Solitary plasmacytoma of the sacrum presenting as a pelvic mass: report of two cases

We describe two unusual cases of solitary plasmacytoma of the sacrum seen as a pelvic mass. Excessive bleeding, a distinct possibility, should be anticipated whenever a biopsy or resection of the tumor is considered. Because of the tumor's apparent radioresponsiveness and known evolution to multiple myeloma in some cases, radiotherapy and chemotherapy are recommended.

Long-term survival in small cell lung cancer with superior vena caval obstruction

Two patients were diagnosed with small cell lung cancer and superior vena caval obstruction. Successful palliation of symptoms with significant reduction in size of the intrathoracic lesion was achieved with radiation therapy and chemotherapy. Treatment resulted in complete remission with long-term (more than 3 years) survival. These two cases affirm the fact that, despite the generally recognized poor prognosis of small cell lung cancer associated with this syndrome, aggressive therapy can sometimes provide rewarding results.

Heparin-induced thrombotic thrombocytopenia

OBJECTIVE

To report a case of heparin-induced thrombotic thrombocytopenia (HITTS) and discuss the incidence, possible mechanisms, complications, and treatment for this syndrome.

DATA SOURCES

Case reports and review articles identified by MEDLINE from 1980 through 1991. Older articles located by manual searches.

DATA EXTRACTION

Data were extracted and reviewed from published sources. Cases were selected on the basis of case presentation, time of disease onset, pathophysiology of disease, and therapeutic options.

SETTING

A 600-bed university teaching hospital and an affiliated community hospital.

PATIENT

A 36-year-old woman with insulin-dependent diabetes mellitus, sepsis, adult respiratory distress syndrome, diabetic ketoacidosis, oliguric renal failure developed HITTS and subsequent gangrene of her right arm.

INTERVENTION

Immediate cessation of all heparin use and amputation of the patient's right arm.

RESULTS

The patient's condition improved progressively over the following 60 days and she was discharged to outpatient care.

CONCLUSIONS

Heparin has been associated with thrombocytopenia and thrombotic events. Laboratory tests for HITTS are unreliable and the diagnosis is usually suspected by the clinical presentation of the patient. Platelet counts should be monitored closely during heparin use. In the event of a marked decrease in platelet count associated with venous or arterial thrombosis, heparin therapy should be stopped immediately. If further anticoagulation is necessary, oral anticoagulants such as warfarin may be used instead. As the onset of warfarin may take several days to become therapeutic, aspirin, dipyridamole, or both may be used effectively. Healthcare workers should be aware that in these patients, the use of even small amounts of heparin can produce catastrophic results.

Ischiogluteal bursitis in cancer patients: an infrequently recognized cause of pain

We report eight patients with metastatic malignancy who developed severe back and leg pain caused by ischiogluteal bursitis. Careful evaluation excluded the possibility of bony metastases. Ischiogluteal bursitis is an easily diagnosed condition that can be effectively treated with local injection of corticosteroids. Recognition of this disorder will allow prompt therapy and unnecessary evaluation expenses.

Kaposi's sarcoma involvement of the bone marrow

Kaposi's sarcoma (KS) is a predominantly cutaneous malignancy with several clinical variants. Extracutaneous sites of involvement are uncommon in all disease variants except epidemic KS (human immunodeficiency virus related) and the African lymphadenopathic variant. Extracutaneous KS usually involves the lymph nodes, gastrointestinal tract, and respiratory tract. The authors report the first description of a patient with classic KS to have bone marrow involvement. Two additional patients with KS variants and bone marrow involvement have been described. Bone marrow tumor invasion should be considered in patients with KS and hematologic abnormalities.

Occult antithrombin III deficiency: a potentially lethal complication of the postphlebitic limb

Chronic venous insufficiency is a frequent sequel to lower extremity venous thrombosis. A relatively uncommon, but potentially lethal, cause of the thrombosis is congenital antithrombin III deficiency. Recognition and treatment of this occult deficiency is critical. The following report describes a family treated by the authors for this problem. In one generation of nine siblings, three males had documentation of the disease with functional antithrombin III levels in the range of 50% to 60%. Before evaluation for the deficiency one female sibling died at the age of 20 years as a consequence of a proven pulmonary embolus. Antithrombin III levels in another female sibling, who was free of symptoms, were normal (80% to 120%). Four other siblings who were free of symptoms (one female, three males) refused evaluation. All three men with the deficiency had severe, chronic, bilateral, lower extremity, venous insufficiency manifested by pain, varicosities, edema, pigmentation, and ulceration. Despite chronic warfarin therapy, one experienced recurrent pulmonary embolization with eventual loss of perfusion of the entire right lung. Ascending venography in the symptomatic males with the deficiency revealed evidence of recurrent and diffuse venous thrombosis with partial recanalization. Recurrent lower extremity venous thrombosis consequent to antithrombin III deficiency causes a particularly fulminant postphlebitic syndrome with characteristic venographic findings. Although potentially lethal if unrecognized and treated simply as venous insufficiency, chronic therapy with warfarin offers palliation and prolongs life.

Antinuclear antibodies in sickle cell disease

The frequency of antinuclear antibodies (ANA) and other antinuclear factors was prospectively evaluated in patients with sickle cell disease (SCD). Ten of 44 patients studied (22.7%) had positive ANA determinations at titers greater than or equal to 1:40 compared to 3 of 46 healthy controls (6.5%; p less than 0.03). Eight SCD patients had ANA titers of 1:160 or greater compared to none of the controls (p less than 0.003). No antibodies directed against other nuclear factors were found. An analysis of the patient histories revealed no statistical differences between the ANA-positive and ANA-negative SCD patients when correlated with disease activity.

Phase II evaluation of bisantrene in acute leukemia. A Southwest Oncology Group Study

Twenty-nine patients with heavily pretreated acute leukemia in relapse were treated with bisantrene (maximum dose 120 mg/m2/day x 5) in a phase II study. Twenty-seven of the 29 patients were evaluable for response, receiving a total of 53 courses of treatment. There were three complete remissions (11%) lasting 27, 107, and 115 days. One brief partial remission of 43 days was also seen for a total response rate of 15%. Toxicity was mainly limited to the expected myelotoxicity with minimal nonhematologic toxicity seen. Although the complete remission rate is low, an antileukemic effect was seen in the majority of the patients treated. Sixty-one percent of the patients had at least a 50% decrease in the circulating blast count and 32% had at least a 50% decrease in the number of bone marrow blasts. We conclude that bisantrene does have an antileukemic effect, but that the optimal starting dose is not yet established.

Parathyroid hormone and anaemia--an erythrocyte osmotic fragility study in primary and secondary hyperparathyroidism

Parathyroid hormone (PTH) has been shown in vitro to enhance erythrocyte osmotic fragility (EOF) and has been incriminated as a factor in the anaemia seen in patients with primary hyperparathyroidism and in patients with renal disease and secondary hyperparathyroidism. Enhanced EOF has also been shown in patients with chronic renal failure but did not correlate with PTH levels. We studied a group of patients with primary hyperparathyroidism with and without anaemia, and patients with secondary hyperparathyroidism and anaemia. We found that EOF studies in these patients did not differ from normal control groups and that there was no relation between PTH, EOF, and haematocrit in either study group. We conclude that PTH over a range of concentrations seen in vivo does not affect erythrocyte osmotic fragility or cause anaemia.

Reversible acute sensorineural hearing loss associated with essential thrombocytosis

The isolated occurrence of reversible acute sensorineural hearing loss associated with thrombocytosis without other neurologic or hematologic manifestations has not been previously reported in the English literature, to our knowledge. We treated a patient with essential thrombocytosis who developed acute sensorineural hearing loss associated with marked thrombocytosis and in whom the hearing loss reversed after plateletpheresis.

Immune thrombocytopenia and ulcerative colitis

We have described a patient with simultaneous onset of antibody-positive immune thrombocytopenic purpura and ulcerative colitis, an association that must be extremely rare. Although the colitis responded to steroid therapy, the thrombocytopenia required splenectomy. The antibody was monomeric, with HLA specificity against A3 and B8 platelets.

Predictive value of trypan blue exclusion viability measurements for colony formation in a human tumor cloning assay

Specimens (173) were evaluated to assess the predictive value of cell viability as measured by Trypan Blue exclusion on colony formation in a human tumor cloning system. Overall, there was no significant correlation between Trypan Blue exclusion-determined viability and colony formation in soft agar for these specimens (p = 0.43). This lack of significant correlation was maintained for primary, metastatic, solid, and fluid tumor specimens. These data suggest that, in this soft agar system, specimens containing cells with low Trypan Blue exclusion viability should not be excluded from testing, and that it may not be advantageous to plate on the basis of "viable cells" as measured by Trypan Blue exclusion.

The hypereosinophilic syndrome in acute lymphocytic leukemia

A 21-year-old white man presented with marked peripheral blood eosinophilia that later evolved into acute lymphocytic leukemia (FAB2 ALL). He died precipitously from refractory congestive heart failure immediately after antileukemic therapy was started. Autopsy revealed multiorgan infiltration with eosinophils and the typical cardiac findings of Löfflers endocarditis. Clinical and pathologic features of this and the 14 other cases of ALL and the hypereosinophilic syndrome (HES) reported in the English-language literature are described. The eosinophilia in these cases is reactive and resolves with successful leukemia remission induction. Hydroxyurea is effective in rapidly lowering eosinophil counts. Early use of hydroxyurea in this disease may improve patient survival and decrease the risk of sudden cardiac death.