Shogo Murata

Acute Leukemia Showing t(8;22)(p11;q11), Myelodysplasia, CD13/CD33/CD19 Expression and Immunoglobulin Heavy Chain Gene Rearrangement

t(8;22)(p11;q11) is a rare but recurrent chromosome translocation that has been reported in 11 cases of myeloproliferative neoplasm or B-acute lymphoblastic leukemia. This translocation results in an in-frame fusion of FGFR1 on 8p11 and BCR on 22q11, and causes constitutive activation of the tyrosine kinase of the BCR/FGFR1 chimera protein. Here, we report the twelfth case of hematological tumor bearing t(8;22)(p11;q11). The bone marrow showed hypoplastic and tri-lineage dysplasia with 24.4% abnormal cells. The abnormal cells were not defined as myeloid or lymphoid morphologically, lacking a myeloperoxidase reaction. Flow cytometric analysis of the bone marrow cells revealed that the abnormal cells expressed CD13, CD33, CD34, and CD19, and that a fraction of the abnormal cells was positive for CD10. Southern blot analysis of the bone marrow cells showed rearrangement of the immunoglobulin heavy chain gene, a genetic hallmark of B-cell differentiation. Previously reported cases with t(8;22)(p11;q11) suggested an association between myeloid and B-lymphoid tumors, whereas other chromosome translocations involving FGFR1 on 8p11 showed a link between myeloid and T-lymphoid tumors. Our observation supports that t(8;22)(p11;q11) might define a dual myeloid and B-lymphoid disorder.

Molecular cloning of IGλ rearrangements using long‐distance inverse PCR (LDI‐PCR)

Malignant cells of mature B‐cell origin show tumor‐specific clonal immunoglobulin gene (IG) rearrangements, including V(D)J recombinations, nucleotide mutations, or translocations. Rapid molecular cloning of the breakpoint sequence by long‐distance inverse PCR (LDI‐PCR) has so far been applied to rearrangements targeted to IGH joining, IGH switch, and IGκ regions. We tended to apply LDI‐PCR method for cloning of IGλ rearrangements.

Successful treatment with liposomal doxorubicin for widespread Kaposi’s sarcoma and human herpesvirus-8 related severe hemophagocytic syndrome in a patient with acquired immunodeficiency syndrome

Hemophagocytic syndrome (HPS) sometimes occurres in patients with acquired immunodeficiency syndrome (AIDS). Human herpesvirus-8 (HHV-8)/Kaposi’s sarcoma (KS)-associated herpesvirus has so far been recognized as a trigger of HPS in immunosuppressed subject. We describe a 39-year-old man with AIDS who had widespread mucocutaneous and pulmonary KS and severe HPS. No opportunistic infections or neoplasias were detected except for KS. HHV-8-DNA could be detected in this patient by polymerase chain reaction (PCR) in the serum. Clinical symptoms and cytopenia originating from HPS were reduced by pulse therapy of corticosteroid, antibiotics, and virucides, but recurred with dose reduction of the steroid. Mucocutaneous tumors, edema, and dyspnea had progressed rapidly at this time. Liposomal doxorubicin was given and showed marked effects on both mucocutaneous and plural tumors. HPS also subsided and the serum HHV-8 DNA level markedly decreased after initial treatment with liposomal doxorubicin. HHV-8 clearance with liposomal doxorubicin has recently been reported. Liposomal doxorubicin suppressed not only the widespread KS tumors, but also HHV-8 viremia resulting in decreased HPS in this patient.

Real-time monitoring of antimicrobial use density to reduce antimicrobial resistance through the promotion of antimicrobial heterogeneity in a haematology/oncology unit

BACKGROUND In haematology/oncology units, the frequent and heavy use of broad-spectrum antimicrobials can lead to outbreaks of antimicrobial resistance. Increasing antimicrobial heterogeneity might be a useful strategy for preventing such resistance. METHODS A real-time antimicrobial use density (AUD) monitoring system (RAMS) was developed to precisely assess antimicrobial heterogeneity. This study was prospectively conducted over a 39 month period and involved 970 patients. Patient-specific antimicrobial therapy with five carbapenems (meropenem, biapenem, panipenem/betamipron, imipenem/cilastatin and doripenem) and four non-carbapenems (piperacillin/tazobactam, ceftazidime, cefozopran and cefepime) was prescribed in the first 12 months. A first-line antimicrobial was selected from among nine antimicrobials according to a predetermined schedule for the next 15 months. AUD-based antimicrobial selection was implemented using the RAMS during the last 12 months. We compared our findings for the RAMS period with those for the other periods to determine the effects of RAMS-based AUD monitoring on antimicrobial resistance. RESULTS The mean absolute difference between the AUD values of carbapenems and non-carbapenems (AUD deviation) was 6.0% in the RAMS period (range 0.5%-15.8%) and antimicrobial heterogeneity (AUD deviation <10%) was achieved in 10 out of 12 months (83.3%). Furthermore, during the RAMS period, AUD deviation was significantly smaller and the frequency of outbreaks of antimicrobial-resistant strains other than Stenotrophomonas maltophilia was significantly decreased (from 7.9% to 3.5%; P < 0.01) compared with the other periods. CONCLUSIONS The longer period of stable antimicrobial heterogeneity achieved by the RAMS strengthened its preventive effects against antimicrobial resistance. Optimal antimicrobial heterogeneity based on real-time AUD monitoring could reduce the frequency of outbreaks of antimicrobial resistance.

Occupancy of whole blood cells by a single PIGA-mutant clone with HMGA2 amplification in a paroxysmal nocturnal haemoglobinuria patient having blood cells with NKG2D ligands.

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Refractory Ascites with Liver Fibrosis Developed in Late Phase Allogeneic Hematopoietic Stem Cell Transplantation: Report of Three Patients.

We report cases of three patients of refractory ascites without other fluid retention that occurred around five months after allogeneic hematopoietic stem cell transplantation (allo-HSCT). All three patients expired and postmortem examinations revealed unexpected liver fibrosis lacking histological evidences of graft-versus-host-disease (GVHD). The three patients showed normal hepatic function and size before transplantation. During their clinical courses, serum biochemistry test showed no elevation of hepatic enzymes and bilirubin; however, imaging studies demonstrated hepatic atrophy at the onset of ascites. One of the liver specimens showed bile obstruction, which could be seen in hepatic damage by GVHD. Although ascites resulting from venoocclusive disease in early phase allo-HSCT is well documented, ascites associated with hepatic fibrosis in late phase allo-HCST has not been reported. Further clinico-pathological studies on similar patients should be required to ascertain refractory ascites associated with liver fibrosis after allo-HSCT.

B-Cell-Rich T-Cell Lymphoma Associated with Epstein-Barr Virus-Reactivation and T-Cell Suppression Following Antithymocyte Globulin Therapy in a Patient with Severe Aplastic Anemia

B-cell lymphoproliferative disorder (B-LPD) is generally characterized by the proliferation of Epstein-Barr virus (EBV)-infected B lymphocytes. We here report the development of EBV-negative B-LPD associated with EBV-reactivation following antithymocyte globulin (ATG) therapy in a patient with aplastic anemia. The molecular autopsy study showed the sparse EBV-infected clonal T cells could be critically involved in the pathogenesis of EBV-negative oligoclonal B-LPD through cytokine amplification and escape from T-cell surveillances attributable to ATG-based immunosuppressive therapy, leading to an extremely rare B-cell-rich T-cell lymphoma. This report helps in elucidating the complex pathophysiology of intractable B-LPD refractory to rituximab.

Severe graft-versus-host disease after allogeneic hematopoietic stem cell transplantation with residual mogamulizumab concentration

We read with great interest the two articles by Tsubokura et al. and Ishitsuka et al. on allogeneic hematopoietic stem cell transplantation (allo-HSCT) for adult T-cell leukemia/ lymphoma (ATLL) [1, 2]. Regimens containing mogamulizumab (Mog), an anti-CC chemokine receptor 4 (CCR4) monoclonal antibody, are expected to achieve good disease control before allo-HSCT and may result in low relapse rate after allo-HSCT. However, there is a concern that the use of Mog before allo-HSCT may cause severe acute graftversus-host disease (aGVHD), as Mog eradicates normal CCR4-positive cells, including regulatory T cells (Tregs). Fuji et al. reported that Mog administration is associated with significantly increased risk of severe aGVHD due to such reduction in Tregs [3]. At present, there is no consensus on how to use Mog before allo-HSCT in Japan. Recently, Tsubokura et al. reported that monitoring of Tregs was useful for avoiding severe aGVHD [1]. Ishitsuka et al. demonstrated that the interval between the last administration of Mog and transplantation affected aGVHD [2]. In addition to monitoring of Tregs and the interval of administration, Fuji et al. proposed that monitoring of serum Mog level in peripheral blood is warranted [3]. However, little is known about the association between serum Mog level, Tregs, and aGVHD at the moment, and the threshold of serum Mog concentration at allo-HSCT has not been established. Here, we report the clinical course of an ATLL patient in whom Tregs and serum Mog concentration were measured after allo-HSCT (Fig. 1). The patient was a 59-year-old man diagnosed with acutetype ATLL. He received chemotherapy, resulting in partial remission with residual abnormal lymphocyte in peripheral blood. He received 10 cycles of Mog (1 mg/kg) and achieved complete remission. He underwent unrelated bone marrow transplantation from HLA-C locus mismatched donor at 40 days after the last Mog administration in October 2012. He was given a reduced-intensity conditioning regimen, consisting of fludarabine, melphalan, and 2 Gy of total body irradiation. aGVHD prophylaxis was tacrolimus and short-term methotrexate. Engraftment was achieved by day 16 after transplantation. He developed grade II aGVHD (skin 3, gut 0, liver 0) at engraftment and given prednisolone (2.0 mg/kg/day). However, he developed diarrhea due to intestinal aGVHD and was administered mycophenolate mofetil on day 42. His serum concentration of Mog was 317.6 ng/mL. Tregs, which were identified as CD25-positive, CD127-negative cells, were counted as 4.1% in the CD4-positive T-cell gate. Total and CD4-positive lymphocytes at that time were counted as 153/μL and 11/μL, respectively. Because skin rush and diarrhea persisted, he received rabbit antithymoglobulin 1 mg/kg intravenously on day 48. The highest grade and stage of aGVHD were grade IV, skin 4, gut 3 and liver 0. He developed melena with decreased platelet count and elevated LDH due to thrombotic microangiopathy. His serum level of Mog was < 5 ng/mL on day 120 after allo-HSCT. Tregs increased to 31.5% in the CD4positive T-cell gate. Total and CD4-positive lymphocyte were 554/μL and 12/μL, respectively. He died on day 133 * Takashi Sonoki sonoki@wakayama-med.ac.jp

Enforced expression of MIR142, a target of chromosome translocation in human B-cell tumors, results in B-cell depletion

MicroRNA142 (MIR142) is a target of chromosome translocations and mutations in human B-cell lymphomas. We analyzed an aggressive B-cell lymphoma carrying t(8;17)(q24;q22) and t(6;14)(p21;q32), and sought to explore the role(s) of MIR142 in lymphomagenesis. t(8;17)(q24;q22) involved MYC on 8q24 and pri-MIR142 on 17q22. MYC was activated by a promoter substitution by t(8;17)(q24;q22). t(8;17)(q24;q22) was an additional event after t(6;14) (p21;q32), which caused the over-expression of CCND3. Southern blot analyses revealed that the MIR142 locus was deleted from the affected allele, whereas Northern analyses showed over-expression of MIR142 in tumor cells. Although previous studies reported an over-expression of mutations in MIR142 in B-cell lymphomas, limited information is available on the functions of MIR142 in lymphomagenesis. Therefore, we generated bone marrow transplantation (BMT) and transgenic (Eμ/mir142) mice, which showed enforced expression in hematopoietic progenitor cells and B cells, respectively. BMT mice showed decreased numbers of all lineage-positive cells, particularly B cells, in peripheral blood. Eμ/mir142 mice showed decreased numbers of IgM-positive splenocytes, and exhibited altered B-cell phenotypic changes induced by lipopolysaccharide. Our results suggest that over-expression of MIR142 alters B-cell differentiation, implying multi-step lymphomagenesis together with MYC activation and CCND3 over-expression.

Long-term complete remission of early hematological relapse after discontinuation of immunosuppressants following allogeneic transplantation for Sezary syndrome

Sezary syndrome (SS) is a leukemic form of cutaneous T-cell lymphoma and is chemo-resistant. Allogeneic hematopoietic stem cell transplantation is a promising therapy for SS; however, relapse is common. Therapeutic options after relapse have not been established. We managed an SS patient with hematological relapse within one month after transplantation. After discontinuation of immunosuppressants, she achieved complete remission and remained relapse-free. The chimeric analyses of Tcells showed that the full recipient type became complete donor chimera after immunological symptoms. This clinical course suggested that discontinuation of immunosuppressants may result in a graftversus- tumor effect, leading to the eradication of lymphoma cells.