Roberto Marra

Fatal haemoptysis in pulmonary filamentous mycosis: An underevaluated cause of death in patients with acute leukaemia in haematological complete remission. A retrospective study and review of the literature

A retrospective study on a consecutive series of 116 patients affected by acute leukaemia with documented pulmonary filamentous mycosis (FM) admitted between 1987 and 1992 to 14 tertiary‐care hospitals in Italy was made in order to evaluate the characteristics of those patients who developed fatal massive haemoptysis.

The Role of Bronchoalveolar Lavage in the Microbiological Diagnosis of Pneumonia in Patients with Haematological Malignancies

In the aetiological diagnosis of pulmonary infections in patients affected by haematological malignancies we evaluated the utility of bronchoalveolar lavage (BAL). One hundred and twenty-seven BAL were performed in 119 patients. In our series, we identified the agent of pneumonia in 53.5% of episodes with the best results in aspergillosis, very common in these patients. The previous empirical anti-infective treatment was modified in 14 episodes (11%). The procedure was generally well tolerated and only one patient bled. We maintain that BAL is a useful diagnostic tool for detecting the agents of pulmonary infections in patients with haematological malignancies, especially when the routine microbiological procedures fail, and it also represents a good alternative to more invasive procedures.

The yield of bronchoalveolar lavage in the etiological diagnosis of pneumonia in leukemia and lymphoma patients

To the Editor: Pulmonary infection is a very frequent complication in hematological malignancies. It represents the major cause of morbidity and mortality in leukemic patients. The early etiological diagnosis allows the timely start of an aimed therapy. Various invasive procedures have been proposed for this purpose: fiberoptic bronchoscope with transbronchial biopsy, transthoracic fine needle aspiration, open-lung biopsy. Yet they are associated with a high risk of complications. Bronchoalveolar lavage (BAL) performed by a fiberoptic bronchoscopy has been proposed as a good diagnostic tool for the diagnosis of pulmonary infections in immunocompromised patients (1-4). Sixty-five bronchoscopic procedures with BAL were performed in 63 leukemia and lymphoma patients. All cases presented a focal or diffuse pneumonia during the aplastic phase after an aggressive antiblastic treatment. The patients (m/f 43/20, aged 17-68) were affected by acute myeloblastic leukemia (AML) (35) , acute lymphoblastic leukemia (ALL) (6), non-Hodgkin’s lymphoma (NHL) (18), Hodgkin’s disease (HD) (4). Patients with other hematological malignancies or submitted to allogeneic bone marrow transplantation (BMT), as well as patients who had received thoracic radiotherapy, were excluded from this study. One AML patients was not evaluable because the procedure was interrupted by bleeding. The median time between the diagnosis of pulmonary infection and BAL procedure was 4 d (range 2-1 1). In all cases before the execution of BAL, routine microbiological cultural and serological tests were performed; at the onset of neutropenia a prophylaxis treatment with oral quinolonics and Amphotericin B was started. Prophylactic administration of Cotrimoxazole twice-weekly was added in ALL and LNH. At the onset of the fever all patients were treated with an empirical broad-spectrum antibiotic association according to the GIMEMA infective program (5). After 3-5 d of antibiotic therapy without improvement or recovery, antifungal therapy was added. Furthermore, in the cases with a diffuse interstitial infiltration suspect for a cytomegalovirus (CMV) infection, an antiviral treatment (Ganciclovyr) was started. In 12 patients (8 ALL and 4 LNH) therapeutic doses of Cotrimoxazole towards Pneumocystis carinii (PC) were administered, even in the absence of a specific diagnosis. The BAL fluid was stained and cultured for aerobic and anaerobic bacteria, fungi (Aspergillus and Candida species), mycobacteria, viruses (CMV, Herpes-simplex HSV, Varicella-zooster HZV, Influenza). The search for CMV was performed by immunofluorescence technique. The presence of PC in BAL was tested with optical microscopic examinations using special stains and, in the last 22 cases, with monoclonal antibodies. BAL was diagnostic in 37 cases (60 %). Fig. 1 lists the microbiological agents identified. In 13 cases pulmonary Aspergillosis was diagnosed by BAL fluid culture. In the 4 cases who performed brushing, Aspergillus isolated in BAL was present in brushing too. In 3 cases the diagnosis was confirmed by the autopsy. In 3 cases the fungus was demonstrated in a cutaneous biopsy too. In 2 patients the presence

The role of antithrombin III in the perioperative management of the patient with unstable angina.

BACKGROUND To evaluate the effectiveness of intraoperative administration of antithrombin III (AT III) to improve anticoagulation and preserve the hemostatic mechanisms during cardiopulmonary bypass (CPB) in patients with unstable angina under heparin treatment. METHODS We divided 22 patients, scheduled for coronary artery bypass grafting, into two groups. Group A (11 patients) received 3000 International Units (IU) of AT III concentrates plus heparin before aortic cannulation. Group B (11 patients) received only heparin. Blood drainage, allogeneic blood transfusions, and intraoperative activated coagulation time were recorded. Also, AT III, thrombin-antithrombin complex (TAT), fragment 1.2 (F 1.2), and D-dimers were measured during the operation and the first postoperative day. RESULTS Group A patients had fewer transfusions and had less chest-tube drainage. In group A, AT III levels increased after AT III concentrates administration and were always higher than in group B. In group B, F 1.2 and TAT increased significantly more after CPB and at the end of operation. Differences in D-dimers between the groups were not significant. CONCLUSIONS Intraoperative administration of AT III concentrates allowed adequate anticoagulation during CPB and attenuated the coagulative cascade activation and the consequent consumptive coagulopathy.

Prevalence of obesity in young adults with acute lymphoblastic leukemia

SummaryWe studied the hormonal pattern of nine patients with acute lymphoblastic leukemia. The patients were treated with standard therapeutic regimens. They were overweight by a mean of 52% at the end of the consolidation treatment, and this persisted after a followup of 2 years. The only endocrine alteration observed was a moderate decrease in serum testosterone levels in male patients. The other parameters studied were in the normal range. We conclude that prolonged treatment with high doses of corticosteroids, which have a depressive effect on metabolism, was responsible for the obesity.

Antithrombin III during High-Dose Cytosine Arabinoside Therapy with or without Asparaginase

Fourteen patients with hematologic neoplasia (11 acute myeloid leukemias, 2 non-Hodgkins lymphomas and 1 blast crisis of chronic myeloid leukemia) who underwent high-dose cytosine arabinoside (HIDARAC) therapy with or without sequential asparaginase (ASNase) were investigated in order to evaluate liver toxicity and a possible decrease in antithrombin III (AT III) plasma level. AT III was found decreased only in patients who received ASNase, whereas HIDARAC alone did not influence AT III levels. It is pointed out that a single dose of ASNase seems to be sufficient to induce a decrease in AT III. A mild and transient liver toxicity due to HIDARAC therapy does not seem to be of any clinical relevance.

Partial duplication of chromosome 1q preceding the development of an L3 lymphoblastic leukemia with t(8;14), secondary to treatment for Hodgkin's disease

We report on a case of secondary lymphoblastic leukemia L3 in a patient treated with chemo‐ radiotherapy for a previous Hodgkins disease. The typical chromosome translocation t(8;14) was found in association with a translocation t(9;19) and a marker chromosome 1, dup(1q). The same marker chromosome had been detected in a few cells of peripheral blood 2 years before the onset of the acute leukemia and may represent a proliferation‐associated change, responsible for the initiation of the process of leukemogenesis.

Apparent Isolated Skin Relapse in Acute Monocytic Leukemia. A Case Report

A case of acute monocytic leukemia with an apparent isolated skin relapse is reported. The cutaneous involvement was associated with a morphological bone marrow remission but a cytogenetic relapse was present. Regression of the skin lesions was obtained with a protocol including daunoblastine, aracytin and thioguanine, but the patient relapsed and died a few months later without achieving another remission. The relation between cutaneous and medullary disease is discussed.

Cerebrospinal fluid beta-2-microglobulin: A reliable index of leukaemic infiltration of central nervous system

Cerebrospinal fluid (CSF) beta‐2‐microglobulin (B2m) has been proposed as a marker of central nervous system (CNS) involvement in myelo‐lymphoproliferative diseases. Recently its reliability has been put in question because of false positive and false negative results. In our study, B2m was measured in 574 CSF samples collected from 74 patients affected by ALL, ANLL or lymphomas; 20 of these patients had CNS‐involvement while they were under observation. There was a significant difference in CSF B2m between the patients with and without CNS‐involvement (p < 0.001). No false positive or false negative results were obtained. In 4 cases the rising of CSF B2m was observed 8, 6, 4 and 4 wk before the clinical and laboratory diagnosis of CNS‐involvement. In all patients the clinical and laboratory improvement of the neurological disease was associated with a progressive decrease of CSF B2m. Some hypotheses about the origin of CSF B2m are discussed. The authors conclude that CSF B2m is a useful and reliable marker of CNS‐involvement in myelo‐lymphoproliferative disease.

Ph1-Chromosome-Positive Chronic Myelogenous Leukemia following a 1-Year ‘Off-Therapy’ Acute Lymphoblastic Leukemia

In this paper we describe a patient with acute lymphoblastic leukemia followed after 4 years by a Ph1-positive chronic myelogenous leukemia. The possible relationship between these two diseases is discussed.