 1,2 The relationship between CAR T-cell mediated inflammatory responses and infections is not well-established. With CAR T-cell therapies more readily available, practitioners must identify which patient, disease and CAR T-cell specific parameters are associated with an increased risk of infection to optimize outcomes. We provide a comprehensive analysis of infection risk within the first 30 days after CAR T-cell infusion across multiple types of CAR T-cell trials targeting distinct antigens. Methods: This was a single-center, retrospective study conducted at the National Cancer Institute analyzing infectious complications in subjects who underwent CAR T-cell therapy on one of four phase I clinical trials, targeting CD19, CD22, B-cell maturation antigen (BCMA) or disialoganglioside (GD2) from 2012 though 2018. Baseline characteristics are in Table 1. The primary objective was to establish the incidence of infections between initiation of lymphodepleting (LD) chemotherapy through day 30 after CAR T-cell infusion. The secondary objective was to identify risk factors for infection. Patients were censored at relapse and/or initiation of alternative therapy, including treatment for relapse or consolidative hematopoietic stem cell transplantation (HSCT). Univariate screening methods were used to identify parameters associated with increased risk of infection Results: Amongst 144 subjects, 52 (36.1%) received anti-CD19 CAR T-cells (CAR-T); 53 (36.8%) received anti-CD22 CAR-T, 26 (18.1%) received anti-BCMA CAR-T; and 13 (9%) received anti-GD2 CAR-T. The median age was 18 years (range: 4 to 66). Sixty-one (42.4%) had undergone at least one prior allogeneic hematopoietic stem cell transplant (HSCT) and 24 (16.7%) had at least one prior autologous HSCT. Sixty-eight (47.2%) had a history of a recent infection within 100 days of initiation of LD chemotherapy, of which 17 were a major chronic infection and 9 were considered severe. Fifty-eight (40.3%) subjects experienced a total of 103 infections from initiation of LD chemotherapy through day 30 post CAR T-cell infusion, with the median time to first infection being 6 days post-CAR infusion. Twenty-eight (19.4%) subjects had more than 1 infection; 20 (13.9%) subjects had C. difficile infection. The 103 infections consisted of 47 (45.6%) distinct episodes of focal bacterial infections (e.g., sinusitis, pneumonia, urinary tract infection), 25 (24.2%) episodes of bacteremia, 22 (21.4%) viral infections, and 9 (8.7%) invasive fungal infections. Fourteen infections (13.6%) occurred between initiation of LD chemotherapy and day 0 (prior to CAR T-cell infusion). Fever and neutropenia, without a source, was documented as a distinct entity in 85 patients (59.0%). Using univariate statistical screening methods, we identified 4 parameters that were individually associated with an increased risk of infection: increasing number of prior therapies (p=0.0034), prior history of recent infection within the past 100 days (p=0.0064), age > 18 (p =0.028), or enrollment on the CD22 CAR trial (p=0.0028). Eliminating the trial, since that is not generalizable, and combining these into a multivariable logistic regression model identified age > 18, prior history of infection and prior lines of therapies jointly associated with an increased risk of infection. Using these parameters, a predictive model was developed, which, when applied to the data set used to develop the model, can correctly predict 69 of 86 patients without an infection (80.3%; CI: 70.3-88.0%) as well as 32 of 58 patients with an infection (55.2%; 95% CI: 41.5- 68.3%). Conclusion: In this retrospective analysis, we provide the largest experience to date analyzing infection in the setting of CAR T-cell therapy across multiple CAR constructs. Our study demonstrates that adult age, prior history of infection, increased number of prior therapies and enrollment on a particular CAR T-cell trial, in this case the CD22 CAR-T trial, may lead to a higher risk of infection than in those without these risk factors. Further investigations are underway to evaluate clinical outcomes with infection which occur in the peri CAR T-cell setting and potential strategies to minimize infection risk. Generalizability of this model will be tested in an independent data set. Disclosures Lee: Kite, a Gilead Company: Research Funding; Harpoon Therapeutics: Consultancy; Juno Therapeutics: Other: External Advisory Board; ACI Clinical on behalf of Celgene:: Other: Independent Central Quality Review Committee. Mackall:Obsidian: Research Funding; Lyell: Consultancy, Equity Ownership, Other: Founder, Research Funding; Nektar: Other: Scientific Advisory Board; PACT: Other: Scientific Advisory Board; Bryologyx: Other: Scientific Advisory Board; Vor: Other: Scientific Advisory Board; Roche: Other: Scientific…

Immune reconstitution following hematopoietic stem cell transplantation (HCT) beyond one year is ... more Immune reconstitution following hematopoietic stem cell transplantation (HCT) beyond one year is not completely understood. Many transplant recipients who are free of graft versus host disease (GVHD) and not receiving any immunosuppression more than a year after transplant seem to be able to mount appropriate immune responses to common pathogens and respond adequately to immunizations. However, two large registry studies over the last two decades seem to indicate that infection is a significant cause of late mortality in some patients, even in the absence of concomitant GVHD. Research on this topic is particularly challenging for several reasons. First, there are not enough long term follow-up clinics able to measure even basic immune parameters late after HCT. Second, the correlation between laboratory measurements of immune function and infections is not well known. Third, accurate documentation of infectious episodes is notoriously difficult. Finally, it is unclear what measures can be implemented to improve the immune response in a clinically relevant way. A combination of long-term multicenter prospective studies that collect detailed infectious data and store samples as well as a national or multinational registry of clinically significant infections (e.g., vaccine-preventable severe infections, opportunistic infections) could begin to address our knowledge gaps. Obtaining samples for laboratory evaluation of the immune system should be both calendar driven and eventdriven. Attention to detail and standardization of practices regarding prophylaxis, diagnosis and definitions of infections would be of paramount importance to obtain clean, reliable data. Laboratory studies should specifically address the neogenesis, maturation and exhaustion of the adaptive immune system and in particular how these are influenced by persistent alloreactivity, inflammation and viral infection. Ideally, some of these long-term prospective studies would collect information on long-term changes in the gut microbiome and their influence on immunity. Regarding enhancement of immune function, prospective measurement of the response to vaccines late after HCT in a variety of clinical settings should be undertaken to better understand the benefit as well as the limitations of immunizations. The role of intravenous immunoglobulin is still not well defined, and studies to address it should be encouraged.

Biology of Blood and Marrow Transplantation, Mar 1, 2016

characterizing the effector (cytolytic capacity) profile of the expanded cells, and plan to map i... more characterizing the effector (cytolytic capacity) profile of the expanded cells, and plan to map immunodominant T cell epitopes. Finally, to verify the importance of T cell immunity in providing in vivo protection against PIV-3 we isolated blood from 2 post-HSCT recipients who naturally controlled their infections and in both cases, detected an amplification of endogenous T cells directed to M, HN, N, F and PC coincident with viral clearance. Thus, we have demonstrated the feasibility of generating PIV-3-directed VSTs in vitro and have preliminary evidence demonstrating the protective capacity of reactive cells in vivo. Our ultimate goal is to develop an immune-based therapy for allogeneic HSCT recipients with active infections whose endogenous immunity is lacking.

Medicine, Jun 18, 2021

Abstract Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not... more Abstract Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not requiring hospitalization. However, no study has detailed the evolution of symptoms in the first month of illness. At our institution, we conducted remote (telephone and video) visits for all adult outpatients diagnosed with COVID-19 within 24 h of a positive nasopharyngeal polymerase chain test for SARS-CoV-2. We repeated regular video visits at 7, 14, and 28 days after the positive test, retrospectively reviewed the prospective data collected in the remote visits, and constructed a week by week profile of clinical illness, through week 4 of illness. We reviewed the courses of 458 symptomatic patients diagnosed between March 12, 2020, and June 22, 2020, and characterized their weekly courses. Common initial symptoms included fever, headache, cough, and chest pain, which frequently persisted through week 3 or longer. Upper respiratory or gastrointestinal symptoms were much shorter lived, present primarily in week 1. Anosmia/ageusia peaked in weeks 2 to 3. Emergency department visits were frequent, with 128 visits in the 423 patients who were not hospitalized and 48 visits among the 35 outpatients (7.6%) who were eventually hospitalized (2 subsequently died). By the fourth week, 28.9% said their illness had completely resolved. After the 4-week follow up, 20 (4.7%) of the 423 nonhospitalized patients had further medical evaluation and management for subacute or chronic COVID-19 symptoms. Mild to moderate outpatient COVID-19 is a prolonged illness, with evolving symptoms commonly lasting into the fourth week of illness.

Biology of Blood and Marrow Transplantation, Mar 1, 2020

Results: First, we focused on the clone diversity in the transferred immunity group (n = 7) and i... more Results: First, we focused on the clone diversity in the transferred immunity group (n = 7) and identified 78 clones. The top 2 clones in each case at one month after HCT exclusively accounted for >75% (range: 78-100%) of CMV-CTLs in all cases (Fig.1). In addition, these top 2 clones were also dominant in their corresponding donors (n = 3), suggesting that the transferred CMV immunity from donors would play a critical role for the prevention of CMV reactivation. Next, looking at the naively-introduced immunity group (n = 13) where 139 clones were identified, the similar skewed CMV-CTL repertoire reconstitution was also observed, and the top 2 clones accounted for >75% in 10 of the 13 cases (range: 61-100%) at 3 months after HCT (Fig.1). Focusing on the diversity of CMV-CTLs in the late phase after HCT (range: 6-24 months, n = 16), some novel clones appeared and became one of dominant clones in several cases, but the top 1 dominant clones at the early phase in each case stayed at top in 13 of the 16 cases. TRBV7 and BJ1-2 were frequently used in their CDR3 of CMV-CTLs (Fig. 2). In terms of specific amino acid sequences of CDR3 of TCR-ƒ A, no common motif was found through all cases. However, [TSG, Q(G)GG, DPG, and NQG] motifs were frequently observed 3 months after HCT in the naively-introduced group, while [G(Q)GG or DPG] was observed even among the different cases of the transferred-immunity group. Single-cell RNA sequences demonstrated relatively uniform population in terms of gene expression even if different CMV-CTL clones existed in a patient (Fig.3). Conclusion: In vivo clone-monitoring and gene expression of CMV-CTLs using NGS could provide an insight into the mechanism of immunological reconstitution following HCT.

British Journal of Haematology, Aug 16, 2004

Mixed chimaerism and graft rejection are higher after reduced-intensity allogeneic stem cell tran... more Mixed chimaerism and graft rejection are higher after reduced-intensity allogeneic stem cell transplantation (RIST) with T-cell depleted (TCD) allografts. As host immune status before RIST affects engraftment, we hypothesized that targeted depletion of host lymphocytes prior to RIST would abrogate graft rejection and promote donor chimaerism. Lymphocyte-depleting chemotherapy was administered at conventional doses to subjects prior to RIST with the intent of decreasing CD4(+) counts to <0.05 x 10(9)cells/l. Subjects (n = 18) then received reduced-intensity conditioning followed by ex vivo TCD human leucocyte antigen-matched sibling allografts. All evaluable patients (n = 17) were engrafted; there were no late graft failures. At day +28 post-RIST, 12 patients showed complete donor chimaerism. Mixed chimaerism in the remaining five patients was associated with higher numbers of circulating host CD3(+) cells (P = 0.0032) after lymphocyte-depleting chemotherapy and was preferentially observed in T lymphoid rather than myeloid cells. Full donor chimaerism was achieved in all patients after planned donor lymphocyte infusions. These data reflect the importance of host immune status prior to RIST and suggest that targeted host lymphocyte depletion facilitates the engraftment of TCD allografts. Targeted lymphocyte depletion may permit an individualized approach to conditioning based on host immune status prior to RIST.

Emerging Infectious Diseases, Jul 1, 2012

We report a case of disseminated microsporidiosis in a patient with multiple myeloma who had rece... more We report a case of disseminated microsporidiosis in a patient with multiple myeloma who had received an allogeneic stem cell transplant requiring substantial immunosuppression. The causative organism was identifi ed as Tubulinosema acridophagus, confi rming this genus of microsporidia as a novel human pathogen.

Social Science Research Network, 2021

Acta Oto-laryngologica, 1994

Page 1. Acta Otolaryngol (Stockh) 1994; 114: 663-668 Functional and Phenotypic Analysis of T-lymp... more Page 1. Acta Otolaryngol (Stockh) 1994; 114: 663-668 Functional and Phenotypic Analysis of T-lymphocytes in Laryngeal Carcinoma FRANCISCO M. GONZALEZ,' JUAN ANTONIO VARGAS,2 JUAN C. GEA-BANACLOCHE,' JOSE ...

Transplant Infectious Disease, Nov 9, 2022

Biology of Blood and Marrow Transplantation, Mar 1, 2018

Open Forum Infectious Diseases, 2015

Journal of Clinical Immunology, Jul 21, 2020

This is a report of a successful bone marrow transplant in an IFN-γR1 patient with progressive my... more This is a report of a successful bone marrow transplant in an IFN-γR1 patient with progressive mycobacterial infection. Purpose Hematopoietic cell transplant in patients with interferon gamma receptor deficiencies has been fraught with challenges, not the least of which is failure of engraftment and infectious complications. Methods This is a report of a successful hematopoietic cell transplant in an actively infected patient of advanced age. Results This case report shows successful engraftment and resolution of infection posttransplant using a matched related donor in a single institution. Conclusion A successful curative HCT despite persistent, disseminated, nontuberculous mycobacterial infection in a patient with AD-IFNγR1 suggests that this approach, while difficult, may be useful in other patients with otherwise refractory disease.

Case reports in critical care, Jan 22, 2021

Background. Hemophagocytic lymphohistiocytosis (HLH) was originally described in pediatric patien... more Background. Hemophagocytic lymphohistiocytosis (HLH) was originally described in pediatric patients presenting with fever, hepatosplenomegaly, and blood cell abnormalities. Later, HLH was recognized to occur in adults, often associated with hematologic malignancies or serious infections. Conclusion. Patients presenting with HLH are critically ill, and rapid diagnosis is key. In adults, the search for the trigger must begin promptly as time to diagnosis effects survival. The underlying trigger in our patients was Histoplasma capsulatum infection, which is rare in the southwestern United States. Prompt diagnosis led to recovery in one patient, while the other did not survive.

Transplant Infectious Disease, Feb 21, 2022

We analyzed events and therapies related to febrile neutropenia in patients receiving hematopoiet... more We analyzed events and therapies related to febrile neutropenia in patients receiving hematopoietic cell transplantation (HCT) for chronic granulomatous disease (CGD).

Biology of Blood and Marrow Transplantation, Feb 1, 2014

This "first-in-man" study demonstrated the safety and feasibility of manufacturing both CD34-TK75... more This "first-in-man" study demonstrated the safety and feasibility of manufacturing both CD34-TK75+ T cells and [ 18 F]FHBG onsite for administration to patients. A future upfront haploidentical transplant study will employ 100-fold more CD34-TK75 modified T cells.

MBio, Oct 29, 2019

Strains of Pseudomonas aeruginosa with deficiencies in DNA mismatch repair have been studied in t... more Strains of Pseudomonas aeruginosa with deficiencies in DNA mismatch repair have been studied in the context of chronic infection, where elevated mutational rates ("hypermutation") may facilitate the acquisition of antimicrobial resistance. Whether P. aeruginosa hypermutation can also play an adaptive role in the more dynamic context of acute infection remains unclear. In this work, we demonstrate that evolved mismatch repair deficiencies may be exploited by P. aeruginosa to facilitate rapid acquisition of antimicrobial resistance in acute infection, and we directly document rapid clonal succession by such a hypermutating lineage in a patient. Whole-genome sequencing (WGS) was performed on nine serially cultured blood and respiratory isolates from a patient in whom ceftazidime-avibactam (CZA) resistance emerged in vivo over the course of days. The CZA-resistant clone was differentiated by 14 mutations, including a gain-of-function G183D substitution in the PDC-5 chromosomal AmpC cephalosporinase conferring CZA resistance. This lineage also contained a substitution (R656H) at a conserved position in the ATPase domain of the MutS mismatch repair (MMR) protein, and elevated mutational rates were confirmed by mutational accumulation experiments with WGS of evolved lineages in conjunction with rifampin resistance assays. To test whether MMR-deficient hypermutation could facilitate rapid acquisition of CZA resistance, in vitro adaptive evolution experiments were performed with a mutS-deficient strain. These experiments demonstrated rapid hypermutation-facilitated acquisition of CZA resistance compared with the isogenic wild-type strain. Our results suggest a possibly underappreciated role for evolved MMR deficiency in facilitating rapid adaptive evolution of P. aeruginosa in the context of acute infection. IMPORTANCE Antimicrobial resistance in bacteria represents one of the most consequential problems in modern medicine, and its emergence and spread threaten to compromise central advances in the treatment of infectious diseases. Ceftazidime-avibactam (CZA) belongs to a new class of broad-spectrum betalactam/beta-lactamase inhibitor combinations designed to treat infections caused

Biology of Blood and Marrow Transplantation, 2020

Allogeneic blood or marrow transplantation (BMT) is a potentially curative therapy for patients w... more Allogeneic blood or marrow transplantation (BMT) is a potentially curative therapy for patients with primary immunodeficiency (PID). Safe and effective reduced-intensity conditioning (RIC) approaches that are associated with low toxicity, use alternative donors, and afford good immune reconstitution are needed to advance the field. Twenty PID patients, ranging in age from 4 to 58 years, were treated on a prospective clinical trial of a novel, radiation-free and serotherapy-free RIC, T-cell-replete BMT approach using pentostatin, low-dose cyclophosphamide, and busulfan for conditioning with post-transplantation cyclophosphamide-based graft-versus-host-disease (GVHD) prophylaxis. This was a high-risk cohort with a median hematopoietic cell transplantation comorbidity index of 3. With median follow-up of survivors of 1.9 years, 1-year overall survival was 90% and grade III to IV acute GVHD-free, graft-failure-free survival was 80% at day +180. Graft failure incidence was 10%. Split chimerism was frequently observed at early post-BMT timepoints, with a lower percentage of donor T cells, which gradually increased by day +60. The cumulative incidences of grade II to IV and grade III to IV acute GVHD (aGVHD) were 15% and 5%, respectively. All aGVHD was steroid responsive. No patients developed chronic GVHD. Few significant organ toxicities were observed. Evidence of phenotype reversal was observed for all engrafted patients, even those with significantly mixed chimerism (n = 2) or with unknown underlying genetic defect (n = 3). All 6 patients with pre-BMT malignancies or lymphoproliferative disorders remain in remission. Most patients have discontinued immunoglobulin replacement. All survivors are off immunosuppression for GVHD prophylaxis or treatment. This novel RIC BMT approach for patients with PID has yielded promising results, even for high-risk patients. Published by Elsevier Inc. on behalf of the American Society for Transplantation and Cellular Therapy.

Biology of Blood and Marrow Transplantation, Feb 1, 2013

Blood, Nov 13, 2019

Background: Early data from anti-CD19 chimeric antigen receptor (CAR) T-cell trials suggest that ... more Background: Early data from anti-CD19 chimeric antigen receptor (CAR) T-cell trials suggest that concurrent infection can lead to poor outcomes. 1,2 The relationship between CAR T-cell mediated inflammatory responses and infections is not well-established. With CAR T-cell therapies more readily available, practitioners must identify which patient, disease and CAR T-cell specific parameters are associated with an increased risk of infection to optimize outcomes. We provide a comprehensive analysis of infection risk within the first 30 days after CAR T-cell infusion across multiple types of CAR T-cell trials targeting distinct antigens. Methods: This was a single-center, retrospective study conducted at the National Cancer Institute analyzing infectious complications in subjects who underwent CAR T-cell therapy on one of four phase I clinical trials, targeting CD19, CD22, B-cell maturation antigen (BCMA) or disialoganglioside (GD2) from 2012 though 2018. Baseline characteristics are in Table 1. The primary objective was to establish the incidence of infections between initiation of lymphodepleting (LD) chemotherapy through day 30 after CAR T-cell infusion. The secondary objective was to identify risk factors for infection. Patients were censored at relapse and/or initiation of alternative therapy, including treatment for relapse or consolidative hematopoietic stem cell transplantation (HSCT). Univariate screening methods were used to identify parameters associated with increased risk of infection Results: Amongst 144 subjects, 52 (36.1%) received anti-CD19 CAR T-cells (CAR-T); 53 (36.8%) received anti-CD22 CAR-T, 26 (18.1%) received anti-BCMA CAR-T; and 13 (9%) received anti-GD2 CAR-T. The median age was 18 years (range: 4 to 66). Sixty-one (42.4%) had undergone at least one prior allogeneic hematopoietic stem cell transplant (HSCT) and 24 (16.7%) had at least one prior autologous HSCT. Sixty-eight (47.2%) had a history of a recent infection within 100 days of initiation of LD chemotherapy, of which 17 were a major chronic infection and 9 were considered severe. Fifty-eight (40.3%) subjects experienced a total of 103 infections from initiation of LD chemotherapy through day 30 post CAR T-cell infusion, with the median time to first infection being 6 days post-CAR infusion. Twenty-eight (19.4%) subjects had more than 1 infection; 20 (13.9%) subjects had C. difficile infection. The 103 infections consisted of 47 (45.6%) distinct episodes of focal bacterial infections (e.g., sinusitis, pneumonia, urinary tract infection), 25 (24.2%) episodes of bacteremia, 22 (21.4%) viral infections, and 9 (8.7%) invasive fungal infections. Fourteen infections (13.6%) occurred between initiation of LD chemotherapy and day 0 (prior to CAR T-cell infusion). Fever and neutropenia, without a source, was documented as a distinct entity in 85 patients (59.0%). Using univariate statistical screening methods, we identified 4 parameters that were individually associated with an increased risk of infection: increasing number of prior therapies (p=0.0034), prior history of recent infection within the past 100 days (p=0.0064), age > 18 (p =0.028), or enrollment on the CD22 CAR trial (p=0.0028). Eliminating the trial, since that is not generalizable, and combining these into a multivariable logistic regression model identified age > 18, prior history of infection and prior lines of therapies jointly associated with an increased risk of infection. Using these parameters, a predictive model was developed, which, when applied to the data set used to develop the model, can correctly predict 69 of 86 patients without an infection (80.3%; CI: 70.3-88.0%) as well as 32 of 58 patients with an infection (55.2%; 95% CI: 41.5- 68.3%). Conclusion: In this retrospective analysis, we provide the largest experience to date analyzing infection in the setting of CAR T-cell therapy across multiple CAR constructs. Our study demonstrates that adult age, prior history of infection, increased number of prior therapies and enrollment on a particular CAR T-cell trial, in this case the CD22 CAR-T trial, may lead to a higher risk of infection than in those without these risk factors. Further investigations are underway to evaluate clinical outcomes with infection which occur in the peri CAR T-cell setting and potential strategies to minimize infection risk. Generalizability of this model will be tested in an independent data set. Disclosures Lee: Kite, a Gilead Company: Research Funding; Harpoon Therapeutics: Consultancy; Juno Therapeutics: Other: External Advisory Board; ACI Clinical on behalf of Celgene:: Other: Independent Central Quality Review Committee. Mackall:Obsidian: Research Funding; Lyell: Consultancy, Equity Ownership, Other: Founder, Research Funding; Nektar: Other: Scientific Advisory Board; PACT: Other: Scientific Advisory Board; Bryologyx: Other: Scientific Advisory Board; Vor: Other: Scientific Advisory Board; Roche: Other: Scientific…

Immune reconstitution following hematopoietic stem cell transplantation (HCT) beyond one year is ... more Immune reconstitution following hematopoietic stem cell transplantation (HCT) beyond one year is not completely understood. Many transplant recipients who are free of graft versus host disease (GVHD) and not receiving any immunosuppression more than a year after transplant seem to be able to mount appropriate immune responses to common pathogens and respond adequately to immunizations. However, two large registry studies over the last two decades seem to indicate that infection is a significant cause of late mortality in some patients, even in the absence of concomitant GVHD. Research on this topic is particularly challenging for several reasons. First, there are not enough long term follow-up clinics able to measure even basic immune parameters late after HCT. Second, the correlation between laboratory measurements of immune function and infections is not well known. Third, accurate documentation of infectious episodes is notoriously difficult. Finally, it is unclear what measures can be implemented to improve the immune response in a clinically relevant way. A combination of long-term multicenter prospective studies that collect detailed infectious data and store samples as well as a national or multinational registry of clinically significant infections (e.g., vaccine-preventable severe infections, opportunistic infections) could begin to address our knowledge gaps. Obtaining samples for laboratory evaluation of the immune system should be both calendar driven and eventdriven. Attention to detail and standardization of practices regarding prophylaxis, diagnosis and definitions of infections would be of paramount importance to obtain clean, reliable data. Laboratory studies should specifically address the neogenesis, maturation and exhaustion of the adaptive immune system and in particular how these are influenced by persistent alloreactivity, inflammation and viral infection. Ideally, some of these long-term prospective studies would collect information on long-term changes in the gut microbiome and their influence on immunity. Regarding enhancement of immune function, prospective measurement of the response to vaccines late after HCT in a variety of clinical settings should be undertaken to better understand the benefit as well as the limitations of immunizations. The role of intravenous immunoglobulin is still not well defined, and studies to address it should be encouraged.

Biology of Blood and Marrow Transplantation, Mar 1, 2016

characterizing the effector (cytolytic capacity) profile of the expanded cells, and plan to map i... more characterizing the effector (cytolytic capacity) profile of the expanded cells, and plan to map immunodominant T cell epitopes. Finally, to verify the importance of T cell immunity in providing in vivo protection against PIV-3 we isolated blood from 2 post-HSCT recipients who naturally controlled their infections and in both cases, detected an amplification of endogenous T cells directed to M, HN, N, F and PC coincident with viral clearance. Thus, we have demonstrated the feasibility of generating PIV-3-directed VSTs in vitro and have preliminary evidence demonstrating the protective capacity of reactive cells in vivo. Our ultimate goal is to develop an immune-based therapy for allogeneic HSCT recipients with active infections whose endogenous immunity is lacking.

Medicine, Jun 18, 2021

Abstract Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not... more Abstract Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not requiring hospitalization. However, no study has detailed the evolution of symptoms in the first month of illness. At our institution, we conducted remote (telephone and video) visits for all adult outpatients diagnosed with COVID-19 within 24 h of a positive nasopharyngeal polymerase chain test for SARS-CoV-2. We repeated regular video visits at 7, 14, and 28 days after the positive test, retrospectively reviewed the prospective data collected in the remote visits, and constructed a week by week profile of clinical illness, through week 4 of illness. We reviewed the courses of 458 symptomatic patients diagnosed between March 12, 2020, and June 22, 2020, and characterized their weekly courses. Common initial symptoms included fever, headache, cough, and chest pain, which frequently persisted through week 3 or longer. Upper respiratory or gastrointestinal symptoms were much shorter lived, present primarily in week 1. Anosmia/ageusia peaked in weeks 2 to 3. Emergency department visits were frequent, with 128 visits in the 423 patients who were not hospitalized and 48 visits among the 35 outpatients (7.6%) who were eventually hospitalized (2 subsequently died). By the fourth week, 28.9% said their illness had completely resolved. After the 4-week follow up, 20 (4.7%) of the 423 nonhospitalized patients had further medical evaluation and management for subacute or chronic COVID-19 symptoms. Mild to moderate outpatient COVID-19 is a prolonged illness, with evolving symptoms commonly lasting into the fourth week of illness.

Biology of Blood and Marrow Transplantation, Mar 1, 2020

Results: First, we focused on the clone diversity in the transferred immunity group (n = 7) and i... more Results: First, we focused on the clone diversity in the transferred immunity group (n = 7) and identified 78 clones. The top 2 clones in each case at one month after HCT exclusively accounted for >75% (range: 78-100%) of CMV-CTLs in all cases (Fig.1). In addition, these top 2 clones were also dominant in their corresponding donors (n = 3), suggesting that the transferred CMV immunity from donors would play a critical role for the prevention of CMV reactivation. Next, looking at the naively-introduced immunity group (n = 13) where 139 clones were identified, the similar skewed CMV-CTL repertoire reconstitution was also observed, and the top 2 clones accounted for >75% in 10 of the 13 cases (range: 61-100%) at 3 months after HCT (Fig.1). Focusing on the diversity of CMV-CTLs in the late phase after HCT (range: 6-24 months, n = 16), some novel clones appeared and became one of dominant clones in several cases, but the top 1 dominant clones at the early phase in each case stayed at top in 13 of the 16 cases. TRBV7 and BJ1-2 were frequently used in their CDR3 of CMV-CTLs (Fig. 2). In terms of specific amino acid sequences of CDR3 of TCR-ƒ A, no common motif was found through all cases. However, [TSG, Q(G)GG, DPG, and NQG] motifs were frequently observed 3 months after HCT in the naively-introduced group, while [G(Q)GG or DPG] was observed even among the different cases of the transferred-immunity group. Single-cell RNA sequences demonstrated relatively uniform population in terms of gene expression even if different CMV-CTL clones existed in a patient (Fig.3). Conclusion: In vivo clone-monitoring and gene expression of CMV-CTLs using NGS could provide an insight into the mechanism of immunological reconstitution following HCT.