Advantageous tactics with certain probiotics for the treatment of graft-versus-host-disease after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) becomes a standard form of cellular therapy for patients with malignant diseases. HSCT is the first-choice of immunotherapy, although HSCT can be associated with many complications such as graft-versus-host disease (GVHD) which is a major cause of morbidity and mortality after allogeneic HSCT. It has been shown that certain gut microbiota could exert protective and/or regenerative immunomodulatory effects by the production of short-chain fatty acids (SCFAs) such as butyrate in the experimental models of GVHD after allogeneic HSCT. Loss of gut commensal bacteria which can produce SCFAs may worsen dysbiosis, increasing the risk of GVHD. Expression of G-protein coupled receptors such as GPR41 seems to be upre-gulated in the presence of commensal bacteria, which might be associated with the biology of regulatory T cells (Tregs). Treg cells are a suppressive subset of CD4 positive T lymphocytes implicated in the prevention of GVHD after allogeneic HSCT. Here, we discuss the current findings of the relationship between the modification of gut microbiota and the GVHD-related immunity, which suggested that tactics with certain probiotics for the beneficial symbiosis in gut-immune axis might lead to the elevation of safety in the allogeneic HSCT.

Typhoid with pancytopenia: Revisiting a forgotten foe: Two case reports

BACKGROUND

Typhoid fever is a public health problem in Asia and Africa. Pancytopenia has been rarely reported during the 20^th century. Reports during the last 20 years are scarce.

CASE SUMMARY

Our first patient was a young adult male presenting with febrile neutropenia whose blood and bone marrow cultures grew Salmonella typhi. He recovered before discharge from the hospital. The second was a primigravida who had an abortion following a febrile illness and was found to have pancytopenia. The Widal test showed high initial titers, and she was presumptively treated for typhoid. Convalescence showed a doubling of Widal titers.

CONCLUSION

Typhoid fever continued to show up as a fever with cytopenia demanding significant effort and time in working up such patients. In developing countries, the liaison with typhoid continues.

Venous thromboembolism prophylaxis of a patient with MYH-9 related disease and COVID-19 infection: A case report

BACKGROUND

The May-Hegglin anomaly is among a group of genetic disorders known as MYH9-related disease. Patients with inherited platelet disorders such as May-Hegglin anomaly are at a variably increased risk for bleeding due to a com-bination of platelet dysfunction and thrombocytopenia. Patients admitted to the hospital with coronavirus disease 2019 (COVID-19) infection are at an increased risk for a venous thromboembolism event (VTE). The National Institutes of Health COVID-19 treatment guidelines recommend using a prophylactic dose of heparin as VTE prophylaxis for adults who are receiving high-flow oxygen. We describe a patient admitted for COVID-19 infection with pneumonia and a history of May-Hegglin anomaly. The patient presented a challenge to determine prophylactic anticoagulation as there are no clear guidelines for this patient population.

CASE SUMMARY

Herein, we describe the case of a 39-year-old woman admitted with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. She had a history of May-Hegglin anomaly and demonstrated risk for bleeding since childhood, including a life-threatening bleeding event at the age of 9 years requiring blood and platelet transfusions. Her baseline platelet count was 40-50 × 10⁹/L throughout her adult life. Her family history was also notable for May-Hegglin disorder in her mother, maternal uncle, maternal grandfather and her son. Computed tomography/ pulmonary angiography revealed bilateral consolidative opacities consistent with multifocal pneumonia. Complete blood count was notable for platelet count of 54 × 10⁹/L. She was admitted for inpatient respiratory support with high-flow oxygen per nasal cannula and was managed with guideline-directed therapy for COVID-19, including baricitinib and dexamethasone. The Hematology/Oncology consultation team was requested to assist with management of VTE prophylaxis in the setting of active COVID-19 infection and an inherited bleeding disorder. After review of the literature and careful consideration of risks and benefits, it was decided to treat the patient with prophylactic enoxaparin. She was closely monitored in the hospital for bleeding and worsening thrombocytopenia. She had no bleeding or signs of VTE. Her respiratory status improved, and she was discharged home after 5 d of hospitalization with supplemental oxygen by nasal cannula and dexamethasone. At the 6-month follow-up, the patient successfully discontinued her home oxygen use after only a few weeks following discharge.

CONCLUSION

The patient presented a challenge to determine prophylactic anticoagulation as anticoagulation guidelines exist for patients with COVID-19, but there are no clear guidelines for management of patients with COVID-19 and inherited bleeding disorders, particularly those with MYH9- related disease. She was discharged after recovery from the COVID-19 infection without bleeding or thrombosis. As there are no published guidelines for this situation, we present a pragmatic, informed approach to a patient with MYH9-related disease who had an indication for anticoagulation.

Cardiopulmonary changes in patients with sickle cell anemia: A systematic review

BACKGROUND

Given the high prevalence of cardiovascular and pulmonary abnormalities associated with sickle cell anemia (SCA), the clinical impact caused in addition to compromising the quality of life of patients and the overcharge that it represents to the public health system, this study systematized and evaluated scientific publications on pulmonary complications and cardiovascular diseases in sickle cell patients from 1920 to 2020. This compilation aims to provide knowledge for health professionals and managers in order to draw attention to the importance of chronic diseases in SCA patients and in addition to providing elements that provide improvements in management of useful resources that contribute to improve the quality and increase the life expectancy of these patients.

AIM

To systematically compile information about cardiopulmonary changes in patients with SCA.

METHODS

A systematic literature review was performed based on the PRISMA recom-mendation including scientific articles indexed in the Scientific Electronic Library Online databases of the United States National Library of Medicine and Biblioteca Virtual de Saúde. The search period was delimited between 1990 and 2020 and selected in Portuguese, English and Spanish. Three sets of descriptors were used for each database including research carried out with human beings. After reading the articles, those useful for this review were extracted using a collection instrument designed for this purpose.

RESULTS

The final selection included 27 studies. The year with the highest number of publications was 2016 with 5 studies (18.51%), followed by 2017 with 4 (14.81%). The type of study most carried out in the period was cohort 10 (37.03%) followed by cross-sectional and case-control with 8 studies in each (29.62%). Regarding the language of publication, the distribution was as follows: 25 (92.59%) in English, 1 (3.70%) in Spanish and 1 (3.70%) in Portuguese.

CONCLUSION

The findings of the present study suggest that cardiopulmonary alterations represent a serious clinical repercussion of SCA. Of the analyzed studies, the high occurrence of pulmonary hypertension, ventricular hypertrophy and diastolic dysfunction stands out as the main cardiopulmonary complications. In view of the increased survival in SCA, there is a need for surveillance and the development of strategies aimed at preserving the cardiopulmonary function and consequently improving the quality of life of these patients.

Late ischemic stroke and brachiocephalic thrombus in a 65-year-old patient six months after COVID-19 infection: A case report

BACKGROUND

Although it is well established that coronavirus disease 2019 (COVID-19) is associated with inflammation and a prothrombotic state leading to stroke and venous thromboembolism (VTE), the nuances of this association are yet to be uncovered[1]. Many studies link elevations in inflammatory markers to cases of thromboembolism. Most reports of thromboembolism associated with COVID-19 occur in the venous circulation during or just after the initial hospitalization due to COVID-19[2]. It is unclear how long the hypercoagulable effect of COVID-19 lasts.

CASE SUMMARY

We present a unique case of a 65-year-old-female who presented to her primary care doctor with a sore throat, cough, fatigue, congestion, diarrhea, headache, and anosmia. She tested positive for severe acute respiratory syndrome coronavirus 2 and received a bamlanivimab infusion 9 days later. After recovering from the acute illness, she received the Pfizer-BioNTech COVID-19 vaccine. Months later, she presented to the Emergency Department (ED) complaining of right sided shoulder pain and motor weakness in her left hand while trying to type on a keyboard. On presentation to the ED, her calculated Padua prediction score for risk of VTE was two and inflammatory markers were not elevated. She was found to have a brachiocephalic artery occlusion as well as an ischemic stroke which was treated with heparin.

CONCLUSION

This case suggests hypercoagulability due to COVID-19 may extend further than current literature suggests, to at least six months.

Efficacy of HA330-II column hemoadsorption in Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis combined with liver failure: A case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a severe and potentially deadly condition associated with extensive inflammation and immune activation. Cytokine adsorption may serve as a supportive treatment that can stabilize organ function in affected patients by reducing their circulating cytokines levels. To date, no descriptions of clinical experiences associated with the use of HA330-II column hemoadsorption for the treatment of children affected by HLH have been published.

CASE SUMMARY

We describe the case of an 11-year-old child with Epstein-Barr virus-associated HLH complicated by liver failure. She underwent HA330-II column hemoadsorption and chemotherapy and exhibited reductions in levels of inflammatory cytokines, including interleukin (IL), IL-6, IL-8, IL-10, and interferon-γ. The patient’s condition and laboratory parameters gradually improved with treatment.

CONCLUSION

Hemoadsorption may play an important role in cytokine storm elimination in children with HLH combined with liver failure and consequent multiple organ failure.

Central nervous system recurrence in a patient treated for acute promyelocytic leukemia, resulting in sideroblastic anemia: A case report

BACKGROUND

Previous cases that have been stated in this article have displayed that around 1% to 7% of patients that have been treated with chemotherapy for acute promyelocytic leukemia developed myelodysplastic syndrome or acute myeloid leukemia. One can see that’s why this case presentation of a 60-year-old man that had a good response to acute promyelocytic leukemia treatment, that later presented with a central nervous system recurrence of acute promyelocytic leukemia and acquired sideroblastic anemia (a form of myelodysplasia) from treatment is a unique case report.

CASE SUMMARY

The presence of central nervous system relapse in acute promyelocytic leukemia patients is very unlikely compared to recurring mainly in the bone marrow. It is also uncommon to be diagnosed with sideroblastic anemia (form of myelodysplastic syndrome) as a result from treatment for acute promyelocytic leukemia. This case report highlights the detection, treatment/maintenance with idarubicin, all-trans-retinoic-acid, arsenic trioxide, methotrexate, 6-mercaptopurine, and ommaya reservoir intrathecal methotrexate administration in a patient that had central nervous system relapse of acute promyelocytic leukemia and acquired sideroblastic anemia.

CONCLUSION

In essence, first time relapse concerning the central nervous system in treated acute promyelocytic leukemia patients who had a good response to therapy is very uncommon. The acquirement of a myelodysplastic syndrome such as ringed sideroblastic anemia is also rare regarding this patient population. Although such cases are infrequent, this case report represents a unique insight of the detection, treatment, and maintenance of a 60-year-old man diagnosed with acute promyelocytic leukemia, resulting in the acquirement of sideroblastic anemia and central nervous system relapse.

Adult Langerhans cell histiocytosis and immunomodulatory drugs: Review and analysis of thirty-four case reports

Langerhans cell histiocytosis (LCH) is a rare neoplastic disease in dendritic cells. LCH is classified as either a single-system (SS) or multisystem (MS) disease. There is not a standard first-line treatment for LCH in adults. We analyzed the efficacy and safety of immunomodulatory drugs (IMiDs) by searching PubMed/MEDLINE for case reports previously published. The clinical response (nonactive disease or active disease that regressed) was 94% in SS and 53% in MS. IMiDs should only be considered for adults with cutaneous SS involvement; in MS, they should be used only for patients not eligible for more aggressive treatments.

miRNA and platelet genetic machinery

Platelets are responsible for blood haemostasis. Although anucleate, a complete translational machinery has been found in platelets, which is responsible for new protein generation. Recently, the role of miRNAs in platelets has started to become apparent. In this editorial I highlight this topic in the hope that other scientists may be attracted to work in this area to aid a more complete understanding of protein regulation in platelets and its impact on platelet function.

Aspirin cures erythromelalgia and cerebrovascular disturbances in JAK2-thrombocythemia through platelet-cycloxygenase inhibition

Hypersensitive (sticky) platelets in JAK2-mutated essential thrombocythemia (ET) and polycythemia vera (PV) with thrombocythemia spontaneously activate at high shear in arterioles, secrete their inflammatory prostaglandin endoperoxides and induce platelet-mediated arteriolar fibromuscular intimal proliferation. Constitutively activated JAK2 mutated hypersensitive (sticky) platelets spontaneously aggregate at high shear in the endarteriolar circulation as the cause of aspirin responsive erythromelalgia and platelet arterial thrombophilia in JAK2-mutated thrombocythemia patients. Increased production of prostglandin endoperoxides E2 and thromboxane A2 released by activated sticky platelets in arterioles account for redness warmth and swelling of erythromelalgia and platelet derived growth factor can readily explain the arteriolar fibromuscular intimal proliferation. Von Willebrand factor (VWF) platelet rich occlusive thrombi in arterioles are the underlying pathobiology of erythromelalgic acrocyanosis, migraine-like transient cerebral attacks (MIAs), acute coronary syndromes and abdominal microvscular ischemic events. Irreversible platelet cyco-oxygenase inhibition by aspirin cures the erythromelalgia, MIAs and microvascular events, corrects shortened platelet survival to normal, and returns increased plasma levels of beta-TG, platelet factor 4, thrombomoduline and urinary thromboxane B2 excretion to normal in symptomatic JAK2-thrombocythemia patients. In vivo activation of sticky platelets and VWF-platelet aggregates account for endothelial cell activation to secrete thrombomoduline and sVCAM followed by occlusion of arterioles by VWF-rich platelet thrombi in patients with erythromelalgic thrombotic thrombocythemia (ETT) in ET and PV patients. ETT is complicated by spontaneous hemorrhagic thrombocythemia (HT) or paradoxical ETT/HT due to acquired von Willebrand disease type 2A at platelet counts above 1000 × 10⁹/L and disappears by cytoreduction of platelets to normal (< 400 × 10⁹/L).

Oxidative alterations in sickle cell disease: Possible involvement in disease pathogenesis

Sickle cell disease (SCD) is the first molecular disease in the literature. Although the structural alteration and dysfunction of the sickle hemoglobin (HbS) are well understood, the many factors modifying the clinical signs and symptoms of the disease are under investigation. Besides having an abnormal electrophoretic mobility and solubility, HbS is unstable. The autooxidation rate of the abnormal HbS has been reported to be almost two times of the normal. There are two more components of the oxidative damage in SCD: Free radical induced oxidative damage during vaso-occlusion induced ischemia-reperfusion injury and decreased antioxidant capacity in the erythrocyte and in the circulation. We will discuss the effects of oxidative alterations in the erythrocyte and in the plasma of SCD patients in this review.

Management of unstable angina in a patient with Haemophilia A

Hemophilia A is an X-linked recessive disorder characterized by a deficiency of coagulation factor VIII (FVIII) and therefore by a greater risk of bleeding during percutaneous interventional procedures and during the dual antiplatelet therapy (DAPT) in patients with ischemic heart disease. Information regarding safe percutaneous procedures in hemophiliacs is limited. Since the introduction of FVVIII concentrates, the life expectancy of hemophiliac patients has improved and consequently, the rate of ischemic heart disease in this population is increased. Frequently the replacement therapy can trigger the onset of an acute coronary syndrome. We report a case of a patient with mild Hemophilia A, who presents with unstable angina, treated successfully with coronary angioplasty and drug eluting stent implantation without replacement of FVVIII, treated with long term DAPT without major bleeding after six months of follow up.

Intestinal heme absorption in hemochromatosis gene knock-out mice

AIM

To investigat the influence of hemochromatosis gene (Hfe) mutation on ⁵⁹Fe labelled duodenal heme absorption in mice.

METHODS

Heme absorption was measured in Hfe wild type and Hfe^(-/-) mice by the duodenal tied loop and by oral gavage methods. The mRNA expression of heme oxygenase (HO-1), Abcg2 and Flvcr1 genes and levels were determined by quantitative polymerase chain reaction.

RESULTS

Heme absorption was significantly increased in homozygous Hfe^(-/-) mice despite significant hepatic and splenic iron overload. While duodenal HO-1 mRNA was highly expressed in the wild type and Hfe^(-/-) heme-treated group following 24 h heme administration, Flvcr1a mRNA decreased. However, Abcg2 mRNA expression levels in duodenum remained unchanged.

CONCLUSION

Heme absorption was enhanced in Hfe^(-/-) mice from both duodenal tied-loop segments and by oral gavage methods. HO-1 mRNA levels were enhanced in mice duodenum after 24 h of heme feeding and may account for enhanced heme absorption in Hfe^(-/-) mice. Implications for dietary recommendations on heme intake by Hfe subjects to modulate iron loading are important clinical considerations.

Allogeneic stem cell transplantation in chronic myeloid leukemia patients: Single center experience

Chronic myeloid leukemia (CML) is a myeloproliferative disease which leads the unregulated growth of myeloid cells in the bone marrow. It is characterized by the presence of Philadelphia chromosome. Reciprocal translocation of the ABL gene from chromosome 9 to 22 t (9; 22) (q34; q11.2) generate a fusion gene (BCR-ABL). BCR-ABL protein had constitutive tyrosine kinase activity that is a primary cause of chronic phase of CML. Tyrosine kinase inhibitors (TKIs) are now considered standard therapy for patients with CML. Even though, successful treatment with the TKIs, allogeneic stem cell transplantation (ASCT) is still an important option for the treatment of CML, especially for patients who are resistant or intolerant to at least one second generation TKI or for patients with blastic phase. Today, we know that there is no evidence for increased transplant-related toxicity and negative impact of survival with pre-transplant TKIs. However, there are some controversies about timing of ASCT, the optimal conditioning regimens and donor source. Another important issue is that BCR-ABL signaling is not necessary for survival of CML stem cell and TKIs were not effective on these cells. So, ASCT may play a role to eliminate CML stem cells. In this article, we review the diagnosis, management and treatment of CML. Later, we present our center’s outcomes of ASCT for patients with CML and then, we discuss the place of ASCT in CML treatment in the TKIs era.

Role of plasmapheresis in early allograft dysfunction following deceased donor liver transplantation

The role of plasmapheresis in liver failure and hepatic encephalopathy is undefined and its use as a strategy to salvage patients with severe allograft dysfunction after liver transplantation remains investigational. We present a case of early allograft dysfunction following deceased donor liver transplantation (DDLT) where plasmapheresis was effective as a bridge to recovery and possibly avoiding a retransplantation. A 16 years old boy, known to have decompensated Wilson’s disease underwent DDLT at our Public Sector Hospital. He received a healthy liver from a brain-dead donor, whose liver was considered too large for the boy. The graft was reduced in situ to a left lobe graft. Surgery was uneventful and the recipient was well for the initial 96 h. On Doppler and further computed tomography scan, a partial portal vein thrombus was noted. He was reexplored and a Fogarty endothombecteomy was performed. Following the second surgery, he developed severe allograft dysfunction with a peak bilirubin of 40 mg/dL. He underwent imaging to rule out technical causes for the dysfunction, followed by a liver biopsy, which revealed acute cellular rejection. Multiple cycles of plasmapheresis were initiated. Over the next two weeks, the graft demonstrated a gradual recovery. He was discharged on the 30^th postoperative day, with a serum bilirubin of 5.5 mg/dL. He remains well on follow-up, with the liver function tests improving further. Our report demonstrates the beneficial effect of plasmapheresis, which appears to be an effective treatment option for early allograft dysfunction following liver transplantation and may obviate the need for retransplantation.

Current approach to disseminated intravascular coagulation related to sepsis - organ failure type

Disseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood clotting, which generates large amount of intravascular thrombin and fibrin. Various diseases may cause acceleration of the clotting cascade, inactivate the endogenous anticoagulants and modify fibrinolysis, having thus the formation of micro thrombi in the systemic circulation. The abnormalities in the hemostatic system in patients with DIC result from the sum of pathways that generate both hypercoagulability and augmented fibrinolysis. When the hypercoagulability state prevails, the main manifestation is organic failure. This subtype of DIC is often referred as “organ impairment” type, frequently seen in patients suffering from severe sepsis. To identify the underlying infection, early initiation of culture-based antimicrobial treatment, and to resolve any infection source promptly are keystone actions of DIC related to sepsis prevention and treatment. These should be combined with specific treatment related to each DIC subtype. In the context of septic shock, DIC is associated to increased severity, greater number and seriousness of organ failures, more frequent side-effects from treatment itself, and worse outcomes. Therefore, we ought to review the information available in the literature about approach and management of DIC in severe sepsis.

P2X7 receptor activation causes phosphatidylserine exposure in canine erythrocytes

AIM

To determine if activation of the ATP-gated P2X7 receptor channel induces phosphatidylserine (PS) exposure in erythrocytes from multiple dog breeds.

METHODS

Peripheral blood was collected from 25 dogs representing 13 pedigrees and seven crossbreeds. ATP-induced PS exposure on canine erythrocytes in vitro was assessed using a flow cytometric Annexin V binding assay.

RESULTS

ATP induced PS exposure in erythrocytes from all dogs studied. ATP caused PS exposure in a concentration-dependent manner with an EC₅₀ value of 395 μmol/L. The non-P2X7 agonists, ADP or AMP, did not cause PS exposure. The P2X7 antagonist, AZ10606120, but not the P2X1 antagonist, NF449, blocked ATP-induced PS exposure.

CONCLUSION

The results indicate that ATP induces PS exposure in erythrocytes from various dog breeds and that this process is mediated by P2X7 activation.

Successful lower leg microsurgical reconstruction in homozygous sickle cell disease: Case report

We present an 18-year-old female with sickle cell disease, who presented with an extensive lower leg ulcer over a 12-year course of the disease. Definitive reconstruction was made using a free latissimus dorsi flap and split-skin grafts. One week before the surgery, the plasmapheresis protocol and blood transfusion were administered, in order to achieve a hemoglobin S level of ≤ 30%. Intraoperatively, the flap pedicle was rinsed with plasminogen activator inhibitor-1 until the thrombolytic agent was obtained from the comitant vein; after the arterial flow had been released, an intravenous bolus dose of heparin (2000 U) was administrated. No vascular complications occurred. Postoperatively, the patient received a 10-d course of hemodilution and a 14-d course of full-dose anticoagulation. After 8 mo postoperatively, the patient was able to walk and run, and showed complete wound healing. This case indicates that sickle cell disease is not a contraindication to free tissue transfer; however, the complications, their rate and overall outcomes for these cases are not yet clear. Herein, we provide an algorithm based on our clinical experience in this type of case and treatment, including several recommendations that may help to reduce thrombosis risk and systemic complications.

Identifying changes in punitive transcriptional factor binding sites from regulatory single nucleotide polymorphisms that are significantly associated with disease or sickness

AIM

To identify punitive transcriptional factor binding sites (TFBS) from regulatory single nucleotide polymorphisms (rSNPs) that are significantly associated with disease.

METHODS

The genome-wide association studies have provided us with nearly 6500 disease or trait-predisposing SNPs where 93% are located within non-coding regions such as gene regulatory or intergenic areas of the genome. In the regulatory region of a gene, a SNP can change the DNA sequence of a transcriptional factor (TF) motif and in turn may affect the process of gene regulation. SNP changes that affect gene expression and impact gene regulatory sequences such as promoters, enhancers, and silencers are known as rSNPs. Computational tools can be used to identify unique punitive TFBS created by rSNPs that are associated with disease or sickness. Computational analysis was used to identify punitive TFBS generated by the alleles of these rSNPs.

RESULTS

rSNPs within nine genes that have been significantly associated with disease or sickness were used to illustrate the tremendous diversity of punitive unique TFBS that can be generated by their alleles. The genes studied are the adrenergic, beta, receptor kinase 1, the v-akt murine thymoma viral oncogene homolog 3, the activating transcription factor 3, the type 2 demodkinase gene, the endothetal Per-Arnt-Sim domain protein 1, the lysosomal acid lipase A, the signal Transducer and Activator of Transcription 4, the thromboxane A2 receptor and the vascular endothelial growth factor A. From this sampling of SNPs among the nine genes, there are 73 potential unique TFBS generated by the common alleles compared to 124 generated by the minor alleles indicating the tremendous diversity of potential TFs that are capable of regulating these genes.

CONCLUSION

From the diversity of unique punitive binding sites for TFs, it was found that some TFs play a role in the disease or sickness being studied.

Changing insights in the diagnosis and classification of autosomal recessive and dominant von Willebrand diseases 1980-2015

The European Clinical Laboratory and Molecular (ECLM) criteria define 10 distinct Willebrand diseases (VWD): recessive type 3, severe 1, 2C and 2N; dominant VWD type 1 secretion/clearance defect, 2A, 2B, 2E, 2M and 2D; and mild type 1 VWD (usually carriers of recessive VWD). Recessive severe 1 and 2C VWD are characterized by secretion and multimerization defects caused by mutations in the D1-D2 domain. Recessive 2N VWD is a mild hemophilia due to D’-FVIII-von Willebrand factor (VWF) binding site mutations. Dominant 2E VWD caused by heterozygous missense mutations in the D3 domain is featured by a secretion-clearance-multimerization VWF defect. Dominant VWD type 2M due to loss of function mutations in the A1 domain is characterized by decreased ristocetin-induced platelet aggregation and VWF:RCo, normal VWF multimers and VWF:CB, a poor response of VWF:RCo and good response of VWF:CB to desmopressin (DDAVP). Dominant VWD type 2A induced by heterozygous mutations in the A2 domain results in hypersensitivity of VWF for proteolysis by ADAMTS13 into VWF degradation products, resulting in loss of large VWF multimers with triplet structure of each individual VWF band. Dominant VWD type 2B due to a gain of function mutation in the A1 domain is featured by spontaneous interaction between platelet glycoprotein Ib (GPIb) and mutated VWF A1 followed by increased proteolysis with loss of large VWF multimers and presence of each VWF band. A new category of dominant VWD type 1 secretion or clearance defect due to mutations in the D3 domain or D4-C1-C5 domains consists of two groups: Those with normal or smeary pattern of VWF multimers.

Role of microRNA in regulation of myeloma-related angiogenesis and survival

Multiple myeloma (MM) is a malignant disease caused by clonal proliferation of plasma cells that result in monoclonal gammopathy and severe end organ damage. Despite the uniform clinical signs, the disease is very diverse in terms of the nature and sequence of the underlying molecular events. Multiple cellular processes are involved in helping the malignant cells to remain viable and maintain proliferative properties in the hypoxic microenvironment of the bone marrow. Specifically, the process of angiogenesis, triggered by the interactions between the malignant MM cells and the stroma cells around them, was found to be critical for MM progression. In this review we highlight the current understanding about the epigenetic regulation of the proliferation and apoptosis of MM cells and its dependency on angiogenesis in the bone marrow that is carried out by different microRNAs.

Insights into myelodysplastic syndromes from current preclinical models

In recent years, there has been significant progress made in our understanding of the molecular genetics of myelodysplastic syndromes (MDS). Using massively parallel sequencing techniques, recurring mutations are identified in up to 80% of MDS cases, including many with a normal karyotype. The differential role of some of these mutations in the initiation and progression of MDS is starting to be elucidated. Engineering candidate genes in mice to model MDS has contributed to recent insights into this complex disease. In this review, we examine currently available mouse models, with detailed discussion of selected models. Finally, we highlight some advances made in our understanding of MDS biology, and conclude with discussions of questions that remain unanswered.

Retrospective study of a cohort of adult patients with hematological malignancies in a tropical area

AIM: To review the characteristics of hematological malignancies in tropical areas, and to focus on the specific difficulties regarding their management.

METHODS: This is a retrospective narrative review of cases of patients with hematological malignancies. All medical files of patients with malignant disease whose treatment was coordinated by the Hemato-Oncology service of the Cayenne Hospital in French Guiana between the 1^st of January 2010 and the 31^st of December 2012 were reviewed. Clinical data were extracted from the medical files and included: Demographic data, comorbidities, serological status for human immunodeficiency virus, human T-lymphotropic virus 1 (HTLV1), hepatitis B virus and hepatitis C virus infections, cytology and pathology diagnoses, disease extension, treatment, organization of disease management, and follow-up. The subgroup of patients with hematological malignancies and virus-related malignancies were reviewed. Cases involving patients with Kaposi sarcoma, and information on solid tumor occurrence in virus-infected patients in the whole patient population were included. Since the data were rendered anonymous, no informed consent was obtained from the patients for this retrospective analysis. Data were compiled using EXCEL^® software, and the data presentation is descriptive only. The references search was guided by the nature of the data and discussion.

RESULTS: In total, the clinical files of 594 patients (pts) were reviewed. Hematological malignancies were observed in 87 patients, and Kaposi sarcoma in 2 patients. In total, 70 patients had a viral infection, and 34 of these also had hematological malignancies. The hematological diagnoses were: Multiple myeloma in 27 pts, lymphoma (L) in 43 pts, myeloproliferative disorders in 17 pts and Kaposi sarcoma in two patients. The spectrum of non-Hodgkin lymphomas (NHL) was: Burkitt L (1 pt), follicular L (5 pts), chronic lymphocytic leukemia (5 pts), high-grade NHL (9 pts), mucosa-associated lymphoid tissue NHL (4 pts), T-cell lymphoma (4 pts), Adult T-cell lymphoma-leukemia (ATL)/lymphoma/leukemia (12 pts); three patients had Hodgkin disease. The spectrum of myeloproliferative diseases was: Chronic myelogenous leukemia (8 pts), thrombocytemia (5 pts) and acute leukemia (4 pts). There were no polycythemia vera, myelosclerosis, and myelodysplastic diseases. This appears to be due to bias in the recruitment process. The most important observations were: The specificity of HTLV1- related ATL malignancies, and the high incidence of virus infections in patients with hematological malignancies. Further, we noted several limitations regarding the treatment and organization of disease management. These were not related to the health care organization, but were due to a lack of board-certified hemato-oncology specialists, a lack of access to diagnostic tools (e.g., cytogenetic and molecular diagnosis, imaging techniques), the unavailability of radiotherapy, and the physical distance from mainland France. Yet the geography and cultures of the country also contributed to the encountered difficulties. These same limitations are seen in tropical countries with low and intermediate household incomes, but they are amplified by economic, social, and cultural issues. Thus, there is often little access to diagnostic procedures, adequate clinical management, and an unavailability of suitable medical treatments. Programs have been developed to establish centers of excellence, training in pathology diagnosis, and to provide free access to treatment.

CONCLUSION: Management of hematological malignancies in tropical areas requires particular skills regarding specific features of these diseases and in terms of the affected populations, as well as solid public health policies.

Advances and perspectives on cellular therapy in acquired bone marrow failure diseases

Acquired bone marrow failure diseases (ABMFD) are a class of hematopoietic stem cell diseases with a commonality of non-inherited disruption of hematopoiesis that results in pancytopenia. ABMFDs also are a group of heterogeneous diseases with different etiologies and treatment options. The three most common ABMFDs are aplastic anemia, myelodysplastic syndrome, and paroxysmal nocturnal hemoglobinuria. Stem cell transplantation is the only treatment that can cure these diseases. However, due to high therapy-related mortality, stem cell transplantation has rarely been used as a first line treatment in treating ABMFD. With the advance of personalized medicine and precision medicine, various novel cellular therapy strategies are in trial to increase the efficiency and efficacy of ABMFD treatment. This article aims to review current available stem cell transplantation protocols and promising cellular therapy research in treating ABMFD.

Clinical approach to diarrheal disorders in allogeneic hematopoietic stem cell transplant recipients

Diarrhea is a common complication of allogeneic hematopoietic stem cell transplant (HSCT), with an average incidence of approximately 40%-50%. A wide variety of etiologies can contribute to diarrhea in HSCT patients, including medication-induced mucosal inflammation, infections, graft-vs-host disease and cord colitis syndrome in umbilical cord blood transplant. Clinical manifestations can vary from isolated diarrheal episodes, to other organ involvement including pneumonia or myocarditis, and rarely multiorgan failure. The approach for diagnosis of diarrheal disorders in HSCT patients depends on the most likely cause. Given the risk of life-threatening conditions, the development of clinically significant diarrhea requires prompt evaluation, supportive care and specific therapy, as indicated. Serious metabolic and nutritional disturbances can happen in HSCT patients, and may even lead to mortality. In this review, we aim to provide a practical approach to diagnosis and management of diarrhea in the post-transplant period.

Storage lesion: History and perspectives

Red blood cell concentrates (RBCCs) are the major labile blood component transfused worldwide to rescue severe anemia symptoms. RBCCs are frequently stored in additive solutions at 4 °C for up to 42 d, which induces cellular lesion and alters red blood cell metabolism, protein content, and rheological properties. There exists a hot debate surrounding the impact of storage lesion, with some uncertainty regarding how RBCC age may impact transfusion-related adverse clinical outcomes. Several studies show a tendency for poorer outcomes to occur in patients receiving older blood products; however, no clear significant association has yet been demonstrated. Some age-related RBCC alterations prove reversible, while other changes are irreversible following protein oxidation. It is likely that any irreversible damage affects the blood component quality and thus the transfusion efficiency. The present paper aims to promote a better understanding of the occurrence of red blood cell storage lesion, with particular focus on biochemical changes and microvesiculation, through a discussion of the historical advancement of blood transfusion processes.

Treatment of Epstein-Barr virus-related hemophagocytic lymphohistiocytosis: Study protocol of a prospective pilot study

In this manuscript, a number of debatable issues related to the diagnosis and treatment of Epstein-Barr virus-related hemophagocytic lymphohistiocytosis (EBV-HLH) will be addressed. Considering the heterogeneous nature of EBV-HLH, diagnostic efforts are required to clarify the precise nature of the disease at diagnosis, the number of EBV genome copies in peripheral blood, and localization of the EBV genome in lymphoid cells (B, T, or natural killer cells). Although the majority of cases of EBV-HLH develop without evidence of immunodeficiency, some cases have been found to be associated with chronic active EBV infection, genetic diseases such as X-linked lymphoproliferative disease (XLP, type 1, or type 2), or familial HLH (FHL, types 2-5). Due to such background heterogeneity, the therapeutic results of EBV-HLH have also been found to vary. Patients have been found to respond to corticosteroids alone or an etoposide-containing regimen, whereas other patients require hematopoietic stem cell transplantation. Thus, decision-making for optimal treatment of EBV-HLH and its eventual outcome requires evaluation in consideration of the precise nature of the disease. A protocol for a pilot study on the treatment of patients with EBV-HLH is presented here.

European vs 2015-World Health Organization clinical molecular and pathological classification of myeloproliferative neoplasms

The BCR/ABL fusion gene or the Ph¹-chromosome in the t(9;22)(q34;q11) exerts a high tyrokinase acticity, which is the cause of chronic myeloid leukemia (CML). The 1990 Hannover Bone Marrow Classification separated CML from the myeloproliferative disorders essential thrombocythemia (ET), polycythemia vera (PV) and chronic megakaryocytic granulocytic myeloproliferation (CMGM). The 2006-2008 European Clinical Molecular and Pathological (ECMP) criteria discovered 3 variants of thrombocythemia: ET with features of PV (prodromal PV), “true” ET and ET associated with CMGM. The 2008 World Health Organization (WHO)-ECMP and 2014 WHO-CMP classifications defined three phenotypes of JAK2^V617F mutated ET: normocellular ET (WHO-ET), hypercelluar ET due to increased erythropoiesis (prodromal PV) and ET with hypercellular megakaryocytic-granulocytic myeloproliferation. The JAK2^V617F mutation load in heterozygous WHO-ET is low and associated with normal life expectance. The hetero/homozygous JAK2^V617F mutation load in PV and myelofibrosis is related to myeloproliferative neoplasm (MPN) disease burden in terms of symptomatic splenomegaly, constitutional symptoms, bone marrow hypercellularity and myelofibrosis. JAK2 exon 12 mutated MPN presents as idiopathic eryhrocythemia and early stage PV. According to 2014 WHO-CMP criteria JAK2 wild type MPL⁵¹⁵ mutated ET is the second distinct thrombocythemia featured by clustered giant megakaryocytes with hyperlobulated stag-horn-like nuclei, in a normocellular bone marrow consistent with the diagnosis of “true” ET. JAK2/MPL wild type, calreticulin mutated hypercellular ET appears to be the third distinct thrombocythemia characterized by clustered larged immature dysmorphic megakaryocytes and bulky (bulbous) hyperchromatic nuclei consistent with CMGM or primary megakaryocytic granulocytic myeloproliferation.

Intravascular proliferating anaplastic lymphoma kinase-positive anaplastic large-cell lymphoma

An 82-year-old Japanese man visited our emergency unit complaining of dyspnea. Laboratory data showed 15% atypical lymphocytes in peripheral blood which expressed the T-cell phenotype. Chest/abdominal computed tomography depicted hepatosplenomegaly and swelling of systemic lymph nodes. The patient died of advanced respiratory failure 5 d after the first occurrence of his dyspnea. At autopsy, the pathological features revealed a diffuse infiltration of large atypical lymphocytes to systemic organs including the spleen and lung. In immunohistochemical staining, these cells expressed CD30, TIA-1, anaplastic lymphoma kinase (ALK), CD5 and CD3. An advanced surface molecule analysis revealed a lack of CD54 (intercellular cell adhesion molecule-1) and CD56 (neural cell adhesion molecule). We observed the proliferation and infiltration of these lymphoma cells specifically at the intravascular lesions similar to intravascular lymphoma (IVL). T-cell IVL is not established as an independent clinical entity in the World Health Organization classification, and our patient’s ALK-positive T-IVL in lung appears to be the first reported case.

Role of novel oral anticoagulants in the management and prevention of venous thromboembolism

Venous thromboembolism (VTE) encompasses deep vein thrombosis and pulmonary embolism and is a major health burden, both medically and economically. Anticoagulation is the primary treatment and can be divided into three stages: initial, long term and extended treatment. Initial anticoagulation is given to reduce the risk of complications including fatal pulmonary embolism, while long term and extended treatment are aimed at prevention of recurrent VTE. Until recently, initial anticoagulation has only been achievable with administration of parental agents such as unfractionated or low molecular weight heparin, while vitamin K antagonists such as warfarin, have been the mainstay of long term and extended treatment. Factor-Xa inhibitors and direct thrombin inhibitors are oral anticoagulants that are being increasingly utilized as an alternative form of anticoagulation. This article aims to review the current guidelines in the management of VTE, the recent literature regarding novel anticoagulants in VTE, suggested treatment regimes and limitations.

Granulysin and its clinical significance as a biomarker of immune response and NK cell related neoplasms

Granulysin is a cytotoxic granular protein that was identified from human T cells by using the gene subtraction method in 1987. Based on its amino acid homology, granulysin belongs to the saposin-like protein family. The bioactive 9-kDa form of granulysin is processed from the 15-kDa pro-product in the cytoplasmic granules. It is expressed in CD8-positive αβT cells 5 d after mitogenic stimulation and constitutively in natural killer (NK) cells and γδT cells, although regulation of its expression has not yet been precisely determined. The 9-kDa granulysin form has anti-microbial activity against microorganisms such as bacteria, fungi, mycobacteria and parasites, as well as tumoricidal activity against some tumors at 1-10 μmol/L concentrations. Granulysin is secreted in both Ca-dependent and -independent manners. In sera, only the 15-kDa form is detectable and is expected to be a biomarker for immune potency, acute viral infection, anti-tumor immune reaction, acute graft vs host disease, and NK cell associated neoplasm.

Follicular helper T lymphocytes in health and disease

A correct antibody response requires the participation of both B and T lymphocytes and antigen presenting cells. In this review we address the role of follicular helper T lymphocytes (T_FH) in this reaction. We shall focus on the regulation of their development and function in health and disease. T_FH can be characterized on the basis of their phenotype and the pattern of secretion of cytokines. This fact is useful to study their participation in the generation of antibody deficiency in primary immunodeficiency diseases such as common variable immunodeficiency, X-linked hyper IgM syndrome or X-linked lymphoproliferative disease. Increased numbers of T_FH have been demonstrated in several autoimmune diseases and are thought to play a role in the development of autoantibodies. In chronic viral infections caused by the human immunodeficiency virus, hepatitis B or C virus, increased circulating T_FH have been observed, but their role in the protective immune response to these agents is under discussion. Likewise, an important role of T_FH in the control of some experimental protozoan infections has been proposed, and it will be important to assess their relevance in order to design effective vaccination strategies.

Tbl3 encodes a WD40 nucleolar protein with regulatory roles in ribosome biogenesis

AIM: To investigate the subcellular localization and the function of mouse transducin β-like 3 (Tbl3).

METHODS: The coding sequence of mouse Tbl3 was cloned from the cDNAs of a promyelocyte cell line by reverse transcription-polymerase chain reaction. Fusion constructs of Tbl3 and enhanced green fluorescent protein (EGFP) were transfected into fibroblasts and examined by fluorescence microscopy to reveal the subcellular localization of tbl3. To search for nucleolar targeting sequences, scanning deletions of Tbl3-EGFP were constructed and transfected into fibroblasts. To explore the possible function of Tbl3, small hairpin RNAs (shRNAs) were used to knock down endogenous Tbl3 in mouse promyelocytes and fibroblasts. The effects of Tbl3 knockdown on ribosomal RNA (rRNAs) synthesis or processing were studied by labeling cells with 5,6-³H-uridine followed by a chase with fresh medium for various periods. Total RNAs were purified from treated cells and subjected to gel electrophoresis and Northern analysis. Ribosome profiling by sucrose gradient centrifugation was used to compare the amounts of 40S and 60S ribosome subunits as well as the 80S monosome. The impact of Tbl3 knockdown on cell growth and proliferation was examined by growth curves and colony assays.

RESULTS: The largest open reading frame of mouse Tbl3 encodes a protein of 801 amino acids (AA) with an apparent molecular weight of 89-90 kilodalton. It contains thirteen WD40 repeats (an ancient protein-protein interaction motif) and a carboxyl terminus that is highly homologous to the corresponding region of the yeast nucleolar protein, utp13. Virtually nothing is known about the biological function of Tbl3. All cell lines surveyed expressed Tbl3 and the level of expression correlated roughly with cell proliferation and/or biosynthetic activity. Using Tbl3-EGFP fusion constructs we obtained the first direct evidence that Tbl3 is targeted to the nucleoli in mammalian cells. However, no previously described nucleolar targeting sequences were found in Tbl3, suggesting that the WD40 motif and/or other topological features are responsible for nucleolar targeting. Partial knockdown (by 50%-70%) of mouse Tbl3 by shRNA had no discernable effects on the processing of the 47S pre-ribosomal RNA (pre-rRNA) or the steady-state levels of the mature 28S, 18S and 5.8S rRNAs but consistently increased the expression level of the 47S pre-rRNA by two to four folds. The results of the current study corroborated the previous finding that there was no detectable rRNA processing defects in zebra fish embryos with homozygous deletions of zebra fish Tbl3. As ribosome production consumes the bulk of cellular energy and biosynthetic precursors, dysregulation of pre-rRNA synthesis can have negative effects on cell growth, proliferation and differentiation. Indeed, partial knockdown of Tbl3 in promyelocytes severely impaired their proliferation. The inhibitory effect of Tbl3 knockdown was also observed in fibroblasts, resulting in an 80% reduction in colony formation. Taken together, these results indicate that Tbl3 is a newly recognized nucleolar protein with regulatory roles at very early stages of ribosome biogenesis, perhaps at the level of rRNA gene transcription.

CONCLUSION: Tbl3 is a newly recognized nucleolar protein with important regulatory roles in ribosome biogenesis.

Unusual cytogenetic abnormalities associated with Philadelphia chromosome

Cytogenetic abnormalities are the hallmark of leukemias. We report here two cases of unusual cytogenetic abnormalities associated with Philadelphia chromosome, one with mixed phenotypic acute leukemia showing monosomy 7 and t(9;22) (q34;q11.2) and the other with chronic myeloid leukemia and additional translocation involving chromosomes 10 and 13. Both patients achieved complete remission following imatinib based treatment.

Current approach to relapsed acute lymphoblastic leukemia in children

Recurrent acute lymphoblastic leukaemia (ALL) is a common disease for pediatric oncologists and accounts for more deaths from cancer in children than any other malignancy. Although most patients achieve a second remission, about 50% of relapsed ALL patients do not respond to salvage therapy or suffer a second relapse and most children with relapse die. Treatment must be tailored after relapse of ALL, since outcome will be influenced by well-established prognostic features, including the timing and site of disease recurrence, the disease immunophenotype, and early response to retrieval therapy in terms of minimal residual disease (MRD). After reinduction chemotherapy, high risk (HR) patients are clear candidates for allogeneic stem cell transplantation (SCT) while standard risk patients do better with conventional chemotherapy and local therapy. Early MRD response assessment is currently applied to identify those patients within the more heterogeneous intermediate risk group who should undergo SCT as consolidation therapy. Recent evidence suggests distinct biological mechanisms for early vs late relapse and the recognition of the involvement of certain treatment resistance related genes as well cell cycle regulation and B-cell development genes at relapse, provides the opportunity to search for novel target therapies.

Age is an independent adverse prognostic factor for overall survival in acute myeloid leukemia in Japan

AIM: To elucidate risk factors for survival of elderly acute myeloid leukemia (AML) patients in a real-world practice by observational study.

METHODS: We conducted a population-based study in 213 adult and elderly AML patients (127 males and 86 females) in Kagawa Prefecture, Japan. To construct this cohort, we gathered all data for patients diagnosed with AML at 7 hospitals in Kagawa between 2006 and 2010. The primary end point was overall survival (OS) after AML diagnosis. Unadjusted Kaplan-Meier survival plots were used to determine OS in the overall cohort. Multivariate analysis was used to determine the independent adverse prognostic factors for OS, with the covariates of interest including age, gender, race/ethnicity, CCI, education, median income, metropolitan statistical area size and history of myelodysplastic syndrome.

RESULTS: The average population of Kagawa during the study period was 992489, and the incidence of AML was 4.26 per 100000 person-years. A total of 197 patients with non-acute promyelocytic leukemia (non-APL) (119 males and 78 females) were also included. The median age of non-APL patients was 70 years (average 67, range 24-95). The 5-year OS rate was 21.1%. Subsequent analysis by age group showed that the survival rate declined with age; the 5-year OS rates of non-APL patients younger than 64 years, 65-74 years, and older than 75 years were 41.5%, 14.1%, and 8.9%, respectively. Multivariate analysis revealed that unfavorable risk karyotype, older age, poor performance status (PS) (3-4), lack of induction chemotherapy, and antecedent haematological disease were independent prognostic predictors. In the subgroup analysis, we also found that older patients with non-APL had lower complete remission rates and higher early death rates than younger patients, irrespective of PS. However, intensive chemotherapy was a significant predictor for longer survival not only in the patients < 75 years of age, but also in those over 75 with PS 0-2.

CONCLUSION: Age would contribute considerable life expectancy to indicate induction chemotherapy with eligible dose of cytotoxic drugs for a favorable case even in advanced elderly.

Myelofibrosis: Prognostication and cytoreductive treatment

Myeloproliferative neoplasms include three diseases: polycythemia vera, essential thrombocythemia and primary myelofibrosis (PMF), currently diagnosed according to the 2008 World Health Organization criteria. Patients with PMF may encounter many complications, and, among these, disease progression is the most severe. Concerning prognostication of Myelofibrosis (MF), the International Prognostic scoring system (IPSS) (International Prognostic Scoring System) model at diagnosis and the Dynamic IPSS (DIPSS) anytime during the course of the disease may be useful to define survival of MF patients. The IPSS and the DIPSS are based on age greater than 65 years, presence of constitutional symptoms, hemoglobin level less than 10 g/dL, leukocyte count greater than 25 × 10⁹/L, and circulating blast cells 1% or greater. Cytogenetic profile and mutational analysis seem to be the next step to implement MF prognostication. Concerning treatments, hydroxyurea has been considered until now the drug of choice when an anti-myeloproliferative effect is needed, but recent data on JAK inhibitors demonstrated a significant effect of these drugs on splenomegaly and symptoms.

Hemophagocytic lymphohistiocytosis: Recent progress in the pathogenesis, diagnosis and treatment

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome that develops as a primary (familial/hereditary) or secondary (non-familial/hereditary) disease characterized in the majority of the cases by hereditary or acquired impaired cytotoxic T-cell (CTL) and natural killer responses. The molecular mechanisms underlying impaired immune homeostasis have been clarified, particularly for primary diseases. Familial HLH (familial hemophagocytic lymphohistiocytosis type 2-5, Chediak-Higashi syndrome, Griscelli syndrome type 2, Hermansky-Pudlak syndrome type 2) develops due to a defect in lytic granule exocytosis, impairment of (signaling lymphocytic activation molecule)-associated protein, which plays a key role in CTL activity [e.g., X-linked lymphoproliferative syndrome (XLP) 1], or impairment of X-linked inhibitor of apoptosis, a potent regulator of lymphocyte homeostasis (e.g., XLP2). The development of primary HLH is often triggered by infections, but not in all. Secondary HLH develops in association with infection, autoimmune diseases/rheumatological conditions and malignancy. The molecular mechanisms involved in secondary HLH cases remain unknown and the pathophysiology is not the same as primary HLH. For either primary or secondary HLH cases, immunosuppressive therapy should be given to control the hypercytokinemia with steroids, cyclosporine A, or intravenous immune globulin, and if primary HLH is diagnosed, immunochemotherapy with a regimen containing etoposide or anti-thymocyte globulin should be started. Thereafter, allogeneic hematopoietic stem-cell transplantation is recommended for primary HLH or secondary refractory disease (especially EBV-HLH).

Chronic disseminated candidiasis complicated with a ruptured intracranial fungal aneurysm in ALL

An 11-year-old boy with acute lymphocytic leukemia (ALL) contracted disseminated candidiasis during induction therapy, which was complicated with rupture of a fungal cranial aneurysm. Ventricular drainage and coil embolization of a residual aneurysm in combination with intensive antifungal therapy rescued the patient. Although clinical improvement was achieved, high fever and elevated levels of C-reactive protein and β-D-glucan continued for more than 10 mo. One year later, the ALL relapsed during maintenance therapy with methotrexate and 6-mercaptopurine. After salvage chemotherapy, the patient received unrelated bone marrow transplantation (BMT) in a non-complete remission condition and survived. During subsequent chemotherapy and BMT, no recurrence of the fungal infection was observed under the prophylactic anti-fungal therapy with micafungin.

Ex vivo expansion of hematopoietic stem and progenitor cells: Recent advances

Hematopoietic stem cells (HSCs) have become the most extensively studied stem cells and HSC-based cellular therapy is promising for hematopoietic cancers and hereditary blood disorders. Successful treatment of patients with HSC cells depends on sufficient number of highly purified HSCs and progenitor cells. However, stem cells are a very rare population no matter where they come from. Thus, ex vivo amplification of these HSCs is essential. The heavy demands from more and more patients for HSCs also require industrial-scale expansion of HSCs with lower production cost and higher efficiency. Two main ways to reach that goal: (1) to find clinically applicable, simple and efficient methods (or reagents) to enrich HSCs; (2) to find new developmental regulators and chemical compounds in order to replace the currently used cytokine cocktails for HSCs amplification. In this Editorial review, we would like to introduce the current status of ex vivo expansion of HSCs, particularly focusing on enrichment and culture supplements.

Anti-CD20 monoclonal antibodies and associated viral hepatitis in hematological diseases

Over the past decade, the administration of anti-CD20 monoclonal antibodies such as rituximab has demonstrated various degrees of effectiveness and has improved patients’ outcomes during the treatment of autoimmune hematological disorders and hematological malignancies. However, the depletion of B-cells, the distribution of T-cell populations, and the reconstruction of host immunity resulting from the use of anti-CD20 monoclonal antibodies potentially lead to severe viral infections, such as hepatitis B virus (HBV), hepatitis C virus (HCV), parvovirus B19, and herpes viruses, in patients who are undergoing immune therapy or immunochemotherapy. Of these infections, HBV- and HCV-related hepatitis are a great concern in endemic areas because of the high morbidity and mortality rates in untreated patients. As a result, prophylaxis against HBV infection is becoming a standard of care in these areas. Parvovirus B19, a widespread pathogen that causes red blood cell aplasia in immunocompromised hosts, also causes hepatitis in healthy individuals. Recently, its association with hepatitis was recognized in a patient treated with rituximab. In addition, adenovirus, varicella-zoster virus, hepatitis E virus, and rituximab itself have been linked to the occurrence of hepatitis during or after rituximab treatments. The epidemiologies and pathogeneses of these etiologies remain unknown. Because of the increasing use of anti-CD20 monoclonal antibodies for the treatment of hematological malignancies or autoimmune hematological disorders, it is imperative that physicians understand and balance the risks of hepatotropic virus-associated hepatitis against the benefits of using anti-CD20 monoclonal antibodies.

A concise, practical guide to diagnostic assessment for mast cell activation disease

As recognition of mast cell (MC) involvement in a range of chronic inflammatory disorders has increased, diagnosticians’ suspicions of MC activation disease (MCAD) in their chronically mysteriously inflamed patients have similarly increased. It is now understood that the various forms of systemic mastocytosis - diseases of inappropriate activation and proliferation of MCs seemingly driven by a small set of rare, usually constitutively activating mutations in assorted MC regulatory elements - comprise merely the tip of the MCAD iceberg, whereas the far larger and far more clinically heterogeneous (and thus more difficult to recognize) bulk of the iceberg consists of assorted forms of MC activation syndrome (MCAS) which manifest little to no abnormal MC proliferation and may originate from a far more heterogeneous set of MC mutations. It is reasonable to suspect MCAD when symptoms and signs of MC activation are present and no other diagnosis better accounting for the full range of findings is present. Initial laboratory assessment should include not only routine blood counts and serum chemistries but also a serum total tryptase level, which helps direct further evaluation for mastocytosis vs MCAS. Appropriate tissue examinations are needed to diagnose mastocytosis, while elevated levels of relatively specific mast cell mediators are sought to support diagnosis of MCAS. Whether assessing for mastocytosis or MCAS, testing is fraught with potential pitfalls which can easily yield false negatives leading to erroneous rejection of diagnostic consideration of MCAD in spite of a clinical history highly consistent with MCAD. Efforts at accurate diagnosis of MCAD are worthwhile, as many patients then respond well to appropriately directed therapeutic efforts.

A concise, practical guide to diagnostic assessment for mast cell activation disease

As recognition of mast cell (MC) involvement in a range of chronic inflammatory disorders has increased, diagnosticians’ suspicions of MC activation disease (MCAD) in their chronically mysteriously inflamed patients have similarly increased. It is now understood that the various forms of systemic mastocytosis - diseases of inappropriate activation and proliferation of MCs seemingly driven by a small set of rare, usually constitutively activating mutations in assorted MC regulatory elements - comprise merely the tip of the MCAD iceberg, whereas the far larger and far more clinically heterogeneous (and thus more difficult to recognize) bulk of the iceberg consists of assorted forms of MC activation syndrome (MCAS) which manifest little to no abnormal MC proliferation and may originate from a far more heterogeneous set of MC mutations. It is reasonable to suspect MCAD when symptoms and signs of MC activation are present and no other diagnosis better accounting for the full range of findings is present. Initial laboratory assessment should include not only routine blood counts and serum chemistries but also a serum total tryptase level, which helps direct further evaluation for mastocytosis vs MCAS. Appropriate tissue examinations are needed to diagnose mastocytosis, while elevated levels of relatively specific mast cell mediators are sought to support diagnosis of MCAS. Whether assessing for mastocytosis or MCAS, testing is fraught with potential pitfalls which can easily yield false negatives leading to erroneous rejection of diagnostic consideration of MCAD in spite of a clinical history highly consistent with MCAD. Efforts at accurate diagnosis of MCAD are worthwhile, as many patients then respond well to appropriately directed therapeutic efforts.

Pseudohemophilia of Erik von Willebrand caused by homozygous one nucleotide deletion in exon 18 of the VW-factor gene

The original description of a novel severe bleeding disorder as “Hereditary Pseudohemophilia” by Erik von Willebrand can currently be labelled as von Willebrand disease (VWD) type 3. VWD type 3 is autosomal recessive caused by homozygous or double heterozygous null mutations in the von Willebrand factor (VWF) gene and typically characterized by prolonged bleeding time and APTT, FVIII: C levels below 2%, undetectable VWF: Ag, VWF: RCo and VWF: CB and absence of ristocetin induced platelet aggregation (RIPA). Autosomal recessive von Willebrand disease type 3 VWD with virtual complete VWF deficiency are homozygous or compound heterozygous for two null alleles (gene deletions, stop codons, frame shift mutations, splice site mutations, and absence of mRNA). Reports on severe recessive VWD compound heterozygous for a null allele and a missense mutation and homozygous or double heterozygous for missense mutations are associated with very low but measurable FVIII and VWF: Ag and should be reclassified as severe recessive type 1 VWD. Homozygous missense or compound missense/null mutations related to recessive severe type 1 VWD have been indentified in the VWF prosequence D1 and D2 domains, the D4, B1-3, C1-2 domains, and only a very few in the dimmerization site (D3 domain). The detection of even tiny amounts of VWF: Ag after desmopressin acetate (DDAVP) or in hidden sites like platelets allows the differentiation between patients with VWD type 3 and homozygous or double heterozygous recessive severe type 1. Carriers of a null allele related to VWD type 3 or a missense mutation related with severe recessive type 1 VWD may present with mild VWD with low penetrance of bleeding in particular when associated with blood group O. Heterozygous obligatory carriers (OC) of a null mutation or a missense mutation related to recessive VWD type 3 or severe type 1 both present with asymptomatic or mild VWD type 1 in particular when associated with blood group O. The response to DDAVP of OC of either a nonsense or a missense mutation appears to be abnormal and diagnostic with a 3-times higher response of FVIII: C as compared to VWF: Ag. In contrast, the responses to DDAVP of FVIII: C and VWF: Ag are equally good in individuals with low VWF levels related to blood group O and a normal VWF gene and protein (pseudo-VWD). These observations are completely in line with and extend the original observations of von Willebrand in a large family with VWD type 3 and asymptomatic or mild true type 1 VWD in OC.

Gemcitabine cures metastatic hepatic carcinoma and bone metastasis

We report a case of a 59-year-old gentleman who had suffered from low back pain for several months. Abdominal sonogram showed multiple heteroechoic nodules in the bilateral liver and an enlarged pancreatic head. Abdominal computer tomography (CT) favored pancreas head tumor with liver and bone metastasis. Endoscopic retrograde cholangiopancreatography (ERCP) disclosed pancreatic duct invasion over the distal portion of the pancreatic duct with prestenotic dilatation. Liver biopsy showed undifferentiated carcinoma. As suggested by the pathologist, the nasopharyngeal area was checked by the ear, nose and throat doctor, was negative and nasopharyngeal carcinoma was excluded. Therefore, the patient was treated with Gemcitabine (1500 mg/wk), as the suggested treatment schedule, for 24 wk in opioid dependency program. Sequential abdominal CT during follow up showed the disappearance of liver metastasis and shrinkage of the pancreatic tumor. Repeated ERCP after treatment showed re-channelization of the pancreatic duct. During 11 years of follow up, 5 CT scans disclosed not only the disappearance of the hepatic tumor but also no cancer recurrence. Progressive shrinkage of pancreatic head was also noted. Therefore, we can say this malignant case was cured by monotherapy with gemcitabine.

Blood groups, hemoglobin phenotypes and clinical disorders of consanguineous Yansi population

AIM: To study frequency of blood groups, prevalence of sickle-cell anemia trait and glucose-6-phosphate dehydrogenase deficiency (G6PD), among consanguineous Yansi tribe.

METHODS: A total of 525 blood samples were collected, of which 256 among the Yansi population, and 269 for the unrelated control group in the Bandundu province of Democratic Republic of Congo. Blood group antigens were determined in the following systems: ABO, Rh, Kell, Duffy, Kidd and MNS. Blood grouping and extended phenotype tests were performed according to standard immunohematological procedures. Spot tests and tandem mass spectrometry were used respectively for the assessment of G6PD and sickle-cell anemia trait.

RESULTS: The frequency of ABO phenotypes conformed to the following order O>A>B>AB with notably 62.5%, 23.8%, 12.1% and 1.6% for the Yansi, and 54.6%, 27.5%, 14.1% and 3.7% for the unrelated control group, respectively (P = 0.19). As for the Rh phenotypes, the most frequent were ccD.ee, ccD.Ee, CcD.ee, corresponding to 71.5%, 12.1% and 12.1% for the Yansi, and 70.6%, 15.6% and 8.2%, for the unrelated control group (P = 0.27). The frequency of MN and Ss phenotypes were statistically different between groups (P = 0.0021 and P = 0.0006). G6PD was observed in 11.3% of subjects in the Yansi group, and in 12.4% of controls (P = 0.74). The sickle-cell anemia trait was present in 22.4% of Yansi subjects and 17.8% in the control group (P = 0.24). Miscarriages and deaths in young age were more common among Yansi people.

CONCLUSION: This study shows a significant difference in MNS blood group distribution between the Yansi tribe and a control population. The distribution of other blood groups and the prevalence of hemoglobinopathies did not differ in the Yansi tribe.

First contributors in the history of leukemia

While the modern era of leukemia chemotherapy began recently, the recognition of leukemias has been mainly recorded in the second part of the nineteenth century. This brief historic review reports the first descriptions of the disease and the major advances in its history from its roots to the beginning of the twentieth century. Although most treatments for leukemia were ineffective until the middle of the twentieth century, it seemed of interest to review some pertinent exemples of the evolution in the knowledge of this disease (relied upon chronology as an organizing framework, while stressing the importance of themes), since our current knowledge about leukemia is still mainly based on the first accounts of scientific and medical discovery. Early in the nineteenth century, a small number of cases of patients with uncommon or peculiar alterations of the blood were published. Of the cases, four might suggest symptoms of chronic leukemia. The first published case was the detailed report prepared by John Hughes Bennett in the “Edinburgh Medical and Surgical Journal” October 1845. Leukemia gradually became accepted as a distinct disease and published case reports grew in number. Concomitantly, clinical and pathological description of the disease became more detailed.

PVSG and WHO vs European Clinical, Molecular and Pathological Criteria for prefibrotic myeloproliferative neoplasms

The Polycythemia Vera Study Group (PVSG), World Health Organization (WHO) and European Clinical, Molecular and Pathological (ECMP) classifications agree upon the diagnostic criteria for polycythemia vera (PV) and advanced primary myelofibrosis (MF). Essential thrombocythemia (ET) according to PVSG and 2007/2008 WHO criteria comprises three variants of JAK2^V617F mutated ET when the ECMP criteria are applied. These include normocellular ET, hypercellular ET with features of early PV (prodromal PV), and hypercellular ET due to megakaryocytic, granulocytic myeloproliferation (ET.MGM). Evolution of prodromal PV into overt PV is common. Development of MF is rare in normocellular ET (WHO-ET) but rather common in hypercellular ET.MGM. The JAK2^V617F mutation burden in heterozygous mutated normocellular ET and in heterozygous/homozygous or homozygous mutated PV and ET.MGM is of major prognostic significance. JAK2/MPL wild type ET associated with prefibrotic primary megakaryocytic and granulocytic myeloproliferation (PMGM) is characterized by densely clustered immature dysmorphic megakaryocytes with bulky (bulbous) hyperchromatic nuclei, which are never seen in JAK2^V617F mutated ET, and PV and also not in MPL⁵¹⁵ mutated normocellular ET (WHO-ET). JAK2^V617 mutation burden, spleen size, LDH, circulating CD34⁺ cells, and pre-treatment bone marrow histopathology are mandatory to stage the myeloproliferative neoplasms ET, PV, PMGM for proper prognosis assessment and therapeutic implications. MF itself is not a disease because reticulin fibrosis and reticulin/collagen fibrosis are secondary responses of activated polyclonal fibroblasts to cytokines released from the clonal myeloproliferative granulocytic and megakaryocytic progenitor cells in ET.MGM, PV and PMGM.

Management of adult Langerhans cell histiocytosis based on the characteristic clinical features

To find out the most appropriate management, clinical features of 18 cases of adult multisystem langerhans cell histiocytosis (LCH) have been analyzed. The patients comprising of 9 males and 9 females were median age of 36 years, ranging from 18-53 years at diagnosis. Regarding the initial symptoms, 7 patients (2 males and 5 females) showed central diabetes insipidus (CDI) and other endocrine symptoms with thickened pituitary stalk or a mass at the hypothalamic region. Additional 2 patients initiated the disease with CDI with no immediate diagnosis. In the remaining patients, the disease begun with single (n = 3) or multiple (n = 1) spinal bone lesion(s) in 4 patients (all males), with multiple bone lesions in 3 patients (1 male and 2 females), with single skull lesion in one female patient and with ambiguous symptoms including hypothyroidism in the remaining one male patient. We also recognized the correlation between pregnancy/childbirth and LCH in 4 patients. In terms of treatment, 9 patients received systemic immuno-chemotherapy alone, of which the majority received vinblastine-based chemotherapy while 4 received 2-chlorodeoxyadenosine. Five had a combination of immuno-chemotherapy with surgical resection or radiotherapy, 2 had immunotherapy alone, 2 had surgical resection followed by observation alone to date. Three patients received hematopoietic stem cell transplantation after extensive chemotherapy. In terms of outcome, 15 patients are alive (9 with active disease, 6 without active disease), with a median of 66 mo (range 17-166 mo), two died of disease while the remaining 1 lost to follow-up. Based on these results, we think that early diagnosis and rapid introduction of appropriate treatment are essential, in order to overcome the problems relevant to adult LCH.

Another look at the life of a neutrophil

Neutrophils are considered as the privates of the innate immune system. They are born in the bone marrow, migrate to the tissues where they kill putative intruders. After their job they are quickly removed from the battlefield by macrophages. This view of a predetermined pathway fitted nicely in their short lifespan of 5 h. However, recent studies indicated that their lifespan was in the order of several days. Recently, it became clear that neutrophils have functions beyond killing of pathogens. The reported half-life of 5 h is hardly compatible with those functions. Moreover, the organism actively invests in rescuing primed neutrophils from clearance by the body. It appears that their half-life is highly dependent on the method used to measure their life span. Here, we discuss the literature and show that neutrophils compartmentalize which could explain partially the differences reported for their lifespan. Moreover, the methodology to label neutrophils ex-vivo could have similar deteriorating effects on their lifespan as found for transfused red blood cells.