Konstantinos Liapis

The microenvironment of AIDS-related diffuse large B-cell lymphoma provides insight into the pathophysiology and indicates possible therapeutic strategies

Despite the use of highly active antiretroviral therapy (HAART), AIDS-related lymphoma remains common. We investigated the tumor, microenvironment, and viral components in 41 AIDS-related diffuse large B-cell lymphomas (AR-DLBCLs) in the pre- and post-HAART era. The outcome has improved and the frequency of the prognostically unfavorable immunoblastic histology has decreased after HAART. Compared with sporadic cases, AR-DLBCL demonstrated increased hyperproliferation (P < .001) and c-Myc rearrangements, reduced CD4(+) (P < .001) and FOXP3(+) T cells (P < .001), increased activated cytotoxic cells (P < .001), but no difference in tumor-associated macrophages. Our analysis showed that AR-DLBCL is highly angiogenic with higher blood-vessel density than sporadic cases (P < .001) and highlighted the role of Epstein-Barr virus in angiogenesis. We recognized viral profiles and as a second step examined the reactive cytotoxic cell infiltrates. Our observation of markedly higher numbers of cytotoxic cells in AR-DLBCL with LMP1 and/or p24 compared with cases lacking viral antigens (P < .001) has important clinical implications, implicitly linked to the immunosurveillance theory. Whereas early initiation of HAART should improve immunosurveillance and reduce the incidence of LMP1-positive AR-DLBCL, cases without viral antigens appear able to avoid immunologic reaction and likely require additional strategies to improve surveillance.

Arginine deprivation using pegylated arginine deiminase has activity against primary acute myeloid leukemia cells in vivo

The strategy of enzymatic degradation of amino acids to deprive malignant cells of important nutrients is an established component of induction therapy of acute lymphoblastic leukemia. Here we show that acute myeloid leukemia (AML) cells from most patients with AML are deficient in a critical enzyme required for arginine synthesis, argininosuccinate synthetase-1 (ASS1). Thus, these ASS1-deficient AML cells are dependent on importing extracellular arginine. We therefore investigated the effect of plasma arginine deprivation using pegylated arginine deiminase (ADI-PEG 20) against primary AMLs in a xenograft model and in vitro. ADI-PEG 20 alone induced responses in 19 of 38 AMLs in vitro and 3 of 6 AMLs in vivo, leading to caspase activation in sensitive AMLs. ADI-PEG 20-resistant AMLs showed higher relative expression of ASS1 than sensitive AMLs. This suggests that the resistant AMLs survive by producing arginine through this metabolic pathway and ASS1 expression could be used as a biomarker for response. Sensitive AMLs showed more avid uptake of arginine from the extracellular environment consistent with their auxotrophy for arginine. The combination of ADI-PEG 20 and cytarabine chemotherapy was more effective than either treatment alone resulting in responses in 6 of 6 AMLs tested in vivo. Our data show that arginine deprivation is a reasonable strategy in AML that paves the way for clinical trials.

High levels of serum angiogenic growth factors in patients with AL amyloidosis: comparisons with normal individuals and multiple myeloma patients

Serum levels of five angiogenic cytokines were evaluated in 82 patients with primary systemic amyloidosis (AL). Angiopoietin‐1, vascular endothelial growth factor, basic fibroblast growth factor and angiogenin were higher in AL patients than in controls (n = 35) and newly‐diagnosed, symptomatic, myeloma patients (n = 35). Angiopoetin‐1/Angiopoetin‐2 ratio was lower in AL compared to controls but higher than in myeloma patients. Angiopoetin‐2 correlated with cardiac dysfunction indices; however, none of the angiogenic growth factors was prognostically significant. The increased angiogenic cytokine levels observed in AL seem to represent either a toxic effect of amyloid fibrils or light chains, or a compensatory response to organ dysfunction.

EBV-associated hemophagocytic syndrome†

Introduction Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome characterized by fever, pancytopenia, organomegaly, multiorgan dysfunction, and hemophagocytosis by a large number of macrophages in bone marrow and other tissues [1]. Central to the pathophysiology is the impaired activity of NK and cytotoxic T lymphocytes resulting in uncontrolled immune activation, hypercytokinemia, and proliferation of macrophages. The diagnosis of HLH relies upon wellestablished criteria [2]. The syndrome has been described in familial conditions or as a secondary phenomenon to infections, malignancies, and collagen vascular diseases. HLH in the context of infection is best described in association with EpsteinBarr virus (EBV). EBV-associated HLH can occur either in primary infection or as a consequence of viral reactivation. EBV can also be the trigger in both familial and secondary cases. Although uncommon, hemophagocytic syndrome is a serious complication of EBV infection and can be fatal in many cases. Early recognition and prompt initiation of treatment are of great importance to reduce the high morbidity and mortality associated with this condition. The history and representative images from a case of EBV-associated hemophagocytic syndrome are described. The patient’s consent has been obtained. A 25-year-old woman was admitted with fever, pancytopenia, and hepatic dysfunction. Five weeks previously, she was diagnosed with infectious mononucleosis on the basis of pharyngitis, fever, and positive EBV antibodies. In the weeks after diagnosis, she continued to complain of intermittent fevers and sweating. Past medical and family history were unremarkable. Physical examination revealed temperature 388C, icteric sclera, and hepatosplenomegaly. Laboratory values included hemoglobin 8.1 g/dL, leucocytes 2,100 lL, neutrophils 720 lL, platelets 40,000 lL, bilirubin 7.4 mg/dL, ALT 135 U/L, LDH 1,080 U/L, triglycerides 459 mg/dL, and ferritin 6,070 ng/ mL. Peripheral blood film morphology was unremarkable. The direct and indirect antiglobulin test and screening for cold autoagglutinins gave negative results. The reticulocyte automated count and absolute value were 1.11% and 31,900 lL, respectively, indicating impaired production of red cells. Bone marrow aspiration showed numerous macrophages with striking phagocytosis of blood cells and marrow precursors (Images 1 and 2). EBV serologies indicated primary infection, and the EBV-PCR result was 18,000 copies/mL. Genetic testing for familial HLH was negative. The patient was treated with methylprednisolone and intravenous immunoglobulins and eventually recovered completely.

Cutaneous cryptococcosis in Hodgkin lymphoma

Multiple erythematous dermal nodules developed on the face of a 56-year-old man receiving chemotherapy for stage IV classical Hodgkin lymphoma (HL) (left). He had no fever and the dermal lesions were asymptomatic. Needle aspiration was performed from one of the nodules and the acquired material was submitted for morphological and microbiological analysis. On microscopy of Giemsa-stained smears, round budding yeast cells were seen (right). The yeasts were enveloped by a capsule, which was more easily seen when the cell was contained within a macrophage (panel A, arrows). Narrow-necked buds (panel B, arrows), phagocytosis of fungal spores by foamy macrophages (panel C) and occasional short pseudohyphae (panel D) were noted. The identification of encapsulated yeasts suggested cryptococcus, and fungal cultures of the specimen subsequently yielded Cryptococcus neoformans. To rule out meningoencephalitis, the patient underwent cerebrospinal fluid examination without significant findings. Blood cultures, radiological assessment and serum cryptococcal antigen were negative. After the diagnosis of isolated cutaneous cryptococcosis was established, oral fluconazole 400 mg/day given for nine months resulted in complete resolution of the infection. The association of HL with cryptococcus is linked to impaired cellular immunity caused by HL. Risk factors for cryptococcosis in HL include the presence of cutaneous anergy, lymphocyte count <1 9 10/l, HL duration of more than 12 months, advanced stage disease, corticosteroid therapy and extensive previous treatment. Cutaneous cryptococcosis can occur as infiltrated nodules or plaques, umbilicated papules resembling molluscum contagiosum or pustular or acneiform lesions. Bleeding and ulceration can occur. Skin biopsies reveal granulomas with yeast-packed macrophages or gelatinous changes with mucin and extracellular cryptococci. Although skin lesions typically accompany meningoencephalitis, prodromal lesions may rarely antedate meningoencephalitis by months so that prompt recognition and treatment can avoid life-threatening sequelae.

The role of the tumor microenvironment in HIV-associated lymphomas

There has been considerable interest in the role of the lymphoma microenvironment. Despite the use of highly active antiretroviral therapy (HAART), AIDS-related diffuse large-B-cell lymphoma remains common and HIV-relatedHIV-associated classical Hodgkins lymphoma is increasing in incidence. Less is known about the impact HIV and HAART have on the lymphoma microenvironment. AIDS-related diffuse large B-cell lymphoma is highly angiogenic, demonstrates increased lymphoblastic histology, proliferation, increased activated cytotoxic T cells, reduced CD4(+) and FOXP3(+) T cells, but no differences in tumor-associated macrophages. Early initiation of HAART improves immunosurveillance, but cases without viral antigens appear able to avoid immunologic reaction. Increased T cell infiltrates seen with HAART treatment in HIV-related classical Hodgkins lymphoma may contribute to malignant cell growth.

Hemolysis in Wilson's disease.

Dear Editor, We read with interest the article by Mehta et al. regarding stomatocytosis as a heralding sign of acute Wilsonian crisis [1]. Stomatocyte formation is frequently observed in liver disease irrespective of the underlying etiology and has been attributed to an increase of lysolecithin in the inner layer of the red cell membrane. The degree of stomatocytosis is analogous to the severity of liver disease [2]. Stomatocytosis per se is not characteristic of Wilsons disease, but as the authors indicate, evidence of liver dysfunction in a young patient should raise suspicions for the disease. However, it is important to note that Wilsons disease can cause both acute hemolytic anemia with no or non-specific morphologic abnormalities and a distinctive hemolytic crisis with the characteristic features of oxidant-induced erythrocyte damage [2]. In our letter, we comment on an adolescent who manifested brisk oxidative hemolysis as the presenting symptom of Wilsons disease. A 17-year-old girl, previously in good health, was admitted with a 5-day history of weakness and jaundice. The patient denied any exposure to drugs or chemicals and there was no family history of anemia or jaundice. On examination, she was alert, temperature was 37.5°C and the liver span enlarged at 15 cm. Spleen was not palpable and no neurological abnormalities were detected. The hemoglobin level was 6.7 g/dL, mean corpuscular volume 100 fL, the leucocyte count 22,000/μL, and platelets 186,000/μL. Serum level of total bilirubin was 37 mg/dL (conjugated bilirubin 22 mg/dL), ALT 25 U/L, AST 133 U/L, LDH 550 U/L and alkaline phosphatase 10 U/L. Serum creatinine level was normal and the prothrombin time ratio was prolonged at 1.6. The reticulocyte count was 12% and serum haptoglobulin <7 mg/dL. The blood film showed polychromasia, basophilic stippling, many irregularly contracted cells and occasional blister cells (Fig. 1). A Heinz body preparation with methyl violet at 1-h incubation was positive, confirming thus the oxidative nature of hemolysis. Coombs test and screening for hemoglobin instability and G6PD deficiency gave negative results. Wilsons disease was

Primary renal MALT lymphoma presenting with cryoglobulinaemia

Primary renal lymphoma is a rare clinicopathologic entity that typically presents as renal mass or renal impairment with enlarged kidneys. We describe the case of a 66-year-old woman who presented with type II mixed cryoglobulinaemic vasculitis as the first manifestation of underlying low-grade primary renal lymphoma.

Green-grey crystals in acute myeloid leukaemia

A 78-year-old man presented with progressive dyspnea, generalized weakness and weight loss. One year earlier he had been diagnosed with myelodysplastic syndrome, refractory anaemia with excess blasts type 1, and treated with azacitidine. Laboratory tests showed pancytopenia with a haemoglobin concentration of 91 g/l, white cell count of 1 0 9 10/l, neutrophil count of 0 3 9 10/l and platelet count of 111 9 10/l. A bone marrow aspirate contained 40% myeloblasts with Auer rods, 15% abnormal promyelocytes and 25% immature monocytes, compatible with acute myelomonocytic leukaemia. One striking finding was the presence of macrophages packed with a large number of oblong, green-grey crystals, ranging from 8 to 20 lm (image). Various forms of crystals were seen, including “cigar” and “needle” shapes. Free crystals were also noted scattered throughout the field. Cytogenetic analysis of the bone marrow showed no evidence of chromosomal abnormalities. The patient elected to pursue palliative care. The presence of green-grey crystals inside bone marrow macrophages is a form of acquired lipidosis of the bone marrow, a group of disorders in which lipid inclusions accumulate within histiocytes in the bone marrow. Other forms include pseudo-Gaucher cells, birefringent blue crystals and sea-blue histiocytes. Green-grey crystals consist of crystallized compound lipids generated from the breakdown of granulocyte membranes. It seems likely that the size and rigidity of these crystals cause fragmentation of the cell during film preparation so that free crystals may also be observed. Light green crystals are seen in less than 1% of patients with acute myeloid leukaemia. This morphological finding strongly supports a non-lymphoid origin of an acute leukaemia. They should not be confused with Charcot‒Leyden crystals composed of eosinophil lysophospholipase. Unlike green-grey crystals, Charcot‒Leyden crystals are bipyramidal and birefringent under polarized light microscopy. Charcot‒Leyden crystals occur in haematological malignancies or inflammatory conditions associated with eosinophilia.

A patient with rheumatoid arthritis, cryoglobulinaemia, and an “accidental” finding

A 60 year old woman, originally from Greece, was admitted after burning herself while trying to warm her legs on an electric heater. She had rheumatoid arthritis treated with methotrexate and adalimumab. She had been well until four months earlier, when pain and stiffness developed in her metacarpophalangeal and interphalangeal joints, right ankle, and both knees. Six weeks before admission, she presented with severe arthralgia, a temperature of 37.6°C, a net-like rash on her legs compatible with livedo reticularis, and purpuric lesions around the malleoli. With the warming of her legs, the rash temporarily improved. Laboratory examinations at that time showed haemoglobin 109 g/L (reference range 130-170), leucocytes 2.9×109/L (4-10×109), neutrophils 1.2×109/L (2-7×109), platelets 170×109/L (150-410×109), rheumatoid factor 183 IU/mL (<20), hypergammaglobulinaemia, antinuclear antibodies 1:640 (<1:80), complement C4 0.04 g/L (0.14-0.54), anti-double stranded DNA antibody 8.6 IU/mL (0.0-7.0), negative antibodies to extractable nuclear antigens, and a positive test for cryoglobulins. Additional tests showed that the cryoglobulins were composed of polyclonal IgM, IgG, and IgA. Serological tests for HIV, hepatitis B, and hepatitis C viruses were negative. On admission, fever (38.7°C) and pancytopenia (leucocytes 1.8×109/L, neutrophils 0.5×109/L, haemoglobin 90 g/L, platelets 126×109/L) were noted. She had no hepatosplenomegaly or lymphadenopathy. A blood film was unremarkable. Broad spectrum antibiotics were started empirically because of the possibility of neutropenic sepsis, but no improvement was seen. Cultures of blood, urine, and sputum; computed tomography of the chest, abdomen, and pelvis; a polymerase chain reaction assay of the peripheral blood for cytomegalovirus, and a tuberculin skin test were negative. A detailed history identified that she had travelled to Athens seven months earlier and had stayed with relatives who kept several dogs. For diagnostic evaluation of pancytopenia, she underwent bone marrow …