William B. Scharfman

Chronic granulocytic leukemia following successful renal transplantation

The use of immunosuppressive therapy has markedly increased over the past several years, and concomitant with its use has been an increased frequency of associated neoplasia. The patient presented is a 22‐year‐old white male who, following two renal transplants and prolonged immunosuppressive therapy with azathioprine and methylprednisolone, developed chronic granulocytic leukemia. Chromosome karyotyping demonstrated the somewhat unusual development of a Philadelphia chromosome with translocation to the # 7 of the C group. A review of transplantation centers revealed that five cases of chronic granulocytic leukemia have occurred in a population of 25,000 renal transplant patients, a 5‐fold increased incidence over the general population. Possible etiologies that may be responsible for the development of chronic granulocytic leukemia in patients on immunosuppressive therapy are discussed. It is our hope that by the introduction of these reports of chronic granulocytic leukemia into the medical literature, the need for caution in the use of immunosuppressive drugs in nonmalignant disease will again be emphasized.

Granulocytic sarcoma: Three unusual patients

This report describes three unusual patients with lesions due to myeloblasts. In one instance, the patient presented with massive adenopathy. The second patient had bone lesions and a pathologic fracture. The third patient, with myelodysplasia, had diffuse skin lesions infiltrated with myeloblasts. These cases fit the diagnostic category of granulocytic sarcoma. Granulocytic sarcoma is a tumor of immature myeloid cells that may involve any site in the body but that most commonly affects the skin, soft tissues, lymph nodes, bone, and periosteum. Lesions can predate leukemia or occur late in an established chronic granulocytic leukemia or acute granulocytic leukemia. The most common presentation occurs late in the course of acute granulocytic leukemia or in chronic granulocytic leukemia as a herald to blastic transformation. Therapy for localized lesions is radiotherapy, which produces prompt shrinkage of the lesions but relapse occurs subsequently. Systemic chemotherapy also produces satisfactory clinical results. In all instances, therapy can only be considered palliative since virtually all patients have a short survival following the appearance of an extramedullary myeloblastic lesion. Recognition of this pathologic entity at an early stage may give us information on the best management for these patients.

Myasthenia gravis with a myeloma-type, gamma-G (IgG) immunoglobulin abnormality

Abstract A patient with myasthenia gravis improved after thymectomy but subsequently suffered a severe relapse. A serum globulin of the myeloma type was present and because of this evidence of a plasma cell dyscrasia the patient was treated with melphalan when the myasthenia became life-threatening. An essentially complete remission of myasthenia followed, but this was not associated with a significant change in the serum concentration of the M-protein. Depression of the bone marrow developed and persisted after administration of melphalan was discontinued. Numerous blood transfusions were required, and the patient ultimately died of hepatitis and lung abscess. Whether therapy with melphalan was actually responsible for the remission of myasthenia is uncertain, but the association with an M-protein adds to the growing list of immunologic abnormalities in patients with myasthenia gravis.

Prolonged diarrhea with near-fatal hemorrhage due to hypoprothrombinemia.

Excerpt This report is concerned with a severe hemorrhagic disease which followed prolonged diarrhea. The patient presented as a medical emergency which was promptly relieved by appropriate therapy...