Ioannis Klonizakis

Peripheral blood haematopoietic progenitor cells in patients with beta thalassaemia major receiving desferrioxamine or deferiprone as chelation therapy.

Objectives: The main adverse effect of deferiprone is the development of neutropenia, which occurs via an unknown mechanism. We aimed to gain insight into the pathogenesis of deferiprone‐induced neutropenia by assessing the peripheral blood haematopoietic progenitor cells. Methods: Sixteen patients with beta thalassaemia were studied; nine (Group A) were receiving desferrioxamine and seven (Group B) deferiprone. Ten healthy individuals comprised the control group (Group C). Results: Granulocyte‐erythrocyte‐monocyte‐megakaryocyte colony forming units were significantly more in Groups A and B compared with Group C. Granulocyte‐macrophage colony forming units (CFU‐GM) were significantly more in Group B compared with Group C. Macrophage colony forming units were significantly less in Group B compared with Group C. Granulocyte colony forming units (CFU‐G) were significantly more in Group A compared with Group C. We found a trend in the difference in the number of CFU‐G between patients’ groups (P = 0.123). Adding serum from patients receiving deferiprone to cultures of controls resulted in a maturation arrest of the granulocytic lineage. Conclusion: Our findings point to a maturation arrest at the level of CFU‐GM as a potential mechanism of deferiprone‐induced neutropenia.

Pure Red Cell Aplasia and Lymphoproliferative Disorders: An Infrequent Association

Pure red cell aplasia (PRCA) is a rare bone marrow failure syndrome defined by a progressive normocytic anaemia and reticulocytopenia without leukocytopenia and thrombocytopenia. Secondary PRCA can be associated with various haematological disorders, such as chronic lymphocytic leukaemia (CLL) or non-Hodgkin lymphoma (NHL). The aim of the present review is to investigate the infrequent association between PRCA and lymphoproliferative disorders. PRCA might precede the appearance of lymphoma, may present simultaneously with the lymphoid neoplastic disease, or might appear following the lymphomatic disorder. Possible pathophysiological molecular mechanisms to explain the rare association between PRCA and lymphoproliferative disorders are reported. Most cases of PRCA are presumed to be autoimmune mediated by antibodies against either erythroblasts or erythropoietin, by T-cells secreting factors selectively inhibiting erythroid colonies in the bone marrow or by NK cells directly lysing erythroblasts. Finally, focus is given to the therapeutical approach, as several treatment regimens have failed for PRCA. Immunosuppressive therapy and/or chemotherapy are effective for improving anaemia in the majority of patients with lymphoma-associated PRCA. Further investigation is required to define the pathophysiology of PRCA at a molecular level and to provide convincing evidence why it might appear as a rare complication of lymphoproliferative disorders.

High Prevalence of Helicobacter pylori Infection in Greek Patients with Myelodysplastic Syndromes

Background/Aims/Methods: To determine the frequency of Helicobacter pylori infection (Hp-I) in 73 patients with myelodysplastic syndromes (MDS) and 40 controls, serologic analyses of Hp and 13C-urease breath tests (INFAI) were performed. Gastric mucosal biopsy specimens were obtained to determine the presence of Hp-I using a rapid urease test, i.e. the Campylobacter-like organism (CLO) test, and cresyl violet staining. Peripheral blood (PB) flow cytometry for CD3, CD4, CD8, CD14, CD19 and CD34 was conducted in 35 patients and in controls. Results:Hp-I was detected by: (a) serology in 75.34% of patients (p = 0.000), (b) INFAI in 57.69% of patients, (c) CLO in 60.71% of patients and (d) histological confirmation in 80.36% of patients (p = 0.001). No correlation between Hp-I and CD3, CD4, CD8, CD14, CD19 expression, leukemic transformation or death was observed. However, in 20 cases, significant variation in the PB lymphocytic proportion possibly attributable to Hp-I was ascertained, in contrast to the expected MDS ratio. Conclusion: Although there is no evidence for a causal relationship between Hp-I and MDS, the increased prevalence of Hp-I among the MDS patients is an interesting finding that deserves further investigation as it may indicate a common factor causing susceptibilities to both MDS and Hp-I or that Hp might influence the pathophysiology of MDS.

Detection of CD55- and CD59-deficient granulocytic populations in patients with myelodysplastic syndrome.

Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by absence of CD55 and CD59 from the surface of affected cells. PNH has been associated with myelodysplastic syndromes (MDS). The aim of our study was to estimate the prevalence of the PNH clone in MDS patients by detecting CD55 and CD59 deficiency. We studied 90 MDS patients: 19 patients with RA, 15 with refractory anemia with ringed sideroblasts (RARS), 18 with refractory anemia with excess of blasts (RAEB), 17 with refractory anemia with excess of blasts in transformation (RAEB-t), and 21 with chronic myelomonocytic leukemia (CMML). Twenty healthy individuals were also studied as the control group. We studied the PNH clone on granulocytes of these patients with the aid of flow cytometry. CD55- and CD59-deficient granulocytic populations were detected in 15.5% of MDS patients compared to 2.8% of normal individuals. Among the subgroups of the study, significant difference was present in three cases: (1) between CMML and control, (2) between CMML and RA, and (3) between CMML and RARS. These data indicate a possible association between PNH phenotype and MDS. MDS patients of worse prognosis (CMML) express more strongly the PNH clone compared to those of better prognosis (RA and RARS). Perhaps, the examination of MDS patients for the PNH clone by flow cytometry could provide us with a valuable prognostic tool.

Haematoma caused by bone marrow aspiration and trephine biopsy

We report a case of a bone marrow aspiration and trephine biopsy (BMATB) associated haematoma in an 85-years old male without any predisposing risk factors. Six days after BMATB, he suffered from a massive thigh and buttock haematoma and a fall in haematocrit. It is important to know that BMATB can have complications aiding early recognition and therapy.

Parotid gland oncocytoma: a case report

Oncocytomas are a rare group of neoplasms of the parotid gland which have been correlated to various viral infections. We report the first case of a patient with parotid oncocytoma and a previous history of chronic HBV infection.

Helicobacter pylori infection might protect from the leukaemic transformation of myelodysplastic syndromes.

MDD. Another recent study analyzed data from about 7000 members of the Vietnam Era Twin Registry [4]. This study is the first to use a twin design to quantify the degree to which a common genetic vulnerability explains the etiology of the association between PTSD and MDD. The authors found substantial genetic overlap between PTSD and MDD and suggested that genes implicated in the etiology of MDD are strong candidates for PTSD and vice versa. This observation supports the idea that comorbid PTSD and MDD may be a distinct neurobiological condition that can be named ‘‘post-traumatic mood disorder.’’ Post-traumatic mood disorder is associated with greater symptom severity and higher risk for suicidal behavior compared to PTSD [1,2]. Traumatic experiences are common, if we consider the preponderance of individuals exposed to sexual or non-sexual assault, natural disasters (e.g. flooding), accidents (e.g. work, motor vehicle), and war [5]. Many individuals exposed to traumas may have post-traumatic mood disorder. Studies of PTSD and PTSD with symptoms of major depression are merited. References

Pure red cell aplasia complicating B cell small lymphocytic lymphoma: a case report

Pure red cell aplasia (PRCA) is characterized by severe normocytic, normochromic anemia, reticulocytopenia and absence of erythroblasts from an otherwise normal bone marrow [1]. According to PRCA classification, secondary forms are associated with thymoma, hematologic malignancies, solid tumors, systemic autoimmune diseases, drugs, viruses and chronic renal failure [2]. The association of B cell small lymphocytic non-Hodgkin lymphoma with PRCA is considered to be extremely rare [1]. In this case report, we present a patient with PRCA and B cell lymphocytic lymphoma. A 70-year-old male patient, undergoing trans-urethral prostatectomy for benign prostate hyperplasia, was found with leukocytosis (WBC = 27,000/lL), lymphocytosis (65%) and normocytic, normochromic anemia (Hb = 7 g/ L), during pre-operative investigation. After successful operation, he was referred to our department for further investigation. Previous medical history was unremarkable. Physical examination revealed hepato-splenomegaly and peripheral lymphadenopathy. Extensive screening for viruses (HBV, HCV, HIV, PARVO B19, etc.) proved negative; no immunological abnormalities suggesting an underlying systemic autoimmune disease were detected. Reticulocyte count was\0.5%. Bone marrow aspiration revealed diffuse infiltration by lymphocytes with complete absence of erythroblasts (\3%) and normal megacaryocytes. Peripheral blood immunophenotype and lymph node biopsy led to the diagnosis of CD20 (?) B cell small lymphocytic lymphoma. Additionally, peripheral blood immunophenotyping revealed FMC7 (?) and CD5(-). The patient was administered combined therapy with rituximab and CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) in 21-day intervals; prednisolone was administered uninterruptedly. Unfortunately, he suffered an acute allergic reaction to rituximab and the drug was discontinued. After three cycles of CHOP, lymphadenopathy and leukocytosis were markedly improved; however, anemia was refractory and maintained by frequent blood transfusions (approximately 3–4 units of packed RBCs every 2 weeks). Cyclosporine A (dose 5 mg/ kg) was added to the therapeutic regimen; after 1 month, the patient needed no further transfusions and he managed to complete eight cycles of CHOP. After 18 months of follow up, the patient remains in remission, regarding both PRCA and B cell lymphoma. Treatment with low-dose cyclosporine A (5 mg/kg) was continued with no further need for RBC transfusions and no adverse effects. Diagnosis of PRCA relies mainly on the absence of erythroblasts from the bone marrow combined with reticulocytopenia. A defined upper cut-off value of erythroblasts required for diagnosis is still controversial; different studies advocate values ranging from 0.5 to 5% [3]. In this patient, there was almost complete absence of erythroblasts, as well as low reticulocyte count. The pathogenetic basis of PRCA remains to be elucidated; nevertheless, evidence support involvement of immune mechanisms, such as marrow infiltration by CD8? T cells and cell-mediated cytotoxicity [4]. Latest reports on the favorable outcome of refractory PRCA with rituximab suggests B cell involvement [5, 6]. It is possible, though, that multiple factors contribute to disease pathophysiology E. Vlachaki (&) K. Tselios S. Charalambidou E. Ioannidou I. Klonizakis Hematology Unit, 2nd Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos St. 49, 54642 Thessaloniki, Greece e-mail: efivlachaki@yahoo.gr

Fatal chylous ascites, pericarditis and extensive venous thrombosis, due to an aggressive T cell non-Hodgkin lymphoma.

Dear Editor, Chylous ascites or chyloperitoneum is the extravasation of milky peritoneal fluid rich in triglycerides in the abdominal cavity, because of lymphatic obstruction or trauma. Cirrhosis, malignancies and infectious agents are frequent etiologies, whereas congenital, inflammatory, post-operative and traumatic causes have been described [1]. The incidence of chylous ascites is between 1 in 50,000 and 1 in 187,000 hospital admissions. Neoplasms are mainly responsible for chyloperitoneum, with lymphomas predominating among malignant causes in young patients [2]. We report a case of a young patient presenting with chylous ascites, chylothorax, pericarditis and venous thrombosis in several anatomic regions, due to an aggressive T cell non-Hodgkin lymphoma (T-NHL). To the best of our knowledge, this is the first case of such co-existing pathologic features, revealing a T-NHL. The need for effective treatment is essential in such medical incidents, especially when young patients suffer from aggressive neoplasms. However, rarity of such cases and lack of guidelines concerning therapeutic options impede the task of haematologists. Therefore, reporting lymphomas combined with chyloperitoneum facilitates the choice of appropriate treatment and the outcome comparison between similar incidents. A 38-year-old man with 3-month recurrent effusive right pleuritis, after being initially treated for presumed tuberculosis, was referred to our centre. The patient had increasing abdominal distention and shortness of breath. Physical examination revealed ascites, left axillary lymphadenopathy and upper limb oedema. Lymph node biopsy was diagnostic of peripheral T-NHL, unspecified. There was complete effacement of the nodal architecture, along with infiltration by neoplasmatic, lymphoid cells with abundant mitotic figures. They were medium-sized or enlarged with slightly eosinophilic cytoplasm and irregular-shaped nuclei. Immunohistochemically, tumour cells were strongly positive for CD5, mildly positive for CD3 and negative for CD20, CD79a, CD30, CD56, CD23 and cyclin D1 (Fig. 1). Peripheral, unspecified T-NHLs derive from post-thymic T cells at various differentiative stages. Computed tomography (CT) scan revealed ascites, ambilateral pleuritic fluid causing mediastinal compression, pericarditis and excessive left axillary, mediastinal, mesenteric and retroperitoneal lymphadenopathy (Fig. 2). Enlarged lymph nodes surrounding the thymus were traced. The presence of pericardial fluid was confirmed by an echocardiogram. Paracentesis elicited chylous-effusive pleuritic fluid and creamy white ascetic fluid with elevated triglycerides (1,212 mg/dl), low protein (2.6 g/dl) and cell count (550 cells per decilitre) with lymphocytic predominance. Moreover, thrombosis was detected in the left brachiocephalic, subclavian and internal jugular veins, as a result Ann Hematol (2009) 88:371–373 DOI 10.1007/s00277-008-0570-0