Selective IgA deficiency and anaphylactoid transfusion reaction: a case report

Anaphylactoid transfusion reaction following the administration of incompatible blood products can be life threatening, but accounts for only a very small proportion of all transfusion reactions. One of the causes of anaphylactoid transfusion reaction is the reaction of patient's anti-immunoglobulin A(IgA) with plasma IgA which is usually present in transfused blood. We report a case who had anaphylactoid transfusion reactions after transfusion of only a few milliliters of packed RBC from 3 consecutive donors, in spite of compatible pretransfusion crossmatches. The patient's serum revealed IgA deficiency accompanied by high-titer anti-IgA. The family study showed that one of her sons had partial IgA deficiency accompanied by anti-IgA2. In conclusion, although selective IgA deficiency is rare in Taiwan, it may still occasionally result in severe anaphylactoid transfusion reactions.

Trisomy 21 in acute myeloid leukemia

We report two cases of acute myeloid leukemia (AML), constitutionally normal, with trisomy 21. Trisomy 21 does not often occur as a sole numerical karyotypic abnormality in AML leukemia. The possible prognostic significance of the finding in acute leukemia is discussed.

Adjuvant methotrexate, vinblastine and cisplatin chemotherapy for invasive transitional cell carcinoma: Taiwan experience

PURPOSE

The feasibility of adjuvant cisplatin, methotrexate and vinblastine chemotherapy was evaluated in Taiwanese patients with invasive transitional cell carcinoma at high risk for recurrence.

MATERIALS AND METHODS

We assigned 56 patients with high risk transitional cell carcinoma (vascular or lymphatic invasion in the primary tumor, poorly differentiated stage P2, P3, P4 or N+ and M0) to receive adjuvant chemotherapy after radical urological surgery. The chemotherapy consisted of 40 mg./m.2 methotrexate and 4 mg./m.2 vinblastine on days 1 and 8, and 100 mg./m.2 cisplatin on day 2 given in 6 courses at 21-day intervals.

RESULTS

Median followup was 44 months. An average of 4.63 cycles of chemotherapy was administered. The median actual survival was 44 months, and the 1 and 3-year survival probabilities were 92% and 50%, respectively. The median disease-free survival was 15.5 months, and the 1 and 3-year disease-free survival probabilities were 66% and 28%, respectively. Only 5 (9%) and 1 (2%) patients had grades 3 and 4 leukopenia, respectively, and none died of sepsis.

CONCLUSIONS

The use of adjuvant cisplatin, methotrexate and vinblastine chemotherapy in patients with invasive transitional cell carcinoma at high risk for recurrence is feasible with tolerable toxicity but randomized controlled trials will be required to assess the benefit.

Treatment of advanced gastric cancer with a modified regimen of etoposide/leucovorin/5-fluorouracil

The efficacy and toxicity of a combination of etoposide 100 mg/m2/day iv on day 2-4, leucovorin 300 mg/m2/day iv, and 5-FU 500 mg/m2 day iv on day 1-5 every 4 weeks were assessed in 21 patients with advanced gastric cancer with measurable or evaluable diseases. Eight patients had an objective response, including 3 in CR. The overall response rate was 38.1% (95% CI 33.4-42.8%). Five of 8 patients who exhibited locally advanced and unresectable diseases had an objective response (2 CR, 3 PR). The response rate in patients with metastatic disease was 23.0% (95% CI 14.4-31.6%). The median progression-free interval and overall survival time were 7 and 10 months, respectively. The most frequent side effect was alopecia (Gr I/II 71.4%). No treatment-related death occurred. Modified ELF is a relatively effective and tolerable combination regimen for advanced gastric cancer and can be safely administered to elderly patients and patients with systemic diseases.

Allogeneic peripheral blood progenitor cell transplant after bone marrow graft failure: report of a case

A 31-year-old woman diagnosed with acute myelocytic leukemia received an allogeneic peripheral blood progenitor cell (PBPC) transplant one month after a previous bone marrow graft failed. PBPCs were mobilized with granulocyte-colony-stimulating factor and collected by apheresis. T-cell depletion was not performed and no further chemo- or radiotherapy was given for the second transplant. Engraftment was prompt, with the peripheral blood leukocyte count rising dramatically to 2,400/microL, six days after completion of PBPC transplant. The platelet count reached 36,000/microL on the eighth day and was self-sustained thereafter. Both blood grouping and bone marrow karyotyping confirmed donor origin of the engraftment. At the time of writing, the patient has been disease-free for over 200 days without any complications of acute or chronic graft-versus-host disease.

Comparison of intravenous granisetron with metoclopramide in the treatment of chemotherapy-induced emesis

BACKGROUND

It is well known that chemotherapy-induced nausea and vomiting not only produce undesirable physical effects but also reduce patients' willingness to continue chemotherapy. The effect of a 5HT3 receptor antagonist, granisetron, on antiemesis was studied in patients who were receiving cisplatin-based chemotherapy.

METHODS

Forty patients with malignant diseases, who were scheduled to receive cisplatin-based chemotherapy, were randomly assigned to receive either a single intravenous dose of granisetron (3 mg) (n = 20) or multiple doses of metoclopramide (2 mg/kg) (n = 20) as trial. The efficacy of antiemetic therapy was assessed based on the patient's subjective assessment of nausea and vomiting, and the physician's global evaluation of nausea and vomiting in the first 24 hours and during the following 6 days.

RESULTS

During the first 24 hours, there was a statistically significant advantage for the granisetron group in terms of prevention of both nausea and vomiting. The number of complete responders in the first 24 hours for the granisetron and metoclopramide groups was 16 (80%) and 9 (45%), respectively (p < 0.05). The control rate of anti-nausea over 6 days was 45% and 5% in the granisetron and metoclopramide groups, respectively (p < 0.001). The frequency of adverse events in the granisetron and metoclopramide groups was 10% and 45%, respectively. Analysis of laboratory data showed no significant difference between these two groups prior to and after administration of chemotherapy.

CONCLUSIONS

A single 5-minute infusion of 3 mg granisetron was more effective and produced a less adverse effect than multiple doses of metoclopramide in controlling chemotherapy-induced emesis, both in the first 24 hours and over a 6-day period.

Identification of Asp258 as the metal coordinate of pigeon liver malic enzyme by site-specific mutagenesis

Pigeon liver malic enzyme was inactivated by ferrous sulfate in the presence of ascorbate. Manganese and some other divalent metal ions provided complete protection of the enzyme against the Fe(2+)-induced inactivation. The inactivated enzyme was subsequently cleaved by the Fe(2+)-ascorbate system at Asp258-Ile259, which was presumably the Mn(2+)-binding site of the enzyme [Wei, C. H., Chou, W. Y., Huang, S. M., Lin, C. C., & Chang, G. G. (1994) Biochemistry 33, 7793-7936]. For identification of Asp258 as the putative metal-binding site of the enzyme, we prepared four mutant enzymes substituted at Asp258 with glutamate (D258E), asparagine (D258N), lysine (D258K), or alanine (D258A), respectively. These mutant proteins were recombinantly expressed in a bacterial expression system (pET-15b) with a stretch of histidine residues attached at the N-terminus and were successfully purified to apparent homogeneity by a single Ni-chelated affinity column. Among the four mutants, only D258E possessed 0.8% residual activity after purification; all other purified mutants had < 0.0001% residual activity in catalyzing the oxidative decarboxylation of L-malate. The D258E mutant was susceptible to inactivation by the Fe(2+)-ascorbate system, albeit with much slower inactivation rate, and was protected by the Mn2+ to a lesser extent as compared to the wild-type enzyme. None of the mutants were cleaved by the Fe(2+)-ascorbate system under conditions that cleaved the natural or wild-type enzyme at Asp258.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver disease after bone marrow transplantation--the Taiwan experience

To investigate the causes of impaired liver function (LF)* after BMT, 88 patients were included for analysis of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, transplant methods, preconditioning regimens, and graft-versus-host disease (GVHD). Fifty of them (56.8%) developed abnormal LF after BMT and among them, 29 (32.9%) developed chronic hepatitis (CH). By univariate analysis, HCV infection, pretransplant abnormal LF, allogeneic BMT, and preconditioning regimen with total body irradiation were all significantly related to higher incidence of post-BMT impaired LF. However, only HCV infection, pretransplant abnormal LF, and acute GVHD were associated with higher incidence of CH. By multivariate logistic regression analysis, HCV infection and pretransplant abnormal LF were the two most significant interpreters for abnormal LF, especially for CH (odds ratios: 7.86 and 4.735, respectively) after BMT. Although the incidence of abnormal LF was found high in this study, there was no significant disadvantage in terms of survival for patients who developed abnormal acute and chronic liver function after BMT. However, a long-term follow-up is needed to evaluate survival pathology of CH, such as liver cirrhosis and hepatoma.

Cytogenetic studies in de novo acute nonlymphocytic leukemia

BACKGROUND

There is currently considerable interest in the cytogenetic analysis of leukemia. The improvement of banding techniques has made it possible to rather precisely identify deletion, translocation, inversions, and other structural chromosome abnormalities. Specific recurring chromosome abnormalities associated with distinctive morphologic features are thus increasingly recognized in acute nonlymphocytic leukemia. For example, uneven geographic distribution of nonrandom specific chromosome aberrations has been reported. We herein report the results of chromosome studies on 30 Chinese patients with de novo acute nonlymphocytic leukemia.

METHODS

Cytogenetic studies were performed at Veterans General Hospital-Taipei, from 1988 to 1993, on unselected samples of 30 patients with de novo acute nonlymphocytic leukemia. Chromosome analysis was performed by short-term culture techniques on bone marrow material obtained from patients at diagnosis. Metaphase chromosomes were banded by the conventional trypsin-Giemsa banding technique and then karyotyped according to the International System for Human Cytogenetic Nomenclature (ISCN). Classification of leukemia was based on the criteria of the French-American-British cooperative group.

RESULTS

Of the 30 patients with adequate specimens, 17 (56%) demonstrated clonal chromosome abnormalities. Six patients were found to have structural rearrangements and seven patients have a numerical change as the sole abnormality. Four patients showed both structural and numerical anomalies. t(8;21) was found in 1 of the 8 M2 type ANLL patients and two of them had monosomy 21. Four of the 6 patients with acute promyelocytic leukemia (APL; M3 subtype) showed t(15;17). Two patients with M4 type leukemia and abnormal bone marrow eosinophils showed inv(16)(p13q22). One patient with M4 type leukemia demonstrated the loss of chromosome #7 and none showed the loss or deletion of chromosome #5.

CONCLUSIONS

This study revealed a consistent finding of t(15;17) in APL; however, a low incidence of t(8;21), -5/5q- and -7/7q- in our patients demonstrated the possible difference in the incidence of chromosomal abnormalities in ANLL between the oriental peoples and the whites.

Induction of proteinuria by adriamycin or bovine serum albumin in the mouse

To establish models of proteinuria in the mouse, BALB/c mice were injected with puromycin aminonucleoside (PAN, 1.5 or 4.5 mg/10 g body weight), adriamycin (AD, 0.2 mg/10 g body weight) intravenously or bovine serum albumin (BSA, 100 mg/10 g body weight) intraperitoneally. Proteinuria was measured as the ratio of urinary albumin (micrograms/ml) to creatinine (mg/dl) and further characterized by isotyping the immunoglobulin. Although not obtained with PAN (followed for 4 weeks), proteinuria was readily attained in the mouse after treatment with AD or BSA. Most AD-treated mice (5/7) developed an abrupt increase of proteinuria at day 2 after injection, with the ratio of urinary albumin to creatinine in the range 0.28-0.45. The degree of proteinuria increased with time and all mice tested (7/7) showed overt proteinuria at day 4. These mice became anuric at day 5 and died at days 6 and 7. For BSA, 4 h after administration, four of seven mice showed enhanced proteinuria, lasting 8 h with urinary albumin and creatinine in a ratio < 0.05. Isotyping of urine samples collected at the time of heavy proteinuria (ratio of urinary albumin to creatinine: > 0.40 for AD-treated mice, > 0.15 for BSA-treated mice) showed that all of the mice (7/7) with AD-induced proteinuria (ADp) and three of four mice with BSA-induced proteinuria (BSAp) revealed urinary IgG2b and IgA, while only one of seven control mice showed IgG2b alone in urine. The mice were sacrificed at the time they presented with heavy proteinura for pathologic and anionic studies on renal tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

Affinity cleavage at the putative metal-binding site of pigeon liver malic enzyme by the Fe(2+)-ascorbate system

Pigeon liver malic enzyme was rapidly inactivated by micromolar concentrations of ferrous sulfate in the presence of ascorbate at neutral pH and 0 or 25 degrees C. Omitting the ascorbate or replacing the ferrous ion with manganese ion did not lead to any inactivation. Manganese, magnesium, zinc, cobalt, or calcium ion at 200 molar excess over ferrous ion offered complete protection of the enzyme from Fe(2+)-induced inactivation. Ni2+ provided partial protection, while Ba2+ or imidazole was ineffective in protection. Addition of 4 mM Mn2+ or 5 mM EDTA into a partially modified enzyme stopped further inactivation of the enzyme. Inclusion of substrates (L-malate or NADP+, singly or in combination) in the incubation mixture did not affect the inactivation rate. The enzyme inactivation was demonstrated to be followed by protein cleavage. Native pigeon liver malic enzyme had a subunit M(r) of 65,000. The inactivated enzyme with residual activity of only 0.3% was cleaved into two fragments with M(r) of 31,000 and 34,000, respectively. The cleavage site was identified as the peptide bond between Asp258 and Ile259. Native pigeon liver malic enzyme was blocked at the N-terminus. Cleavage at the putative metal-binding site exposed a new N-terminus, which was identified to be at the 34-kDa fragment containing the C-terminal half of original sequence 259-557. Our results indicated that Fe2+ catalyzed a specific oxidation of pigeon liver malic enzyme at Asp258 and/or some other essential amino acid residues that caused enzyme inactivation. The modified enzyme was then affinity cleaved at the Mn(2+)-binding site.

Bone marrow transplantation in Taiwan: low incidence of acute GVHD in patients with hematologic malignancies and severe aplastic anemia

A total of 116 consecutive patients, including 82 cases of hematologic malignancies and 34 cases of severe aplastic anemia (SAA), were treated by allogeneic bone marrow transplantation (BMT). The conditioning regimens and post-graft immunosuppressive agents were as described by Thomas in Seattle and Santos in Baltimore. The incidence of grades II-IV acute GVHD in patients with hematologic malignancies with a full HLA match, with one locus and with two loci mismatches was 6.3% (4 of 63), 0% (0 of 11) and 37.5% (3 of 8), respectively. None of SAA patients developed grade II-IV acute GVHD. The low incidence of acute GVHD after BMT among Chinese patients may be associated with the use of isolation in laminar airflow rooms and a relatively low level of genetic diversity in histocompatibility antigens. This is an interesting issue for further study.

Epithelioid leiomyosarcoma of the breast: report of a case

A 36-year-old female presented with a palpable mass in the right breast. She received a modified radical mastectomy after admission. Brain and multiple bony metastases were noted 10 months later. Microscopically, the tumor was composed of nodules of small spindle and large round cells showing abundant eosinophilic, vacuolated cytoplasm and prominent nucleoli. No glandular or ductular differentiation could be identified. By immunohistochemistry, the tumor cells were positive for vimentin and desmin in focal areas, but negative for cytokeratin, S-100, epithelial membrane antigen, actin, myoglobin, or alpha-1-antichymotrypsin. Electron microscopy showed focally cohesive large cells maintained together by poorly-defined intercellular junctions and surrounded segmentally by thin basal laminae. Intracytoplasmic filaments were identified in some tumor cells, diffusely arranged in the cytoplasm. These findings indicate that this was a case of epithelioid leiomyosarcoma of the breast. The literature concerning this rare neoplasm is reviewed.

Lupus nephritis, emphasizing tubulointerstitial lesions: a clinico-pathological analysis

Tubulointerstitial lesions (TIL) such as interstitial inflammation, fibrosis and tubular atrophy are frequently found in classes of lupus nephritis. A retrospective study evaluate lupus nephritis, the relationship between TIL and glomerular lesions, and the significance of TIL in assessing the severity and prognosis for cases of lupus nephritis. Between June 1983 and Jan 1990, 492 renal biopsies were performed. Lupus nephritis was diagnosed in 37 patients who fulfilled the American Rheumatology Association (ARA) criteria for Systemic lupus erythematosus (SLE). The results showed a significant correlation between degree of TIL and impairment of renal function. Degree of TIL and severity of glomerular lesions must be considered simultaneously to predict renal function of patients with lupus nephritis.

Intracerebral malignant fibrous histiocytoma: case report and review of the literature

A 50-year-old woman developed an intracerebral malignant fibrous histiocytoma at the site of a previously clipped aneurysm in the right temporal lobe. This tumor rarely originates within the brain. Review of the literature suggests that postoperative and/or postirradiation effects may contribute to the growth of this particular tumor.

Reactive sites of an anticarcinogenic Bowman-Birk proteinase inhibitor are similar to other trypsin inhibitors

The three-dimensional structure of the Bowman-Birk type proteinase inhibitor (PI-II) has been determined by x-ray crystallography and refined at 2.5-A resolution. This protein is a specific inhibitor of trypsin. Two reactive site loops, one at each end of the PI-II molecule, are structurally similar to each other and to reactive-site loops of pancreatic secretory trypsin inhibitor (Bolognesi, M., Gatti, G., Menegatti, E., Guarneri, M., Marquart, M., Papamokos, E., and Huber, R. (1982) J. Mol. Biol. 162, 839-869) and bovine pancreatic trypsin inhibitor (Deisenhofer, J., and Steigemann, W. (1975) Acta Crystallogr. B31, 238-250). PI-II is the first reported Bowman-Birk type inhibitor structure to be refined at high resolution, providing further insight into inhibitor mechanisms.

Focal glomerulosclerosis: a clinico-pathological analysis of 36 adult patients with idiopathic nephrotic syndrome

A retrospective study was conducted to determine the clinicopathological correlation of focal glomerulosclerosis in 36 adult patients with idiopathic nephrotic syndrome. All cases were divided into two groups, focal segmental glomerulosclerosis (FSGS, 23 cases) and focal global glomerulosclerosis (FGBG, 13 cases), on the basis of pathological findings. Most patients with FSGS were non-responsive/partial-responsive (22/22) to the corticosteroid treatment. By contrast, those with FGBG gave a relatively high responsive rate of 7/12 to the same therapy. The 5 non-responders with FGBG, however, were noted to have intensive interstitial fibrosis/mononuclear cell infiltrate of the renal lesions (4 cases), or diffusely glomerular Clq deposition without other coexisting immune deposits (1 case). Most cases of FSGS (20/23) became steroid dependent or remained heavy proteinuria resistant to corticosteroids/other immunosuppressive agents over a mean of 3.4 (ranged, 1 to 7) years after renal biopsy. Three of the 5 patients of FGBG initially non-responsive/partial-responsive to corticosteroids turned out to have protein-free urine (less than 4 mg/hr/m2) (2 patients) 1 month after leaving the hospital and became mildly proteinuric (1 patient) two months after discharge, respectively. The remainders of FGBG (10/13) were free of protein in their urine sample or had occasional episodes of proteinuria over a mean duration of 4.1 (ranged, 1 to 7) years. In addition, chronic renal insufficiency on discharge was noted in 2 cases of FSGS (2/23) and 1 case of FGBG (1/13). Only two cases of FSGS (2/23) progressed into a uremic status 3 and 5 years, respectively, after the time of the presumed clinical onset of their disease. These findings suggest that FGBG clinically behaves similar to a minimal change disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous renal cell carcinoma and angiomyolipoma in a kidney--a case report and literature review

Renal cell carcinoma (RCC) is the most common tumor of the kidney. Angiomyolipoma is frequently present in the patient who has the stigma of tuberous sclerosis. We reported a case of a 39-year-old female, without the stigma of tuberous sclerosis, who was admitted on account of a firm, huge, fixed and palpable mass over the left flank region for one week. After radical nephrectomy, the pathological report was renal cell carcinoma, granular cell type, associated with angiomyolipoma. The literature concerning this unusual case is reviewed.

A new crystal form of ricin-OR

Ricin-OR, an antitumor toxin, has been crystallized in space group P2 with cell parameters a = 8.77 nm, b = 4.64 nm, c = 7.64 nm and beta = 101 degrees. There is one molecule in the asymmetric unit and the solvent content is estimated to be 48% by volume. The crystals diffract to 0.25 nm resolution which is higher than that of the previously reported C2 crystal form which had a solvent content of 65%.

Crystallization of two cubic forms of soybean trypsin inhibitor E-I, a member of the Bowman-Birk inhibitor family

The soybean trypsin inhibitor E-I, known to be relatively rich in methionine and cysteine, has been crystallized at room temperature in the presence of polyethylene glycol 4000, sodium chloride, and ammonium sulfate. A pronounced polymorphism in the crystals has been observed and two distinctly different cubic forms have been identified. Of the two, one form crystallizes in a unit cell of symmetry F432 with parameters a = b = c = 128.0 A, and diffracts at least to 2.6-A resolution. Each of the 96 asymmetric units contains one protein molecule, and has a solvent content of 60% by volume. The other form is of space group P4132 or P4332 with the unit-cell edge 87.1 A, and diffracts barely to 3-A spacings. The unit cell is composed of 24 asymmetric units, each of which probably also contains one molecule and has a solvent content of 69% by volume. The former cubic form appears to be more suitable for x-ray study than the latter in terms of stability and the extent of diffraction.

Preliminary crystallographic data for Bowman-Birk inhibitor from soybean seeds

A well characterized soybean protease inhibitor, the Bowman-Birk inhibitor, has been crystallized at room temperature in the presence of polyethylene glycol 4000 by vapor diffusion against an ammonium sulfate solution containing 2-methyl-2,4-pentanediol. An x-ray diffraction study reveals that the inhibitor crystallizes in a hexagonal unit cell of symmetry P6122 (or P6522) and dimensions a = b = 91.36(2) A and c = 63.92(2) A. Each of the 12 asymmetric units contains 2 molecules of molecular weight 8000. The crystal, which diffracts barely to 3-A spacings, is fairly stable to x-irradiation and has a solvent content of approximately 52% by volume.