Successful treatment of pustulosis palmaris et plantaris with granulocyte colony stimulating factor in a patient with hereditary neutropenia

A 26-year-old female with hereditary neutropenia had Pustulosis Palmaris et Plantaris. Drug administration did not improve her symptoms. Following administration of granulocyte colony stimulating factor (G-CSF; filgrastim), her neutrophil count increased from 300 to 58,000/microliters, and her dermatosis improved. Pustulosis Palmaris et Plantaris has been described as a representative second lesion of focal infection. Neutropenia may be one cause of Pustulosis Palmaris et Plantaris due to refractory focal infection. In the present case, increase in neutrophils with G-CSF may have improved focal infection, resulting in improvement in refractory Pustulosis Palmaris et Plantaris.

Determination of hematopoietic stem cells in peripheral blood by an automated hematology analyzer (SE-9000)

We evaluated the usefulness of an automated hematology analyzer (SE-9000) for the identification and counting of peripheral blood stem cells (PBSCs). The samples tested were from 14 patients with hematological malignancies. Peripheral blood samples were collected from the subjects before and after a course of chemotherapy. From the leukapheresis sample, CD34+ cells, assumed to be hematopoietic stem cells, were obtained with an immunomagnetic cell separator. The CD34+ cells obtained accumulated in the gate corresponding to low recurrent frequencies of the automated hematology analyzer. This gate shows results of the 'immature information' (IMI) channel. Software for detection of only the cells that accumulated in this gate was therefore developed. With this trial program, the regression coefficient between the percentage of leukocytes from the blood samples that were CD34+ and the percentage of such leukocytes that appeared on the IMI channel was 0.79. With this analyzer, the number of PBSC could be counted in about 80 s. The identification and counting of cells picked up by the IMI channel should be clinically useful for the monitoring of changes in PBSC after chemotherapy for mobilization.

Peripheral blood stem cell transplantation for non-Hodgkin's lymphoma in complete remission

High-dose chemotherapy with PBSCT as consolidation therapy was administered to 15 patients with non-Hodgkin's lymphoma admitted to our department between November 1991 and March 1998. The average number of CD34-positive cells harvested was 3.1 x 10(6)/kg and the median time to a granulocyte count above 500/microliter was 12.8 days. Of the patients, one died from cytomegalovirus pneumomonia after WBC count recovered, 2 relapsed, and 12 patients are still alive and disease-free. The average disease-free survival period was 50.0 months. Stem cell harvesting is relatively simple and hematopoietic recovery is mory rapid with PBSCT than with ABMT. Our findings suggest that PBSCT can be used for consolidation therapy in NHL patients who have achieved complete remission with standard chemotherapy.

Localization of myosin, actin, alpha-actinin, tropomyosin and vinculin in surface-activated, spreading human platelets

We observed the localization of the contractile proteins myosin, filamentous actin, alpha-actinin, tropomyosin, and vinculin in surface-activated, spreading human platelets using a single fluorescence staining procedure and conventional fluorescence microscopy. Myosin was distributed in a speckled pattern that extended radially from the granulomere. F-actin demonstrated cable-networks. Tropomyosin and alpha-actinin occurred in a punctuate distribution, and vinculin was localized at adhesion sites. Although myosin, F-actin, alpha-actinin, tropomyosin, and vinculin were not studied in resting platelets, our data support the idea that these contractile proteins are reorganized and reassembled in activated platelets during platelet function.

Expression of the leptin receptor in human leukaemic blast cells

The leptin receptor is a member of the cytokine receptor superfamily, and is expressed in CD34 haemopoietic stem cells. We examined expression of the leptin receptor in fresh human leukaemia cells. Northern blot analysis showed the leptin receptor was expressed in leukaemic cells from patients with acute myeloblastic leukaemia, acute lymphoblastic leukaemia and chronic myeloid leukaemia (CML). In CML, higher expression was observed in blast crisis than in chronic phase. The expression of leptin receptor decreased during in vitro differentiation of leukaemic blast cells. It appeared that expression of the leptin receptor was associated with immature leukaemic blast cells. Our findings may indicate the possibility that leptin has some role in leukaemia.

Irinotecan (CPT-11) in combination with weekly administration of cisplatin (CDDP) for non-small-cell lung cancer

PURPOSE

CPT-11 (60 mg/m2 on days 1, 8 and 15) in combination with CDDP (80 mg/m2 on day 1) has shown promising antitumor activity for non-small-cell lung cancer (NSCLC), but dose-limiting toxicities (DLT) are leukopenia and diarrhea, with a wide variation among patients. To estimate weekly CDDP administration in combination with CPT-11, a phase I study for patients with advanced NSCLC was conducted.

METHODS

Patients were treated with CPT-11 at a fixed dose of 60 mg/m2 together with CDDP at 27 mg/m2 (level 1, 6 patients), 33 mg/m2 (level 2, 12 patients), and 40 mg/m2 (level 3, 6 patients) with 1600 ml hydration on days 1, 8 and 15 over 4 weeks. During the treatment course, drug was not administered on the day it was due in the presence of leukopenia (< 3000/ml) and/or diarrhea.

RESULTS

The planned administration was completed in 5 of 6 patients at level 1, 6 of 12 patients at level 2, and 2 of 6 patients at level 3. The most common toxicity observed was leukopenia (five patients with grade 3 and one patient with grade 4). Leukopenia was considered to be a DLT, and the maximum tolerated dose (MTD) was level 2. Although there were patients who suffered from diarrhea (four patients with higher than grade 2), diarrhea was judged not to be a DLT with this weekly regimen. Nausea and vomiting were mild. Pharmacokinetic analysis of free platinum from CDDP demonstrated that the area under the curve (AUC) from 33 mg/m2 CDDP was 0.92 +/- 0.29 microg/ml h. In 13 patients evaluated for response, the response rate was 54%.

CONCLUSION

The value of weekly administration of CDDP in combination with CPT-11 was shown by (1) diarrhea not being dose-limiting, (2) mild nausea, (3) well-maintained AUC of free platinum, and (4) promising activity.

Problems with assays based on fibrin clot formation principle: analysis of multilaboratory data

In order to investigate the inter-laboratory differences of coagulation assays, three different control plasmas were distributed for coagulation assays to 162 institutes. Three types of coagulation tests, that is, prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen (Fbg) assay were carried out by routine methods in each institute. In our laboratory, the Fbg concentrations were measured in two different plasmas using one instrument and nine reagents, and the Fbg concentrations were measured in ten control plasmas using three instruments and one reagent. Results were obtained as follows: (1) The coefficient of variance (CV) for control plasma with the highest value was significant in the PT assay and APTT assay. (2) Inter and intra-institute differences in PT and APTT assays were observed when the reagent or the instrument used was changed. (3) Inter and intra-institute differences in PT and APTT assays were also observed when both the reagent and the instrument were changed. (4) Inter and intra-institute differences in the PT and APTT assays were observed between the manual and the mechanical methods. (5) The CVs for the Fbg assays were the largest in the plasma at the lowest concentration of the three plasmas. (6) When control plasmas of three different Fbg concentrations were assayed, the number of the institutes which obtained a value greater than 3 standard deviations (SDs) was highest for the control plasma with the lowest concentrations of Fbg, and some of the instruments were not able to measure such a low Fbg concentration. (7) When the fibrinogen concentration was measured in various kinds of commercially-available control plasmas with a calibrated instrument, the values determined were different from the assigned ones and varied significantly from instrument to instrument. From the results, we concluded that standardization of the quality of control plasma, and its value assignment to the plasma should be established as soon as possible, and that a reliable standard fibrinogen assay should be developed.

Thyroxine (T4) metabolism in an athyreotic patient who had taken a large amount of T4 at one time

As we had an opportunity to take blood samples from a totally thyroidectomized patient who had attempted suicide by taking 2,000 microg of Levothyroxine (L-T4), the serum levels of thyroid hormones were sequentially measured to investigate the metabolism of circulating thyroid hormones in an athyreotic human. The serum concentrations of most thyroid hormones reached a peak on the second day, but the serum T3 level showed a peak one day later. The maximum concentrations of T4 (315 microg/l), FT4 (48.8 ng/l) and rT3 (0.80 microg/l) were very high, while the peak T3 level (1.92 microg/l) did not exceed the upper limit of the normal range. The serum T4 and rT3 levels returned to their normal range 13-17 days after the suicide attempt. The TSH level was suppressed rapidly and reached its nadir (0.044 mU/l) on the 6th day. During this period, the T1/2 and MCR of serum T4 were 10.4 days and 0.64 l/day, respectively, which values were almost equivalent to those observed during 15 days after discontinuation of the maintenance L-T4 therapy. In summary, the oral intake of a large amount of L-T4 at one time does not induce a proportional increase in the T3 level in an athyreotic person. The MCR of serum T4 is decreased and the T1/2 of serum T4 is prolonged, probably due to the lack of intrathyroidal deiodination. These findings support the conclusion that the D1 activity in the thyroid is one of the major determinants in the metabolic clearance of serum T4.

[Treatment of hepatosplenic candidiasis with liposomal amphotericin B in a patient with acute leukemia; a case report of the experience of use of liposomal amphotericin B]

We report a 26-year-old male patient with acute myelocytic leukemia and hepatosplenic candidiasis during his clinical course. His hepatosplenic candidiasis was refractoty to itraconazole and fluconazol. He developed serious side-effect such as renal dysfunction, when conventional amphotericin B was given. Then he was treated with liposomal amphotericin B (Abelcet). This therapy was safe and effective for him. He was able to be treated with 3075 mg of a liposomal amphotericin B. This was ten times as much as the dose of conventional amphotericin B which was given earlier until amphotericin B was stopped because of renal dysfunction. Liposomal amphotericin B seems to be a safe and effective therapy for systemic fungal infectin and should be considered more in Japan.

[Acute myelogenous leukemia with hyperkalemia induced by pentamidine administration]

A 27-year-old male with acute myelogenous leukemia received an allogeneic bone marrow transplantation (allo-BMT). Pneumocystis carinii pneumonia developed on day 65 after the allo-BMT. The patient was intravenously treated with pentamidine. This resulted in a prompt improvement of his dyspnea and fever, but hyperkalemia occurred during the pentamidine therapy. Treatment with pentamidine was stopped and emergent treatment was started. Nevertheless, the serum potassium level rose to 7.7 mEq/l. Urgent dialysis was performed and the serum potassium level fell to 5.0 mEq/l after treatment. Careful monitoring of the serum potassium level is recommended during intravenous therapy with pentamidine.

[Peripheral blood stem cell transplants: clinical considerations and observations in practice in a general hospital]

Of 36 patients with malignant tumors who had been subjected to peripheral blood stem cell harvests (PBSCHs), 22 had undergone peripheral blood stem cell transplants (PBSCTs) since 1993. Flow cytometry recorded higher CD34+ cell yields in the PBSCHs of those patients with high white blood cell (WBC) counts as well as those who had been under intensive chemotherapy. Also, higher CD34+ cell yields were recorded in patients whose peripheral blood WBCs recovered more rapidly from their nadir state. WBC counts recovered rapidly in patients who received transfusions of at least 2.0 x 10(6) CD34+ cells/kg. However, patients with acute non-lymphocytic leukemia (ANLL) demonstrated a delayed recovery in their platelet counts following PBSCT. The mean disease-free survival rate and mean disease-free period were 60% and 12.8 months for the 5 patients with ANLL; and 100% and 11.3 months for the 4 patients with acute lymphocytic leukemia. These findings suggest PBSCT is a safe and effective treatment for patients with malignant tumors following high-dose chemotherapy, and can be performed in a private general hospital.

[Simple method for determination of hematopoietic stem cells]

We investigated on the rapid and easy method for the determination of peripheral blood stem cell (PBSC) using the immature information channel (IMI) of the automated hematology analyzer (SE-9000). The IMI channel provides information regarding immature leukocytes, including blast cells and immature granulocytes. CD34 positive cells, which are detected as the CD34 antigen on hematopoietic stem cells, were purified from the fractionated peripheral blood stem cell harvesting samples using Isolex. These purified CD34 positive cells accumulated in the gate corresponding to low Recurrent Frequency values which was presented on IMI channel analysis. Thus, the software for the IMI channel analysis to detect only the cells accumulated in this gate was developed (HPC program). The peripheral blood samples were collected from the subjects (22 cases) before and after chemotherapy. Using HPC program, the regression coefficient value between the ratio of IMI positive cells and CD34 positive cells in the peripheral blood samples was 0.81 (n = 122). As SE-9000 enables to determine the number of PBSC easily and rapidly, the measurement of IMI positive cells is clinically useful for the monitoring of the rise in PBSC after chemotherapy for mobilization.

Metabolism of dacarbazine by rat liver microsomes contribution of CYP1A enzymes to dacarbazine N-demethylation

The N-demethylation of dacarbazine in liver microsomes was significantly increased by treatment of rats with beta-naphthoflavone, dexamethasone, or phenobarbital. However, the extent of increase in the N-demethylation observed in beta-naphthoflavone-treated rats was much greater than that observed in dexamethasone-treated rats. A good correlation between N-demethylation of dacarbazine and O-deethylation of phenacetin was observed when a low concentration of phenacetin was used. Furthermore, the activity of dacarbazine N-demethylase in rat liver microsomes was highly correlated with the amounts of CYP protein immunochemically determined with anti-rat CYP1A2 antibodies. In addition, antibodies to rat CYP1A2, and furafylline and alpha-naphthoflavone, which are known inhibitors of CYP1A enzymes, exhibited inhibitory effects on dacarbazine N-demethylation. These results indicated that CYP1A enzymes may be responsible for N-demethylation of dacarbazine in rat liver microsomes.

[Factitious anemia with severe iron deficiency caused by self-venesection]

A 22-year-old unmarried female student of nurse school was admitted to our hospital because of hypochromic anemia and fever of unknown origin. She was diagnosed as having iron-deficiency anemia and was treated with iron, but progressive anemia recurred periodically. In particular, rapidly progressive anemia was observed after the patient stayed overnight, so we strongly suspected factitious anemia. A search of her locker in the sickroom and her room at home revealed many syringes, injection needles and a bottle of blood. Factitious anemia was diagnosed and she confessed to self blood-drawing. After a psychiatric consultation, anemia tended to to resolve gradually. However she did not go to the hospital after 6 months from her discharge. Physicians should consider factitious anemia in a patient with severe chronic hypochromic anemia who dose not respond to adequate iron therapy, particularly in a patient with medical training.

A preliminary study of HLA class II alleles in Thai patients with non Hodgkin's lymphoma

The HLA class II alleles were analyzed by the PCR-SSP technique in the DNA samples obtained from 27 Thai patients with non Hodgkin's lymphoma (NHL). It was found that (1) the incidence of HLA-DRB1*15 and HLA-DRB1*09 was slightly decreased (P > 0.05). On the other hand, the incidence of HLA-DQB1 alleles was the same as control. However, further study is suggested in order to conclude the close relationship between the presence of certain HLA class II alleles and susceptibility to NHL in Thai patients.

Thrombopoietin inhibits in vitro osteoclastogenesis from murine bone marrow cells

To determine whether thrombopoietin (TPO) can modulate the osteoclastic differentiation from hematopoietic stem cells, we investigated the effect of TPO on in vitro osteoclastogenesis by using the coculture of murine bone marrow cells with the stromal cell line (ST2) in the presence of 1alpha,25-dihydroxyvitamin D3 and dexamethasone. Recombinant human TPO inhibited the formation of tartrate-resistant acid phosphatase-positive multinucleated cells in a dose-dependent manner (0.02-200 ng/ml). The effect of TPO on differentiation of bone-resorbing capacity was investigated by pit assay. TPO dose dependently decreased the areas oftoluidine blue-stained resorption pits (2.0-200 ng/ml). To identify the cellular target of TPO, we used a variety of bone marrow/stromal cell coculture methods. Initially, we found that TPO mainly exerted its effect on the early stage of osteoclastic differentiation in delayed addition experiments. Consequently, the majority of TPO's inhibition of osteoclastic cell formation was due to its effect on bone marrow cells. Finally, we examined whether transforming growth factor-beta (TGFbeta) and platelet-derived growth factor (PDGF), major cytokines produced by megakaryocytes, mediate the inhibitory effect of TPO. The addition of either anti-TGFbeta or anti-PDGF antibody to bone marrow cell culture completely antagonized the effect of TPO on osteoclastogenesis. Furthermore, treatment of bone marrow cells with TGFbeta or PDGF mimicked the inhibitory effect of TPO. These data suggest that TPO inhibits osteoclastogenesis through stimulating thrombopoiesis and that TGFbeta and PDGF mediate the effect of TPO by impacting on macrophage-lineage cells as osteoclast precursors.

[Thrombopoietin is a multifunctional factor]

Thrombopoietin (TPO) is the critical regulator of proliferation and differentiation of megakaryocytic lineage. TPO has potent stimulatory effects on platelet production in patients with chemotherapy-induced thrombocytopenia. In addition to sustaining megakaryocytopoiesis, TPO may play an important role in regulating neutrophil activation and erythropoiesis. Furthermore, TPO induces proliferation of acute myeloblastic leukemia cells in vitro in some cases. These results suggest that TPO may be multifunctional factor. Recently osteosclerosis is observed in TPO transgenic mice. To determine whether TPO can modulate the osteoclastic differentiation from hematopoietic stem cells, we investigated the effect of TPO on in vitro osteogenesis. TPO inhibited the formation of osteoclastic cells and decreased the areas of bone resorption pits in a dose-dependent manner. We examined whether transforming growth factor-beta (TGF-beta) and platelet derived growth factor (PDGF), major cytokines produced by megakaryocytes, mediate the inhibitory effect of TPO. The addition of either anti-TGF-beta or anti-PDGF antibody to bone marrow cell cultures completely antagonized the effect of TPO on osteoclastogenesis. These data suggest that TPO inhibits osteoclastogenesis by stimulating thrombopoiesis and that TGF-beta and PDGF mediate the effect of TPO by impacting macrophage-lineage cells as osteoclast precursors.

[Current problems in quality control (QC) in hematology]

Total quality control (TQC) is one of the most important issues in laboratory hematology. As for complete blood count (CBC), almost all blood cell counters possesses quality control (QC) programs for its determination, and values of high quality can be provided by the counters. Reticulocytes can be determined precisely as well. However, mean cell volume (MCV) were slightly different among blood cell counters when semifixed QC materials were used for its surveillance. No QC materials to evaluate white cell differential functions have not be found for the common use now. Thus, urgent matter would be the development of appropriate QC materials to be used for overall blood cell counters. In coagulation testings, trials for common use of international normalized ratio (INR) for the prothrombin time (PT) test has been continued yearly due to the varieties of biophysical characteristics among PT reagents. Similar variation are also present among activated partial thromboplastin time (APTT) reagents. Some improvement would be required.

[A case of an adult neuroblastoma with bone-marrow metastases: 131I-MIBG scintigraphy in comparison with MRI]

To detect a primary neuroblastoma lesion and its metastases, 131I-MIBG scintigraphy was performed for a 24-year-old woman who had a high level of serum catecholamine. 131I-MIBG scintigrams showed high radioactivity in the left upper quadrant, pelvic bone, and vertebral bodies. A biopsy of the pelvic bone revealed metastasis from the neuroblastoma. After four chemotherapy courses, the accumulation of 131I-MIBG decreased after each course; however, scintigraphy performed after the last chemotherapy course showed focal mild uptake in the right sacroiliac. The presence of residual tumor in the sacroiliac was confirmed histologically. On the other hand, T1-weighted and T2-weighted MR images performed before the treatment showed low signal intensity and high signal intensity in the pelvic bone, respectively. After the fourth chemotherapy course, T2-weighted MR images showed low signal intensity in the pelvic bone; however, it was difficult to determinate whether it should improve. To assess the effect of treatment of neuroblastoma, 131I-MIBG scintigraphy was considered more useful than MRI.