Takaki Shimada

Prognostic factors of hemophagocytic syndrome in adults: analysis of 34 cases

Abstract: Hemophagocytic syndrome (HPS) presents with fever, pancytopenia, liver dysfunction and increase in hemophagocytic histiocytes in various organs. Although there are two major classifications of HPS in adults, malignant and reactive histiocytosis, it is often very difficult to distinguish between these disorders. We analyzed the laboratory data of patients with HPS to evaluate prognostic factors. Of 34 patients, 14 survived, and 20 died. The median age of survivors was 29.6 ± 11.5 yr significantly younger than those who died (54.7 ± 17.8 yr). Twenty patients had no obvious underlying disease, the other 13 had hematological malignancies or viral infections. Comparison of laboratory data revealed that nonsurvivors had significantly lower Hb and platelet values on admission. During treatment, worsening of anemia and thrombocytopenia, increase of transaminase and biliary enzymes were similarly more prominent. Risk factors associated with death were: age over 30 yr, presence of disseminated intravascular coagulation, increased ferritin and β2‐microglobulin, anemia accompanied by thrombocytopenia and jaundice. Our data suggests that patients with HPS and any of these risk factors should be treated aggressively with sufficient chemotherapy and supportive care.

Long‐term administration of G‐CSF for aplastic anaemia is closely related to the early evolution of monosomy 7 MDS in adults

There is an increasing incidence of the evolution of myelodysplastic syndrome (MDS) from aplastic anaemia (AA) with immunosuppressive treatment. In paediatric patients G‐CSF is also reported to increase MDS evolution, but this process is not precisely understood in children or in adults. Therefore risk factors of MDS evolution in adults are evaluated here. Of 72 patients, five developed MDS. In 47 patients without cyclosporine (CyA) or antithymocyte globulin (ATG) therapy, only one developed MDS with trisomy 8, 242 months after diagnosis. But of 25 patients treated with either CyA or ATG, four developed monosomy 7 MDS within 3 years. Of these 25 patients, 18 were treated with G‐CSF and the four patients (22.2%) who developed MDS were found in this group. The cumulative dose and the duration of G‐CSF administration were significantly elevated in patients who developed MDS when compared with those who did not, 822.3 ± 185.0 v 205.4 ± 25.5 μg/kg (P < 0.05) and 187.5 ± 52.5 v 72.0 ± 24.6 d (P < 0.002), respectively. However these two values for CyA did not differ significantly. Statistically, treatment with CyA, G‐CSF and combined G‐CSF and CyA were significantly related to MDS evolution. The administration of G‐CSF for more than a year was the most important factor (P = 0.00). These results suggested that a close relationship exists between G‐CSF and subsequent monosomy 7 MDS from AA in adults who receive immunosuppressive therapy. Long‐term administration of G‐CSF should be prohibited in order to prevent MDS evolution.

Methotrexate-associated lymphoproliferative disorders: management by watchful waiting and observation of early lymphocyte recovery after methotrexate withdrawal

No optimum treatment of iatrogenic immunodeficiency-associated lymphoproliferative disorders due to methotrexate in patients with rheumatoid arthritis (MTX-LPD) has yet been established, although MTX withdrawal is known to have a substantial effect on tumor regression. Here, we retrospectively analyzed 20 cases of MTX-LPD. Tumor shrinkage occurred in 18 of 20 cases, but only following MTX withdrawal. This tumor regression ratio was considerably better than in previous reports, and appeared due to longer “watchful waiting.” Lymphocyte recovery at 2 weeks after MTX withdrawal was significantly higher in cases with tumor regression in 1 month than in those without tumor regression (p = 0.001). Median time to maximal efficacy after MTX cessation in cases without chemotherapy was 12 weeks (range 2–76). In conclusion, watchful waiting for a longer period after MTX cessation with observation of early lymphocyte recovery and uninterrupted continuation of other anti-rheumatoid drugs may be an acceptable management plan for MTX-LPD.

Combination Chemotherapy with G-CSF, M-CSF and EPO: Successful Treatment for Acute Myelogenous Leukemia without Blood Transfusion at Lower Medical Costs

A 55-year-old Jehova’s Witness was treated for acute myelogenous leukemia (AML) by intensive chemotherapy with enocitabine, 6-mercaptopurine and daunorubicin. G-CSF, M-CSF and EPO were subsequently administered. Even though no blood transfusion was given for religious reasons, complete remission was achieved without serious infection and hemorrhage. The total cost for induction chemotherapy was less expensive than is the case for elderly AML patients. This case indicates that the administration of cytokines might reduce the incidence of infection and the necessity for blood products, which would result in favorable cost effectiveness for the treatment of elderly patients with AML.

Immunohistochemical localization of keratin in bull, goat, and sheep anterior pituitary glands

SummaryImmunohistochemical localization of keratin, an intermediate filament protein, was studied in bull, goat, and sheep anterior pituitary glands, i.e., in animals of the order Artiodactyla. Strong immunoreactivity was detected in the cells of the marginal layer of bull and goat, as well as in cysts or large follicles in the anterior lobe of all 3 species. In addition, a number of stellateshape cells were immunoreactive for keratin and were distributed throughout the anterior lobe. The localization of keratin-positive cells in light-microscopic preparations correlated precisely with the localization of folliculo-stellate cells in adjacent ultrathin sections. In ultrastructural studies, many slender and elliptical membranous components which were different from smooth endoplasmic reticulum were observed in the cytoplasm of the some keratin-positive cells. Some of the folliculostellate cells in the 3 species were also immunoreactive for the α subunit of S-100 protein, which exists in some epithelial cells. On the other hand, immunolocalization of glial fibrillary acidic protein, a glial cell marker, could not be demonstrated in the anterior pituitary glands of the 3 species studied. These results suggest that keratin-positive folliculo-stellate cells express epithelial-like characteristics.

Dome formation of keratin-containing agranular cells from rat anterior pituitary gland in vitro

SummaryA certain kind of cell in the pituitary gland exhibited immunoreactive keratin and dome formations in vitro. We obtained epithelial cells, which were able to subculture, from the outgrowth of anterior pituitary organ cultures. These cells lacked hormone secretory granules and exhibited immunoreactive keratin. Furthermore, they produced dome formations or cystic structures in monolayer culture and under three-dimensional culture condition using type I collagen gel. Dome formation was stimulated by dibutyryl cyclic AMP (dbcAMP, 10−3 to 10−5M). Their responsiveness to dbcAMP is similar to that of several other epithelial cells that possess transport functions in vivo and in vitro. Although the origin of our cultured cells is unknown, these cells formed dome formations that possessed transport function and were related to cystic structures in the pituitary gland in vivo.

Rapid progression and unusual premortal diagnosis of mucormycosis in patients with hematologic malignancies: analysis of eight patients

Mucormycosis is a rare but emerging group of life-threatening opportunistic mycoses. We described experience of eight patients who developed mucormycosis. These patients had developed hematologic malignancies, and none achieved complete remission. Six of the eight patients presented with neutropenia, five received corticosteroid, and four had concomitant hyperglycemia. The most frequent physical finding was fever, and five patients complained of facial pain, headache, or chest pain. Four patients presented with concomitant bacterial infection, pulmonary aspergillosis, or intestinal candidiasis. Premortal diagnosis of mucormycosis was made in only one patient. Postmortem biopsy or autopsy was the diagnostic tool for the other patients. Although patients who were treated with amphotericin B survived longer than those treated with micafungin or voriconazole, all patients died due to the progression of mucormycosis. Estimated median survival was 23 days. Premortal diagnosis was rarely achieved as biopsy of infected tissues was the only diagnostic tool, and four patients who revealed dual infection were diagnosed with aspergillosis or bacterial infections. In patients with a high risk of mucormycosis presenting with pain and uncontrollable fever, mucormycosis should be included in the differential diagnosis. High dosages of liposomal amphotericin B should be given and surgical debridement should be performed promptly in cases highly suggestive of mucormycosis.

Successful Immunosuppressive Therapy with Cyclosporine A for Posthepatitis B-Cell Deficiency With Activated Cytoplasmic Interferon-γ-Positive T-Lymphocytes

We describe a patient with transient disappearance of B-cells, hypogammaglobulinemia, and mild pancytopenia after acute hepatitis. Both HLA-DR+CD8+ and intracellular interferon-γ+/interleukin-4- cell levels were markedly increased, resulting in an increase in the cytotoxic T-cell (TC)1/TC2 and helper T-cell (Th)1/Th2 ratios. After immunosuppressive therapy with cyclosporine A, these parameters of T-cell activation were clearly decreased, and hematologic recovery, including an increase in B-lymphocytes and immunoglobulin concentration, was obtained. These results suggest that there had been suppression of B-cells by activated T-cells. Some patients with common variable immunodeficiency show similar activation of T-cell function, and the present findings suggest the possibility of immunosuppressive therapy for such patients.

Epstein-Barr Virus-associated Lymphoproliferative Disorder with Encephalitis Following Anti-thymocyte Globulin for Aplastic Anemia Resolved with Rituximab Therapy: A Case Report and Literature Review

Epstein-Barr virus (EBV)-associated lymphoproliferative disorders (LPDs) sometimes occur following Anti-thymocyte globulin (ATG) administration for allogenic stem cell transplantation but are rare in aplastic anemia (AA) patients. A 55-year-old woman with AA following ATG developed refractory fever and was diagnosed with EBV-LPD. She was successfully treated with weekly rituximab monotherapy; however, she developed EBV encephalitis. She was admitted to the intensive care unit and finally recovered from unconsciousness. EBV-LPD should be considered after ATG for AA when symptoms appear. Because EBV-LPD following ATG for AA can rapidly progress, weekly monitoring of EBV-DNA and early intervention may be necessary.

Cyclosporine and Entrapment Neuropathy

Accessible online at: http://BioMedNet.com/karger Cyclosporine (CyA) is a useful immunosuppressive agent for transplantation and aplastic anemia. Its known major side effects are renal damage, hepatic damage including elevation of serum bilirubin, electrolyte disturbance, and gingival swelling. We recently studied 2 patients treated with CyA for different diseases who developed peripheral entrapment neuropathy of the hands, one with the carpal tunnel syndrome and the other with the ulnar (Guyon) tunnel syndrome.