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  • Letter to the Editor
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Response from Dr Kamble and colleagues

Bone Marrow Transplantation volume 40, page 1096 (2007)Cite this article

We agree that diagnosis of central nervous system (CNS) GVHD may be controversial and that the diagnosis currently remains one of exclusion. As we stated,1 the possibility of post transplant progressive multifocal leukoencephalopathy (PML)2 was indeed considered in both patients. The diagnosis of ‘possible PML’ has to be entertained in the presence of the typical clinical and radiologic picture of PML in the absence of demonstrable JC virus (JCV) infection. In the immunocompromised host, JCV DNA detection in the cerebrospinal fluid (CSF) has a sensitivity of 72–92% and specificity of 92–100%.3 As one-third of patients may not yield JCV DNA in CSF, brain biopsy with immunohistochemical studies along with tissue JCV DNA amplification by PCR remains the gold standard for diagnosis of PML. We did indeed seek the characteristic pathological changes of PML, namely, JCV-infected glial cells, bizarre asytrocytes, lipid-laden macrophages and demyelination, but they were lacking in our cases. Hence the absence of characteristic pathologic changes, the negative JCV studies (negative immunohistochemical stain in case no. 1 and negative CSF PCR in case no. 2), the rapid response to steroids and the exclusion of other etiologies lead one to consider the possibility of CNS GVHD. While PML is indeed a worthy candidate for consideration in cases of this type, it would be unwise to force this label on all ‘white matter disease of uncertain origin’ in the immunocompromised host. Continued reporting of similar cases may help delineate whether brain tissues truly are targets for the development of GVHD.

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References

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Authors and Affiliations

  1. Center for Cell and Gene Therapy, Baylor College of Medicine and Methodist Hospital, Houston, TX, USA

    R T Kamble & G Carrum

  2. Department of Pathology, Methodist Hospital, Weill Medical College of Cornell University, Houston, TX, USA

    C-C Chang

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  1. R T Kamble
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  2. C-C Chang
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  3. G Carrum
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Correspondence to R T Kamble.

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Kamble, R., Chang, CC. & Carrum, G. Response from Dr Kamble and colleagues. Bone Marrow Transplant 40, 1096 (2007). https://doi.org/10.1038/sj.bmt.1705876

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