Jack Pinkhas

Idiopathic deep vein thrombosis in an apparently healthy patient as a premonitory sign of occult cancer

An association between migratory venous thrombosis or acute pulmonary embolism and occult cancer has been previously suggested. The relationship between the commoner deep venous thrombosis (DVT) in an otherwise healthy individual and occult cancer is not known. The incidence of cancer in 35 otherwise healthy patients with idiopathic DVT (group A) was compared to 48 patients with DVT due to a known etiology, excluding cancer (group B). In 12 patients of group A (34%), a diagnosis of cancer was established 4–68 months after the DVT episode, compared to 2 patients of group B (4%) (P = 0.001). The origin of the earliest discovered cancer (up to 8 months) was the reproductive organs (ovary, endometrium, prostate, breast), while the later discovered malignancies were of colon, pancreas, lung and a lymphoma. At the initial idiopathic DVT episode, patients found subsequently to have cancer, were older than the control group (P <0.01), had hemoglobin concentration lower than 12.4 g/dl (P <0.02), and had eosinophil counts higher than 3% (P <0.01). A score devised from these parameters could identify 83% of the patients with cancer and 91% of those without malignancy (P = 0.00003). These findings indicate that there is a correlation between idiopathic DVT and occult cancer and that the majority of the patients at risk may probably be identified early by the score devised.

Bleeding Due to Thrombocytopenia in Acute Leukemias and Reevaluation of the Prophylactic Platelet Transfusion Policy

Prophylactic platelet administration is indicated at counts below 20×109/1. The bleeding tendency and severity were compared between thrombocytopenic patients with acute-lymphocytic leukemia (ALL) and acute non-lymphocytic leukemia (ANLL) in the ranges of 10–20×109/1 platelets, while prophylactic platelet administration was given only below 10×109/1. The bleeding tendency for ALL was quite similar at platelet counts above or below 10×109/1. The bleeding tendency was significantly lower (p<0.001) when the platelets were above this level in ANLL patients. When the thrombocytopenia was caused by chemotherapy, the bleeding was significantly lower in both types of leukemia above 10×109/1 (p<0.05 for ALL, p<0.001 for ANLL) as compared with lower counts. When the thrombocytopenia was caused by leukemia, the bleeding tendency was similar in both types of leukemia and at all platelet counts (below 20×109/1). Fever, not associated with sepsis, augmented the bleeding severity of patients with ANLL. Stable or rising counts of platelets were associated with significantly lower bleeding tendency above 10×109/1 only in ANLL patients. The decision for prophylactic platelet administration at counts below 20×109/1 should be guided by the type of the leukemia (ALL vs. ANLL), the cause of throm-bocytopenia (chemotherapy vs. leukemia per se), the trend of the platelet counts, presence of fever and patients age (below or above 18 years). Prophylactic platelet administration can be safely postponed until the count is below 10 × 109/1 in paitents with ANLL, without fever, with chemotherapy-induced thrombocytopenia and older than 18 years, regardless of the platelet trend.

Acute Coronary Events Following Cisplatin-Based Chemotherapy

Six patients with no previous signs or symptoms suggestive of coronary artery disease developed acute coronary ischemia/infarction shortly after cis-diamine-dichloroplatinum II (cisplatin) -based chemotherapy. In two patients this was the sole chemotherapeutic agent used. One patient underwent coronary angiography which disclosed no pathology, but following which, while on a calcium channel blocking agent regimen, he had an uneventful course of chemotherapy with cisplatin. Documentation of cisplatin-related vascular events is important in view of the growing number of patients who undergo cisplatin-based chemotherapy.

The leukergy test in patients with ischemic heart disease

In search of a simple method for potential evaluation of leukocyte aggregation in states of infarction, we compared the leukergy test, which consists of leukocyte aggregation visualized in a peripheral blood test, to the neutrophil aggregation activity (NAA) test, which consists of in vitro aggregation of neutrophils from normal donors by a patients plasma. Seventy-five patients participated in the study; 20 with ischemic heart disease and no infarction, 41 with relatively small myocardial infarctions, and 14 with large myocardial infarctions, the respective values of leukergy being 6.9 +/- 3.2, 10.8 +/- 4.6, and 20.5 +/- 14%. On the other hand, neutrophil aggregation activity was the same in a group of 10 patients without myocardial infarction and 10 with myocardial infarction. In these two groups, which showed no difference in the NAA test, the respective leukergy values were 4 +/- 1.5 and 21.7 +/- 10.6%. Thus leukergy correlates better with the clinical picture than does the NAA test.

Neisseria catarrhalis Endocarditis

Excerpt To the editor: Pollock and Holzman (1) reported in this journal a patient with a prosthetic valve in whomNeisseria catarrhalisendocarditis was found.N. catarrhalisendocarditis appears to ha...

Serum immunoglobulin changes after accidental splenectomy in adults

Serum immunoglobulin levels were examined in a group of twelve healthy adults who underwent accidental splenectomy. Depressed mean IgM levels and elevated mean IgA levels were found in these patients as compared with the control group consisting of forty-five healthy, untraumatized volunteers. Immunoglobulin changes may have some relevance for the increased tendency to severe infections which has been noted after splenectomy.

Native Valve staphylococcus epidermidis Endocarditis: Report of Seven Cases and Review of the Literature

This report describes seven patients from three university hospitals whose native valve infective endocarditis was caused by Staphylococcus epidermidis. The literature on endocarditis caused by S. epidermidis is also reviewed and the clinical features of patients with native valve endocarditis due to this organism are compared with those of patients from a general series of infective endocarditis cases. Compared with infective endocarditis caused by other organisms, S. epidermidis endocarditis tends to occur more frequently in male patients. Patients with S. epidermidis endocarditis exhibit fewer embolic complications and skin manifestations. The frequency of congestive heart failure is lower in this group. The relative indolent course and apparent rarity of native valve S. epidermidis endocarditis necessitate a high index of suspicion for early diagnosis.

Adult T-cell lymphoma in Israeli patients of Iranian origin.

The clinical and laboratory features of four Israeli patients with adult T‐cell lymphoma‐leukemia (ATL) are presented. In three of them evidence for human T‐cell lymphotropic leukemia virus (HTLV‐I) infection was obtained. Interestingly, all of the patients immigrated to Israel from the same regions in Iran. Except for lack of skin involvement, the clinical course was typical for ATL as described worldwide. This is the first report of ATL in an Iranian cohort. This observation suggests that Iranian patients with ATL‐like illness should be studied for the presence of HTLV‐I infection.

Aortic stenosis associated with gastrointestinal bleeding. A survey of 612 patients

A retrospective study was done in order to examine the association between aortic stenosis (AS) and gastrointestinal tract (GIT) bleeding. Four groups of patients included a group of 152 patients with AS, a control group of 152 patients with MS, and another two groups of 154 patients each with and without GIT bleeding. GIT bleeding of known and of idiopathic sources was significantly more prevalent among patients with AS (three and four patients, respectively) than among those with MS (none). Moreover, AS was significantly more prevalent in association with idiopathic GIT bleeding (seven out of 24, 29.1%), in comparison to its association with bleeding from a known source (two out of 130, 1.5%), and its incidence in routinely admitted patients without GIT bleeding (three out of 154, 1.9%). This study supports the assumption that GIT bleeding may be associated with AS.

Familial Hypouricemia Due to Isolated Renal Tubular Defect

A 37-year-old female was found to have hypouricemia (1.1-1.9 mg%) with markedly increased uric acid clearance (24.7039.5 ml/min). Uric acid excretion was only slightly affected by pyrazinamide, a drug which suppresses renal tubular uric acid secretion, and by probenecid, a drug which inhibits tubular uric acid reabsorption. The attenuated response in this subject to both drugs suggest a renal tubular defect in the proximal high capacity-high affinity uric acid reabsorption mechanism. No other renal tubular or metabolic abnormalities were detected. A survey of the family-three sisters and two brothers, revealed two similarly affected sisters. The abnormality described in this family is defined as familial renal hypouricemia due to an isolated renal tubular defect with attenuated response of uric acid clearance to probenecid and pyrazinamide.