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\begin{document}

\title{Acute Exacerbation of Graft-versus-Host Disease following SARS-CoV2
infection after Hematopoietic Stem Cell Transplant in Two Pediatric
Patients.}



\author[1]{Michelle Choe}%
\author[1]{Caridad Martinez}%
\author[1]{Robert Krance}%
\author[1]{Erin Doherty}%
\affil[1]{Texas Children's Hospital}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
The novel coronavirus, SARS-CoV2 has affected over 28 million people in
the United States as of February 2021.1 Limited literature describe the
effects of SARS-CoV2 infection on pediatric patients who have received
hematopoietic stem cell transplant (HSCT). Graft-versus-host disease
(GVHD) is a significant cause of morbidity and mortality in
post-transplant patients. Although the pathophysiology of GVHD is
well-described; identification of risk factors and successful treatment
of severe, refractory GVHD is still wanting. We present two pediatric
cases of acute GVHD exacerbation after SARS-CoV2 infection to recognize
a potential risk factor for development of GVHD in pediatric HSCT
recipients.%
\end{abstract}%



\sloppy


Acute Exacerbation of Graft-versus-Host Disease following SARS-CoV2
infection after

Hematopoietic Stem Cell Transplant in Two Pediatric Patients.

Michelle Choe\textsuperscript{1,2}* Caridad
Martinez\textsuperscript{1,2}, Robert Krance\textsuperscript{1,2}, Erin
Doherty\textsuperscript{1,2}

\textsuperscript{1} Cancer and Hematology Center, Texas Children's
Hospital, Houston, Texas

\textsuperscript{2} Department of Pediatrics, Baylor College of
Medicine, Houston, Texas

*Corresponding Author:

6701 Fannin St. Ste. 1510

Houston, TX 77030

P: 832-822-4242

F: 832-825-1453

Word Count:

Abstract: 98

Main Text: 1199

Figures: 2

Running Title: Graft-versus-Host Disease and SARS-CoV2 infection

Keywords: Graft-vs-Host disease, SARS-CoV2, COVID-19, ALL, CMML

Abbreviations key:

- HSCT: Hematopoietic stem cell transplant

- GVHD: Graft-versus-host disease

- HLA: Human leukocyte antigen

- COG: Children's Oncology Group

- ALL: Acute lymphoblastic leukemia

- CMML: Chronic myelomonocytic leukemia

- MRD: Minimal residual disease

- CAR: Chimeric antigen receptor

- FISH: Fluorescence in situ hybridization

Declaration of Interest: None

Abstract:

The novel coronavirus, SARS-CoV2 has affected over 28 million people in
the United States as of February 2021.\textsuperscript{1} Limited
literature describe the effects of SARS-CoV2 infection on pediatric
patients who have received hematopoietic stem cell transplant (HSCT).
Graft-versus-host disease (GVHD) is a significant cause of morbidity and
mortality in post-transplant patients. Although the pathophysiology of
GVHD is well-described; identification of risk factors and successful
treatment of severe, refractory GVHD is still wanting. We present two
pediatric cases of acute GVHD exacerbation after SARS-CoV2 infection to
recognize a potential risk factor for development of GVHD in pediatric
HSCT recipients.

Introduction:

Graft-versus-host disease (GVHD) is a significant cause of morbidity and
mortality in patients receiving hematopoietic stem cell transplant
(HSCT). It is estimated that about 50\% of patients who undergo HSCT
develop some grade of GVHD,\textsuperscript{2} and patients with grade
3-4 GVHD have mortality rates reported as high as 50\%. The
pathophysiology behind GVHD is complex but can be described in three
main steps. The first step involves damage to the host tissue resulting
in production of pro-inflammatory cytokines. This activates the host
antigen presenting cells (APC), which in turn leads to activation of
donor T cells. Finally, cellular cytotoxicity and destruction of host
target tissue occurs, while the host is unable to mount a response
against the activated donor T cells.\textsuperscript{2,3}Corticosteroids
are the first line therapy used to treat GVHD. However, many patients
are refractory to steroid therapy and there is no consensus on second
line therapies in pediatric patients.\textsuperscript{2} This makes
severe cases of GVHD difficult to treat and contributes to the high rate
of morbidity and mortality.

There are many risk factors for developing GVHD including infectious
triggers.\textsuperscript{2,4} Human herpesvirus-6 (HHV-6) and CMV
reactivation are most notably reported to increase risk of
GVHD.\textsuperscript{5,6,7,8,9,10} \textsuperscript{11,12,13,14} The
underlying mechanism explaining this relationship is not elucidated,
though is likely related to how the infectious agent affects the donor's
T cell response and activation in the host.\textsuperscript{6}

We observed two pediatric cases of acute exacerbation of GVHD after
SARS-CoV2 infection during the post-transplant period. To date, there is
limited literature regarding sequelae of SARS-CoV2 infection in
pediatric patients after
HSCT\textsuperscript{15,16,17,18,19,20,21,22,23} and no reports of the
effects on GVHD after infection. We hope to recognize SARS-CoV2
infection (without COVID-19 disease) as a potential trigger for acute
GVHD exacerbation.

Methods:

We reviewed two cases of patients who received bone marrow
transplantation at Texas Children's Hospital and developed GVHD after
SARS-CoV2 infection.

Results:

Case \#1:

Patient 1 is a 13-year-old male with history of very-high-risk
refractory Philadelphia-like B-cell acute lymphoblastic leukemia (ALL).
He was referred for bone marrow transplant due to refractory disease
with 25.2\% blasts reported in bone marrow studies at the end of interim
maintenance according to the Children's Oncology Group (COG) protocol
AALL1131. The patient achieved complete remission with negative minimal
residual disease after receiving CD19-specific chimeric antigen receptor
(CAR) T cells as a bridge to transplant. He was then conditioned with
fludarabine, total body irradiation, and post-transplant
cyclophosphamide in order to receive a haploidentical bone marrow
transplant from his mother. He engrafted sixteen days after stem cell
infusion, with negative MRD on bone marrow studies from day +30 and day
+100.

The patient's GVHD prophylaxis included post-transplant
cyclophosphamide, mycophenolate mofetil, and tacrolimus. Soon after
engraftment, the patient developed grade 1 GVHD of the gut, for which he
received IV methylprednisolone 1 mg/kg/day and a single dose of
basiliximab. He was discharged home with oral prednisone after
significant improvement on three days of IV steroids. Steroids were
weaned off as an outpatient, with resolution of GI symptoms, until 122
days post-transplant. At that time, he became positive for SARS-CoV2 by
RT-PCR, which was obtained prior to scheduled line removal. The patient
remained asymptomatic and did not require hospitalization or any viral
directed therapy for immediate sequelae of SARS-CoV2 infection.

However, about one month after testing positive for SARS-CoV2, the
patient developed worsening rash and diarrhea. With onset of
hematochezia, he was diagnosed with late onset, grade 4, acute lower
gastrointestinal GVHD. He then had a prolonged hospitalization, during
which he received methylprednisolone and other immunomodulatory agents.
He was able to be discharged and continued GVHD management with twice
weekly extracorporeal photopheresis (ECP), as well as multiple
immunomodulatory drugs. No other viral infections or GVHD triggers were
identified during this time period. Despite continued therapy, he
developed GVHD of his liver (Fig. 1), which was confirmed by biopsy
about 13 months post-transplant and unfortunately at the time of
publication, patient has passed away due to complications secondary to
GVHD.

Case \#2:

Patient 2 is a 16-year-old female with history of chronic myelomonocytic
leukemia (CMML) that developed three years after completing treatment
for pre-B lymphoblastic lymphoma. This patient received a matched
related bone marrow transplant from her brother due to persistent
monosomy 7 on fluorescence in situ hybridization (FISH). Her
myeloablative conditioning regiment consisted of busulfan and
cyclophosphamide. She engrafted seventeen days after stem cell infusion.

The patient received tacrolimus and methotrexate as GVHD prophylaxis.
There was no concern for acute GVHD immediately after transplant;
however, the patient's course was complicated by positive SARS-CoV2
detected by RT-PCR on pre-procedural surveillance, 34 days
post-transplant. The patient was otherwise asymptomatic. Due to her
close proximity to transplant at the time of this positive test, she was
treated with a dose of bamlanivimab, a monoclonal antibody for the
treatment of mild to moderate COVID-19 in patients at high risk for
progressing to severe COVID-19. The patient remained asymptomatic and
did not require hospitalization.

About three weeks after testing positive for SARS-CoV2, the patient was
noted to have exam findings concerning for skin and upper GI GVHD, as
well as elevation in transaminases (Fig 2) . She subsequently underwent
a liver biopsy which confirmed grade 2 GVHD of her liver. She was
treated with steroids as well as other immunomodulatory medications,
with which symptoms of GVHD improved. She is currently tolerating a wean
in immunosuppression without recurrence of transaminitis.

Discussion:

GVHD is a major cause of morbidity and mortality in patients after HSCT.
Manifestations range from acute onset of skin, gastrointestinal, and
hepatic symptoms to chronic syndromes that can affect nearly every organ
system.\textsuperscript{24} Although there is agreement in utilization
of corticosteroids as first-line therapy for GVHD, there is no consensus
on treatment of steroid-refractory cases.\textsuperscript{2} Given the
severity of symptoms, impact on long-term survival and quality of life,
and clinical presentation that is consistent with many other
post-transplant complications, it is important to be able to recognize
risk factors and hopefully diagnose and treat GVHD earlier in its
course.

Potential triggers for acute GVHD are viral infections such as HHV-6 and
CMV. With known viral triggers, patients are often started on
prophylactic anti-viral medication and monitored closely. SARS-CoV2 is a
novel coronavirus that has rapidly spread across the world. To date,
there is no literature describing long-term sequelae of SARS-CoV2
infection in pediatric patients who have received HSCT. We present two
cases of acute exacerbation of GVHD in patients who tested positive for
SARS-CoV2 after HSCT. We hypothesize that SARS-CoV2 may serve as a
trigger for GVHD. Furthermore, we note that patient 2 received
SARS-CoV2-directed therapy, after which we observed a less severe course
of GVHD that to date is controlled with oral corticosteroids and a
calcineurin inhibitor. Meanwhile, patient 1 did not receive directed
therapy after which he required prolonged hospitalization to treat acute
exacerbation of lower GI GVHD in addition to skin GVHD. He also
subsequently developed liver GVHD requiring biweekly photopheresis, and
prolonged use of immunomodulatory agents and systemic corticosteroids
prior to his passing.

Further studies to identify long-term sequelae of SARS-CoV2 are
warranted, and if a strong correlation between SARS-CoV2 infection and
acute exacerbation or onset of GVHD is found, it may be beneficial for
post-transplant patients to receive SARS-CoV2-directed therapy even when
asymptomatic or with mild symptoms.

References:

1. CDC. COVID Data Tracker. Centers for Disease Control and Prevention.
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https://covid.cdc.gov/covid-data-tracker

2. Jamil MO, Mineishi S. State-of-the-art acute and chronic GVHD
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doi:10.1007/s12185-015-1785-1

3. Beres A, Drobyski W. The Role of Regulatory T Cells in the Biology of
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Legend:

FIGURE 1: (A) Liver transaminase and (B) direct and indirect bilirubin
trend for Case 1- Patient underwent hematopoietic stem cell
transplantation on 3/5/2020. He was positive for SARS-CoV2 by RT-PCR on
7/5/2020. On 8/14/2020, he was admitted for acute exacerbation of GI
GVHD, followed by development of liver GVHD confirmed by biopsy on
4/14/2021.

FIGURE 2: Liver transaminase trend for Case 2- Patient underwent
hematopoietic stem cell transplantation on 11/20/2020, followed by
positive SARS-CoV2 by RT-PCR on 12/24/2020. She received bamlanivimab on
12/28/2020. On 1/19/2021, biopsy confirmed liver GVHD.\selectlanguage{english}
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