Acquired factor XI inhibitor in chronic lymphocytic leukaemia

A 71 year old man with chronic lymphocytic leukaemia (CLL) experienced excessive bleeding following transurethral resection of the prostate. Investigations showed a prolonged kaolin cephalin clotting time (KCCT) with low concentrations of factor XI. The prolonged KCCT was largely corrected by mixing with normal plasma but this correction was lost on incubation, confirming the presence of an inhibitor. He was treated with pulsed methylprednisolone and chlorambucil which resulted in the resolution of the bleeding problem and the loss of detectable circulating inhibitor.

Comparison of the multiple dose pharmacokinetics of two formulations of itraconazole during remission induction for acute myeloblastic leukaemia

This double-blind cross-over study compares the serum pharmacokinetics of a polyethylene glycol formulation of itraconazole (ITRA-PEG; 4 x 50 mg once daily) with a new pelleted formulation (ITRA-PEL; 2 x 100 mg once daily) during remission induction for acute myeloblastic leukaemia. Each formulation was administered for 28 days with a seven day washout period. Five of eight patients (median age 52 years, range 18-65) entering completed both arms of the study. At day 7 for ITRA-PEL (n = 8) the mean +/- one standard deviation and median maximum concentrations (Cmax) were 307 +/- 155 ng/mL and 275 ng/mL respectively and for ITRA-PEG (n = 6) 272 +/- 212 ng/mL and 193 ng/mL. At day 14 for ITRA-PEL (n = 8) the mean +/- S.D. and median Cmax were 412 +/- 227 ng/mL and 375 ng/mL respectively and for ITRA-PEG (n = 5), 315 +/- 177 ng/mL and 327 ng/mL. The Cmax mean and median values were therefore greater with ITRA-PEL but the differences between the two formulations were not statistically significant. Adequate therapeutic levels of itraconazole can be achieved in this clinical setting. However, the wide variation within and between patients suggests that an ITRA-PEL dosage of 400 mg/day may ensure earlier and more consistent therapeutic levels. Measurement of serum levels may be indicated in suspected failure of prophylaxis or treatment.

Duplex sonography in splenomegaly

The aetiology of splenomegaly is seldom clear from either clinical or imaging assessment of the spleen. In the majority of cases sonographic assessment of the spleen produces a homogeneous enlargement of variable echodensity, but with very poor correlation with pathology. A study has been undertaken to assess the Doppler characteristics of the splenic artery in splenomegaly, excluding cases of portal hypertension in an attempt to provide further diagnostic information. Duplex assessment of 18 normal subjects and 10 patients with splenomegaly due to five different causes was undertaken. Analysis of waveform, peak frequency and pulsatility index were compared and failed to demonstrate any significant change. In the normal subject there is a broad systolic spectrum related to the tortuosity of the splenic artery, with persistence of forward flow throughout diastole, a reflection of the low peripheral resistance of the spleen. In splenomegaly the broad systolic spectrum is unchanged, since vessel tortuosity persists. Pathological and physiological assessment of the spleen in splenomegaly shows that a low resistance circulation persists, explaining maintenance of the diastolic flow pattern in splenomegaly. Increased blood flow to the spleen in splenomegaly occurs either as a result of an increase in vessel diameter or an increase in flow velocity, or a variable combination of the two which does not seem to be governed by specific pathology. An increase in peak frequency in some cases reflected some increase in flow velocity but provided no useful correlation. Analysis of the pulsatility index supported the above findings without adding further information.

Haematological toxicity compromises MOPP/ABVD chemotherapy in Hodgkin's disease

A total of 23 patients with previously untreated Hodgkin's disease received MOPP/ABVD hybrid chemotherapy and response to treatment and toxicity were assessed. Of these 14 (61% (95% confidence limits 38.5%-80%] achieved complete remission with chemotherapy alone, six (26% (10.2%-48.4%)) achieved partial remission and there were three treatment failures (13%). Toxicity was mainly haematological resulting in treatment delays and dose reductions. Those in partial remission after chemotherapy achieved complete remission with additional radiotherapy. So far five of the 20 who remitted (25%) have relapsed. We conclude that the haematological toxicity from this regimen compromises dose intensity. The results from using this hybrid regimen are not superior to those using MOPP or ABVD alone in our experience.

Alopecia totalis and vitiligo in common variable immunodeficiency

Three cases of severe and irreversible alopecia occurring in patients with common variable immunodeficiency are described. In all three cases, hair loss developed after the diagnosis of immune deficiency; one of the patients also had extensive vitiligo. A fourth patient had vitiligo in the absence of alopecia. No change in the alopecia or vitiligo was noted in any patient as a result of immunoglobulin replacement therapy.

Prophylaxis of fungal infections with itraconazole during remission-induction therapy

Deep fungal infections are an increasing problem in the treatment of acute leukemias and malignant lymphomas. Risk factors are known but unavoidable. Because of diagnostic difficulties most patients are treated empirically with intravenous amphotericin B. This drug's toxicity increases morbidity and mortality. An orally absorbable triazole derivative, itraconazole, may offer effective and safe prophylaxis against deep candidosis and aspergillosis in these patients. Such infections have been treated successfully with oral itraconazole even when resistant to intravenous amphotericin B. In retrospective comparative studies there are significantly less deep fungal infections in patients given itraconazole. The significance of the difference varies between studies. Pharmacokinetic data confirm therapeutic plasma levels of itraconazole but with wide variation within and between patients. The current large, multi-centre, randomised, double-blind, prospective trial of oral itraconazole versus placebo in the U.K. will test its prophylactic efficacy against deep fungal infections during treatment of haematological malignancies.

Lack of significant effect of therapeutic propranolol on measurable platelet function in healthy subjects

Propranolol, a non-selective beta blocker, was administered orally in therapeutic doses. The effects of a single dose (160 mg) and one week's treatment (80 mg twice a day) on platelet function were compared in healthy young subjects. There were no significant changes in circulating platelet aggregates, template bleeding time, platelet factor 3 availability and thromboxane beta 2 (TX beta 2) generation. Platelet aggregation responses as assessed by angle of slope and maximal percentage aggregation (all agonists) and lag phase (collagen) showed no changes of biological importance, although minor changes reaching significance were observed with some agonists. These findings suggest that propranolol does not significantly affect platelet function when taken at doses commonly encountered in clinical practice.

Clonal evolution in Ph-negative, bcr-positive chronic myeloid leukaemia before and after bone marrow transplantation

A 26-year-old man, who presented with bilateral fundal haemorrhages, was found to have chronic myeloid leukaemia (CML). The Ph chromosome was not present but a clone with t(1;9) (p32;q34) was detected. On referral for bone marrow transplant (BMT) he was found to be in accelerated phase with clonal evolution in three cell lines inv(3)(q21q26); inv(3)(q),i(17q); inv(3q)+8. Molecular investigation revealed a breakpoint on chromosome 22 within the breakpoint cluster region (bcr) similar to that found in Ph+ cases. After BMT, from an HLA-identical sister, successful engraftment (46,XX) was accompanied by evidence of a residual host cell population with further evolution (del(7)(q22)) and persistence of the bcr+ clone. Acute myeloid leukaemia, detected 5 months later, was associated with predominance of the clone 46XY,t(1;9),inv(3q),del(7)(q22) which failed to respond to treatment and the patient died 6.5 months after BMT. This case indicates that BMT, after the acquisition of additional chromosomal change in accelerated phase, may fail owing to persistence of the leukaemic clone. In addition the BMT conditioning regimen may produce further abnormalities which confer drug resistance on the persisting clone, which can emerge as an intractable myeloid blast crisis.

Treatment of acute myeloid leukaemia with early intensive induction therapy

Patients with primary acute myeloid leukaemia were treated with induction therapy consisting of daunorubicin 50 mg/m2 (days 1 and 2) and continuous cytosine arabinoside 400 mg/m2 (days 1-5) with a 7-10-day gap between courses. Consolidation therapy consisted of one further similar course and a final course of cytosine 1 g/m2 infusion (days 1-5). Patients were randomised to receive no further treatment or monthly maintenance therapy consisting of thioguanine 100 mg/m2 twice daily and etoposide 100 mg/m2 twice daily (days 1-5) alternating with CCNU 50 mg/m2 once to a total of 6 courses. 64 patients entered the study; median age was 54 years (range 18-74 years) and 51 patients entered complete remission (79.7%). Thirty-two patients completed consolidation and were randomised between maintenance therapy (n = 16) and no treatment (n = 16). 21 patients have relapsed with neither remission duration nor relapse rate being affected by maintenance therapy.

Acute myeloblastic leukaemia in the elderly

Acute myeloblastic leukaemia (AML) is a disease of the elderly with a median age at presentation in the seventh decade and a peak incidence in the U.K. of greater than 20 patients per 100,000 population per yr between the ages of 80 and 84. Most major AML trials are carried out on a younger population of patients with low recruitment of the elderly. The results in older patients are much worse than younger patients and often no better than the natural history of the disease. These poor results may be partly due to poor tolerance of treatment in the elderly, but are also due to intrinsic differences between AML in the elderly and AML in younger patients. These problems all justify randomised, prospective trials designed specifically for elderly patients to test prognostic scoring and various levels of intensity of therapy.

Restoration of active haemopoiesis in a patient with myelofibrosis and subsequent termination in acute myeloblastic leukaemia: case report and review of the literature

A patient with polycythaemia vera developed typical myelofibrosis after 15 yr. After a further 8 months, during which time she was pancytopenic and transfusion-dependent, a slow spontaneous recovery in haemopoiesis occurred and the full blood count became normal. 6 months later pancytopenia recurred and soon afterwards the patient developed acute myeloblastic leukaemia from which she died. The evolution of bone marrow morphology and isotopic studies. Only 2 previous reports of this kind of transformation exist in the literature, although restoration of normal or polycythaemic haemopoiesis has been reported in 8 patients with myelofibrosis. It is likely that these transformations occur because of alterations in stem cell behaviour rather than as a result of therapy.

Prospective comparison of laser nephelometry with standard agglutination techniques for detection of rheumatoid factor

IgM rheumatoid factor was assayed by three routine methods: latex fixation; haemagglutination; and end point laser nephelometry in 69 patients with definite or classical rheumatoid arthritis and 58 patients with other non-rheumatoid arthropathies, selected prospectively according to the American Rheumatism Association clinical criteria. The operators of the assays were unaware of the clinical diagnoses. In the group with rheumatoid arthritis 75.4% were positive by latex fixation, 73.9% by haemagglutination, and 55.1% by nephelometry. In the group with non-rheumatoid arthropathies 10.4% were positive by latex fixation, 8.6% by haemagglutination, and 10.4% by nephelometry. Thus the simple and inexpensive latex fixation test was as good as the haemagglutination test, and both were significantly better than nephelometry in the laboratory confirmation of the clinical diagnosis of definite or classic rheumatoid arthritis (chi 2 = 5.40 and 4.56, and p less than 0.025 and less than 0.05, respectively). None of these tests was significantly better or worse than the others in producing positive results in the group with non-rheumatoid arthropathies.

Pulmonary aspergillosis in immunosuppressed patients with haematological malignancies

Invasive pulmonary aspergillosis as a cause of mortality and morbidity in patients with haematological malignancies is becoming more common. Predisposing factors are powerful immunosuppressive chemotherapy, neutropenia and synergistic combinations of antibiotics of great potency and wide spectrum of activity. Clinical and radiological signs are heterogeneous, sometimes misleading and often absent. Treatment is often empirical on suspicion alone. Amphotericin B is the only effective drug but it has marked toxicity, mainly renal. Infection is usually fatal without adequate treatment. This paper describes eight cases of invasive pulmonary aspergillosis seen in one centre in two years, reviews the literature and assesses associated problems.

Meningeal relapse in Ph1-positive acute lymphoblastic and lymphoid blast crisis of chronic granulocytic leukemia. Is CNS-prophylaxis indicated?

Two cases of Ph1-positive acute lymphoblastic leukemia (ALL) and one case of lymphoid blast crisis (LyBc) of chronic granulocytic leukemia (CGL) treated with standard chemotherapy for ALL are presented. Hematologic remissions lasting 6, 12, and 15 months were achieved in all cases. Meningeal relapse occurred in all three, terminating remission in two cases and occurring immediately after systemic relapse in the third. No CNS-prophylaxis was given to the patient who relapsed at six months. Methotrexate (MTX) alone or combined with cranial irradiation formed the prophylaxis given in the other cases. Experience of these patients together with an analysis of reported cases of Ph1 ALL and CGL-LyBc suggests CNS-prophylaxis may prolong first remission. A large scale trial of this appears indicated.

Diagnosis and treatment of venous thromboembolism by consultants in Scotland

A questionnaire was sent to 508 consultants in Scotland likely to encounter deep vein thrombosis and pulmonary embolism to assess their current standard practice in diagnosis and treatment of these disorders. Replies were received from 358 (70.5%). In deep vein thrombosis 47% and in pulmonary embolism 33% of consultants usually depended on clinical observation alone for diagnosis. In deep vein thrombosis 37% used venography to supplement clinical diagnosis and in pulmonary embolism 13% used angiography and 53% used isotopic scanning. Almost all consultants treated deep vein thrombosis (95%) and pulmonary embolism (99%) with anticoagulants. Most consultants (81%) gave heparin by intravenous infusion. Although many consultants gave intravenous heparin for more than three days (49.5% in deep vein thrombosis and 61% in pulmonary embolism), 25% of these consultants did not use any laboratory monitoring of heparin's effect. Large numbers of consultants gave warfarin for more than three months (20% in deep vein thrombosis and 47% in pulmonary embolism). There was a significant tendency to give heparin (p less than 0.01) and warfarin (p less than 0.001) for longer periods in pulmonary embolism than in deep vein thrombosis. This survey shows a widely varying practice and underlines the need for further controlled studies to provide clear guidance in the management of deep vein thrombosis and pulmonary embolism.

Terminal transferase expression in relapsed acute myeloid leukaemia

In three cases of acute myeloid leukaemia marked increases in expression of the nuclear enzyme, terminal deoxynucleotidyl transferase (TdT), were observed during disease relapse. The first case was heterogeneous at diagnosis, consisting of subpopulations of large TdT- myeloblasts and small TDT+ blasts; however, at relapse there was complete replacement by TdT+ lymphoblasts. The other cases at diagnosis were both typical acute myeloid leukaemia, TdT-; at relapse, one showed a mixture of TdT- myeloblasts and TdT+ lymphoblasts, while in the other, TdT was demonstrated on a subpopulation of myeloblasts. No chromosomal abnormalities were found. It is suggested that in the first two cases these phenomena may have been due to leukaemic involvement of a pluripotential stem cell, or that sub-clones with different properties may have coexisted. In the third case at relapse, TdT was expressed aberrantly by malignant myeloid cells.

Terminal deoxynucleotidyl transferase expression in acute non-lymphoid leukaemia: an analysis by immunofluorescence

Indirect immunofluorescence for terminal transferase enzyme (TdT) was used to study the blasts of 64 patients with acute non-lymphoid leukaemia (ANLL). In 32 patients no TdT positive cells were seen. In 19 cases a small subpopulation of cells expressing TdT was detected; these constituted up to 5% of total nucleated cells, and it was not clear whether these TdT positive cells were part of the leukaemic process or represented residual normal bone marrow lymphoid cells. The remaining 13 patients had TdT positive cells accounting for 7-90% of the total. In two of these cases TdT was expressed on blasts with myeloid features, representing an aberrant expression of TdT by myeloid cells; in contrast, in three cases mixed populations of TdT positive lymphoid blasts and TdT negative myeloid blasts were observed. In the remaining cases it was not possible to determine whether the TdT positive cells had definite lymphoid or myeloid features. Cytogenetic analysis showed no evidence of the Philadelphia chromosome. Response to treatment was assessed in 11 of the 13 patients. Only one patient remitted with the initial choice of therapy (DAT); four failed to respond to initial regimes of vincristine and prednisone (V & P) while the other five patients did not respond to myelotoxic combinations (DAT). Only one patient subsequently entered complete remission on second line therapy (V & P). This group of patients with TdT+ ANLL had a particularly bad prognosis, and appeared to differ from cases of TdT positive acute undifferentiated leukaemia, which often respond to V & P therapy.

Mixed lymphoblastic-myelomonoblastic leukemia in treated Hodgkin's disease

In a case of acute leukemia occurring 5.5 yr after diagnosis of Hodgkin's disease, a mixture of lymphoid and myelomonocytoid blasts was identified by morphological, cytochemical, and immunologic methods. The majority of blasts were characterised as lymphoid by their strong expression of nuclear terminal transferase (TdT) enzyme. In contrast, a minor blast population was identified as myelomonocytoid by the strong nonspecific esterase positivity and lack of TdT. The two distinct blast cell populations showed different sensitivity to the various chemotherapeutic protocols used.