Sayaka Nishina

STAT3 gene mutations and their association with pure red cell aplasia in large granular lymphocyte leukemia

Large granular lymphocyte leukemia (LGL L) has been morphologically characterized as a group of lymphoproliferative diseases that include T‐cell large granular lymphocytic leukemia (T‐LGL L) and chronic lymphoproliferative disorders of natural killer cells (CLPD‐NK). We investigated mutations in the Src homology 2 (SH2) domain of the signal transducer and activator of transcription 3 (STAT3) gene in Asian cohorts of T‐LGL L and CLPD‐NK (n = 42 and 11, respectively). Two mutations, Y640F and D661Y, were identified using direct sequencing or allele‐specific (AS) PCR. Y640F and D661Y mutations were found in seven and 18 patients, respectively. Two patients were positive for both mutations. Frequencies of STAT3 mutations in T‐LGL L and CLPD‐NK were 47.6% and 27.2%, respectively. Pure red cell aplasia (PRCA) was associated with the mutations (P = 0.005). The mutations were persistently found at stable levels in some patients after more than 5 years using AS‐quantitative PCR. The results of the present study indicate that the SH2 domain of the STAT3 gene is frequently mutated in Asian T‐LGL L and CLPD‐NK, and that PRCA is closely correlated with the mutations.

Late relapse of extranodal natural killer/T cell lymphoma, nasal type, after more than ten years

Extranodal NK/T cell lymphoma, nasal type (ENKL) is a malignant lymphoproliferative disorder of NK cells characterized by an invasive nature with vascular damage and necrosis [1–3]. The upper aerodigestive tracts, especially nasal cavities, are commonly involved (the nasal type), and in minor populations, other sites such as the skin, intestines, or soft tissues other than the aerodigestive tracts are the main invasive sites (extranasal type). ENKL is more prevalent in Asians and Central Americans, and a lower incidence among Caucasians is recognized. ENKL is also characterized by a strong association with Epstein-Barr virus (EBV). The clinical outcome of ENKL varies depending on the involved site and clinical stage, and the prognosis is considerably worse than that of other lymphomas, although the recent therapeutic progress including in concurrent chemoand radiotherapy against limited-stage nasal type ENKL and the introduction of hematopoietic cell transplantation (HCT) might improve the outcome [4–6]. Some cases of ENKL have been known to relapse after a long duration of complete response [7,8]; however, the biological mechanisms of ENKL including those of such cases are still unknown. Here, we report three Japanese cases of ENKL who relapsed after a period of longer than 10 years of complete response after the initial treatment. Case one was a 44-year-old male who had suffered from intermittent nasal discharge and was diagnosed with non-Hodgkin lymphoma, diffuse pleomorphic type, with clinical stage IIE in 1991. He had received combination chemotherapy of methotrexate (MTX), doxorubicin (ADR), cyclophosphamide (CY), vincristine (VCR), and bleomycin (MACOP-B) and local irradiation. He achieved complete response (CR) and had been well until 2007, when he noticed hoarseness and was found to have a paralaryngeal tumor. The tumor was diagnosed as ENKL with positivity for cytoplasmic CD3, CD56, TIA1, granzyme B, and EBV by immunohistochemical studies and in situ hybridization, respectively. He needed trachostomy for bronchial obstruction, and multiple skin lesions also developed. He was administered carboplatin, etopside, ifosdamide (IFO), and dexamethasone, with no improvement, so he was also given cytosine arabinoside, IFO, MTX, and L-asparaginase. He reached CR after three courses of chemotherapy. Months later, he died of exacerbation of his ENKL. Re-examination of the histological specimen of the primary lesion taken in 1991 revealed identical morphological features and the same immunophenotypes and EBV positivity as the relapsed lesions. He was clarified as having had a relapse of ENKL after 16 years. The second case was a 36-year-old female who was diagnosed with, diffuse, medium sized, NHL, which was positive for CD45RO and negative for CD20, in a right nasal tumor in 1989. She received four courses of MACOP-B and 50 Gy involved field irradiation (IFR). She had maintained a CR until

Cell size variations of large granular lymphocyte leukemia: Implication of a small cell subtype of granular lymphocyte leukemia with STAT3 mutations

Large granular lymphocyte leukemia (LGL-L) has been morphologically defined as a group of lymphoproliferative disorders, including T-cell large granular lymphocytic leukemia (T-LGL-L), chronic lymphoproliferative disorders of NK cells (CLPD-NK) and aggressive NK cell leukemia. We investigated the morphological features of LGL leukemic cells in 26 LGL-L patients in order to elucidate relationships with current classifications and molecular backgrounds. LGL-L cells were mostly indistinguishable from normal LGL. Patients with STAT3 SH2 domain mutations showed significantly smaller cells compared with patients without STAT3 mutations. Four patients with T-LGL-L showed smaller granular lymphocytes with a median diameter of less than 13μm, which were rarely seen in normal subjects. This small subtype of T-LGL-L was recognized among rather young patients and was associated with D661Y mutations in the STAT3 gene SH2 domain. In addition, all of them showed anemia including two cases with pure red cell aplasia. These results suggest the heterogeneity of T-LGL-L and a specific subtype with small variants of T-LGL-L.

Early detection of Rhizopus DNA in the serum of a patient with rhino-orbital-cerebral mucormycosis following allogeneic hematopoietic stem cell transplantation.

confirmed ROCM compared to those detected by changes in MRI. A 27-year-old woman with a bone marrow relapse of acute myeloid leukemia underwent second peripheral blood stem cell transplantation (SCT) from a human leukocyte antigen-haploidentical mother. Graft-versus-host disease (GVHD) prophylaxis included tacrolimus, and methylprednisolone. Voriconazole was administered to prevent fungal infections. Seven months after second SCT, she had a relapse and therefore immunosuppressive agents were discontinued. Subsequently, she developed persisting diarrhea. Gut GVHD was histologically confirmed and treated with 2 mg/kg/day of methylprednisolone in hospital. Two weeks later, she complained of a right periocular pain (day 0). At onset of symptoms, she did not present neutropenia and had no history of hyperglycemia, iron overload, or invasive fungal infection. Gradually, the pain became worse, and contrast computed tomography (CT) and MRI of the brain were performed on day 3, revealing mucosal thickening in the right maxillary sinus and mucosal thickening with fluid accumulation in the right ethmoid sinus with no evidence of the infection extending to the orbital and cerebral tissues (Fig. 1). A CT scan did not show any bone involvement. At this point, a nasal endoscopic biopsy was not performed due to the nasal bleeding difficult to control in spite of daily platelet transfusion. She developed right facial numbness and weakness on day 6 and diplopia on day 8. Additionally, right periocular edematous erythema appeared with an extension to the right lower malar region. Administration of liposomal amphotericin B (L-AmB) was initiated on day 8 at a dose of 2.5 mg/kg daily and increasing to 5.0 mg/ kg daily, but she developed right-eye proptosis on day 10. A repeat contrast CT scan and MRI of the brain on day 10 showed worsening of the inflammatory lesions, which Dear Sir, Rhino-orbital-cerebral mucormycosis (ROCM) is a rapid, aggressive infection caused by fungi of the order Mucorales, which typically occurs immunocompromised patients. Early diagnosis and prompt therapy are essential for survival and minimizing neurological sequelae. In patients with ROCM, magnetic resonance imaging (MRI) is effective in detecting orbital and central nervous system involvement. However, diagnosis of sinus mucormycosis before the infection extends to the orbital and cerebral tissues is critical to improve outcome and survival [1]. In contrast to aspergillosis, there are no specific or useful serum biomarkers for diagnosing mucormycosis. Millon et al. developed a serodiagnostic tool, utilizing a combination of three quantitative polymerase chain reaction (qPCR) assays, using probes that target Mucor/Rhizopus, Lichtheimia, and Rhizomucor for the detection of circulating Mucorales [2]. We improved their assay in which Mucorales DNA was expressed as number of copies per milliliter to improve quantization for monitoring the activity of mucormycosis [3]. In the present study, we evaluated whether this modified qPCR assay facilitated early detection of Mucorales DNA in the serum of a patient with

Successful Empiric Therapy for Postsplenectomy Sepsis with Campylobacter fetus in an Abattoir Worker with Follicular Lymphoma

Asplenia may yield an increased risk of fulminant sepsis with various pathogens. Human infection with Campylobacter fetus is rare, but it often presents with non-gastrointestinal tract infection among immunocompromised individuals. A 55-year-old abattoir worker presented with a fever. He had had splenectomy for follicular lymphoma and rituximab maintenance therapy by four months before the presentation. Blood cultures yielded C. fetus, and the administration of meropenem dissolved the bacteremia. Further maintenance therapy was withheld, and no recurrence of infection has been observed for seven years. Asplenia, occupational exposure, and/or rituximab maintenance therapy might have been precipitating factors of this rare infection.

Breakthrough Candida guilliermondii (Meyerozyma guilliermondii) fungemia after cord blood transplantation for extranodal NK-cell lymphoma with azole prophylaxis

Fluconazole (FLCZ) is an azole antifungal agent and it has shown excellent clinical activities in suppressing fungemia with Candida albicans after hematopoietic stem cell transplantation. Increased administration of prophylactic FLCZ seems to have given rise to the relatively higher incidence of more resistant Candida non‐albicans infection. We present a case with a rare breakthrough fungemia with C. guilliermondii after cord blood transplantation for Extranodal NK cell Lymphoma, nasal type (ENKL), during antifungal prophylaxis with FLCZ. High level of caution is needed for the breakthrough, especially after long‐term azole administration.

Severe Infection of Pseudomonas aeruginosa during Eculizumab Therapy for Paroxysmal Nocturnal Hemoglobinuria

Eculizumab is the complement inhibitor administered to ameliorate intravascular hemolysis in paroxysmal nocturnal hemoglobinuria. Whether or not the inhibitory mechanism may also increase the susceptibility to non-Neisserial infection is unclear. A 73-year old woman presented with bacteremia, cholecystitis and liver abscess with Pseudomonas aeruginosa. Although she had been neutropenic for 21 years, she had no history of severe infection before eculizumab had been administered. The infection with P. aeruginosa was successfully controlled with antibiotics, granulocyte colony-stimulating factor and cholecystectomy. The present case might be representative of less common bacterial infections than Neisseria spp. among patients treated with eculizumab.

Frequent STAT3 mutations in CD8+ T cells from patients with pure red cell aplasia

Dysregulation of T-cell-mediated immunity is responsible for acquired pure red cell aplasia (PRCA). Although STAT3 mutations are frequently detected in patients with T-cell large granular lymphocytic leukemia (T-LGLL), which is often complicated by PRCA and which is also reported to be associated with acquired aplastic anemia (AA) and myelodysplastic syndrome (MDS), whether STAT3-mutated T cells are involved in the pathophysiology of PRCA and other types of bone marrow failure remains unknown. We performed STAT3 mutation analyses of the peripheral blood mononuclear cells from PRCA patients (n = 42), AA (n = 54), AA-paroxysmal nocturnal hemoglobinuria (AA-PNH; n = 7), and MDS (n = 21) using an allele-specific polymerase chain reaction and amplicon sequencing. STAT3 mutations were not detected in any of the 82 patients with AA/PNH/MDS but were detected in 43% of the 42 PRCA patients. In all 7 STAT3-mutation-positive patients who were studied, the STAT3 mutations were restricted to sorted CD8+ T cells. The prevalence of STAT3 mutation in idiopathic, thymoma-associated, autoimmune disorder-associated, and T-LGLL-associated PRCA was 33% (5 of 15), 29% (2 of 7), 20% (1 of 5), and 77% (10 of 13), respectively. The STAT3-mutation-positive patients were younger (median age, 63 vs 73 years; P= .026) and less responsive to cyclosporine (46% [6 of 13] vs 100% [8 of 8]; P= .0092) in comparison with STAT3-mutation-negative patients. The data suggest that STAT3-mutated CD8+ T cells may be closely involved in the selective inhibition of erythroid progenitors in PRCA patients.

Large vessel vasculitis developed early after allogeneic bone marrow transplant for acute erythroid leukemia

Vasculitis is a well-known manifestation in patients with hematologic malignancies, and large vessel vasculitis (LVV) may also occur [1–3]. LVV derived from immunologic dysfunctions can be improved by autologous or allogeneic hematopoietic stem cell transplant (allo-HSCT) [4–6]. Although a patient who developed LVV during the course of chronic graft-versus-host disease (GVHD) after allo-HSCT for chronic myelogenous leukemia was previously reported [7], LVV-like symptoms developing early after allo-HSCT have not been described. We experienced a patient who developed LVV within a month of allogeneic HSCT, possibly as an immunologic reaction related to HSCT. A 61-year-old male was admitted to another hospital because of fatigue, weight loss and skin rashes in March 2012. Hematologic examination showed a white cell count of 2.69  10 9 /L, a hemoglobin concentration of 8.1 g/dL and a platelet count of 102  10 9 /L. By bone marrow aspiration, erythroid hyperplasia and trilineage dysplastic features were recognized. The percentages of erythroid precursors and blasts in the non-erythroid component in the bone marrow were 87% and 48%, respectively. The karyotype was 46,XY and the patient was diagnosed with acute erythroid leukemia. He received two courses of azacitidine therapy and was transferred to our hospital for allo-HSCT in incomplete remission. The preparative regimen consisted of fludarabine 30 mg/m 2 once daily i.v. for 6 consecutive days and busulfan 3.2 mg/kg/day divided by four times i.v. for 4 days. He underwent allogeneic bone marrow transplant from a human leukocyte antigen-matched brother in June 2012. Cyclosporine A and short-term methotrexate were used for the prophylaxis of acute GVHD. Neutrophil engraftment was observed on day 13. From day 16, he developed fever and suffered from pain in the left temple and both sides of the neck. The sites of the neck pain were found on physical examination to be restricted to the common carotid arteries. C-reactive protein was elevated to 21.27 mg/dL. Magnetic resonance imaging (MRI) on day 21 and computed tomography (CT) on day 23 demonstrated thickened walls of the large vessels from the Figure 1. (a) Magnetic resonance imaging in short-TI-inversion recovery sequence on day 21 after allogeneic bone marrow transplant (BMT) showed thickened walls of the bilateral common carotid arteries, notably on the left (arrow). (b) Contrast-enhancement CT performed on day 23 after allogeneic BMT revealed a thickened wall with delayed contrast enhancement of the aortic arch (arrowheads). aortic arch to the bilateral common carotid arteries, with delayed contrast enhancements (Figure 1). The lumens of the arteries were not narrowed. Other large arteries, including the