Mikhaelova yulia 11.11.1

BSD Michael Y. Shapira MD Office +972-2-6778351 Bone Marrow Transplantation & Cancer Immunotherapy Center Hadassah University Hospital Re – Mikhaelova Yulia, our number Z-899130-4
Mikhaelova Yulia is a 12 years old girl from Russia that was diagnosed on April 2009 as suffering from B-ALL (CD10, HLA DR, CD19, CD22 positive) with normal cytogenetics. The patient was treated according to the ALL MB 2008 protocol and CR achieved. On 2.2011 she relapsed. She was treated according to the BFM ALL REZ 95 protocol, but CR was not achieved. At that time, she was presented to us. Reexamination of the bone marrow here showed ALL without CNS involvement. The patient was treated with the combination of IV nalarabine (650 mg/m2/d x 5 days), IV etoposide (100 mg/m2/d x 5 days) and IV cyclophosphamide (440 mg/m2/d x 5 days). However, after the hematological recovery, she had persistent disease with 18% blasts. The gravity of her condition (with chemo- refractoriness) was explained to the parents and palliative care was offered. They decided to go for a transplant from sister (a 9/10 HLA matched – A antigenic mismatch) despite the low chance of success. In order to prevent infections, she was put into isolation and received acyclovir and cotrimoxazole in high doses. In preparation for transplant, patient received conditioning protocol including: IV fludarabine (30 mg/m2 x 3 days), IV cyclophosphamide (60 mg/kg x 2 days), total body irradiation (2 Gy x 2/d x 3 days). On the 21st of September, 2011 the patient received allogeneic bone marrow cells from her single locus matched sister, O- into O-, CMV – into BSD Michael Y. Shapira MD Office +972-2-6778351 Bone Marrow Transplantation & Cancer Immunotherapy Center Hadassah University Hospital CMV +. A total of 3.7x10^8 TNC/kg, in which 16.3x10^6 were CD 34+ per kilo. To prevent GVHD (graft versus host disease) she received cyclosporine from day -4. In addition, she was treated with mycophenolate mofetil since day +1. During her treatment, the patient displayed the following events: ▪ Engraftment - stable ANC count, on day +18. Donor engraftment was ▪ GVHD - after engraftment the patient developed biopsy proven GVHD grade II with skin and lower digestive system involvement. She was treated with prednisone 2mg/kg with complete resolution of the ▪ Infections - during neutropenia developed fever that was treated according to our local guidelines. Due to persistence of the fever, she was treated with fluconazole with elevation of liver enzymes. The treatment with fluconazole was stopped, and amphotericin was given. This, however, was accompanied by elevation of creatinine and the amphotericin was substituted by micafungin. The colon biopsy that was done due to the diarrhea showed GVHD, but raised suspicion of CMV colitis. At the time, the patient had borderline positive CMV PCR. Treatment was initially given with IV foscarnet and later with oral valganciclovir with resolution of the symptoms. ▪ Leukemia – as mentioned above, the patient entered to the transplant with activity of ALL. Bone marrow assessment is scheduled. Her financial coverage is for 3 months after the transplant, that are about to end at 21st of December, 2011. Her clinical state is not stable yet, and therefore she is not ready for discharge. She needs to continue treatment here for at least 3 more months. The cost of these 3 months is 24,000 Euro, covering medications; daycare visits; procedures such as bone marrow biopsies and lumbar puncture; the cost of other admissions and chemotherapy if needed; donor lymphocyte infusions and immunotherapy; BSD Michael Y. Shapira MD Office +972-2-6778351 Bone Marrow Transplantation & Cancer Immunotherapy Center Hadassah University Hospital blood products including single donor apheresis for platelets and red blood cells (with filtration and irradiation). • For your attention, the amount stated above will not cover non-medical costs (e.g. transportation to and from Israel, etc.) and dental treatment. • Operations or procedures that are unrelated to the transplant, are subject Thanks for the opportunity to help in this case.
Department of Bone Marrow Transplantation & Cancer Immunotherapy Cell Therapy & Transplantation Research Laboratory

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