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Case Reports
Mother
The mother was a 15-year-old Thai girl (gravida 1, para 0) whose pregnancy was unremarkable until two weeks before delivery, when coughing, vomiting, and fever developed. Subsequently, swelling of the legs, dull abdominal pain, and vaginal discharge appeared, and the fever persisted. At 33 weeks' gestation she was hospitalized, appearing acutely ill. The laboratory findings included signs of hemolytic anemia, thrombocytopenia, and elevated levels of liver enzymes. The HELLP syndrome (hemolysis, elevated liver enzymes, and a low platelet count) and sepsis were diagnosed. Fetal distress became evident, requiring an urgent cesarean section. During the procedure, bilateral nodular masses in the mesosalpinx were noted and biopsies performed. The patient's condition deteriorated, and she was transported to Massachusetts General Hospital. Preliminary examination of the biopsy specimens suggested the presence of high-grade lymphoma. A bone marrow aspirate contained 30 percent large pleomorphic cells, a finding also consistent with the possibility of lymphoma (Figure 1).
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Infant
The infant, a 1.6-kg boy born at 33 weeks' gestation, had poor muscle tone and apnea at birth. His initial course was consistent with the presence of transient tachypnea of the newborn. At 10 days of age, he was tolerating feedings and gaining weight and so was transferred to Massachusetts General Hospital to be with his mother.
When he was four weeks old, the infant's temperature rose to 38.6°C and he was lethargic and tachycardic. Blood analysis revealed a white-cell count of 8300 per cubic millimeter (19 percent polymorphonuclear leukocytes, 2 percent band forms, 66 percent lymphocytes, 2 percent atypical lymphocytes, and 11 percent monocytes). On cytologic examination, the cerebrospinal fluid appeared normal. A chest radiograph revealed a thymic shadow and was interpreted as normal. Administration of antibiotics was begun, but the fever persisted and distention of the abdomen and hepatosplenomegaly developed. Blood cultures were sterile. Nasal, conjunctival, and rectal specimens were obtained for viral cultures, and treatment with acyclovir was begun. The nurses wondered whether the infant might have acquired his mother's lymphoma. Two days later, his skin became mottled and he became increasingly lethargic and was transferred to the intensive-care nursery.
The infant's abdominal girth increased, mechanical ventilation became necessary, and melena and thrombocytopenia developed. The blood smear revealed large, abnormal lymphocytes with condensed chromatin and one to four nucleoli, many granules, and occasional vacuoles in the basophilic cytoplasm (Figure 2). His condition continued to deteriorate, and an abdominal film revealed pneumatosis intestinalis. During laparotomy, clear ascitic fluid was removed and an area of pneumatosis was noted. The ascites recurred despite fluid restriction, diuretic therapy, and paracentesis.
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By the infant's fifth week of life, fewer tumor cells were noted in the peripheral blood, but the thrombocytopenia persisted. In an attempt to reduce the tumor burden, a trial of interferon alfa was started. The next day, the infant had hypotension, metabolic acidosis, increased intrapulmonary shunt, and rapid increases in the levels of peripheral white cells and serum levels of lactate dehydrogenase. The interferon alfa was discontinued. The possibility of adrenal insufficiency was considered, and glucocorticoids were administered. The baby died on the 59th day of life.
Methods
Light Microscopy
Light microscopy was used to examine paraffin-embedded specimens from the bone marrow biopsy, the mother's mesosalpingeal mass, the placenta, the mother's and the infant's bone marrow aspirates, and the infant's peripheral blood.
Immunohistochemical Analysis
Paraffin-embedded tissue from the maternal mesosalpingeal mass was used for immunohistochemical analysis. Immunoperoxidase staining was performed with the avidin–biotin complex technique (Vector Laboratories, Burlingame, Calif.). Sections were stained with antibodies to CD45 (panleukocytes; Dako, Carpinteria, Calif.), CD45RO (UCHL-1; Dako), CD3
(T3, T cells and natural killer cells; Dako), CD43 (T cells and a B-cell subgroup; Camfolio, Becton Dickinson, San Jose, Calif.), CD56 (123C3 and natural killer cells; Accurate Chemical and Scientific, Westbury, N.Y.), CD20 (L26, B cells; Dako), CD79a (B cells; Dako), CD1a (cortical thymocytes; Immunotech, Westbrook, Me.), CD5 (T cells; Novocastra, Newcastle-upon-Tyne, United Kingdom), CD8 (cytotoxic–suppressor T cells; Dako), CD30 (Ber-H2, activated lymphoid cells; Dako), CD57 (Leu-7; Becton Dickinson), terminal deoxynucleotidyl transferase (Supertech, Rockville, Md.), myeloperoxidase (Dako), and immunoglobulin kappa and lambda light chains (Dako).
In Situ Hybridization
In situ hybridization was performed on paraffin-embedded sections of the mesosalpingeal mass and the placenta with the use of an oligonucleotide probe for Epstein–Barr virus (EBV)–encoded RNA transcript (EBER-1) (Novocastra). Fluorescence in situ hybridization was performed with commercial probes (Vysis, Downer's Grove, Ill.).
Flow Cytometry
Peripheral-blood lymphocytes from the infant and bone marrow specimens from both the mother and the infant were prepared for staining with the use of standard techniques.6 Samples were stained with the following directly conjugated antibodies, in combinations of four antibodies per tube: CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD14, CD16, CD19, CD20, CD23, CD33, CD34, CD45, CD45RO, CD71, and kappa and lambda light chains (Simultest Anti-Kappa/Anti-Lambda) (all Becton Dickinson); CD43 and CD45RO (Dako); CD1, CD45RA, CD13, and terminal deoxynucleotidyl transferase (Beckman Coulter, Fullerton, Calif.); and glycophorin (Caltag, Burlingame, Calif.). The samples were then incubated at 4°C for no more than 24 hours.
Results
Mother
Biopsy of the right mesosalpingeal mass revealed a lymphoma composed predominantly of large, atypical lymphoid cells with scant cytoplasm. Mitotic figures were common. Many small areas of necrosis were interspersed among the neoplastic cells. Immunohistochemical analysis of paraffin-embedded sections showed that tumor cells expressed CD45, CD45RO, CD3, CD43, and CD56 and did not express CD20, CD79a, CD1a, CD5, CD8, CD30, CD57, terminal deoxynucleotidyl transferase, immunoglobulin light chains, or myeloperoxidase. In situ hybridization revealed that most tumor cells were positive for EBER-1. These results were consistent with the presence of an EBV-positive lymphoma of natural-killer-cell lineage, because of the expression of CD56 and CD3 without the expression of CD3 or other T-cell– or B-cell–specific surface antigens.
Examination of a smear of bone marrow aspirate showed that 30 percent of the cells were large, atypical lymphoid cells with a high ratio of nucleus to cytoplasm and scant basophilic cytoplasm (Figure 1). Some cells had azurophilic granules or cytoplasmic vacuoles. The remaining cells were maturing hematopoietic precursors. Flow-cytometric analysis revealed an abnormal population of cells with light-scatter characteristics typical of large lymphoid cells and monocytes (Figure 3). They accounted for 11 percent of the CD45+ population, expressed CD43, CD45RO, and CD56, and had reduced expression of CD7. Approximately half the cells had reduced expression of CD2; the remainder were CD2–. They lacked other T-cell antigens (CD1, CD3 [surface and cytoplasm], CD45RA, CD4, CD5, and CD8), B-cell antigens (CD10, CD19, CD20, and immunoglobulin light chains), myeloid antigens (CD13 and CD33), erythroid antigens (glycophorin and CD71), or natural-killer-cell–associated antigen CD16. The expression of CD56 and CD2 without surface expression of CD3 suggested an immunophenotype closely associated with natural killer cells. HLA typing of frozen bone marrow cells revealed the following haplotypes: A1, B57, Cw6, DR7, and DQ9; and A33, B58, Cw10, DR3, and DQ2.
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The placenta weighed 274 g, a value below the 10th percentile for 33 weeks' gestation. A 1-cm infarct was present. There were foci of necrotizing inflammation in the decidua, but no inflammation was present from the chorion to the amnion or in the villi or intervillous spaces. Stained sections were negative for microorganisms. No neoplastic lymphoid cells were recognizable on sections of placental tissue stained for light microscopy, but in situ hybridization revealed many cells within the decidua and a few cells within the blood vessels of the chorionic villi that had been transcribing EBV messenger RNA (Figure 4).
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The bone marrow and peripheral blood (Figure 2) obtained from the infant revealed tumor cells with an immunophenotype similar to that of the mother's bone marrow and blood cells, although CD2 was not present and CD7 was detected only in the blood sample. These cells, constituting 10 percent of the cells in the lymphocyte light-scatter gate, had light-scatter characteristics (Figure 3) similar to those of cells observed in the mother's bone marrow. In addition, CD4+ T cells, CD8+ T cells, natural killer cells (CD3–CD56+CD16+), and a polyclonal population of CD19+ B cells were identified in these and subsequent blood samples. During the infant's clinical course, the proportion of circulating tumor cells diminished to 4 to 5 percent of cells in the lymphocyte light-scatter gate. Cell-cycle analysis of samples of peripheral blood revealed a dramatically increased growth fraction (34 percent of cells in S and G2M phases) in CD3–CD56+ cells.
HLA typing of the infant's peripheral blood revealed the presence of A1, B57, and Cw6 (class I); DR7 and DQ9 (class II) (the maternal haplotype); A24, B18, and Cw7 (class I); and DR12 and DQ7 (class II).
Cytogenetic Analysis
Cytogenetic analysis of the mother's bone marrow revealed the following karyotypes: 46,X,der(X)t(X1) (q22;q12)[2]/46,XX[28]; 30 cells in metaphase were analyzed. A clone of two cells showed an unbalanced translocation involving extra material from the long arm of chromosome 1 and an X chromosome (Figure 5). Twenty-eight cells showed a normal female karyotype.
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The clinical and laboratory data are consistent with the transplacental passage of maternal natural-killer-cell lymphoma and subsequent engraftment of these cells in the fetus. The karyotype of this boy's lymphoma was female and carried the same translocation as his mother's tumor cells. The immunophenotypes of their lymphomas were nearly identical.
During pregnancy, cells of various types are transferred between the mother and the fetus. Several studies have reported that small numbers of maternal erythrocytes, platelets, granulocytes, and lymphocytes can cross the placenta.7 When labeled maternal cells were transfused into mothers before delivery, they were identified in umbilical-cord blood.1 Several infants with immunodeficiency have been found to have engrafted maternal cells.2 Cytogenetic studies have detected maternal lymphocytes one to five years after birth in boys who had received in utero transfusions,8 and small numbers of male cells have been found in progenitor-cell populations prepared from the blood of women who gave birth to sons up to 27 years previously.9
The passage of maternal cells across the placenta occurs in species with hemochorial placentae, but the quantity of cells transferred and the timing of embryonic exposure to such cells are not known.10,11 In one study in which lacZ–, scid/scid, or wild-type mouse blastocysts were transferred into pseudopregnant lacZ+ transgenic mice, all fetuses examined late in gestation contained maternal cells. In the scid/scid (immunodeficient) fetuses, maternal cells crossed the placenta about midway through gestation and were found in lymphoid and nonlymphoid organs. In the wild-type (immunocompetent) fetuses, maternal cells were found exclusively in bone marrow.12 Apoptosis of maternal cells that cross the placenta has been observed and may limit the number of such cells that enter the fetus.13
Why was the maternal lymphoma not rejected by the infant in this case? One possibility is that the mother was homozygous for one of the fetus's HLA haplotypes. In this situation, the fetus would not have recognized as foreign the major-histocompatibility-complex antigens on the mother's lymphoma cells. HLA homozygosity was found in one of two reported cases of infantile leukemia thought to be caused by vertical transmission of leukemic cells.14,15 However, in our case, the mother was not homozygous for one of her son's HLA haplotypes. It is also possible that the baby had a congenital immunodeficiency, although this is unlikely because the infant had relatively normal numbers of CD4+ and CD8+ T cells in peripheral blood and because cultured T cells responded in vitro to interleukin-2 (data not shown). Another consideration is that maternal lymphoma cells might have passed to the fetus early in pregnancy. Early in gestation, the fetus is immunologically immature and space is available in developing bone marrow for engraftment of hematopoietic cells. In this situation, donor cells can successfully compete with host cells for growth in the hematopoietic environment. We were unable to ascertain the points during gestation when maternal lymphoma cells reached the fetus. Finally, neoplasms of natural killer cells are among the most aggressive of the non-Hodgkin's lymphomas. They are more prevalent among Asians, are strongly associated with EBV, and may pursue a fulminant course,16,17,18 with rapid development of multiorgan failure, as was seen in both our patients. Since normal decidua exhibits an infiltrate of large granular lymphocytes with a natural-killer-cell phenotype,19 it is possible that the lymphoma in the mother had an affinity for binding to vascular endothelium in decidua. This affinity, coupled with the high proliferative capacity of the lymphoma, resulted in the localization of large numbers of tumor cells in the placenta and consequently their availability for entry into the fetal circulation. However, the paucity of tumor cells in the decidua does not support this idea.
We are indebted to Dr. Drucilla Roberts, the staff of the Partners Cytogenetic Laboratory at Brigham and Women's Hospital, and the nursing, medical, and social-work staff of the special-care nurseries and neonatal and pediatric intensive care units for their contributions to this study.
Source Information
From the Divisions of Neonatology (E.A.C., J.D.R.) and Hematology and Oncology (H.J.W.), Department of Pediatrics (R.E.), the Department of Pathology (F.I.P., J.A.F., A.S.K., L.A.), and the Department of Anesthesia and Critical Care (J.D.R.), Massachusetts General Hospital, Boston.
Address reprint requests to Dr. Weinstein at Blake 2, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, or at weinstein.howard{at}mgh.harvard.edu.
References
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Related Letters:
Disseminated Intravascular Coagulation
Schmaier A. H., Levi M., ten Cate H.
Extract |
Full Text
N Engl J Med 1999;
341:1937-1938, Dec 16, 1999.
Correspondence
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