Takeo Kumura

Efficacy and safety of intravenous itraconazole as empirical antifungal therapy for persistent fever in neutropenic patients with hematological malignancies in Japan

Recently, empirical antifungal therapy with intravenous itraconazole (ITCZ) for neutropenic patients with antibiotics-resistant fever has been approved by Japanese Ministry of Health, Labour and Welfare on the bases of previous multicenter trials of foreign countries. In this study, we conducted a single-arm, multicenter, prospective study in order to evaluate the efficacy of empirical ITCZ injection on Japanese patients. Sixty-eight patients with hematological diseases who underwent anticancer chemotherapy or stem cell transplantation were enrolled. In this study, we found that the overall clinical response rate to ITCZ injection was 67.6% and success rate of achieving composite endpoints including survival, defervescence during neutropenia, no breakthrough fungal infections, and no premature discontinuation of drug was 50.0%. Mild adverse reactions were observed in 6 patients (8.8%). Further analysis revealed that possible/probable deep fungal infection according to the 2002 and 2008 criteria defined by EORTC/MSG were found in 19.1 and 7.5% of the patients, respectively. Interestingly, response rate to ITCZ injection of possible/probable cases according to the 2002 and 2008 criteria was 61.5% (8/13) and 100% (5/5), respectively. These results not only proved the good efficacy and safety of empirical ITCZ injection for Japanese patients, but also indicated a utility of the drug on future “presumptive” approach.

Serum IL-18 levels in patients with various hematological disorders.

Interleukin-18 (IL-18), originary called interferon (IFN γ )-inducing factor, is a recently cloned cytokine of approximately 18 kDa. Its major activity is the induction of IFNγ production from anti-CD3-activated Thl cells, especially in the presence of IL-12. Recently, the human IL-18 cDNA was cloned and expressed in Escherichia coli [1]. It has been revealed that human IL-18 has the capacity to stimulate cytotoxic natural killer (NK) cell activity and stimulates T-cells to produce IFN γ , IL-2, and granulocyte/ macrophage colony-stimulating factor [1]. It is reported that IL-18 is produced by Kupfer cells, activated macrophages, keratinocytes, intestinal epithelial cells, osteoblasts, adrenal cortex cells and murine dincephalon [2, 3]. Taniguchiet al. reported that the IL-18 levels from two groups of acute lymphocytic leukemia (ALL) and chronic myelocytic leukemia (CML) patients is significantly increased compared to the control group [4]. We evaluated the serum IL-18 levels in patients with multiple myeloma (MM), myelodysplastic syndrome (MDS), acute non-lymphocytic leukemia (ANLL), ALL, aplastic anemia (AA), idiopathic thrombocytopenic purpura (ITP), Hodgkin’s disease (HD), non-Hodgkin’s lymphoma (NHL), adult T-cell leukemia (ATL), CML and hemophagocytic syndrome (HPS) in this study. On entry all patients had evidence of active disease and had not received previous therapy. The human serum concentration of IL-18 was measured using an enzyme-linked immunoabsorbent assay kit for IL-18 (MBL,

A Case of Rhabdomyolysis due to Levofloxacin

Quinolone antibacterial agents, which are broad-spectrum drugs with excellent antibacterial activity, have been used widely to treat various bacterial infections in the clinical setting. However, the adverse effects of these drugs on the musculoskeletal system have been observed at an incidence of 1% or less, and consist mainly of myalgia and arthralgia, although tendon disorders have also recently been reported.[1-4] This report highlights a case of rhabdomyolysis induced by levofloxacin.

Hirudin as an anticoagulant for both haematology and chemistry tests

Hirudin, an extract from the leech, has powerful antithrombin activity affecting the blood coagulation pathway. We evaluated the usefulness of hirudin in anticoagulating specimens for routine laboratory tests. Results using blood anticoagulated with hirudin corresponded well with results with blood treated with ethylenediamine tetraacetic acid (EDTA) in the complete blood count (CBC), including white blood cell (WBC) differential count and morphology of blood cells, when CBC was performed within 2 h of blood collection. Clinical chemistry results from hirudin-treated samples were similar to results obtained with serum specimens. Thus, hirudin may be a useful anticoagulant for emergency laboratory medicine.

Lymphoma in Castleman's disease, acute lymphocytic leukemia, adult T-cell leukemia and cutaneous T-cell lymphoma accompanied with high serum soluble Fas ligand levels.

The Fas ligand (FasL) is a member of the tumor necrosis factor family [1]. Cleavage of membrane-bound FasL by a metalloproteinase-like enzyme results in the formation of soluble FasL (sFasL) [2]. sFasL binds to Fas antigen and induces apoptosis which plays a major role during development and in homeostasis against Fas-expressing cells, and is considered to work as a pathological agent in systemic tissue injury [3]. FasL is a 40 kDa glycoprotein that is expressed on the cell membrane of activated cytotoxic cells, including CD4 + and CD8+ T cells and natural killer (NK) cells [4, 5]. A recent report indicated that sFasL is present in the supernatant of activated human peripheral blood T cells [6]. Tanakaet al. reported that serum FasL concentrations were highly elevated in patients with large granular lymphocytic leukemia and NK lymphoma, but were undetectable in patients with adult T-cell leukemia, acute myelogenous leukemia, acute promyelocytic leukemia, acute lymphocytic leukemia, or Tand B-cell lymphoma [2]. Furthermore, it was reported that the serum sFasL level was high on admission, but rapidly decreased to the reference range following chemotherapy in

Urinary trypsin inhibitor levels in the urine of patients with haematological malignancies.

The urinary trypsin inhibitor (UTI) levels in the urine of patients with various haematological malignancies were determined, using automated latex agglutination immunoturbidimetry. The mean UTI levels in urine in acute non-lymphocytic leukaemia, myelodysplastic syndrome, non-Hodgkins lymphoma, and multiple myeloma groups were significantly elevated, compared with the normal control group. It was found that the UTI level in urine changed from an elevated value to a normal value with haematological improvement by chemotherapy in a patient with myelodysplastic syndrome included in a previous study. These results suggest tha

DX-9065a, a specific factor Xa inhibitor, as a universal anticoagulant for blood collection tubes

DX-9065a is a direct and selective factor Xa inhibitor. We evaluated the usefulness of DX-9065a in anticoagulating specimens for routine laboratory tests. Results using blood anticoagulated with DX9065a corresponded well with results with blood treated with ethylendiamine tetraacetic acid (EDTA) in the complete blood count (CBC), including white blood cell (WBC) differential count and morphology of blood cells. Clinical chemistry results from DX-9065a-treated samples were similar to results obtained with serum specimens except for leucine aminopeptidase (LAP) and cholinesterase (Ch-E). Thus, DX-9065a may be a useful universal anticoagulant for laboratory medicine.

MOLECULAR ANALYSIS OF THE T(8;21)(Q22;Q22) TRANSLOCATION IN A CASE OF ACUTE MYELOMONOCYTIC LEUKEMIA (AML-M4)

To the Editor: The t(8;21) translocation with breaks at 8q22 and 21q22 is a frequent karyotypic abnormality found in patients with acute myeloid leukemia (AML) M2. The translocation interrupts two genes, AMLl on chromosome 21 and ETO(MTG8) on chromosome 8, that are consequently fused in the derivative 8 chromosome to produce a novel chimeric gene AML1-ETO(MTG8) and message (1,2). The AMLl gene encodes a DNA binding protein (3). Erickson has reported that the ETO(MTG8) gene may encode a transcriptional factor (4). It has been shown that the ETO(MTG8) gene is not expressed in normal myeloid cells but becomes activated by this fusion (5). This suggests that the fusion protein derived from the chimeric AML1-ETO(MTG8) transcript may be involved in the leukemogenesis. A small population of cases with this translocation are classified as AML M4. We report here a case of AML M4 with t(8;21)(q22;q22) translocation and molecular analysis for this translocation was performed. A 29-yr-old female was admitted to Osaka City University Hospital with fever in August 1994. Peripheral blood showed hemoglobin 8.0 g/dl, platelets 48,0OO/pl, and white blood cells 71,8OO/p1 with 83.0% leukemic cells. The bone marrow smears demonstrated the co-existence of myeloblasts (41%) and monoblasts (12%). The leukemic cells were positively stained for peroxidase. Cytochemically myeloblasts were positively stained for chloracetate esterase, and monoblasts were positively stained for butyrate esterase. Surface marker analysis revealed the 2 populations of the leukemic cells; 1 population showed positivity for CD13 and CD33, the other was positive for CD13, CD14, CD33 and CD36. These data supported a diagnosis of AML M4. Karyotyping of the leukemic cells showed a translocation between 8q22 and 21q22. To examine the translocation between 8q22 and 21q22 in detail, molecular analysis was performed. Total cellular RNA was isolated from heparinized bone marrow aspiration samples by the acid guanidinium thiocyanate-phenol-chloroform method (6). Reverse transcription polymerase chain reaction (RT-PCR) was performed as described previously (7). The sequences of primers AML1-a (5’-AGCCATGAAGAACCAGG-3’) and AML1-b (5’-TACCACAGAGCC ATCAAA-3’) were derived from AMLl cDNA sequence. The sequence of primers ETO-a (5’-AGGCTGTAGGAGAATGG3’) and ETO-b (5’-GTTGTCGGTGTAAATGAA-3’) were derived from ETO(MTG8) cDNA sequences. cDNA was synthesized from 1 pg of total RNA. Thirty-five cycles of the first round PCR was performed on a GeneAmp PCR system 9600 (Perkin Elmer, Norwalk, CO) using the first PCR primers (AML1-a and ETO-a). Each cycle was carried out at 94°C for 30 s, 55°C for 30 s and 72°C for 30s. One-tenth of the first PCR products was used for a second round of amplification for further 35 cycles using a set of nested PCR primers (AML1-b and ETO-b). RT-PCR detected the AML1-ETO(MTG8) hybrid transcript in blast cells of this patient (Fig. 1). To clarify the breakpoint of the AML1-ETO(MTG8) hybrid transcript, DNA sequencing for the RT-PCR products was carried out. The amplified product was cloned into TA cloning vector (Invitrogen, SanDiego, CA) according to the supplier’s manual. The cloned PCR products were sequenced using the T7 sequencing kit (Pharmacia, Uppsala, Sweden). In this patient with AML M4, AML1-ETO(MTG8) hybrid transcript was fused at the same site as commonly found in the leukemic cells of patients with AML M2 (Fig. 2). The patient was treated with a combination chemotherapy which led to complete remission. She then was given bone marrow transplantation. Most of the cases with the t(8;21)(q22;q22) translocation are classified as AML M2. The occurrence of t(8;21) has been reported infrequently in other subtypes of AML (M1 and M4) (8) myelodysplastic syndrome (9), and the blastic phase of chronic myelogenous leukemia (10). We report here a case of AML M4 with t(8;21) translocation and AML1ETO(MTG8) hybrid transcript which was fused at the quite same site as in cases of AML M2. The detailed mechanism of different phenotype

Analysis of IL-18 bioactivity and IL-18 mRNA in three patients with adult T-cell leukaemia, acute mixed lineage leukaemia, and acute lymphocytic leukaemia accompanied with high serum IL-18 levels.

Interleukin-18 (IL-18) bioactivity in sera and IL-18 mRNA expression in leukaemia cells of three patients with adult T-cell leukaemia (ATL), acute mixed lineage leukaemia (AMLL) and acute lymphocytic leukaemia (ALL) accompanied with high serum IL-18 levels have been analysed. There was little serum IL-18 bioactivity in the three patients with ATL, AMLL and ALL, while IL-18 mRNA expression was detected in leukaemia cells of all three patients.

Argatroban as an anticoagulant for both hematologic and chemical tests.

Argatroban possesses strong antithrombin‐like activity. We evaluated the usefulness of argatroban in anticoagulating specimens for routine laboratory tests. Results using blood anticoagulated with argatroban corresponded well with the results of blood treated with ethylendiamine tetra‐acetic acid (EDTA) in the complete blood count (CBC), including the WBC differential count and morphology of blood cells, when the CBC was performed within 2 hr of blood collection. Clinical chemistry results from argatroban‐treated samples were similar to results obtained with serum specimens. Thus, argatroban may be a useful anticoagulant for emergency laboratory medicine. J. Clin. Lab. Anal. 14:136–140, 2000.