Guillain-Barre syndrome following autologous bone marrow transplantation

The pathogenesis of the Guillain-Barre syndrome (GBS) is felt to involve alterations in cellular and humoral immune responses. We report the case of a 44-year-old female with stage IV breast cancer who developed GBS 2 days after receiving high dose chemotherapy with bone marrow and peripheral progenitor cell support, and granulocyte-macrophage colony stimulating factor (GM-CSF). Her clinical status stabilized with plasmapheresis. This report lends further support to hypotheses regarding cellular immune alterations in the pathogenesis of GBS.

A radiologic syndrome after high dose chemotherapy and autologous bone marrow transplantation, with clinical and pathologic features of systemic candidiasis

BACKGROUND

The use of high dose chemotherapy in the treatment of solid tumors is associated with prolonged neutropenia and, consequently, in some patients, systemic candidiasis. The authors describe their experience with a clinicoradiologic syndrome developing after high dose chemotherapy was administered to patients with breast cancer.

METHODS

The authors evaluated the clinical and radiologic records of 12 patients in whom hepatic, splenic, or renal candidiasis developed.

RESULTS

Three patients had positive blood cultures for candida tropicalis. One of these patients and two others had fungal organisms identified with special stains of an organ aspirate. Most patients were asymptomatic, and most of them were treated successfully with antifungal agents, although untreated patients also recovered. There were no fatalities due to the candidiasis.

CONCLUSIONS

A radiographic syndrome resembling hepatic, splenic, or renal candidiasis is described, which occurred after high dose chemotherapy was administered and autologous bone marrow transplantation was performed on patients with breast cancer. This syndrome has a favorable prognosis. Conclusions as to the more indolent nature of this syndrome cannot be made; however, this topic warrants further investigation.

Necrotizing lymphadenitis of the neck (Kikuchi's disease)

Kikuchi's histiocytic necrotizing lymphadenitis is a benign condition originally described in the Japanese literature in 1972. We here describe the clinicopathological features, including fine needle aspirate and bone marrow biopsy, of a case of Kikuchki's disease, which to our knowledge is the first reported from a Scandinavian country. The histopathological features of the enlarged lymph nodes were documented by multiple small necrotic foci showing karyorrhectic debris and haemorrhage. The necrotic foci were surrounded by a mantle of large histiocytic-like cells with vesicular nuclei and clear cytoplasm. The nodal architecture was almost completely effaced and the node infiltrated by a mixture of lymphoid cells of variable size. Neutrophils, eosinophils, and plasma cells were very few. The fine needle aspirate biopsy showed a mixture of small dark lymphocytes, larger activated lymphocytes, and many histiocytes. The bone marrow biopsy showed normal haematopoiesis but some large cells with phagocytosed leukocytes, i.e. similar to haemophagocytosis. Kikuchi's disease has a predilection for lymph nodes in the neck of young women, and is usually self-limited and subsides in 1 to 4 months. The patient described in this report received no treatment. Within 5 weeks the fever subsided and the lymph nodes diminished in size. One year later the patient is well and free of disease. We emphasize the benign nature of Kikuchi's disease, and that SLE and malignant lymphoma are the majori differential diagnoses.

The use of intensive clinic support to permit outpatient autologous bone marrow transplantation for breast cancer

Recent studies have explored feasibility and cost considerations of administering high-dose chemotherapy with hematopoietic support in the outpatient setting. Between October 1991 and April 1993, we studied 110 women with primary metastatic breast cancer undergoing high-dose chemotherapy with hematopoietic support. Ninety-two patients were managed in an outpatient clinic after high-dose chemotherapy and autologous bone marrow transplantation and peripheral blood progenitor cells. The remaining 18 patients received the same high-dose treatment and hematopoietic support in the hospital and were discharged to a nearby hotel each night; these patients were the pilot group for this effort and also served as a control group. High-dose chemotherapy consisted of cyclophosphamide/cisplatin/carmustine. Chemotherapy was well tolerated, allowing 95% of 65 eligible patients enrolled since November 1992 to be discharged soon after chemotherapy for outpatient posttransplant support. Approximately 70% of these patients required either no hospital readmission or brief readmissions of 1 to 4 days. Median days of hospitalization required for historical groups of patients receiving high-dose chemotherapy plus bone marrow support as inpatient therapy, high-dose chemotherapy with colony-stimulating factor-primed peripheral blood progenitor cells and autologous bone marrow transplantation as inpatient therapy in a traditional transplant model, and outpatient management of autologous bone marrow transplantation patients were 37, 24.5, and 7 days, respectively, despite the same high-dose chemotherapy. Charges related to the transplant procedure were reduced by 50% over the last 2 to 5 years using the outpatient management approach. This procedure may be applicable to patients with other forms of cancer receiving intensive chemotherapeutic regimens. The use of outpatient management in a transplant setting is highly cost effective.

Prevention of hemorrhagic cystitis after high-dose alkylating agent chemotherapy and autologous bone marrow support

High-dose cyclophosphamide (CY) is associated with a high risk of hemorrhagic cystitis. The reported frequency ranges from 6.5 to 52% despite the use of hydration protocols. The current study reports a hyperhydration and continuous bladder irrigation protocol which resulted in a very low incidence of microscopic hematuria and no reported cases of visible hematuria. Patients received baseline fluids at 200 ml/m2/h during chemotherapy. Additional fluid boluses were given if urine output fell below 200 ml/h. Bladder irrigation was performed at a rate of 1 l/h during and for 24 h after high-dose CY. Three hundred three evaluable patients with solid tumors received high-dose chemotherapy with CY at a dose of 5625 mg/m2 over 3 days. Patients also received cisplatin 165 mg/m2 and carmustine 600 mg/m2. Some patients received thiotepa 300-750 mg/m2 instead of carmustine. The overall incidence of microscopic hematuria (> 15 RBCs per high power field) was 19%, with only 11% of patients experiencing more than 50 RBCs per high power field. No patient developed visible hematuria or symptomatic hematuria requiring intervention. These results using aggressive hyperhydration and high volumes of continuous bladder irrigation are among the best reported following high-dose CY chemotherapy.

Sequential prophylactic oral and empiric once-daily parenteral antibiotics for neutropenia and fever after high-dose chemotherapy and autologous bone marrow support

PURPOSE

We studied the effectiveness of prophylactic oral ciprofloxacin and rifampin on fever prevention in patients undergoing autologous bone marrow transplantation (ABMT) for breast cancer. Furthermore, we evaluated the toxicity and efficacy of empiric once-daily vancomycin and tobramycin for febrile neutropenia.

PATIENTS AND METHODS

Ninety-nine assessable women received prophylactic ciprofloxacin and rifampin after high-dose chemotherapy (HDC) for advanced or high-risk primary breast cancer supported with either bone marrow and peripheral-blood progenitor cells (PBPCs) or bone marrow purged with chemotherapy and monoclonal antibodies. Neutropenic fever was treated with empiric once-daily vancomycin and tobramycin. Patients were compared with historic controls treated with the identical HDC and bone marrow support regimen.

RESULTS

In patients treated with bone marrow and PBPCs, the incidence of fever during neutropenia was reduced by ciprofloxacin and rifampin from 98% to 57%. Documented infections were reduced from 42% to 13% (P < .01) and bacteremia from 18% to 0% (P < .001). In purged bone marrow recipients, the overall infection rate decreased from 74% to 17% (P < .001), and bacteremia from 29% to 7%. (P = .02). No patient developed breakthrough bacteremia or sepsis syndrome while on study. Serum creatinine level greater than 1.8 g/dL was noted in 7% of controls and 10% of study patients. Increased ototoxicity was not encountered with the higher peak concentrations of vancomycin and tobramycin.

CONCLUSION

The therapeutic strategy of ciprofloxacin and rifampin followed by once-daily vancomycin and tobramycin markedly reduced the incidence of infection and virtually eliminated bacteremia in both purged and nonpurged bone marrow recipients. Once-daily vancomycin and tobramycin was safe and effective and, because of the ease of use, facilitates outpatient management of ABMT patients.

Traumatic pseudoaneurysm of left internal mammary artery graft

Traumatic pseudoaneurysm of the left internal mammary artery was recognized as a possible causal factor in the early recurrence of angina in a 51-year-old man. This patient underwent reoperation for revascularization with the left internal mammary artery graft in situ.

Role of cytokines in autologous bone marrow transplantation

High-dose chemotherapy with autologous bone marrow support has been increasingly used in the treatment of malignant disease. The use of hematopoietic colony-stimulating factors (CSF), particularly when coupled with the use of CSF-primed peripheral blood progenitor cells, has enabled a substantial reduction in the duration of severe leukopenia and in the morbidity associated with bone marrow transplantation. Furthermore, their use has reduced resource utilization and hospital charges and has also permitted the performance of autologous bone marrow transplantation support largely on an outpatient basis.

DNA flow cytometry on breast carcinomas: comparison of a detergent and an enzyme-detergent preparation method

In this study we have compared two different preparation methods for DNA flow cytometry on breast cancer. Tumour cell suspensions from 49 breast cancers were analysed on a Facscan flow cytometer. In seven of 49 cases, additional aneuploid peaks were found after enzyme/detergent treatment (E/D), not seen after the detergent (D) preparation. S-Phase fractions were significantly higher after D than after E/D preparation (mean values, 15 and 8%, respectively), although the correlation was high between the two methods. S-Phase fraction estimated after background correction diminished the differences between the two methods (mean values, 8 and 6%). Furthermore, the fraction of G2/M cells were generally greater with the D method. These differences can be explained by increased number of cell doublets and nuclear fragments after D compared to E/D preparation. This clearly shows that the preparation method influences the result of DNA flow cytometry on human breast cancers.

[The significance of extra-articular manifestations for the differential diagnosis of musculoskeletal diseases in children]

Musculoskeletal complaints comprise about 7% of all pediatric office visits. The differential diagnosis of these complaints is very extensive. A great diagnostic aid offer quality, distribution and temporal course of the pain of joints, bone and muscles, of an objectively detectable arthritis, and especially of the numerous manifestations of other organ systems: Constitutional signs, fever, skin, mucous membranes, eyes, nervous system, heart, vasculature, lungs, digestive system and urogenital system. Combinations of these often early manifestations are crucial to determine the disease category, which is urgent for further diagnostic measures and for therapy: Bacterial, rheumatic, collagen-vascular, traumatic, orthopedic, and neoplastic disease. They are as important for making the final diagnosis and for the early recognition of later manifestations and complications. To achieve an optimal diagnostic efficiency, laboratory investigations should be carefully selected according to the clinical findings and diagnoses. A few regular investigations are valuable for the assessment of disease activity and therapy, and others for the early detection of initially asymptomatic manifestations.

[Effects of ipratropium bromide and salbutamol on isolated lung hyperinflation in symptom-free intervals in asthmatic children]

To evaluate the effects of salbutamol and ipratropium bromide on the isolated hyperinflation, without central airways obstruction, during asymptomatic periods in asthmatic children, 31 children, out of ca. 500, were selected for a double-blind therapy trial, according to the following criteria: Thoracic gas volume greater than 140% predicted (mean +/- 1SD: 162 +/- 16%) and/or trapped-gas greater than 15% (21 +/- 5%); airways resistance less than 140% (105 +/- 25%) and forced expiratory volume in one second greater than 75% (91 +/- 11%). On 4 consecutive mornings spirometry, bodyplethesmography and measurement of functional residual capacity by helium-dilution were performed before and 20' after inhalation of 2 ml of each of 4 solutions respectively. The children received the solution which produced the largest fall of thoracic gas volume and/or trapped-gas, 4 times/day for 4-5 weeks: 1. five children received saline; 2. 13 salbutamol, 2.5 mg; 3. 6 ipratropium, 0.250 mg; 4. 7 both drugs. Clinical aspects and lung function differed not significantly between the 4 groups. Lung function values showed no correlations with duration, clinical severity and typ of asthma. At the beginning and after 4-5 weeks of treatment lung function improved significantly in the groups 2-4, compared with pretreatment values. At study end, the improvements of thoracic gas volume, trapped-gas and airways resistance differed significantly between the groups, salbutamol + ipratropium produced altogether the best effect. With time, the effect of salbutamol + ipratropium on thoracic gas volume and trapped-gas increased and that of salbutamol on airways resistance and forced expiratory volume in one second decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

[Short-term chemotherapy of tuberculosis in children]

The effectiveness of short-term drug treatment of tuberculosis is based on the use of INH, RMP and PZA (with or without SM or EMB), that have a pronounced bactericidal and sterilizing effect in all tissues and on all populations of mycobacteria which, depending upon the oxygen content and acidity of their surroundings, multiply at different rates. Treatment regimens over 6 or 9 months have proved effective in numerous studies involving 1500 children with pulmonary or extra-pulmonary tuberculosis. The recommended treatment of choice comprises a 6-month regimen with INH, RMP and PZA, with or without EMB or SM, the drugs being administered daily for two months, followed by INH and RMP applied daily, or 2 to 3 times a week for 4 months. If resistance to INH and/or SM is suspected, initially four suitable drugs are required, and are effective. Nine months of treatment with INH and RMP (with PZA and/or EMB if resistance is suspected) administered daily for two months and followed by INH and RMP applied daily or 2 to 3 times a week, is also both effective and safe. Overall side effects were observed in fewer than two per cent of the cases, and were severe in fewer than one per cent. Recurrences occurred in fewer than one per cent of the cases. Complementary measures such as bronchological treatment in the case of bronchial invasion of lymph nodes, and surgical measures in tuberculosis of the bone, joints, body cavities, etc., are of decisive importance for the success of therapy.

Atypical spondyloarthritis in children: proposed diagnostic criteria

Clinical and laboratory findings in 26 children with atypical spondyloarthritis were compared with those of 76 children with juvenile rheumatoid arthritis. The sensitivity, specificity, predictive value, and efficiency for diagnosis were calculated. The following findings (major criteria) were much more common in atypical spondyloarthritis than in juvenile rheumatoid arthritis: (1) spondyloarthritis within the family; (2) enthesopathy; (3) arthritis of digital joints; (4) sacro-iliitis; (5) presence of HLA-B27; (6) frequent recurrence of arthritis and arthralgia. Six additional findings (minor criteria) were significantly more common in atypical spondyloarthritis (SA): (1) disease onset after the age of 10 years; (2) male sex; (3) involvement of the lower extremities; (4) acute iridocyclitis or conjunctivitis; (5) arthritis of the hip joints; (6) manifestation following a history of enteritis. In the presence of 4 major criteria or 3 major and 3 minor criteria, the diagnosis of an atypical SA was established with a sensitivity of 84.6%, a specificity of 100%, and an efficiency of 96.1%.

The incidence of analgesics intolerance in asthmatic children detected by history and inhalation challenge with lysine acetylsalicylate

To determine the incidence of adverse reactions to analgesics in unselected asthmatic children, histories were obtained from 486 children, using questionnaires and interviews. Mean age was 11.4 +/- 2.3 (+/- 1 SD) years (range 6-17 years), and mean duration of disease was 7.6 +/- 3.6 (1-15) years. The majority of 21 children gave an equivocal history, and only 7 (1.4%) of all children had a reliable history of adverse reactions to various analgesics. Inhalation challenge with increasing doses of lysine acetylsalicylate (LASA) was performed in 75 randomly selected asymptomatic children. Two boys of these (2.7%) had a positive test, defined as a 25% or more decrease of FEV1 and/or a 50% or more increase of the oscillatory airway resistance, compared with base line values. Both children had a mild airway obstruction, and had no personal or family history of analgesics intolerance. Further 27 children with suspected positive personal or family histories were also challenged. One girl of these manifested a mild urticaria; her pulmonary function remained unchanged. The incidence of analgesics intolerance in unselected asthmatic children is much lower than that of 12.5% to 28% reported in severe chronic asthma. The inhalation challenge with LASA proved simple, safe, effective and time saving, and thus, it offers an alternative method to the oral challenge in suspected children.

[Effect of the diagnosis and prevention of exercise-induced bronchial obstruction on sports participation by asthmatic school children]

To assess the sport activities and the previous management of asthmatic children with an exercise-induced bronchial obstruction (EIB), we studied 124 children, aged 8-17 years, with a history of EIB, which was confirmed in a free-running exercise test. Participation in school sports was regular in 38% of the children, irregular in 45% and absent in 17%. Participation in sports outside the school was even lower: In 26% regularly, 18% irregularly and absent in 56%. 17% of all children were not active in any sport. EIB had previously been diagnosed in 38 (31%) children, and 20 (16%) of these had received an appropriate prophylactic medication. Children who received prophylaxis participated significantly more often in school sports (p less than 0.01) and in other sports (p less than 0.05), compared with those who had been diagnosed but had not received prophylaxis. After exercise, peak expiratory flow decreased by a mean of 41% of the preexercise values, but following a prophylactic administration of 0.2 mg Salbutamol-aerosol it decreased only by 2%. A complete protection of EIB was achieved in 94% of the children and the mean %-protection was 95%. The protective effect of 2 mg DNCG-aerosol in 21 children was significantly lower (53%, p less than 0.05) than that of salbutamol and a complete protection was achieved in only 71% (p less than 0.025) of the children.

Multiblock: an aid in diagnostic immunohistochemistry

Images

[Comparison of sonographic and roentgenologic findings in the paranasal sinuses in children]

Sonography of maxillary sinuses was performed in 362 asymptomatic children with chronic airway diseases, using a 7.5 MHz sector scanner. Pathologic findings were detected in 78 (21.5%) children. Occipito-frontal radiographs of the sinuses were performed in 40 (11%) randomly chosen children and the findings were later compared with those of sonography. An overall agreement in terms of "normal-abnormal" findings was present in 94% of the 80 sinuses examined. In sinuses judged as "normal" or "abnormal" in either of the methods, findings were corresponding as "normal" in 40 of 45 (89%) and as "abnormal" in 35 of 40 (87%) sinuses. A differentiated assessment of pathologic findings showed an agreement in only 19 of 40 (48%) sinuses. Thus, an overall agreement of differentiated findings was present in 59 of 80 (74%) sinuses. Sonography was superior to radiography especially in differentiating the sinus content in secretion, swelling of the mucosa, polyps, cysts and air. In conclusion, sonography offers an accurate screening method for assessment of paranasal sinuses in children.