[Survey on ticks and detection of new bunyavirus in some vect in the endemic areas of fever, thrombocytopenia and leukopenia syndrome (FTLS) in Henan province]

OBJECTIVE

To investigate the distribution, species, seasonal fluctuation of ticks and detect new bunyavirus in some hematophagus in the endemic areas of fever thrombocytopenia and leukopenia syndrome (FTLS) in Henan province.

METHODS

From March to December 2011, the free ticks were collected manually with white cloth from the grassland and the parasitic ticks were collected from the host skin by hand searching in Xinyang and Jiyuan. The density and seasonal fluctuation of ticks were analyzed after classification of the specimen. The hematophagus were collected including gadfly (38 in 16 groups), cattle lice (224 in 16 groups), mosquitoes (238 in 17 groups) and ticks (825 in 77 groups), then RNA of new bunyavirus were detected by RT-PCR.

RESULTS

A total of 12 388 ticks were collected in Xinyang and Jiyuan, consisting of 2 families, 5 geniuses and 6 species. In Xinyang city, 622 ticks were identified, consisting of 2 families, 3 geniuses and 3 species, including 2 (0.32%) Ornithodoros lahorensis, 451 (72.51%) Haemaphysalis longicornis and 117 (18.81%) Boophilus microplus. In Jiyuan city, 11 766 ticks were identified, consisting of 1 family, 4 geniuses and 5 species, including 7718 (65.60%) Haemaphysalis longicornis, 164 (1.39%) H.anatolicum anatolicum and 710 (6.03%) other ticks such as H. detritum, Boophilus microplus and Rhipicephalus sanguineus. Haemaphysalis longicornis were found in both districts as the predominant species in Henan province. Ticks were active from March to October. The average density was 160 per person hour and the peak was from May to July with density 278, 209 and 542 per person hour respectively. The results was positive in RNA detection of new bunyavirus in 11 groups of tick and 3 groups of gadfly by RT-PCR. The results were negative in all other hematophagus.

CONCLUSION

Ornithodoros lahorensis, Haemaphysalis longicornis, Boophilus microplus, H.anatolicum anatolicum, Rhipicephalus sanguineus and H. detritum were found in Henan province. Haemaphysalis longicornis was the predominant species. The density of ticks varied with the seasons. The detection of new bunyavirus by PCR was positive in some ticks and gadflies.

Invasive mechanical ventilation in cancer patients. Prior non invasive ventilation is a poor prognostic factor

PURPOSE

Prior non invasive ventilation (NIV) is associated with an increased mortality in patients with haematological malignancies and acute respiratory failure treated by invasive mechanical ventilation (IMV). We have assessed whether NIV failure is an independent prognostic factor for hospital discharge in a general cancer population treated by IMV.

METHODS

106 patients with solid tumors and 58 patients with haematological malignancies were eligible for this retrospective study; 41 were treated by NIV before IMV.

RESULTS

The main indications for mechanical ventilation were sepsis/shock (35%), acute respiratory failure (33%), cardiopulmonary resuscitation (16%) and neurologic disease (10%). Respectively, 35%, 28% and 24% of the patients were extubated, discharged from the intensive care unit (ICU) and from the hospital. For patients treated with NIV prior to IMV, the rates were 22%, 17% and 10%, respectively. In multivariate analysis, 3 variables were independently associated with a decreased probability of being discharged from the hospital: NIV use before IMV (odds ratio/OR=0.30, 95% confidence interval/CI: 0.09-0.95; p=0.04); leukopenia (OR=0.21, 95% CI: 0.06-0.77; p=0.02) and serum bilirubin >1.1 mg/dl (OR=0.38, 95% CI: 0.16-0.94; p=0.04).

CONCLUSION

NIV failure before IMV is an independent poor prognostic factor in cancer patients treated by IMV.

Autosomal dominant and sporadic monocytopenia with susceptibility to mycobacteria, fungi, papillomaviruses, and myelodysplasia

We identified 18 patients with the distinct clinical phenotype of susceptibility to disseminated nontuberculous mycobacterial infections, viral infections, especially with human papillomaviruses, and fungal infections, primarily histoplasmosis, and molds. This syndrome typically had its onset in adulthood (age range, 7-60 years; mean, 31.1 years; median, 32 years) and was characterized by profound circulating monocytopenia (mean, 13.3 cells/microL; median, 14.5 cells/microL), B lymphocytopenia (mean, 9.4 cells/microL; median, 4 cells/microL), and NK lymphocytopenia (mean, 16 cells/microL; median, 5.5 cells/microL). T lymphocytes were variably affected. Despite these peripheral cytopenias, all patients had macrophages and plasma cells at sites of inflammation and normal immunoglobulin levels. Ten of these patients developed 1 or more of the following malignancies: 9 myelodysplasia/leukemia, 1 vulvar carcinoma and metastatic melanoma, 1 cervical carcinoma, 1 Bowen disease of the vulva, and 1 multiple Epstein-Barr virus(+) leiomyosarcoma. Five patients developed pulmonary alveolar proteinosis without mutations in the granulocyte-macrophage colony-stimulating factor receptor or anti-granulocyte-macrophage colony-stimulating factor autoantibodies. Among these 18 patients, 5 families had 2 generations affected, suggesting autosomal dominant transmission as well as sporadic cases. This novel clinical syndrome links susceptibility to mycobacterial, viral, and fungal infections with malignancy and can be transmitted in an autosomal dominant pattern.

Light chain myeloma with features of the adult Fanconi syndrome: six years remission following one course of melphalan

A 41-year-old woman, presenting with renal failure, renal glucosuria and moderate anemia, was found to have light chain myeloma, indicated by a kappa chain M-component in the serum, heavy urinary excretion of kappa chains and plasma cell infiltration of the bone marrow. After administration of one course of melphalan, resulting in transient pancytopenia, the light chains disappeared completely, renal function returned to normal, glucosuria disappeared and the Hb concentration normalized. During an observation period of six years she has remained in good health and there has been no sign of relapse.

Prophylactic Role of Immunomodulators in Treatment of Systemic Candidiasis in Leukopenic Mice

In the present study, we have evaluated prophylactic role of various immunomodulators viz. lipopolysachharide, protein A and tuftsin to impart protection against experimental candidiasis in leukopenic mice. Both free as well as liposomised form of nystatin was not effective enough in offering complete cure against less susceptible isolate of Candida albicans (JNMCR) infection in immunodebilitant mice. Interestingly, the pretreatment of leukopenic mice with immunomodulators before challenging them with C. albicans increased therapeutic efficacy of the nystatin against systemic candidiasis. Efficacy of the treatment was evaluated on the basis of survival of the animals as well as fungal load in systemic circulation and various organs viz. liver, kidney, spleen and lungs of the treated animals.

Good syndrome coexisting with leukopenia

A 61-year-old man was admitted to our hospital for further examinations of a mediastinal mass. He had underwent an extended thymothymectomy, and had a tumor that was diagnosed as a type B1 thymoma, according to the World Health Organization. One year after surgery he was admitted again for recurrent diarrhea and pneumonia. Laboratory data revealed severe hypogammaglobulinemia with leukopenia. He was diagnosed with Good syndrome with leukopenia. Regular gamma globulin and figrastim injections were successful in keeping the patient symptom free. The prognosis of patients with Good syndrome and leukopenia is very poor; therefore, immediate diagnosis is important. The development of infectious diseases in a patient with thymoma or after the resection of thymoma mandates early and comprehensive immunologic investigation.

An association of soluble CD40 ligand (CD154) with adverse reactions to platelet transfusions

BACKGROUND

Removal of stored supernatant abrogates most transfusion reactions to leukoreduced platelets (PLTs), suggesting that PLT-derived soluble mediators are involved. PLTs are the primary source of soluble CD40 ligand (sCD40L). Engagement of the receptor for CD40L induces synthesis of proinflammatory mediators including interleukin (IL)-6, IL-8, and monocyte chemotactic protein-1 (MCP-1).

STUDY DESIGN AND METHODS

Supernatants from poststorage leukoreduced PLT concentrates were assayed for white cell- (IL-6, IL-8, MCP-1) and PLT-derived (sCD40L, RANTES) inflammatory mediators. These levels were correlated with clinical outcomes.

RESULTS

Of 534 transfusions, there were 12 reported (2.2%) and 2 unreported reactions (0.4%)--10 febrile and 4 allergic. Transfusions with reactions had significantly higher levels of IL-6 (2.3-fold higher; p = 0.005), IL-8 (2.2-fold higher; p = 0.001), MCP-1 (2.6-fold higher; p = 0.002), and sCD40L (1.24-fold higher; p = 0.015), but not RANTES. (1.14-fold higher; p = 0.22). The vast majority (>93%) of patients transfused with mediator levels in the highest quintile had no reactions. When levels of all five mediators were summed, the reaction rates in the first through fifth quintiles increased from 1 to 7 percent (p = 0.027). All but one reaction occurred in patients with hematologic malignancies (13 reactions/380 transfusions; 3.4%; p = 0.04 vs. other diagnoses).

CONCLUSIONS

These are the first data demonstrating that a PLT-derived mediator, sCD40L, is associated with adverse transfusion events. Existing clinical factors, for example, inflammation or leukopenia, may influence whether infused mediators cause reactions.

An unusual hamartoma of the folliculosebaceous-apocrine unit: a case report

Hamartoma is a neoplasm-like lesion composed of an abnormal mixture of tissues native to the area. We report on an unusual example of a hamartomatous lesion that showed an abnormal mixture of elements of the folliculosebaceous-apocrine unit and arrector pili muscle. A 13-year-old female presented with two nodules situated 2 cm apart on the lower leg that were present since birth. The patient reported some enlargement and slight pain of the otherwise asymptomatic lesions during 2 years, before they were surgically removed. The patient obviously had no skin problems afterwards; her 12-year follow-up was significant for leucopenia and nephrolithiasis. The biopsies from both lesions looked identical. Each lesion was biphasic, i.e. composed of a predominant mesenchymal component and epithelial elements. The mesenchymal part resembled a leiomyoma, or in minor areas, the constituting cells had a myofibroblastic appearance. Encased within the mesenchymal component were large infundibulocystic structures and plentiful grouped and scattered roundish solid epithelial nodules, duct-like, glandular, and tubular elements. Some of the epithelial structures were reminiscent of those seen in tubular apocrine adenoma; others resembled syringomatous elements. We interpreted this unusual lesion as a hamartoma of the folliculosebaceous-apocrine unit.

Severe leukopenia and liver biochemistry changes in adult rabbits after calicivirus infection

Calicivirus infection is the major cause of the severe decrease in the stocks of wild and farm rabbits that has occurred worldwide during the last two decades. Adult rabbits (10-weeks-old) were experimentally infected with a calicivirus inoculum that killed all animals by causing rabbit haemorrhagic disease (RHD) within 24-62 h of infection. The rabbits were used to evaluate blood cell numbers and serum biochemistry every 6h, starting 12h after the inoculation of the caliciviruses. No significant changes in blood parameters were observed in most of the rabbits up to 18 h of infection. Severe leukopenia was seen 6h before death of the infected rabbits; both heterophils and lymphocytes contributed to the decrease in circulating white blood cells. Platelets were also severely decreased in number. Marked enhancement in liver enzymes was seen 6-12 h before death of the infected rabbits. There was also evidence both for cholestasis, as expressed by the elevated levels of direct (conjugated) bilirubin, and for hypoglycemia, an alteration that it is likely to contribute for the seizures that rabbits show during the late stages of RHD. Liver ultrastructure of rabbits that died from RHD revealed extensive hepatocyte vacuolization, severe changes in mitochondrial structure, and depletion of glycogen granules. We conclude that: (i) severe leukopenia characterizes the final hours of calicivirus-induced RHD; (ii) hypoglycemia and cholestasis precede death of rabbits from RHD; (iii) the kinetics of liver enzymes allows an accurate prediction of the time of death of rabbits from calicivirus-induced RHD.

Usage of Deoxyspergualin on Steroid-Resistant Acute Rejection in Living Donor Liver Transplantation

Deoxyspergualin (DSG) is an immunosuppressive agent used to treat steroid-resistant acute rejection after kidney transplantation. But in the case of acute rejection after liver transplantation, DSG was reported effective in just a few cases. From July 1991 to November 2005, 96 patients underwent living donor liver transplantation (LDLTx) in our institution. Of them, 9 patients, including 4 ABO incompatible recipients, are presented. Rejection symptoms that did not respond to steroid pulse therapy (methylprednisolone, 10-20 mg/kg/day for 3 days) and were treated with DSG (3 or 5 mg/kg/day) for 4 to 14 days together with a maintenance dose of the steroid. Among them, five responded to treatment with DSG, two did not respond and the other two patients were not evaluated. Six of the nine patients are symptom free at present. Complications such as leukopenia and thrombocytopenia were successfully treated with granulocyte-colony stimulating factor or by platelet transfusion. No recipient died as a direct consequence of the complications induced by DSG. DSG proved effective and safe for some of the LDLTx recipients with steroid-resistant acute rejection but it was not effective for the treatment of accelerated humoral rejection in ABO incompatible recipients.

[Generalized erythema triggered by a rapid decrease of basophils in chronic myeloid leukemia treated with imatinib]

A 57-year-old woman with chronic myeloid leukemia showing severe basophilia (WBC 17.1 X 10(9)/L, basophils 23%) was treated with 400mg imatinib in June 2003. A high basophil count (WBC 10.6 X 10(9)/L, basophils 31%) was still observed after 1 week of therapy. After 9 days of therapy, she developed generalized pruritic skin erythema, chills and high fever. After terminating imatinib treatment, prednisolone therapy was initiated. The rash quickly disappeared. Four days after withdrawal of imatinib, leukocyte count was 13.0 X 10(9)/L with 3% of basophils, suggesting the possibility that rapid decrease in basophils following imatinib therapy may induce severe cutaneous reactions.

Outcomes of febrile children presumed to be immunocompetent who present with leukopenia or neutropenia to an ambulatory setting

To determine significant medical outcomes in febrile children presenting to an ambulatory setting with neutropenia and/or leukopenia.

METHODS

Retrospective medical record review conducted on febrile patients who had a blood culture drawn, with white blood cell counts less than 5,000/mm3 and/or an absolute neutrophil count less than 1000/mm3. Ninety-one patients were identified; 5 with positive blood culture results, 13 with significant non-oncologic disease, and 3 patients with leukemia who had involvement of 2 or more cell lines.

CONCLUSIONS

In the majority of patients, clinical judgment, physical findings, and review of all cell lines of the complete blood cell count identified those with significant disease.

Incorporation of amphotericin B in tuftsin-bearing liposomes showed enhanced efficacy against systemic cryptococcosis in leucopenic mice

OBJECTIVES

The role of the immunomodulator tuftsin in enhancing the antifungal activity of liposomal amphotericin B against Cryptococcus neoformans in leucopenic mice was assessed.

METHODS

In the present study, we investigated the antifungal activity of amphotericin B liposomes with tuftsin grafted on the surface. Mice were treated with free amphotericin B as well as liposomal formulations after C. neoformans infection. For prophylactic studies, mice were pre-treated with liposomal tuftsin (50 microg/mL) for three consecutive days prior to C. neoformans infection (7 x 10(5) cfu/mouse). Chemotherapy, with tuftsin-free and tuftsin-bearing amphotericin B liposomes, was started 24 h post C. neoformans infection. The role of tuftsin in immunoaugmentative therapy was assessed by survival and cfu of treated mice.

RESULTS

Amphotericin B entrapped in tuftsin-bearing liposomes showed increased anticryptococcal activity in the murine model. Moreover, tuftsin pre-treatment further augmented the antifungal activity of liposomal amphotericin B in leucopenic mice. Incorporation of tuftsin in liposomes resulted in increased anticryptococcal activity of liposomal amphotericin B compared with amphotericin B deoxycholate and conventional liposomal amphotericin B formulations.

CONCLUSIONS

The enhanced anticryptococcal activity of amphotericin B in tuftsin-liposomes can be attributed to the immune-stimulating property of tuftsin. Tuftsin activates the key immune cells, due to the presence of its receptors on macrophages and neutrophils, for a better fight against pathogens. Simultaneous liposome-mediated delivery of amphotericin B to the site of infection kills the pathogens more effectively.

Review of ACR hematologic criteria in systemic lupus erythematosus

We have conducted a thorough literature review to evaluate the relative value of the hematologic criterion in making a diagnosis of systemic lupus erythematosus (SLE), its clinical relevance, and its prognostic significance. In the updated 1982 ACR criteria, the presence of one or more of the four elements: 1) hemolytic anemia (with reticulocytosis); 2) leukopenia (<4000/microL on two or more occasions); 3) lymphopenia (< 1500/microL on two or more occasions); or 4) thrombocytopenia (< 100,000/microL in the absence of offending drugs) is now considered as a single hematologic disorder. The sensitivity and specificity of the individual elements of the hematologic criterion range from 18 to 46% and 89 to 99%, respectively. The accuracy of the hematologic criterion requires proper interpretation. For example, many studies reported the presence of anemia that was not clearly defined and likely included anemia from etiologies other than hemolytic anemia, thereby causing an overestimation of the prevalence. In addition, medications such as corticosteroids and cytotoxic agents, and viral infections, can also contribute to a reduction in lymphocyte count. Despite these limitations, the SLICC committee recommends no change in the elements of the hematologic criterion when this criterion is properly interpreted and other causes of cytopenia are excluded.

Leucopenia and thrombocytopenia possibly associated with lamotrigine use in a patient

Haematological side effects are rather exceptional with lamotrigine. We report the case of a 25-year-old woman with epilepsy who developed combined leucopenia and thrombocytopenia eight weeks after starting lamotrigine. Within weeks after lamotrigine was discontinued, all of the haematopoietic abnormalities had disappeared. To our knowledge, this is the first report of combined leucopenia and thrombocytopenia associated with lamotrigine treatment suggesting, in our patient, a causal reaction.

Reversible Leukoencephalopathy Syndrome Associated to Leukopenia in a Chronic Hemodialysis Patient

Reversible leukoencephalopathy syndrome (RLS) is a rare brain disorder, characterized by diffuse attenuation of cerebral white matter, which has been most commonly observed in transplant patients receiving calcineurin inhibitors or in patients with severe hypertension. We report an episode of RLS in a 22-year-old male patient on chronic hemodialysis with well-controlled moderate hypertension who presented with de novo headache and generalized seizures. Cranial magnetic resonance image (MRI) revealed multiple areas of increased signal intensity in the white matter on T2-weighed images which resolved spontaneously at subsequent MRIs. White blood cell count showed leucopenia with normal CD4 count at flow cytometry. A viral etiology could not be demonstrated. Reversible leukoencephaolopathy syndrome symptoms remitted within 72 h but leukopenia persisted over 10 months. The patient received a kidney transplant 15 months after RLS onset and has received cyclosporine since the second post-transplant day. No recurrence of RLS symptoms has been observed. The etiology of the MRI changes in the present case seemed not to be either vasogenic or cytotoxic.

Association of Clinical Complications with Nutritional Status and the Prevalence of Leukopenia among Arsenic Patients in Bangladesh

This study conducted in Bangladesh reports the relationship of clinical complications with nutritional status and the prevalence of leukopenia among arsenic exposed patients living in the rural villages. A total of 115 exposed individuals diagnosed as arsenicosis patients were randomly selected from four known arsenic endemic villages, and age-matched 120 unexposed subjects were enrolled in the study program. The duration of arsenic exposure in about 37% of the patients was at least 10 yrs, while the population mean and range were 7.6 +/- 5.2 yrs, and 1 - 25 yrs, respectively. The mean arsenic concentrations in the drinking water for the exposed and unexposed (control) population were 218.1 microg/L and 11.3 microg/L, respectively. The spot urine sample of the arsenicosis patients contained an average of 234.6 microg/L arsenic. Although very few patients showed elevated WBC count, 16% had leukopenia (below normal count), and the whole population had significantly low WBC count than the control subjects. Prevalences of neutropenia and lymphocytosis were observed in patients with chronic exposure to high levels of arsenic in water. The body mass index was found to be lower than 18.5, the cut-off point for malnutrition (underweight), in about 28% of the arsenicosis cases compared to 15% of the controls. The monthly income and total calorie consumption per day showed the patients were underprivileged than the controls. Arsenical symptoms and complications were more severe in the nutritionally vulnerable (underweight) patients than the overweight ones. Also, the incidences of leukopenia and anaemia were more common in the female patients who were underweight. The findings of this research demonstrate that the poor nutritional status of patients increases the complications of chronic arsenic toxicity; suggest the possibility of other sources of arsenic contamination different from drinking water in the study area; and establish a higher prevalence of leukopenia and lymphocytosis in arsenicosis patients.

[Case report: a Fusarium fungaemia]

In this report, a case of Fusarium fungaemia developed in an acute lymphoblastic leukemia (ALL) patient was presented. A seven year old girl who had weakness, loss of appetite, paleness and ecchymosis on legs applied to Pediatric Hematology Service and cytotoxic chemotherapy was started after she had been diagnosed as ALL-L1. Her chemotherapy was stopped because of increase in fever, leukopenia and neutropenia. Central venous catheter and peripheral blood cultures were obtained. Fusarium thapsinum was recovered from blood cultures, obtained in two consecutive days. Thereupon central venous catheter of the patient was removed and intravenous amphotericin B was added to the therapy. On the fifth day of febrile neutropenia attack, her fever was decreased after the onset of antifungal therapy. Radiological examinations were normal and no fungal growth was observed in the later blood cultures. On the 21st day of amphotericin B therapy, chemotherapy was started again and amphotericin B was changed to peroral itraconazole (200 mg/day) at the fifth week. The patient whose itraconazole therapy was stopped after three months, was still in remission and continued receiving her prolonged therapy. In conclusion, Fusarium infections which manifest with fungaemia and fever as the only symptoms, should be taken into consideration in neutropenic patients receiving immunosuppressive therapy.

Virulence of metallo-beta-lactamase-producing Pseudomonas aeruginosa in vitro and in vivo

We evaluated the virulence of Pseudomonas aeruginosa carrying bla(IMP), a metallo-beta-lactamase gene, and the efficacy of ceftazidime, imipenem-cilastatin, and ciprofloxacin in the endogenous bacteremia model. The presence of bla(IMP) did not practically change the virulence of the parent strain, and ciprofloxacin was effective against infection with P. aeruginosa carrying bla(IMP).

Novel inhalational murine model of invasive pulmonary aspergillosis

We developed a novel model of invasive aspergillosis (IA) that recapitulates human disease. Mice were immunosuppressed with cyclophosphamide and cortisone acetate and then infected in an aerosol chamber. This procedure reproducibly delivered 1 x 10(3) to 3 x 10(3) conidia to the lungs. Lethal pulmonary IA developed over 2 weeks and was prevented by amphotericin B.