Skeletal Trauma Preceding the Development of Plasma Cell Dyscrasia: Eight Case Reports and Review of the Literature

Plasma cell dyscrasias are clonal proliferations and accumulations of plasma cells. The etiology of monoclonal neoplasms still remains elusive. A direct correlation between a history of trauma and the development of plasma cell dyscrasias has not been established. Two recent case reports have described plasmacytomas that were diagnosed in patients who suffered injury at the site of plasma cell neoplasms. We report a series of eight patients who stated a history of trauma to the site where plasma cell neoplasms were later diagnosed. The duration from the date of injury to diagnosis ranged from 2 mo to 20 yr. The M:F ratio was 6:2. The median age was 52 (28-75). Multiple myeloma was confirmed in six patients and plasmacytoma without systemic disease in the other two patients. All eight patients had a kappa monoclonal plasma cell population, and all but one had a detectable peripheral kappa light chain. All patients presented with persistent discomfort at the site where they had experienced trauma. Even though this article does not establish a relationship between trauma, and the development of plasma cell dyscrasia, persistent discomfort at a previous trauma site warrants a complete evaluation and consideration for possible plasma cell dyscrasias.

Arsenic trioxide: a new immunomodulatory agent in the management of multiple myeloma

Arsenic has been used as a medicinal for thousands of years. Several reports from China relative to its use mainly in acute promyelocytic leukemia, especially from the Shanghai group, has caused a resurgence in the investigation of the drug in the management of malignancies with focus on malignancies of hematologic origin. Arsenic is eliminated by many routes (urine, feces, sweat, milk, hair, skin, and lungs), although most is ultimately excreted in urine. Multiple myeloma is characterized by the clonal proliferation of malignant plasma cells in the bone marrow associated with bone loss, renal disease, and immunodeficiency. Preclinical evidence suggests an immunologic mechanism behind the therapeutic effects of As2O3 on myeloma cells. This appears to be achieved by a marked increase in lymphokine-activated killers mediated killing and up-modulation of CD38 and Cd54, two molecules involved in cell-cell interactions. Moreover, As2O3 alone or administered with ascorbic acid may provide a novel therapy for lymphoproliferative disorders. Preliminary clinical data in relapsed/refractory multiple myeloma suggest that As2O3 does have a role in the management of multiple myeloma; however, preclinical data show that the addition of ascorbic acid, and using As2O3 in combination with other active chemotherapeutic agents will enhance its role in managing the disease, and this is probably the position the drug will occupy in the armamentarium against myeloma.

Synthesis and antifungal activity of 3,3'-ethylenebis(5-alkyl-1,3,5-thiadiazine-2-thiones)

In a search for promising antifungal compounds, nine new 3,3'-ethylenebis(5-alkyl-1,3,5-thiadiazine-2-thiones) were synthesized by the reaction of ethylene diamine, carbon disulfide, formaldehyde, and the appropriate alkyl amine. The title compounds were tested for their antifungal activity in vitro against pathogenic (Trichophyton rubrum and Candida albicans), phytopathogenic (Penicillum expansum, Trichoderma hazianum, and Fasarium oxysporum), and aflatoxin producing (Aspergillus flavus) fungi. These compounds exhibited varied inhibitory effects on growth or sporulation of some tested fungal species.

GM-CSF safety and effects in the management of advanced/refractory multiple myeloma patients: a phase I trial

PURPOSE

Some limitations of effective therapy in multiple myeloma include the low growth fraction of the malignant plasma cells, multi-drug resistance, and the presence of other concurrent diseases in this patient population. A phase I study was conducted to evaluate the toxicity of granulocyte macrophage colony stimulating factor (GM-CSF) in myeloma patients as well as the potential effect on the plasma cell labeling index (PCLI). Relapsed patients with multiple myeloma were eligible.

METHODS

The first phase of this trial assessed the toxicity (including the effect on disease progression) of escalating doses (125-500 microg/m2 SC, days 1-5) of GM-CSF, and the effects of this cytokine on PCLI. Patients whose PCLI doubled and increased to > or = 1.7% were treated with chemotherapy including cyclophosphamide, vincristine, prednisone, and GM-CSF. Twenty-two patients were enrolled.

RESULTS

The toxicity of GM-CSF was mild, and no dose-limiting side effects were seen. Twenty-five percent of patients (5/20) achieved the target PCLI, and 4/5 proceeded to receive chemotherapy. No relationship of GM-CSF dose to increases of the PCLI was noted. All patients who received chemotherapy responded.

CONCLUSIONS

GM-CSF has acceptable toxicity in patients with multiple myeloma and produced increases of PCLI in selected individuals. Further studies of GM-CSF alone or in combination with chemotherapy are indicated.

The role of allopurinol and deferoxamine in preventing pressure ulcers in pigs

Ischemia and reperfusion may be important in the pathogenesis of pressure ulcers. On the basis of this hypothesis, the effects of intermittent pressure and the anti-free radical agents allopurinol and deferoxamine were studied in a pig model in which a pressure of 150 mmHg was applied intermittently to the scapulae. Cutaneous blood flow, transcutaneous oxygen tension, skin and muscle damage, and muscle levels of adenosine triphosphate were quantified. A control group of pigs (n = 6) was untreated, the allopurinol group (n = 6) received oral allopurinol beginning 2 days before the experiment, and the deferoxamine group (n = 6) received an intramuscular injection of deferoxamine 2 hours before the experiment. Pressure (150 mmHg) was applied to the scapulae for 210 minutes, and it was relieved for 30 minutes. This 4-hour cycle was repeated continuously for 48 hours, and it resulted in pressure injuries in all animals. Allopurinol and deferoxamine improved cutaneous blood flow and tissue oxygenation, but only deferoxamine could significantly reduce cutaneous and skeletal muscle necrosis (p < 0.001). This study suggests a future role for anti-free radical agents in the reduction of pressure-induced injury.

Isolated primary hepatic lymphoma in a patient with acquired immunodeficiency syndrome

Non-Hodgkin lymphoma (NHL) of the B-cell type is the second most common neoplasm in patients with human immunodeficiency virus (HIV) infection after Kaposi sarcoma (KS). The majority of cases of NHL in patients with acquired immunodeficiency syndrome (AIDS) involve extranodal sites; most frequently the gastrointestinal tract (GIT) and the central nervous system (CNS). Hepatic NHL in patients with AIDS was first described by Reichert et al in 1983 in an autopsy series. It usually presents with multiple large hepatic masses and involvement of other abdominal organs or lymph nodes. The authors present a case of primary hepatic NHL in a patient with AIDS, presenting with innumerable small intrahepatic masses without the involvement of any other organs.

Plasmacytoma of the ovary: a case report and literature review

BACKGROUND

Ovarian plasmacytomas are a unique and unusual presentation of extramedullary plasmacytomas (EMP). A report of the seventh such case is presented with review of the previous six cases.

METHODS

Surgical and medical staging were performed on the present case. The literature is reviewed.

RESULTS

EMP involving the ovary is usually large at the time of presentation, more likely involving the left side, and without evidence of disseminated disease. As in other plasma cell dyscrasia, IgG paraprotein is more frequently involved.

CONCLUSION

Adjuvant treatment for ovarian plasmacytomas is not clearly established; however, if complete surgical resection is achieved and no evidence of multiple myeloma is found, observation should be strongly considered.

Transfusing platelets 2 h after the completion of amphotericin-B decreases its detrimental effect on transfused platelet recovery and survival

Platelet transfusion support is required during bone marrow aplasia following ablative chemotherapy and bone marrow progenitor cell transplantation (BMT). Amphotericin-B is frequently given to these patients, both therapeutically and prophylactically, and has been described to have a negative impact on the results of platelet transfusions. We conducted a prospective study of the effect of amphotericin-B on transfused platelet recovery and survival in 81 BMT or acute leukaemia patients. One hundred and ninety-five platelet transfusions administered to 81 consecutive patients were analysed. The platelets were transfused 2 h after the completion of amphotericin-B. Using this schedule resulted in no effect of amphotericin-B on platelet recovery or survival, although platelet increments were modestly depressed in patients receiving high- vs. low-dose amphotericin-B. We conclude that the timing of amphotericin-B infusion be evaluated in patients demonstrating poor platelet recovery and survival. Transfusing platelets at least 2 h after the completion of amphotericin-B decreases the detrimental effect of this antifungal agent on transfused platelet recovery and survival.

Platelet transfusion therapy for medical and surgical patients

Platelet transfusions have become more common as more patients undergo bone marrow transplantation and aggressive chemotherapy for malignant diseases. This paper reviews the indications for platelet transfusions and the factors that can decrease their effectiveness.

The effect of lymphocytotoxic antibody reactivity on the results of single antigen mismatched platelet transfusions to alloimmunized patients

Despite selection strategies that attempt to maximize the platelet donor pool, significant numbers of alloimmunized patients have few if any available donors. Although the number of potential donors increases when one antigen mismatched platelet transfusions (OAMPT) are considered, transfusions from such donors are often cited to fail to produce satisfactory platelet count increments. The presence of lymphocytotoxic antibody (LCTAB) correlates well with responsiveness to random donor platelet transfusions and serves as a good serologic screen for the diagnosis of alloimmunization. We therefore reviewed the results of OAMPT to alloimmunized patients and assessed the relationship between LCTAB levels in the recipient and posttransfusion platelet count increments. We noted an unexpectedly high percentage of good responses in our patient population: 73% of all OAMPT to recipients with LCTAB < 60% reactive, resulted in successful increments. In recipients with LCTAB > or = 60%, 58% of all transfusions were still successful. Despite a statistically significant inverse relationship between the level of LCTAB and the response of OAMPT to alloimmunized patients, 58% to 73% of recipients will have a satisfactory platelet recovery posttransfusion. These data support extending donor searches for alloimmunized patients to include any single mismatch particularly if a recipient's LCTAB has lower reactivity.

Host-parasite relationships of Wuchereria bancrofti and mosquito hosts, Culex pipiens L. and Aedes caspius pallas

We compared the defense mechanisms directed against Wuchereria bancrofti by a filaria susceptible mosquito, Culex pipiens, and a refractory one, Aedes caspius. The reciprocal deleterious effects of both the mosquito host and its parasite are reported. Anatomical and histological examinations of mosquitoes revealed minor differences in the general structure of the foregut of either species. The cibarial pump of Ae. caspius, however, lacked a cibarial armature and damage inflicted to some of the microfilariae (mf) ingested by this mosquito was not mechanical. In contrast, the cibarial armature of Cx. pipiens consisted of 24 delicate teeth which did not seem to affect ingested mf. The peritrophic membrane (pm) did not constitute a significant barrier to mf migrating through the midgut wall of either mosquito. Indeed, mf forced their way out into the hemocoel, immediately after they have been ingested, and up to 60 min post-feeding, when the pm was still thin and soft. It hardened 16 h post-feeding. Traversing mf perforated the pm and displaced the basement membrane. Within the thorax of Cx. pipiens, the parasite completed its development synchronously. In contrast, mf ingested by Ae. caspius did not develop beyond the sausage stage, and many of these larvae were vacuolated. In both mosquitoes, parasitized thoracic muscle fibers were tunnelled and, only in Ae. caspius, their nuclei were pyknotic. No worm encapsulation or melanization was observed in either mosquito. It is concluded that defense lines to invading parasites in Cx. pipiens are insignificant, and that in Ae. caspius, the main barrier to parasite development resides within the thoracic muscles. In the absence of cellular evidence, it is suggested that such a barrier is physiological in nature.

Modulation of idiotypic and antiidiotypic immunoglobulin G responses in an alloimmune thrombocytopenic patient associated with extracorporeal protein A immunoadsorption

In the present case study, a patient with Non-Hodgkin. Lymphoma underwent combination chemotherapy resulting in severe pancytopenia requiring transfusion support with blood products. The patient became refractory to random donor platelet transfusions and subsequently received five immunoadsorption treatments. The patient's clinical response to immunoadsorption therapy was assessed by monitoring platelet transfusion recovery and survival. In addition, changes in antibody responses were assessed. Early during the course of immunoadsorption therapy, antiplatelet immunoglobulin G (IgG) alloantibody was detected. There was a decline in antiplatelet IgG alloantibody levels by the last immunoadsorption treatment associated with increases to platelet correct count increments after completion of immunoadsorption therapy. In addition, elevated levels of antiidiotypic IgG antibody detected early during the course of therapy were significantly reduced by the last immunoadsorption treatment. This case study suggests that specific alloimmune idiotypic IgG antibody and corresponding antiidiotypic IgG antibody responses may be modulated in association with extracorporeal immunoadsorption employing protein A/silica columns.

Water sources and environmental transmission of multiply resistant enteric bacteria in rural Bangladesh

The role of different water sources in the spread of multiply resistant enteric bacteria was investigated in rural Bangladesh. The prevalence of resistance to commonly used antimicrobial agents in the faecal flora of village children and the water quality and prevalence of resistance in village water sources were studied. Most of the children studied (81%) had multiply resistant faecal coliform bacteria, i.e. bacteria resistant to at least three antimicrobials. Although tubewells provided water with low faecal coliform counts, 62% of household storage pots contained water with moderate to high counts. Most of the storage pots (76%) and each of the river and pond sites tested contained multiply resistant isolates. Contamination of water within the household, and the widespread distribution of resistant coliforms in the environment, contribute to the high prevalence of multiply resistant enteric flora in the community. These findings are of importance in understanding the spread of multiply resistant enteric pathogens.

Selection of histocompatible apheresis platelet donors by cross-matching random donor platelet concentrates

It can be impossible to identify compatible platelet donors for alloimmunized patients whose HLA type cannot be determined or who have uncommon HLA types. We have previously shown that histocompatible donors can be rapidly identified by "mass screening" of platelet concentrates (PC), which are readily available in all blood banks, using a solid-phase adherence platelet cross-matching technique. Compatible PC were given to five alloimmunized patients with multispecific HLA antibodies refractory to random donor (RD) PC and selected single-donor platelet transfusions. After transfusions which produced satisfactory responses, we identified the original whole blood donors to serve as apheresis donors. Thus, the donors selected were compatible in vitro by cross-matching, and in vivo by transfusion. Only 3% to 13% of PC cross-matched for these alloimmunized patients were potentially compatible and it was necessary to screen large numbers (65 to 205 U) of PC per patient. Eighteen of 22 PC-selected transfusions produced satisfactory increments, allowing selection of 12 donors, all of whom were willing to undergo apheresis. Ten of 12 of these single-donor transfusions were successful; the two unsuccessful transfusions were infused 2 weeks after the initial PC cross-match and were still compatible with the original serum, but incompatible with more recent serum, demonstrating a change in antibody reactivity. The HLA types of the successful single donors selected by PC cross-matching differed widely from the patients' HLA types and, therefore, these donors would not have been selected by standard approaches using HLA typing. Cross-matching large numbers of RD PC for the identification of apheresis donors is helpful in the management of the alloimmunized patient and may be of particular utility for blood centers that do not have access to HLA-typed donor pools.

Incubation of platelet concentrates before transfusion does not improve posttransfusion recovery

Incubation of stored platelet concentrates (PCs) at 37 degrees C for 1 hour has been reported to result in a better morphology score and improved platelet recovery. A study was conducted in adult patients with leukemia to determine whether incubation of stored PCs results in an improved platelet recovery as measured by 10-minute posttransfusion corrected count increments (CCI). Eligible patients had platelet counts of less than 30,000 per microL and were clinically stable. Patients were transfused with 6 to 10 units of PC stored for 3 days (15 studies) or 4 days (5 studies). Platelets were pooled and then split in two equal volumes so that each patient received two sequential half-transfusions, one incubated at 37 degrees C for 1 hour and the other kept at 22 degrees C for 1 hour. Patients were randomized as to which half-transfusion was received first. The mean CCI of the incubated half-transfusions was 13.6 x 10(3) when they were given first and 14.5 x 10(3) when given second; this was not significantly different from the mean CCI of the nonincubated half-transfusions: 13.8 x 10(3) when they were given first and 13.8 x 10(3) when given second. In contrast to earlier reports, it can be concluded that incubation of pooled PCs does not improve platelet recovery.

The histochemical localization of ATPase, cholinesterase and acid phosphatase activity in Culex pipiens (Diptera, Culicidae) larvae using a methacrylate embedding technique

A method is described for the demonstration of ATPase, Cholinesterase and acid phosphatase activity in thin sections of mosquito larvae fixed in 1:9 v/v mixture of acetone and 10% neutral buffered formalin and embedded in hydroxyethyl methacrylate (HEMA). ATPase activity, observed as a black brown precipitate, was found in the brush border of gastric caeca and microvilli of columnar epithelial cells of the hind gut and Malpighian tubules. Some basal cell membrane activity could also be seen. Cholinesterase activity was found in thoracic and abdominal ganglia. The reaction product had a fine particulate appearance and predominated in the axonal processes. Azo dye reaction product indicative of acid phosphatase activity was found in the epithelial cells of the midgut and gastric caeca. Lysosomal and extra-lysosomal activity was observed, the larger secondary lysosomal sources predominating in the perinuclear region. The fixation regime and embedding procedure outlined has enabled a sub-cellular localization of enzymatic activities which is superior to that obtainable with conventional procedures.

Platelet transfusions administered to patients with splenomegaly

It is generally felt that increments in platelet counts following platelet transfusions to patients with splenomegaly are severely reduced as a result of splenic sequestration. The results of 631 random-donor platelet transfusions administered to 66 thrombocytopenic patients with palpable splenomegaly were analyzed. Increasing splenomegaly had a significant effect on corrected count increments (CCIs), with the greatest deterioration occurring in patients whose spleens were palpable greater than 2.0 cm below the left costal margin. A similar trend was noted when the percentage of transfusions with satisfactory CCIs was compared, although it should be noted that 42 percent of the transfusions produced CCIs greater than 7500, and a large proportion produced clinically helpful absolute increments. Splenomegaly also had an effect on platelet survival: in patients with CCIs greater than 7500, the mean ratio of 24-hour CCIs to 1-hour CCIs was 0.29 to 0.47 in patients with various degrees of splenomegaly, as compared to an expected value of 0.6 to 0.7. Sixteen patients, most with spleens palpable less than 5.0 cm below the left costal margin, consistently had CCIs greater than 7500. A significant fraction of patients with splenomegaly can benefit from platelet transfusion, and thus splenomegaly should not preclude intensive therapeutic approaches.

Methacrylate embedding as a new technique for histopathological studies on the effect of Bacillus thuringiensis against Culex pipiens

Studies on the pathogen Bacillus thuringiensis in Egypt and its possible role as a biological control agent have been reviewed. More emphasis in research was given to some lepidopterous cotton pests and few other species. Histopathological changes in B. thuringiensis treated larvae could be observed in the midgut. The methacrylate embedding technique achieved satisfactory results in concern of better preservation of histological fine details.

Insect growth regulators: I. Biological activity of some IGR's against the susceptible and resistant strains of Culex pipiens larvae. II. Pattern of cross resistance to IGR's in carbaryl-resistant strain

The biological activity and cross-resistance of some IGR's, Dimilin, BAY SIR 8514 and Chlorofluzuron against susceptible and carbaryl-resistant strains of Culex pipiens were determined. The results indicated that these compounds are highly effective against the larvae of C. pipiens but more potent larvicides against the susceptible larvae than against the resistant ones. The pattern of cross-resistance to the used IGR's in the carbaryl-resistant strain were obtained. The data revealed no three IGR's as larvicides against the susceptible and resistant Culex pipiens. The pattern of cross resistance to other potent IGR's was also studies.

Effect of Bacillus sphaericus and Bacillus thuringiensis on acid-phosphatase activity of mosquito larvae, Culex pipiens and Aedes caspius

The use of Bacillus sphaericus and B. thuringiensis H-14 form one of the important group of biological control agent against mosquito larvae. Acid phosphatase enzyme plays a significant role in determining susceptibility of mosquito larvae to both bacterial species. Biochemical assay showed activation in acid phosphatase in Culex pipiens and Aedes caspius treated with B. thuringiensis. Variation in acid phosphatase activity occurred in both mosquitoes treated with B. sphaericus, while there was no change in acid phosphatase activity in A. caspius. An obvious increase in activity in C. pipiens treated with the same bacteria was observed.

Carcinoma of the vulva arising in condylomata acuminata

A case of carcinoma of the vulva arising in condylomata acuminata is presented. The patient was much younger than is classically reported for carcinoma of the vulva. The vulvar growth was first noted during pregnancy, and it continued to grow and enlarge following delivery. Malignancy appeared to develop after a relatively short time. It is sometimes difficult to distinguish vulvar condylomata acuminata from carcinoma from clinical evidence alone. It is, therefore, mandatory in doubtful cases to take multiple biopsies from the lesion before treatment is instituted.

The overall pattern of hair follicle arrangement in the rat and mouse

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