American Journal of Hematology 40:73 (1992)

Letter to the Editor: Low-Dose Cyclosporin for Severe Ap I ast i c

Majority of patients with severe aplastic anemia (SAA) have T-cell-mediated suppression of the bone marrow [ 13. Thus, while bone marrow transplantation (BMT) remains the therapy of choice for SAA, various modali- ties of immunosuppression have also been used success- fully [ 2 ] . Cyclosporin has been reported to induce a com- plete hematologic remission in SAA at full immuno- suppressive doses alone [3,4] or in combination with other immunosuppressive drugs [5,6]. We recently treated a patient of SAA with low-dose cyclosporin and achieved a complete hematologic remission.

A 15-year-old male presented with a 2 month history of weakness and intermittent fever. The physical examina- tion was unremarkable except for pallor and occasional purpuric patches. Investigations revealed hemoglobin 40 g/liter, leukocytes 2.0 X 109/liter, neutrophils 0.24 X lO’/liter, platelets 10 X lO’//liter, corrected reticulocytes 0.1%, negative sucrose lysis test, and a severely hypocel- Mar marrow (cellularity <20%) on trephine biopsy. SAA was diagnosed, and the patient was maintained on periodic red cell and platelet transfusions as required due to lack of availability of BMT or antilymphocyte globu- lin. Weekly injections of nandrolone decanoate did not help and were discontinued after 4 months.

Six months after diagnosis, he was started on oral cyclosporine 3 mg/kg daily. The patient tolerated the drug very well without any gastrointestinal, hepatic, or renal adverse effects. Hepatic and renal function tests before and during cyclosporine administration remained normal.

Hematologic parameters improved gradually, and transfusion requirements fell over the next 7 months. At this stage, the investigations revealed hemoglobin 105 g/liter, leukocytes 4.3 X 109/liter, neutrophils 2.1 X

1 O’/liter, platelets 95 X IO”/liter, and reticulocytes 2.2%. Cyclosporin was discontinued. The counts contin- ued to improve after the discontinuation of cyclosporin, and investigations 3 months later showed hemoglobin

134 g/liter, leukocytes 6.0 X lO’/liter, neutrophils 3.6 X lO’/liter, platelets 190 X IO’/liter, and reticulo- cytes 1.5%.

Low-dose cyclosporine may benefit some patients with SAA who are not candidates for more definitive therapy such as BMT and has the advantage of being relatively less expensive and less toxic and of not requiring thera- peutic drug monitoring.

Jayesh Mehta Seema Singhal B.C. Mehta Blood Research Centre Bombay, India

Jayesh Mehta and Seema Singhal are now at the Department of Bone Marrow Transplantation, Hadassah University Hospital, POB 12000, IL 91 120 Jerusalem. Israel.

REFERENCES

I . Ascensao J , Pahwa R, Kagan W, Hansen J , Moore M, Good R. Aplastic anaemia: evidence for an immunological mechanism. Lancet i:669- 671. 1976.

2. Bacigalupo A, Hows J , Gluckman E, Nissen C. Marsh J . Van Lint MT, Congiu M. De Planque MM. Emst P. McCann S . Raghavashar A, Frickhofen N , Wursch A, Marmont AM. Gordon-Smith EC: Bone marrow transplantation versus immunosuppression for the treatment of severe aplastic anaemia. Br J Haematol70: 177-1 82, 1988.

3. Stryckmans AA, Dumont JP, Velu T, Debusschar L: Cyclosporin in refractory s e x r e aplastic anaemia. N Engl J Med 310:655456, 1984.

4. Dundar S, Damirkezik A: Cyclosporin for refractory aplastic anemia. Acta Haematol 83:112, 1990.

5. Frickhofen N, Kaltwasser JP, Schrezenmeier H, Raghavachar A, Vogt HG, Hemnann F, Freund M, Meusers P. Salama A. Heimpel H: Treat- ment of aplastic anemia with antilymphocyte globulin and methylpred- nisolone with or without cyclosporine. N Engl J Med 324:1297-1304. 1991.

6 . Doolittle GC, Bodensteiner DC, Skikne BS. Amare M: Therapy of aplastic anemia with sequential antithymocyte globulin and cyclo- sporin. Am J Hematol 36:144-146, 1991.

0 1992 Wiley-Liss, Inc.