The efficacy of therapeutic plasmapheresis for the treatment of fatal hemophagocytic syndrome: two case reports

A potentially fatal hemophagocytic syndrome (HPS) has been noted in patients with reactive HPS. We describe 2 patients with reactive HPS treated with a regimen of therapeutic plasmapheresis and evaluate the efficacy of plasmapheresis for fatal HPS. Case 1 was a 31 year-old woman who had been treated for systemic lupus erythematosus (SLE) with corticosteroid hormones and immunosuppressants. She presented with persistent leukopenia and thrombocytopenia with spiking fever. She had an elevated level of serum ferritin, liver dysfunction, coagulopathy, and plasma inflammatory cytokines. Her bone marrow smear disclosed numerous hemophagocytosis of histiocytes. She was administered therapeutic plasmapheresis with total plasma exchange by fresh frozen plasma. There was an immediate and prominent decrease of cytokines, and she completely recovered. Case 2 was a 34 year-old woman who had been receiving high doses of corticosteroids and plasmapheresis for severe Stevens-Johnson's syndrome. After 18 months, she presented with physical and laboratory findings resembling lupus-like conditions and was administered high doses of corticosteroids and immunosuppressants. Human parvovirus B19 infection was detected by IgM and IgG antibodies and viral DNA from a bone marrow sample; moreover, a bone marrow smear disclosed findings of HPS. Repeated therapeutic plasmapheresis was effective for improving her symptoms and laboratory abnormalities; however, she suffered from septic methicilline resistant staphylococcus aureus infection and finally died of a brain hemorrhage resulting from disseminated intravascular coagulation (DIC).

Detection of bcr/abl fusion transcripts by semiquantitative multiplex RT-PCR combined with a colormetric assay in Ph positive leukemia

We studied the feasibility of the clinical application of a new bcr/abl analysis system, C-TRAK t(9;22), consisting of a multiplex RT-PCR and a colormetric assay. With this system, bcr/abl transcripts could be detected in all of 24 cytogenetic Philadelphia chromosome (Ph) positive leukemia patients and in none of eight Ph negative patients. Multiple bcr/abl transcripts could be detected in three of the 24 Ph positive patients, the fusion of bcr exon 1 to abl exon 2 (e1a2 junction) dominated that of bcr exon 13 to abl exon 2 (b2a2 junction) in two cases and that of bcr exon 14 to abl exon 2 (b3a2 junction) and b2a2 dominated e1a2 in one case. This system was sensitive enough to be able to detect even one bcr/abl transcript-producing cell in 50000 bcr/abl negative background cells, thus making it suitable for semiquantitative evaluation. Minimal residual disease (MRD) was monitored in one Ph positive leukemia patient who underwent allogenic bone marrow transplantation (allo-BMT). After allo-BMT, a weak positivity of the bcr/abl transcript continued with no clinical relapse; this result was consistent with that of a conventional nested PCR assay using ethidium bromide staining. Including all the procedures for RNA extraction, it took only about 10 h to detect the bcr/abl transcripts. Our findings indicate that this bcr/abl analysis system provides a quick and sensitive method for screening bcr/abl transcripts and possibly for monitoring MRD in Ph positive leukemia patients.

Idiopathic CD4+ T-lymphocytopenia in a non-Hodgkin's lymphoma patient

We report a case of idiopathic CD4+ T-lymphocytopenia with malignant lymphoma (diffuse large, B-cell type) for which there was no evidence of human immunodeficiency virus type 1 or type 2 infection and no other known causes of immunodeficiency. She had never suffered from any opportunistic infection until the diagnosis of malignant lymphoma was made, and the CD4+ T-lymphocytopenia persisted after complete remission of the lymphoma. As the clinical features and immune status of the patient differed from those associated with the acquired immunodeficiency syndrome (AIDS)-related syndrome, we conclude that immunodeficiency in this case did not contribute to the opportunistic infection but may have been associated with the genesis of malignant lymphoma.

[Human parvovirus B19 infection mimicking systemic lupus erythematosus: case report]

Human parvovirus B19 (HPV-B19) has been known as the etiologic agents of erythema infectiosum in normal childhood, and chronic anemia and thrombocytopenia in immuno-compromised patients. Recently, this virus has been reported as the association with rheumatic manifestation such as rheumatoid arthritis and systemic lupus erythematosus (SLE). We described here a patient whose HPV-B19 infection was mimiking atypical symptoms of SLE at diagnosis, and was persistent because of immuno-suppressive therapy for SLE. A 34-year-old female was admitted to our hospital on 22 June 1995, presenting fever episode and cervical lymph node swelling. Before eighteen months, she was received methyl-predonisolone pulse therapy and plasma exchange by fresh frozen plasma for the treatment of Stevens-Johnson syndrome, and after several weeks these therapy she was suffered from viral infection with lymphadenopathies with a transient appearance of atypical lymphocytes in her peripheral blood smear. On laboratory examination at the present admission, her peripheral blood showed anemia, thrombocytopenia with atypical lymphocytes. Throughout her hospitalization, anti-nuclear antibody (ANA) suspected SLE including anti-DNA and anti-Sm antibody were all negative except of transient week positive ANA screening test. Her physical condition presented poor clinical course with fever elevation, increased ascites and renal dysfunction showing the elevation of CRP and circulating immune-complex (Clq binding method). Her serum was positive for IgM and IgG antibody against VP-1 and VP-2 antigen of HPV-B19 by ELISA in April 1996. And then, HPV-B19 DNA by polymerase chain reaction (PCR) was positive in bone marrow sample in March 1996, and also positive in spleen necropsy at death. We confirmed persistent chronic HPV-B19 infection by measurement of HPV-B19 IgM and IgG antibody by ELISA and HPV-B19 DNA by PCR. The plasmapheresis and administration of intravenous immunoglobulin showed the possible efficacy for her symptom throughout this clinical course. Moreover, bone marrow smear showed the finding of virus-associated hemophagocytic syndrome, and finally, she was died of cervical hemorrhage accompanied with disseminated intravascular coagulation syndrome on July 1996. HPV-B19 infection can present an atypical clinical picture that is highly suggestive of SLE. We suggest that the therapy of steroids and immuno-suppressive agents should be cautious, because these may potentially cause persistent chronic HPV-B19 infection and induced life-threatening clinical course.

Apoptotic cell death of neutrophils in development of skin lesions of patients with anaphylactoid purpura

The participation of apoptotic cell death of neutrophils in the development of skin lesions of patients with anaphylactoid purpura was examined by the in situ specific labeling of fragmented DNA. In the early stage of the skin lesions, there were few positively stained nuclei in infiltrating cells. The number of positive cells increased markedly in the fully developed stage of the lesions. A number of neutrophils were stained positively. Finally, a few fragmented nuclei were still positive in the late stage of the lesions. It was therefore suggested that fragmentation of neutrophils in the skin lesions from the patients might be due to apoptosis. Inducible nitric oxide synthase and nitrotyrosine were detected in infiltrates, and interleukin-8 was also detected in vascular endothelial cells in those skin lesions. The roles of nitric oxide and interleukin-8 in the apoptosis of neutrophils are discussed.

[Changes in erythrocyte structure and in platelets in elderly patients with disseminated intravascular coagulation]

We measured the platelet distribution width, the mean platelet volume, the volume percentage of platelets, and the platelet-to-large-cell ratio in 15 elderly patients with disseminated intravascular coagulation (DIC). Peripheral venous blood mixed with ehtylenediaminetetraacetic acid was analyzed with a Sysmex E-4000 analyzer. The underlying diseases were sepsis, pneumonia, pyelonephritis, and other inflammatory diseases. The mean duration of survival from the onset of DIC was 16.9 +/- 23.9 days. The distribution of red cell sizes before the onset of DIC did not differ significantly from that in patients without DIC, but fragmentation of erythrocytes on blood films was more common in the early stage of DIC (p < 0.01). Before the onset of DIC, the two groups did not differ significantly in the frequency of giant platelets on blood smears. At the onset of DIC, the platelet distribution width, the mean platelet volume, and the platelet-to-large-cell ratio were significantly higher than in patients without DIC. The concentration of glutamic-oxaloacetic transaminase and those of other serum enzymes did not change significantly, but the serum creatinine concentration and the blood urea nitrogen level increased as the platelet-to-large-cell ratio increased. No significant relation was evident between the levels of serum C-reactive protein and creatinine, between the platelet-to-large-cell ratio and the mean volume of red blood cells, or between the platelet-to-large-cell ratio and the distribution of red cell sizes. These data suggest that studies of platelets are more useful in the diagnosis of DIC at early stages of impaired organ function than are other indicators of inflammation such as the level of C-reactive protein.

[Acute myocardial infarction with idiopathic thrombocytopenic purpura in an elderly patient]

A 71-year-old woman complained of gingival bleeding and epistaxis, and was given a diagnosis of idiopathic thrombocytopenic purpura. She was successfully treated with orally administered prednisolone and azathioprine. She experienced a relapse when she was 77 years old, and immunosuppressive therapy was not effective. Platelet transfusion was performed. She died because of massive gastrointestinal bleeding. An infarct was found in the left anterior part of the myocardium at autopsy. Disseminated intravascular coagulation was not detected on pathological investigation. Abnormal platelet aggregation may be important in the pathogenesis of thrombotic disease in thrombocytopenia.

[Anemia in elderly patients with malignant tumors]

Complications, prognosis, and efficacy of treatments were retrospectively studied in elderly patients, some of whom had lung, stomach, colon, pancreatic, and liver cancers. Hemoglobin concentration and characteristics of erythrocytes were measured for up to sixty months. Eighty-eight patients died of cancer, and malignant tumors were detected before death in 57. The average survival periods were 11 months for patients with gastric cancer. 9 months for those with colon cancer, and 7 months for those with lung cancer. Malignancies of the digestive organs and lung were often detected in elderly patients with anemia. In elderly people who were without cancer for more than 78 months the hemoglobin concentration did not change significantly, but in those with a malignancy the hemoglobin concentration continuously decreased. Patients with colon cancer who were given blood transfusions survived longer than those who were not given the transfusions, but the same was not true of patients with gastric or lung cancers. Iron therapy, however, was generally effective in patients with malignant tumors of the gastrointestinal tract. Among those who were near death, the red cell distribution widths differed significantly between patients with different types of carcinomas, but differences in mean corpuscular hemoglobin and in mean corpuscular volume were not statistically significant. In conclusion, hemoglobin concentration and characteristics of erythrocytes should not be neglected in the diagnosis and treatment of cancers in the elderly.

[Myelodysplastic syndrome developed in a mother and her son whose bone marrow karyotype showed monosomy 7]

Two familial cases of myelodysplastic syndrome (MDS) are reported, one of whom had an abnormal karyotype of 45, XY, -7 (monosomy 7). Case 1 was a 60-year-old woman developed dizziness and nasal bleeding. She was treated with blood transfusion alone. About 11 months after diagnosis, she died of pneumonia. Case 2 was a 22 year-old man, who was the son of case 1, developed febrile disease because of recurrent skin and oral mucosa infections. He had a partial response to low-dose of cytarabine. Thirteen months after diagnosis, he died of severe pneumonia. Both cases were diagnosed as having refractory anemia with excess of blasts due to peripheral blood and bone marrow findings. Both patients had pancytopenia, erythroid hyperplasia in bone marrow, marked dyserythropoiesis, recurrent infectious diseases and severe pneumonia that resulted in death. These symptoms resembled to those reported for monosomy 7 syndrome. Familial MDS with monosomy 7 is rarely reported. These cases are of interest to investigate hereditary factors of MDS.

[Delayed clearance of methotrexate in a patient with malignant lymphoma who developed renal failure]

Malignant lymphoma of diffuse large cell type, was diagnosed in a 70-year-old man with tumors of the nasal cavity and right testis. He was treated with Epi-VEPA regimen and relapsed in the right thalamus just after achieving remission. Total cranial irradiation was effective, but multiple skin lesions were present at the time. He then suffered from renal failure and delayed clearance of MTX after high-dose methotrexate (MTX) administration with citrovorum factor (CF). The serum concentration of MTX decreased to 0.09 microM within 285 hours by multi-clearance techniques as continuous arteriovenous hemoperfusion (CAVH), plasma exchange (PEX), peritoneal dialysis (PD) and charcoal hemoperfusion (CH). Better MTX clearance was observed in CH and PEX than in CAVH and PD, with higher effect in PEX than in CH or CAVH. The patient suffered severe mucositis and myelosuppression, but fatal harm of MTX was prevented. CH and PD were considered the best combination of clearance techniques for removing serum MTX in delayed methotrexate clearance with renal disturbance.

Immunohistochemical analysis of cyclin D1 protein in hematopoietic neoplasms with special reference to mantle cell lymphoma

Immunohistochemical expression of PRAD1/cyclin D1 protein has been investigated in 106 tissue specimens of 104 cases of lymphoma, non-neoplastic lymphoid disorders and other hematologic malignancies by employing the monoclonal antibody 5D4 with formalin-fixed paraffin-embedded sections, using the microwave oven heating method. Positive neoplastic cells were found in 60 (74%) of 81 cases of non-Hodgkin's lymphoma. The positivity pattern was nuclear in 17 (85%) of 20 cases of mantle cell lymphoma in which cytoplasmic staining was also seen. This pattern of cyclin D1 positivity was in contrast to the negative staining of normal reactive mantle zones. In the other cases, positivity appeared to lie within the cell cytoplasm without nuclear staining, and most of the nodal follicular and diffuse B-cell lymphomas variously expressed PRAD1/cyclin D1. In contrast, the reaction was absent in a significant number of T-cell and extranodal B-cell lymphomas. Immunolocalization of PRAD1/cyclin D1 expression appears to be a useful diagnostic adjunct to discriminate mantle cell lymphoma from other non-Hodgkin's lymphomas.

[Anemia and neutropenia in elderly patients caused by copper deficiency for long-term enteral nutrition]

Anemia and neutropenia caused by copper deficiency is a well-known consequence of long term total parenteral nutrition in the literature. We present 6 bed-ridden elderly patients who developed anemia and neutropenia after receiving enteral nutrition for a long time (mean: 3.3 years) In all 6 patients, serum copper and ceruloplasmin level were very low, and the mean of their hematological data were as follows: WBC 2,200/microliters, neutrophil 554/microliters, hemoglobin 8.1 g/dl, platelet 260 x 10(3)/microliters, respectively. The bone marrow examination showed cytoplasmic vacuolization of both myeloid and erythroid precursors, and maturation arrest of granulopoiesis. Then, copper sulfate was administrated by enteral tube to 6 patients, and the improvement of anemia and neutropenia was observed within a month. A 82-year-old woman who received enteral nutrition for 3.5 years with sever anemia (Hb 3.7 g/dl) and neutropenia (neutrophil 350/microliters), showed a marked improvement in hematological data (Hb 8.0 g/dl, neutrophil 4, 092/microliters, respectively) after two months by administering the copper supplementation. The exact cause of the anemia and neutropenia in copper deficiency is unclear, but it is suggested that the decreased activity of enzyme containing copper may be related. Hematological abnormalities due to copper deficiency should be cared during long term enteral nutrition with long termed bed-ridden elderly patients.

[Disseminated intravascular coagulation (DIC) and pre-DIC due to severe infection in the elderly]

Because of pre-thrombotic state frequently present in the elderly, sepsis easily progresses to pre-DIC and DIC, sometimes with a fatal outcome. We assessed 31 elderly patients who developed pre-DIC and DIC due to severe infection. They were divided into two groups, early death group: 14 elderly patients with poor prognosis died within 14 days, and long survival group: 17 patients with good prognosis lived 15 days or more. Controls consisted of 31 elderly thrombotic disease cases and 25 healthy elderly cases. The DIC score was significantly higher in the early death group than in the long survival group, and there was a correlation between DIC score and survival. Moreover, many of the early death group were long-termed bed-ridden patients, serum BUN and Cre levels were significantly increased in the early death group compared to the long survival group. While plasma TAT, PIC and D-dimer levels were increased in thrombotic disease group compared to the healthy control group, TAT and D-dimer were also increased in the pre-DIC and DIC state than in the thrombotic state. In the early death group, D-dimer was higher than in the long survival group. We suggest that early diagnosis by molecular marker is important in the DIC stage, and a high D-dimer level may be a poor prognostic factor.

Monoclonal antibody against PRAD1/cyclin D1 stains nuclei of tumor cells with translocation or amplification at BCL-1 locus

Mouse monoclonal antibodies were produced against the bacterial product encoded by human PRAD1/cyclin D1 gene, which is known to be involved in tumors with translocation or amplification at BCL-1 locus of 11q13. The immunizing antigens used were GST-PRAD1 and T7 gene 10-PRAD1 fusion products. Four antibodies were reactive with both PRAD1 fusion products and cell lysates of B-cell tumor cell lines with t(11;14)(q13;q32) and a breast cancer cell line with 11q13 amplification, on immunoblotting. An immunofluorescence study showed that only one of them stained nuclei of cells with 11q13 abnormalities. Since this antibody proved applicable for conventional paraffin-embedded tissue sections, immunohistologic staining of various lymphoma tissues was performed. Eight of 11 mantle cell lymphomas showed intermediate to strong positivity and 6 of the positive cases demonstrated characteristic staining patterns that were either predominantly nuclear or both nuclear and cytoplasmic. The nuclear staining pattern was not observed with other types of lymphoma and thus may correlate with PRAD1 mRNA overexpression.

[Non-Hodgkin's lymphoma with pulmonary involvement and various immunological abnormalities in an elderly patient]

A 85-year-old female was admitted with general fatigue and chest discomfort in July 1991. Her chest X-ray film showed several pulmonary nodules in the bilateral lung fields without hilar lymphadenopathy. Metastatic lung cancer was suspected, but primary cancer was not detected in spite of cancer screening. Hemoglobin was 8.7 g/dl. The patient also had various immunological abnormalities including increased serum cold agglutinin titer, decreased serum complement, positive anti-nuclear antigen and IgM-kappa monoclonal gammopathy detected by immunoelectrophoresis. She was diagnosed as having autoimmune hemolytic anemia with cold agglutinin disease and M-protein. With the administration of corticosteroids, hemolytic anemia improved temporarily, but the patient died of hemorrhagic gastritis. At autopsy, a lung tumor was detected in the left upper lobe, mainly without hilar lymphadenopathy. The autopsy specimens showed Non-Hodgkin's lymphoma (diffuse medium-sized cell type), differentiated from macroglobulinemia by immunohistochemical studies. In elderly patients, with various immunological abnormalities, B-cell lymphoproliferative disorders such as malignant lymphoma should be suspected.

[Chronic myelogenous leukemia complicated with sarcoidosis]

A 79-year-old man who had been diagnosed as having sarcoidosis when he was 63 year old, was admitted to our hospital because of marked thrombocytosis and leukocytosis in July 1991. The low neutrophil alkaline phosphatase (NAP) score, presence of Philadelphia (Ph1) chromosome in the bone marrow cells, and M-BCR rearrangement by Southern blot hybridization were observed. He was diagnosed as having chronic myelogenous leukemia complicated with sarcoidosis. The coexistence of sarcoidosis and leukemia has rarely been reported. It is difficult to discuss that there is not causal association between of them.

[Non-Hodgkin's lymphoma in a patient with sarcoidosis (the sarcoidosis-lymphoma syndrome)]

A-31-year-old man with right cervical and supraclavicular lymphadenopathy was admitted in March, 1991. He was diagnosed as having muscular sarcoidosis at the age 8 year, and was treated with corticosteroids. Since age 18, his skin was erythematous and ulcerous, and later his skin became gradually atrophic. Lymph node biopsy revealed diffused large cell non-Hodgkin's lymphoma. Lymphoma cells showed TCR-beta gene rearrangement by Southern blot hybridization. His lymphoma was refractory to CHOP and CHOP-Bleo regimens. Complete remission was achieved with cisplatin and etoposide. However, early relapse occurred, and he died of pulmonary hemorrhage 4 months after the diagnosis of non-Hodgkin's T-cell lymphoma. The so called "sarcoidosis-lymphoma syndrome" is uncommon in Japan. In 9 of 10 cases previously reported, malignant lymphoma occurred during the course of sarcoidosis. Most of the sarcoidosis cases were chronic active type, and required systemic administration of corticosteroids. Hodgkin's disease coexistent with sarcoidosis as reported in other countries, was not found in Japan. These findings suggest that the low incidence of sarcoidosis-lymphoma syndrome in our country is due to the relative rareness of Hodgkin's disease. The sarcoidosis-lymphoma syndrome possibly appears as a consequence of immunological abnormalities observed in sarcoidosis.

[Chimerism monitoring by VNTRs polymorphism analysis in a patient who received allogenic bone marrow transplantation]

A 39-year-old female diagnosed as acute myelogenous leukemia received allogenic bone marrow transplantation (BMT) pre-conditioned with busulfan and cyclophosphamide regimen from her HLA identical sibling. To distinguish donor and recipient cells, we analyzed variable numbers of tandem repeats (VNTRs) polymorphisms using a YNH-24 probe by Southern blot hybridization. VNTRs polymorphism analysis documented the engraftment of donor cells, relapse of recipient cells, and mixed hematopoietic chimerism. Assessment of the chimerism state is important for determining the prognosis of patients undergoing BMT, and VNTRs polymorphisms analysis is very useful for identifying the chimerism state.

[Neutrophilic dermatosis in a patient with refractory anemia]

A 46-year-old man diagnosed as refractory anemia was hospitalized because of high fever and extensive erythema with ulceration in the femoral region. His peripheral blood examination showed marked leukocytosis (WBC 31,500/microliter:neutrophilic 90%) and anemia (Hb 8.6 g/dl. In spite of administration of antibiotics, the cutaneous ulcer rapidly extended to the right thigh and became necrotic. The bacterial culture of the cutaneous lesion showed no growth and a skin biopsy showed infiltration of neutrophils in the dermis. He became afebrile and his cutaneous lesion improved after administration of corticosteroid. When the dose of corticosteroid was decreased, cutaneous erythema and nodules appeared at other sites repeatedly, and disappeared after the dose of corticosteroid was increased. The cutaneous lesions had characteristics of both Sweet's syndrome and pyoderma gangrenosum. Moreover, the patient had immunological abnormalities and decreased neutrophilic functions (chemotaxis and O2- generation). Thus, it was suggested that the cutaneous lesions of this patient could be diagnosed as "neutrophilic dermatosis of MDS", and corticosteroid was recognized to be very effective in treating these skin lesions.

[Application of Y-chromosome specific DNA analysis for detection of mixed hematopoietic chimerism after allogeneic bone marrow transplantation]

We report a case involving mixed hematopoietic chimerism after an allogeneic bone marrow transplantation (BMT) from a sex mismatched donor. A 31 year-old-man who was diagnosed as having chronic myelogenous leukemia in the accelerated phase received an allogenic BMT from his HLA-identical sister in March, 1989. To determine the mixed chimerism we used the Y-chromosome specific repeated sequence of DNA using a specific probe (PHY 10). The donor's DNA 3.5 kb band appeared in 1-10% of male DNA by Southern blot hybridization in the peripheral blood 21 days after BMT. The Y-chromosome DNA band decreased day by day, and disappeared 110 days after BMT. The Y-chromosome DNA band could be detected, even though few metaphases were obtained immediately after BMT. Thus this method is very sensitive for determining which cells contain the Y-chromosome, and is therefore useful for detecting mixed chimerism after sex-mismatched BMT. Using this method the clinical significance of mixed chimerism can be assessed.

[Blastic form of acute erythremia: report of an autopsy case]

We report an autopsy case of acute erythremia which terminated in generalized infiltration of immature blasts similar to proerythroblasts. A 61-year-old man was admitted because of general fatigue and fever in June, 1990. Mild anemia and severe thrombocytopenia were noted. The bone marrow was hypocellular with 25.5% blasts similar to proerythroblasts and 36.5% erythroblasts, many of which were polynuclear and megaloblastoid. The blasts were cytochemically negative for POX, but positive for PAS staining. Therefore he was diagnosed as having acute erythremia. Partial remission was achieved by BHAC-EV therapy. But three months later, his marrow was replaced by 52.7% blasts as seen in admission. Those blasts were negative for lymphoid, myelocytic, megakaryocytic markers and antiglycophorin A, but positive for OKT 9. Electron microscopy revealed that some of blasts had characteristics of immature erythroblasts. In spite of low dose Ara-C therapy, he died of sudden gastrointestinal bleeding in December, 1990. The autopsy disclosed widespread infiltration of blasts, involving liver, spleen, lung, kidney and stomach. It was interesting that dysplasia had been confined to erythroid lineage throughout his clinical course. He seemed to be a rare case of blastic form of acute erythremia which should be distinguished from erythroleukemia.

[Pure white cell aplasia (PWCA) with an inhibitor against colony-forming unit of granulocyte-macrophage (CFU-GM)]

We reported here a case of pure white cell aplasia (PWCA). A 23-year-old man was admitted to our hospital in September 1989 because of agranulocytosis, fever, and anal pain. He had no history of toxic-drug exposure or blood transfusion. Laboratory studies were all within the normal range except white blood cell count of 2,300/microliters with no neutrophils and low serum IgA level (28 mg/dl). Bone marrow examination showed hypocellular with erythroid predominance and no granulocyte maturation beyond the myelocyte. Complement-dependent suppression of autologous and heterologous granulocyte-macrophage colony-forming units by the patient's serum could be demonstrated. Though corticosteroid administration was ineffective, neutropenia improved by plasmapheresis. Furthermore, recombinant granulocyte colony stimulating factor (rG-CSF) could release him from persistent bacterial infection of anal fistula by transient improvement of neutropenia. These findings suggest a humoral autoimmune mechanism for the pathogenesis of PWCA and the effectiveness of rG-CSF for the patient with severe infections.

[Chromosomal abnormality of trisomy 4 in a patient with acute nonlymphocytic leukemia (FAB: M2)]

We report a patient with acute nonlymphocytic leukemia (FAB classification: M 2) with trisomy 4, which is the first case in our country. A 42-year-old man was admitted to our hospital because of fever and general fatigue in May, 1988. His WBC count was 8,100/microliters with 90% of leukemic cells and bone marrow smear showed 76.1% leukemic cells. The chromosomal analysis of marrow cells by G-banding revealed 47, XY, +4. In spite of administration of chemotherapy complete remission was not obtained, and he died of septic shock and severe liver damage 4 months after making the diagnosis. Chromosomal abnormality of trisomy 4 has been reported to be associated with predominantly either M 4 or M 2, and to be less than 0.1% of incidence in ANLL, according to the Second MIC Cooperative Study Group. It is suggested that trisomy 4 may be caused by exposure to some environmental factors such as toxic substances, since this chromosomal abnormality has been reported in the last 10 to 20 years.