K Chutkerashvili^1*,2, G Chutkerashvili¹, B Shalamberidze, M Maisuradze², E Mikeltadze², Sh Hodum, K Woltman, Z Abuladze, G Svanishvili², L Mtchedlishvili

¹ International medical, scientific studies and coordination center (USA)

¹ Innova Medical Center, Tbilisi Georgia.

²Department of Clinical Anatomy, Tbilisi State Medical University, Tbilisi, Georgia

*Corresponding Author:K Chutkerashvili,Department of Clinical Anatomy, Tbilisi State Medical University, Tbilisi, Georgia, Tel: +995 32 254 24 39; Fax: +995 32 254 24 39; E-mail:kotemed@gmail.com

Citation: K Chutkerashvili, G Chutkerashvili, B Shalamberidze, M Maisuradze, E Mikeltadze et al. (2023) Autologous Mesenchymal Stem Cell Transplantation in Amyotrophic Lateral Sclerosis - Case Report. Cancer Prog Diagn 7: 132.

Received: February 21, 2023; Accepted: February 24, 2023; Published: February 28, 2023.

Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive neurodegenerative disease of motor neurons with unknown etiology. Only symptom-based and disease modifying management is available nowadays. The stem cell transplantation is a novel disease modifying therapy. Presented research aims to describe subjective and objective improvements in order to show potential therapeutic value and safety of Mesenchymal Stem Cells (MSCs) transplantation in a patient with ALS.

We present a case report of a 52 years old woman, diagnosed with ALS approximately 3 years ago. During the observation, stem cells were transplanted two times.

Patient was observed for 5 months after the transplantation. Amyotrophic Lateral Sclerosis Functional Rating (ALSFRS-r) score increased from 13 to 19. At this stage, the progression of the disease is slowed down, which is manifested by improved respiratory and swallowing functions. No significant side effects of the therapy are presented.

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease,is a progressive neurodegenerative disease of motor neurons with unknown etiology. It is characterized by phenotypic variability and results in progressive weakness of voluntary muscles until a patient’s death from respiratory failure [1]. Recent population-based studies show a rise of incidence and report a prevalence of ALS between 4.1-4.8 per 100?000 persons, the median age of ALS onset is between 60-68 years [2,3,4,5,6]. The median survival time from onset to death ranges from 20 to 48 months, but 10–20% of ALS patients have survival of more than 10 years [7]. Unfortunately, only symptom-based and disease-modifying management is available nowadays. The FDA-approved Riluzole and Edaravone increase patients’ life expectancy for only a few months [15]. Recent studies show that the immune processes, especially inflammation play a role in ALS pathogenesis [14]. MSCs have unique immune properties expressing different types of anti-inflammatory and growth factors, which shows immunosuppressive and tissue regeneration ability [17].

We present a case report of a 52 years old woman, diagnosed with ALS approximately 3 years ago. She couldn’t express her complaints, so anamnesis was gathered from her family members, caregivers, and data from a neurologic center, where she underwent an initial treatment.

The right upper limb weakness was an initial symptom of the disease. Hypotrophy between the first and second fingers occurred. Gradually, weakness developed in other limbs as well. Movement difficulties developed. According to 2017 data, the patient had hyposthenia and fasciculations of the right upper limb, which progressed to lower limbs. Lately, for several months, she has had speech and swallowing difficulties and dyspnea. No family history is presented; therefore, her case is sporadic. No known risk factors: smoking, trauma, occupational factors (e.g., heavy metal or pesticide exposure) [18] apply to this patient. Thirty years ago, she had a single episode head trauma episode due to car accident.

Genetic screening for motor neuron disease (SOD1 FUs C9ORF72 Trddbp pfn1 vcp optn sqstm1) showed no mutations except heterozygous nucleotide change c1019G>T in UBQLN2 gene. No significant clinical correlation was confirmed with the mentioned mutation.

2018 February electromyography showed diffuse low motor neuron irritation. Riluzole was prescribed. She underwent edaravone treatment, which showed satisfying results at first but later was discontinued because of its ineffectiveness.

2019 electromyography examinations showed lower motor neuron irritation. The patient required help for maintaining an upright position. According to her relatives, a prominent drooling was observed before hospitalization. Noninvasive ventilation and suctions were required.

Based on clinical presentation and examinations, motor neuron disease (ALS) was diagnosed.

The patient underwent mesenchymal stem cell transplantation in Innova Medical Center, Tbilisi two times: 15th of May 2020 and 10th of July, 2020.

Neurologic examinations showed: left face asymmetry because of 7th cranial nerve lower branch central palsy; deep tetraparesis; periodic coughs and diffuse tongue fasciculations; equally suspended and languidly contracting soft palate, expressed corticospinal hypertonus in lower limbs. The patient couldn't lift her legs. After muscle irritation, fibrillations were observed. Bilaterally positive Babinski's sign; pelvic organ functions were controlled.

Autologous Bone Marrow Stem Cells Receiving Method

Under local anesthesia we aspirated 100ml bone marrow from the anterior superior iliac spine and placed it in a sterile test-tube containing heparin. Aspirated material was dissolved in phosphate buffer solution in concentration 1:2. The mononuclear fraction was separated with density gradient centrifugation 400 xg during 30 minutes of room temperature with Ficoll Paques Plus or Ficoll Paques Premium (GE Healthcare, USA) solution. We separated approximately 750 million mononuclear cell fractions.

0.4ml of the final product was examined with a triptan blue elimination test and cytometric analysis. According to the protocol, the viability test was made with a triptan blue solution (0.4%) (Sigma, USA). Immunophenotyping was performed with 0.5% BSA/PBS anti-human CD34, anti-human CD45, anti-human CD271(Miltenyi Biotec, Germany), anti-human STR-1 (Santa-Cruz Biotechnology, USA). Flow cytometry was made in BD FACSCalibur flow cytometry (Becton Dickenson, USA). 

Mononuclear cells CD45-/CD34-/CD271+/STRO+ were determined as bone marrow mesenchymal stem cells. Their absolute quantity was counted with great accuracy. We determined hematopoietic stem cells CD45+/CD34+ in the mononuclear cell population.A general quantity of autologous bone marrow cells and bone marrow stem cells is given in table 1.

Table 1: Autologous bone marrow cells fraction percentages and absolute quantities.

Bone marrow stem cells transplantation method

First MSCs administration, which took place on 15th May 2020, was intrathecal with lumbar puncture between L3-L4 under local anesthesia. The second administration was both intrathecal and intravenous. 750 million cell fractions were injected on each transplantation.

The patient was under constant postoperative monitoring and was discharged from the clinic 24 hours after the transplantation.

Assessment methods

The patient was assessed with the neurologic examination, ALSFRS-r (The Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised) and electromyography.

ALSFRS-r is a 12-item functional scale, used to estimate the progression of the disease and a patient's status. It is a valid clinical instrument for monitoring the progression of the disease [20].

 After transplantation on 15th May 2020, the patient was observed periodically for 5 months. Neurologic examination, ALSFRS-r, and EMG are used to monitor clinical progression. One month later after the transplantation, the patient could lift her leg over the bed for about a 10–20-degree angle and independently cross her tibias. Two months later she could lift her leg over the bed for about a 20–30-degree angle. Muscle manual test results are presented in Table 2.

Table 2: Muscle manual test. 0- No visible or palpable contraction; 1-Visible or palpable contraction with no motion; 2 - Full ROM (range of motion) gravity eliminated; 3 - Full ROM against gravity; 4 - Full ROM against gravity, moderate resistance; 5 - Full ROM against gravity, maximal resistance.

Typically, according to ALSFRS-r, disease progression is characterized by a 17% decline in results every 6 months [21]. In our case, ALSFRS-r scores have been improved from 13 to 19 points (15% increase) during 5 months (table 3).

Table 3: ALSFRS-R (Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised). NIPPV - Non-invasive positive pressure ventilation, NA- not applicable.

The patient’s eating habits are significantly improved. Nowadays, she can chew and swallow cut food but is still unable to handle utensils.

Two months later after the transplantation electromyography (EMG) showed: conserved sensory fibers and motor fiber axonal degeneration; upper and lower limb muscle denervation and tongue muscles chronic denervation. Relatively increased spontaneous activity from tongue muscles can be explained by disease progression chronology (bulbar muscles comparatively delayed engagement).

The patient underwent two MSCs transplantations with a 2-month period between them. She was observed for 5 months (from 15th May 2020 to 10th September 2020) and evaluated with the neurologic examination ALSFRS-r, and electromyography. Received results show subjective and objective improvements. Neurologic examinations showed functional improvements of lower limb muscles. According to ALSFRS-r, her speech is more distinguishable and her swallowing is better. She doesn’t require suctions and NIPPV or other oxygen sources anymore.

In this case report, we aimed to represent the safety and importance of stem cell transplantation in the patient with ALS. Different studies from experimental models to clinical trials confirm MSCs efficiency and therapeutic value, especially in immune mediated systemic diseases.It can be explained by MSCs immunomodulatory capacity, plasticity, differentiation and growth factors providing abilities to host tissue. MSCs can produce many types of cytokines, chemokines, immune-relevant receptors (adhesion molecules, chemokine receptors) and interact with immune cells [22]. Moreover, MSCs induce a neuroprotective microenvironment [23].               

 A 51 years old female patient was diagnosed with ALS. No known risk factors were presented in this patient except a single 30 y.o. an episode of head trauma due to a car accident, which is clinically insignificant, since the causal relationship between single head trauma and ALS is unsupported [19].

She had signs of respiratory insufficiency onset. The beginning of respiratory muscle weakness is a sign of a worse prognosis [24]. In addition, the patient suffered from swallowing problems and had excess saliva drooling. Psychosocial factors like depression, stress, and poor mood are associated with a worse prognosis [25]. Due to the low quality of life, the patient's emotional condition was represented by sadness and hopelessness.

First MSCs transplantation was performed intrathecal and second was performed both intrathecal and intravenous. Due to intrathecal administration advantages (accurate delivery to injured sites and safety), this root was selected for both transplantations [26]. No considerable adverse effects were noticed, except transient symptoms caused by intrathecal administration (headaches, local rigidity).

After stem cell therapy, the patient was prescribed physiotherapy to improve her general status and maintain coordination, muscle strength and endurance. Besides, neurorehabilitation enhances the effect of transplanted MSCs by their mobilization and angiogenesis [27].

At this stage, the progression of the disease is slowed down, which is manifested by improved respiratory, swallowing and motor functions. The emotional condition was also improved. From the beginning of the treatment until the end of observation, there has not been any sign of health deterioration.

Limitation

Limitations of this case report are unblinded evaluation, insufficient EMG data due to tetraparesis, and generalized atrophy. Because of the impaired speech of the patient, anamnesis was gathered from relatives, caregivers, and doctors. After the second transplantation, the patient underwent plasmapheresis independently (this procedure could influence the dynamic of disease progression). However, observed improvement and slowing down of the natural progression of the disease indicates potential benefits of MSCs transplantation.

We would like to thank Mardaleishvili Medical Center and Innova Medical center for provided support.

Based on the results obtained, it appears that mesenchymal stem cell transplantation was a safe way of management in the presented case of the patient with ALS. Moreover, the disease course was improved. The positive results could be attributed to the regenerative, neuroprotective, and immunomodulatory properties of MSCs. We believe that future researchers should be directed at identifying mechanisms and effects of stem cell activity in individuals with ALS.

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