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AA Aplastic anemia

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  #1  
Old Thu Oct 18, 2012, 02:32 PM
KMac KMac is offline
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Chronically low lymphocytes post-ATG?

This is a question related to (but separate from) my recent thread on low WBC.

Prior to ATG for SAA, my lymphocytes were the only cells within normal range (i.e. well over 1000). 7+ months post-ATG, my lymphocytes still have not recovered. They usually run about 350 on my weekly CBC.

My understanding is that lymphocyte counts usually bounce back much faster than this post-ATG. Has anyone else experienced prolonged low lymphocytes post-ATG?

Perhaps it is even related to some other drug I am on, or have been on? I am currently still on cyclosporine, acylclovir, amlodipine, and ambien. Post-ATG (but no longer) I was also on prednizone, voriconazole, levofloxacin, and augmentin.

Thank you,
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Kevin, male age 45; dx SAA 02/2012 - Hgb 5.8, platelets 14, ANC 200, 1% cellularity. Received ATG 03/2012. As of 03/2015, significant improvement - Hgb 15, platelets 158, ANC fluctuates around 1000, Lymphocytes 620. Tapering cyclosporine. BMB 20-30% cellularity.
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Old Sat Oct 20, 2012, 05:54 PM
dfantle dfantle is offline
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My recollection is the cyclosporine helps to keep the lymphocyte #'s low to help your cells recover, because in AA, the lymphocytes have a role in cell destruction. Is this correct though? My memory could be off here...
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Dena
Age 54; DX Heavy Chain (AH) Amyloidosis 6/10; AutoSCT 3/11; Amyloidosis remission 6/11; DX SAA 7/11; Horse ATG 3/12; Mini MUD SCT 1/13; Recovered from SAA 5/13 & feeling great

Last edited by dfantle : Tue Oct 23, 2012 at 03:10 AM.
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Old Sat Oct 20, 2012, 06:32 PM
Karenish Karenish is offline
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This is what I thought also. Lymphocites (sp) are the naughty T cells aren't they?
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Old Mon Oct 22, 2012, 03:16 PM
Hopeful Hopeful is offline
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Hi KMac,

I think it is unusual for lymphocytes to stay so low post-horse ATG. It is more commonly seen with rabbit ATG. Looking back at my numbers, my ALC (Absolute Lymphocyte Count) want down to 0 during ATG but came back to normal levels a little over a week after the ATG ended, despite being on high-dose cyclosporine. Later, at about 6 months post-ATG, my doctors played with increasing my cyclosporine dosage again and my ALC decreased slightly, but not as significantly as yours. Platelets were always my nemesis though. Perhaps yours are WBC's. On the positive side, I've also heard and read that slow recoveries are usually more durable then rapid ones. Hope yours continues in that upward direction!
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52 yo female, dx 9/08, AA/hypo-MDS, subclinical PNH, ATG/CsA 12/08, partial response. Tried slow cyclosporine taper over 4+ years. Platelets fell, so back on cyclosporine. Trisomy 6 clone in 5% of cells.
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Old Thu Oct 25, 2012, 01:22 PM
Lisa V Lisa V is offline
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Since ATG is designed to target the T-lymphocytes, wouldn't you want them to be low following treatment? I realize there are other lymphocytes besides the T cells, but I'm not sure what the percentage is. Anyone know?

At any rate, our doctors have always focused on the neutrophils and how they're doing. I've never heard any concern expressed about the lymphocytes as long as the ANC remains in an acceptable range.
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-Lisa, husband Ken age 60 dx SAA 7/04, dx hypo MDS 1/06 w/finding of trisomy 8; 2 ATGs, partial remission, still using cyclosporine
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Old Thu Oct 25, 2012, 04:01 PM
Hopeful Hopeful is offline
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Quote:
Originally Posted by Lisa V View Post
Since ATG is designed to target the T-lymphocytes, wouldn't you want them to be low following treatment? I realize there are other lymphocytes besides the T cells, but I'm not sure what the percentage is. Anyone know?

Here is a recent article from Blood that talks about this. It says:

"Horse ATG is considered moderately lymphocytotoxic through the action of polyclonal Abs that produce transient lymphodepletion (usually 1-2 weeks duration) and longer elimination of activated T cells, which are assumed to contribute to the induction of tolerance. Rabbit ATG is more efficient at depleting peripheral blood lymphocytes in vivo and is more cytotoxic on a weight basis in vitro."

http://bloodjournal.hematologylibrar...119/2/345.long
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52 yo female, dx 9/08, AA/hypo-MDS, subclinical PNH, ATG/CsA 12/08, partial response. Tried slow cyclosporine taper over 4+ years. Platelets fell, so back on cyclosporine. Trisomy 6 clone in 5% of cells.
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Old Fri Nov 23, 2012, 05:20 PM
KMac KMac is offline
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Hi everyone,

Thank you for the replies. Especially thank you to Hopeful for pointing out that article.

Yes, from what I have researched also, my low lymphocyte count is unusual 8+ months out. But in the past couple weeks it has risen a bit, from about 350 to about 450. I guess our disease is just very unusual, and we all heal differently and at our own rates.

I have heard the same thing Hopeful about a slow response often being a more resilient one. And indeed as Karenish said, the errant T-cells that cause AA are a type of lymphocytes, so if something in my counts is going to be down, it might as well be them.

My counts continue to improve, my doctor is talking about seeing me much less often, so all in all I consider myself very fortunate.

Kevin
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Kevin, male age 45; dx SAA 02/2012 - Hgb 5.8, platelets 14, ANC 200, 1% cellularity. Received ATG 03/2012. As of 03/2015, significant improvement - Hgb 15, platelets 158, ANC fluctuates around 1000, Lymphocytes 620. Tapering cyclosporine. BMB 20-30% cellularity.
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Old Thu Nov 29, 2012, 02:37 AM
dfantle dfantle is offline
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Are you still taking cyclosporine or a different immune suppressant following your ATG? My recollection is these type of medications also reduce the lymphocytes so the lymphocytes don't continue to destroy your red cells, white cells or platelets... Following ATG. The gradual increase of your lymphocytes may be happening if your team is weaning you off your immunosuppressant medications. Suggest you ask your Dr though at your next visit.

Great to hear your counts are doing so well following your ATG. This is great news.
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Dena
Age 54; DX Heavy Chain (AH) Amyloidosis 6/10; AutoSCT 3/11; Amyloidosis remission 6/11; DX SAA 7/11; Horse ATG 3/12; Mini MUD SCT 1/13; Recovered from SAA 5/13 & feeling great
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Old Fri Nov 30, 2012, 11:38 AM
marmab marmab is offline
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I have had two horse ATGs, with CSA, and for the first time in 14 months am transfusion free. Looking back at my labs, my lymphocytes have been all over the place, from above normal to below normal (but generally low-normal to below normal), with little apparent rhyme or reason, except of course while undergoing ATG, when the numbers were low. I have also been on varying doses of CSA all this time. The lymphocyte numbers may be tied to the CSA dosage, but I'm not sure (I would have to do some cross referencing to make a correlation). But I, like others, was under the impression that the CSA is supposed to keep the T lymphocytes at bay, thus perhaps resulting in low-ish numbers.

Best regards and stay well!
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Marmab, F65, SAA/hypo MDS dx 7/2011. Tried ATG/CsA, IvIG, Rituxan, prednisone, Promacta -- none of these helped. Transfusion dependent until MUD BMT 7/17/14. Prep. regimen of Campath, Fludarabine & Cytoxan. Doing great. 100% engraftment. No GVHD.
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