Manfred Neubauer

Thrombotic Microangiopathy and Disseminated Intravascular Coagulation Associated With Carcinocythemia in a Patient With Breast Cancer

Case Report A 66-year-old white female was admitted to the emergency department because of increasing dyspnea in September 2008. Medical history included lobular and ductal invasive carcinoma of the right breast with hepatic, skeletal, and pulmonary metastases already present at the time of diagnosis in August 2007. Six cycles of adjuvant chemotherapy with epirubicin and cyclophosphamide were administered between August 2007 and December 2007 but failed to induce remission. Pulmonary computed tomography and computed tomography angiography revealed carcinomatous lymphangiosis and intrapulmonal metastases but no evidence of pulmonary embolism, lung edema, or pneumonia. Laboratory evaluation showed hemolytic anemia with hemoglobin concentrations of 8.8 g/dL, RBC count of 2.41 10/L, mean corpuscular volume of 104 fl, mean corpuscular hemoglobin of 36.3 pg, reticulocyte count of 0.283 10/L (normal range: 0.032 to 0.082 10/L), lactate dehydrogenase concentration of 1,661 U/L (normal range: 120 to 240 U/L), total bilirubin concentration of 3.25 mg/dL (normal range: 0.3 to 1.2 mg/dL) and haptoglobin concentration less than 7 mg/dL (normal range: 30 to 200 mg/dL). Furthermore, thrombocytopenia of 109 10/L and leukocytosis of 18.5 10/L were found. The activated partial thromboplastin time was 44 seconds (normal range: 26 to 37 seconds), quick value of 39% (normal range: 70% to 130%), fibrinogen concentration of 116 mg/dL (normal range: 210 to 400 mg/dL), antithrombin 55% (normal range: 75% to 125%) and D-dimer concentration of 28,640 g/L (normal range: 0 to 550 g/L), which indicated disseminated intravascular coagulation (DIC). Examination of a peripheral blood smear stained with May-Grünwald-Giemsa revealed leukoerythroblastosis, severe microangiopathic changes with 16% schistocytes, and atypical blastlike cells less than 1%. These cells showed large nuclei with one or more prominent nucleoli and slightly gray to basophilic cytoplasm and tended to occur in clusters of up to four cells (Fig 1A). Immunocytochemistry by using the cytokeratin antibody CK AE1/3 (Dako, Copenhagen, Denmark) disclosed the epithelial origin or the cells (Fig 1B). The clinical course was characterized by progressive dyspnea and extensive subcutaneous hemorrhage. Laboratory follow-up showed a marked decrease of the platelet count (20 10/L) and fibrinogen concentration (94 mg/dL) as well as an increase in the D-dimer (31,320 g/L), lactate dehydrogenase (2,388 U/L) and bilirubin (4.64 mg/dL) concentrations. The patient was treated with fresh frozen plasma, platelet transfusions, and packed red cells. Nevertheless, she died on the third day after admission. On autopsy, widespread occlusions of lung capillaries with fibrin thrombi and cytokeratin-19–positive, epithelial tumor cells were demonstrated.

Evaluation of platelet function and pharmacological platelet inhibition in patients with myeloproliferative disorders using multiple electrode aggregometry

BACKGROUND The aim of this study was to describe platelet aggregation characteristics by multiple electrode aggregometry (MEA) and to evaluate MEA for its potential to detect platelet dysfunction and response to anti-aggregatory drugs in patients with myeloproliferative disorders (MPD). METHODS We compared the platelet response to arachidonic acid (ASPI test), adenosine diphosphate (ADP test) and thrombin receptor activating peptide (TRAP test) in hirudin-anticoagulated blood of 55 patients with polycythaemia vera and essential thrombocythaemia and 75 controls. RESULTS Comparing MPD patients and controls no statistically significant difference indicative of platelet dysfunction was found in MPD patients. Analysis of covariance revealed platelet- and leukocyte count as a significant influencing factor on MEA function. Furthermore we could demonstrate that ASA and clopidogrel treatment results in a statistically significant lower ASPI (Controls: p<0.0001, MPD: p<0.0001) and ADPtest value (MPD: p=0.00125) compared to untreated patients thereby validating the method for monitoring of anti-aggregatory therapy. CONCLUSION In this study MEA was confirmed as a valid method for monitoring of ASA and clopidogrel treatment in patients with MPD and normal control subjects. The platelet and leukocyte count were identified as major influencing factors on MEA aggregation tests both in MPD patients and controls. No functional platelet abnormalities were detected in MPD patients.

CEOP-IMVP-Dexa in the treatment of aggressive lymphomas: an Austrian multicenter trial.

PURPOSE This trial evaluated the efficacy, toxicity, and practicability of a new intensive chemotherapy regimen in a multicenter setting of university and community hospitals. PATIENTS AND METHODS We tested a hybrid protocol of two non-cross-resistant regimens, cyclophosphamide, epirubicin, vincristine, and prednisolone (CEOP) and ifosfamide, etoposide (VP-16), methotrexate, and dexamethasone (IMVP-Dexa) given every fourth week, three to six times according to response, in patients with untreated intermediate- and high-grade non-Hodgkins lymphoma. Ten Austrian centers entered 81 patients onto this multicenter trial. Eleven patients were excluded. The median age was 55 years. Twenty-six of 70 patients had stage III or IV disease. The distribution among international risk categories low, intermediate-low, intermediate-high, and high was 20%, 34%, 23%, and 23%, respectively. RESULTS Of 70 eligible patients, 56 (80%) had a complete remission and seven (10%) a partial remission. After a median observation time of 36 months, the estimated time to relapse and overall survival rates are 67% and 72%, respectively. Age and Karnofsky index were the only independent risk factors for survival. Toxicity was primarily hematologic, with a median granulocyte nadir of 0.56 x 10(9)/L. Sixty-seven percent of patients had infections; 25.7% were severe World Health Organization (WHO) grade III or IV. There were three treatment-related deaths. CONCLUSION CEOP-IMVP-Dexa chemotherapy is safe and feasible on a groupwide basis even when used in community hospitals. Neutropenic infections are the major complications. A 72% 3-year survival rate in patients with intermediate- and high-grade non-Hodgkins lymphoma warrants further studies. These data are the basis for a randomized trial to compare cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) with CEOP/IMVP-Dexa.

The anti-VLA-4 antibody natalizumab induces erythroblastaemia in the majority of the treated patients with multiple sclerosis.

The presence of erythroblasts in the peripheral blood is generally associated with severe underlying disorders. The anti-very late antigen-4 (anti-VLA-4) antibody natalizumab, which is approved for treatment of multiple sclerosis, mediates an increase in circulating haematopoietic stem cells and may also trigger erythroblastaemia. We investigated the prevalence of erythroblastaemia in sequential blood smears of 14 natalizumab-treated and 14 interferon-treated patients with multiple sclerosis. Erythroblastaemia was found in 13 natalizumab-treated subjects (93%), whereas all controls were negative (p<0.0001). Knowledge of this frequent side effect is crucial for the correct interpretation of blood smears in natalizumab-treated patients and to avoid unnecessary diagnostic procedures.

Marked elevation of procalcitonin in a patient with a drug related infusion reaction to rituximab.

*Corresponding author: Christoph Robier, MD, Central Laboratory, Hospital of the Brothers of St. John of God, Graz, Bergstr. 27, 8020 Graz, Austria, Phone: +43 316 5989 6671, Fax +43 316 5989 1505, E-mail: christoph.robier@bbgraz.at; and Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria Manfred Neubauer and Gerhard Reicht: Department of Internal Medicine, Hospital of the Brothers of St. John of God, Graz, Austria Letter to the Editor

Crystal-associated pseudoeosinophilia of synovial fluid

Determination of the number of white blood cells (WBCs) in the synovial fluid (SF) is the most important laboratory method for the discrimination between inflammatory and non-inflammatory joint diseases (1). The SF leukocytes can be counted microscopically in a Neubauer chamber or with automated hematology analysers (2). Knowledge of laboratory artefacts, such as pseudoleukocytosis is crucial for the correct interpretation of automated leukocyte counts. Misinterpretation may lead to associated clinical errors. SF pseudoleukocytosis, an artificially increased SF leukocyte count, may result from synovial cells, crystals, fat globules, cartilage fragments or chondrocytes (3, 4). To our knowledge, pseudoeosinophilia of SF has not been described previously. We report five cases of patients with crystal-related arthropathies who showed marked pseudoeosinophilia using automated examination of SF. Using polarized microscopy, three where diagnosed with acute gouty arthritis while the two other patients had arthropathies associated with calcium pyrophosphate dihydrate (CPPD) crystals, each with a high concentration of crystals. Articular calcium deposits found on X-rays, being indicative of chondrocalcinosis, were present in one case. The other patient with CPPD crystals had been diagnosed with osteoarthritis of the shoulder. Two of the patients with gout, each presenting with clinical signs of acute gonarthritis, had increased serum urate concentrations (11.0 and 9.1 mg/dL). For the third patient, no laboratory data apart from SF analysis were available. Automated SF differential counts performed with a CellDyn 3200 (Abbott, Abbott Park, IL, USA) showed eosinophilia of 41.5%–54.8% of leukocytes. Microscopic examination of May-Grünwald-Giemsa stained slides showed an acute inflammatory state in four patients and non-inflammatory SF in one case; no eosinophils were found. The clin-

Calcium pyrophosphate and monosodium urate crystals in synovial fluid as a cause of pseudoeosinophilia.

Abstract Background: Synovial fluid (SF) leukocytes can be counted microscopically in a Neubauer chamber or by automated procedures using haematology analysers. Knowledge of laboratory artefacts is crucial for the correct interpretation of results obtained using automated methods. SF pseudoeosinophilia has recently been described as a new artefact in patients with crystal-related arthropathies. We investigated whether pseudoeosinophilia of SF is restricted to crystal-related disorders, or if it may also occur in other arthropathies. Methods: We compared the percentages of eosinophils in 120 crystal containing SF samples with 185 crystal-free specimens using the Wilcoxon test. Crystal positive samples, determined by polarised microscopy, contained at least two monosodium urate or calcium pyrophosphate crystals per 10 high power fields (630× magnification). True SF eosinophilia was ruled out by microscopic examination of stained slides. Results: Crystal positive samples had significantly higher percentages of eosinophils than the controls (p<0.0001). No significant differences between the two crystal types were found (p=0.693). Thus, pseudoeosinophilia was significantly correlated with the presence of crystals, and none of the distinct crystal types was more likely to be associated with pseudoeosinophilia. Conclusions: In this study, SF pseudoeosinophilia was confirmed as a crystal-related laboratory artefact which has to be considered in the interpretation of automated SF leukocyte differential counts.

Dacryocytes are a common morphologic feature of autoimmune and microangiopathic haemolytic anaemia.

Abstract Background: Dacryocytes are teardrop-shaped erythrocytes which are most frequently observed in peripheral blood smears of patients with primary or secondary myelofibrosis as well as malignant infiltrative disorders of the bone marrow. Dacryocytes have rarely been described in blood smears of patients with autoimmune (AIHA) and microangiopathic haemolytic anaemia (MAHA). The clear prevalence of dacryocytes in AIHA and MAHA is unknown. Methods: We compared the dacryocyte counts in blood smears stained according to the May-Grünwald-Giemsa technique between 20 subjects with AIHA and MAHA with those from 21 controls. The dacryocytes, defined as erythrocytes tapered to a point at one end, were counted as cells per 20 high power fields (HPF) at 630-fold magnification. Results: In AIHA, MAHA and controls, dacryocytes were found in 89%, 91% and 19% of the slides, respectively. The rate of dacryocyte positivity and the dacryocyte counts between haemolytic anaemias and controls differed statistically highly significant (p<0.0001). Conclusions: The results of this study indicate that dacryocytes are commonly apparent in blood smears of patients with AIHA and MAHA. Knowledge of this frequent feature may be beneficial in clinical routine diagnosis.

Extensive elevation of BNP but not NT-ProBNP in a patient with advanced urothelial carcinoma in absence of cardiac failure and volume overload

*Corresponding author: Christoph Robier, MD, Hospital of the Brothers of St. John of God, Bergstrasse 27, 8020 Graz-Eggenberg, Austria, Phone: +43 316 59896671, Fax: +43 316 59891505, E-mail: christoph.robier@bbegg.at Manfred Neubauer: Central Laboratory, Hospital of the Brothers of St. John of God, Graz-Eggenberg, Austria; and Department of Internal Medicine, Hospital of the Brothers of St. John of God, Graz-Eggenberg, Austria Georg Binter: Department of Internal Medicine, Hospital of the Brothers of St. John of God, Graz-Eggenberg, Austria Reinhard B. Raggam: Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria

Changes in response to antiaggregatory treatment in patients with myeloproliferative neoplasms: a sequential study using multiple electrode aggregometry.

In the present study, we used multiple electrode aggregometry (MEA) to investigate the response to aspirin and clopidogrel treatment, and its potential changes over a long-time disease course in patients with myeloproliferative neoplasms (MPNs). arachidonic acid (ASPI), ADP, and thrombin receptor activating peptide (TRAP) tests were performed at two timepoints between 32–50 months in 21 patients with MPN and 1–46 months in 29 controls. We further checked the medical records of the participants to identify a potential correlation of changes in the treatment response with clinical events. In MPN, four out of 13 patients treated with 100 mg of aspirin, no patients receiving 50 mg of aspirin, and one out of five clopidogrel-treated patients showed a therapeutic antiplatelet effect. In the subsequent examinations, five patients changed from response to nonresponse or vice versa. Initial nonresponse and changes from an initial response to nonresponse were observed in six patients with thrombotic events. In the controls, 25 out of 26 aspirin-treated patients and two out of three clopidogrel-treated patients showed an initially adequate in-vitro response. Except from one patient changing from initial aspirin nonresponse to response, all controls showed a stable response state. One control with two ischemic strokes showed a nonresponse to clopidogrel. In conclusion, MEA detects the response to antiaggregatory treatment, as well as its changes during the disease course in patients with MPN. An initial or subsequent nonresponse was observed in patients with thrombotic events.