Aggressive treatment with high-dose i.v.
melphalan followed by auto-SCT (HDM/SCT) is effective in inducing hematological and clinical remissions, and in extending survival in
AL amyloidosis. Tandem cycles of HDM/SCT have been shown to increase hematologic complete response rates in patients with
AL amyloidosis. Between April 1994 and July 2008, 57 patients with
AL amyloidosis at the Boston University Medical Center were treated with a second cycle of HDM/SCT after failing to achieve a complete response after a first
transplantation. A total of 11 of 57 patients (19%) treated with tandem
transplantation developed high
fever 12-24 h after
melphalan administration. The average peak temperature was 39.1 degrees C. Other clinical features include
hypotension,
acute renal failure and
skin rash. No infectious etiology was identified. One of the patients had serum available for measurement of
cytokines before, during and after the febrile reaction. The concentration of several pro-inflammatory
cytokines, including
IL-6 and
TNFalpha, increased significantly, showing a clear physiological response correlating with the clinical findings. We conclude that an unusual
cytokine-mediated febrile reaction can occur in patients with
AL amyloidosis exposed to a second cycle of high-dose
melphalan, which we have termed a '
melphalan recall' reaction.