Influence of dietary taurine on vitamin D absorption

To evaluate the influence of dietary taurine supplementation on vitamin D absorption, we studied three groups of infants: 21 (11 preterm) were fed a taurine-free formula, 21 (10 preterm) were fed a taurine-supplemented formula (50 mg/100 g of powder) and 20 (9 preterm) were fed human, not heat-treated milk. Taurine, total bile acids, glyco-(GBA) and tauro-(TBA) conjugated bile acids, 25-hydroxyvitamin D3 (25OHD3) and 1,25-dihydroxyvitamin D3 (1,25OH2D3) were determined in all infants at birth in blood cord and at one and three months of life. In preterm infants fed a taurine-free formula, we found lower plasma taurine levels than in infants of other groups at one and three months of life. In these infants, GBA predominated, with a G/T ratio of 1.1 and 1.4 at one and three months of life, whereas in all other infants TBA predominated with a G/T ratio always < 1. Also, 25OHD3 and 1,25OH2D3 levels were significantly lower in preterm infants fed a taurine-free formula than in infants fed a taurine-enriched formula or human milk. Term infants fed a taurine-free formula did not show differences in the parameters studied in comparison to infants of other groups. Low taurine dietary intake appears to compromise vitamin D absorption in preterm infants, and therefore taurine supplementation of preterm infant formulas should be encouraged.

Cyclosporine as possible prophylaxis for obstructive airways disease after allogeneic bone marrow transplantation

The objective of this study was to evaluate the impact of cyclosporine (cyclosporin A; CyA) prophylaxis for graft-versus-host disease (GVHD) on the development of obstructive airways disease (OAD) after allogeneic bone marrow transplantation (BMT) in leukemic patients. Patients with normal pulmonary function tests (PFTs) prior to BMT were followed with serial PFTs for the development of OAD. Follow-up PFTs were performed at 3, 6, 9, and 12 months, and thereafter at consecutive yearly intervals. Obstructive airways disease was defined as FEV1 less than 80 percent, ratio of FEV1 over the forced vital capacity (FEV1/FVC) less than 80 percent of predicted, maximal midexpiratory flow rate at 50 percent vital capacity less than 65 percent of predicted, or residual volume greater than 120 percent of predicted. In the period prior to CyA prophylaxis for GVHD development (March 1983 to September 1986), 17 (39 percent) of the 44 patients undergoing BMT developed OAD, compared with 2 (4 percent) of 45 in the post-CyA period (September 1986 to March 1990) (chi 2 = 17; p < 0.00005). Age, sex, type of leukemia, severity of GVHD, histocompatibility status, presence of acute GVHD, and sex mismatch between donor and recipient were not associated with development of OAD. Although chronic GVHD was associated with OAD in univariate analysis, a multivariate logistic regression analysis showed that the only significant independent predictor for OAD was the use of CyA. We conclude that CyA is protective against the development of OAD after BMT in leukemic patients.

Long-term sequelae after recovery from cytomegalovirus pneumonia in allogeneic bone marrow transplant recipients

The clinical course of cytomegalovirus (CMV) pneumonia in seven consecutive bone marrow transplant (BMT) recipients during a 24-month period was studied. Retrospective analysis of clinical data on the recipients with CMV pneumonia during the illness and prospective follow-up of those who recovered from the pneumonia was performed. Those who had CMV as the sole pathogen and with lymphocytosis in the BAL or the peripheral blood during the illness recovered from the pneumonia. On the contrary, those who had mixed bacterial or fungal infection with peripheral lymphopenia died. Persistent lymphocytosis in the BAL and the peripheral blood, in the absence of CMV infection, was observed in the survivors. Two subsequently developed restrictive lung disease and two had relapse of their primary malignancy. These data suggest that CMV pneumonia in BMT patients is associated with significant long-term sequelae. The phenomenon of persistent lymphocytosis in the BAL and the peripheral blood, in the absence of CMV infection, supports Grundy's hypothesis that CMV pneumonia in BMT recipients is an immunopathologic condition.

[Prostacyclin in the treatment of persistent fetal circulation syndrome]

Persistent pulmonary hypertension of the neonate (PPHN), described initially by Gersony in 1969 as persistent foetal circulation (PFC syndrome), results from a flawed transition from foetal to extrauterine pulmonary circulation. It is primarily characterised by persistence of, or return to, the suprasystemic pulmonary vascular resistance and pressure normally found in the foetus. The increased pulmonary pressure causes right to left shunting through the ductus arteriosus or the foramen ovale, or both. The resulting hypoxaemia and acidosis may produce further pulmonary vasoconstriction and lead to a vicious cycle of shunting, hypoxia and acidosis. Infants with a wide variety of underlying clinical conditions develop PPHN. This condition is reversible, but can cause very severe and unrelenting respiratory failure and ultimate death when uncontrolled. Although vasodilating agents, such as tolazoline, have been used with variable success in the treatment of PPHN, a generally acceptable therapy is still lacking. We report here the use of prostacyclin (epoprostenol, PGI2) in two infants with severe and refractory hypoxaemia secondary to pulmonary vasoconstriction.

Point mutation in the cytoplasmic domain of the neutrophil p22-phox cytochrome b subunit is associated with a nonfunctional NADPH oxidase and chronic granulomatous disease

Chronic granulomatous disease (CGD) is a congenital disorder in which phagocytes cannot generate superoxide (O2-) and other microbial oxidants due to mutations in any one of four components of the O2(-)-generating complex, NADPH oxidase. We report here a female CGD patient in whom a missense mutation in one of these components, the p22-phox subunit of the neutrophil membrane cytochrome b [where phox indicates phagocyte oxidase (used to designate protein components of the phagocyte NADPH oxidase)] results in a nonfunctional oxidase and failure of neutrophils to produce O2- in response to phorbol 12-myristrate 13-acetate. Cytochrome b in the patient's neutrophils was normal in appearance and abundance as determined by visible spectroscopy and by immunoblots of the gp91 and p22 subunits. However, the neutrophil plasma membranes were devoid of activity in the cell-free oxidase activation system, whereas the cytosol functioned normally. We postulated that the patient was homozygous for a mutation in p22 that results in the synthesis of normal levels of a nonfunctional cytochrome b. A single-base substitution (C----A) was found in the patient's mononuclear cell p22-phox cDNA that predicts a nonconservative Pro----Gln substitution at residue 156. The same mutation was also identified in all clones sequenced from patient genomic DNA, demonstrating homozygosity for the mutant allele. An antipeptide antibody against p22 residues 153-164 was found to bind only to permeabilized neutrophils, indicating that the mutation occurs in a cytoplasmic domain. These studies establish that this domain of p22-phox is cytoplasmic and that mutations in this region can have profound effects on cytochrome b function.

Sodium lithium countertransport is acutely influenced by heparin-induced extracorporal LDL precipitation

Sodium lithium countertransport may be a genetic marker for arterial hypertension and for the risk of diabetic nephropathy in type 1 diabetic patients. Since various factors seem to influence the transport velocity including serum lipid alterations, erythrocytes of seven patients with severe hyperlipoproteinaemia who were chronically and intermittently treated with LDL apheresis were examined before and immediately after therapy. The LDL apheresis reduced sodium lithium countertransport significantly (0.383 vs 0.269, P less than 0.02). Therefore, we conclude that serum lipid composition must be considered when interpreting sodium lithium countertransport velocity.

[Chronic intermittent duodenal obstruction in childhood]

Chronic intermittent duodenal obstruction caused by stenosis of the distal duodenum is a rare disease. Tight fixation of the ligament of Treitz, compression due to mesenteric lymphomatas or abnormal attachment of the mesocolon can cause intermittent impairment of intestinal passage. It will be necessary to differentiate this against genuine arterio-mesenteric duodenal obstruction as well as nerve motility disorders. History in the appropriate cases reports on postprandial episodes of regurgitation, sensation of fullness, nausea, vomiting and paroxysmal upper abdominal colicky pain. Radiograms always reveal gastroptosis and a varying degree of duodenal obstruction, usually with retroperistalsis. The passage is markedly delayed, with an impairment sometimes at the site of the duodenojejunal flexure. Therapy is always surgical. 8 own cases were cured by leftsided duodenal mobilisation according to Clairmont with additional caudad positioning and fixation of the duodenojejunal flexure.

Cytomegalovirus pneumonia in allogeneic bone marrow transplantation. An immunopathologic process?

Recent literature suggests that CMV pneumonia is an immunopathologic process. This case report summarizes the clinical course of a patient which supports this hypothesis. The patient is the recipient of an allogeneic BMT who recovered from an episode of CMV pneumonia that occurred about two months after the transplant. Despite recovery from the viral infection, follow-up BALs revealed persistent lymphocytosis in an apparent asymptomatic patient. He subsequently developed BOOP about four months after the initial CMV infection. These observations suggest that the viral infection may have resulted in the activation of the host's cell-mediated response and provides evidence to support the hypothesis that CMV pneumonia is an immune-mediated process.

The maintenance of busulphan-induced remissions in chronic granulocytic leukaemia with recombinant interferon alpha-2b

Interferon (IFN) shows no specificity in inhibiting the growth of colonies of myeloid leukaemia blasts in culture as compared to normal haemopoietic precursors, but does reduce the self-renewal capacity of myeloblasts. We have tested the ability of IFN to slow the leukocyte doubling time (Ldt) and to prolong remissions induced by busulphan in 14 patients with chronic granulocytic leukaemia (CGL). Patients served as their own controls; the Ldt during relapse from a busulphan-induced remission on no therapy was determined and compared with the Ldt on IFN maintenance therapy. The initial dose of IFN (2 x 10(6) U M-2 subcutaneously, three times per week) was adjusted up, or down, to prevent the leukocyte count from rising and the platelet count from falling below 75 x 10(9) l-1. The dose of IFN required to prevent relapse in seven patients ranged from 1 x 10(6) U M-2 three times per week to 5.2 x 10(6) U M-2 daily, with a median of 2 x 10(6) U M-2 three times per week. IFN maintenance therapy has prevented relapse in six patients for more than 22 months to more than 68 months. In five patients the Ldt was slowed initially but the disease later progressed in four patients to enter the accelerated (three patients) or blast phase (one patient). The Ldt during IFN therapy did not change from the Ldt on no therapy in one patient; this patient later progressed to the blast phase. In two additional patients the leukaemia progressed during the first course of IFN, with shortening of the Ldt; both of these patients entered the blast phase. In the four patients who have discontinued IFN following relapse in the chronic phase, the Ldt remained prolonged for at least one relapse after the IFN was stopped. IFN maintenance therapy failed to control the leukocyte count in the six patients with a control Ldt of less than 40 days and five of these have progressed to enter the accelerated or blast phase. The early survival of this group of patients resembles the survival of 'good risk' CGL patients reported by others. We conclude that IFN maintenance therapy does alter the relapse pattern of a subset of CGL patients, either slowing the Ldt or preventing relapse.

[Diabetic nephropathy. Pathogenetic, diagnostic and therapeutic concepts]

Today the clinical picture of diabetes mellitus is often determined by its late complications. Diabetic nephropathy appears in about 40% of all diabetic patients with type 1 (insulin-dependent) diabetes mellitus within a period of 10-15 years. Early diagnosis is crucial for the prognosis as appropriate therapy may delay or even arrest the reduction of filtration fraction and terminal renal failure. Most important for the early diagnosis is the measurement of albumin and protein excretion.

Experience with Ommaya reservoir in 120 consecutive patients with meningeal malignancy

The Ommaya Reservoir plays an important role in a select group of neuro-oncology patients with meningeal malignancy. The benefits derived must be balanced against potential complications associated with insertion and use of the apparatus. Side effects may be minimized by careful attention to patient selection, pre-operative CAT scan (or MRI), precise surgical technique, perioperative prophylactic antibiotics and meticulous procedure during use of the reservoir.

[Late sequelae of severe injuries to the viscerocranium: clinical, radiographic and CT findings]

After 1 to 7 years the late results of the surgical treatment of 21 patients with partly severe viscerocranial fractures have been evaluated by means of clinical as well as radiographic and CT examinations (with special thin sections and reconstructions). In demonstrating fractures and hemorrhages or mucosal swelling in the sinuses CT was found to be superior--except for fractures of the floor of the orbita and the nasal bone. Clinical dysfunctions and disorders included among others impaired eye motility (5), optic nerve lesions (2), bone prominences (14; predominantly at the orbital margins, in one case resulting in severe deformity of the face), dental and functional masticatory disorders (10), sinus problems and headache (11). The number of fractures that could be demonstrated by radiography and CT was reduced from 336 to 186, and that of fragment dislocations even to less than a quarter of the original figure. Apart from mucosal swelling and 2 hemorrhages, the sinuses--although in some cases severely injured--were well pneumatized again.

Surface antigenic profile and globin phenotype of two new human erythroleukemia lines: characterization and interpretations

Detailed characterization of the composite phenotype of two newly established erythroleukemia lines (OCIM1, OCIM2) shows that these lines share many of their erythroid markers (ie, surface antigens and globin program) as well as several of their nonerythroid properties (myeloid/monocytic/megakaryocytic) with the two known erythroleukemia lines (K562, HEL). In addition, each displays novel and instructive features. We argue that the surface and globin phenotype of all erythroleukemia lines is nonrandom and that it may be of physiologic relevance; it could represent the most prevalent phenotype of cells transformed by leukemia in vivo, and it raises the possibility that cells with similar potentials exist transiently during normal hematopoietic differentiation before their irreversible commitment to a single lineage. As such, these cells demonstrate a greater phenotypic adaptability in vitro than do their single lineage-committed counterparts since they can differentiate toward more than one lineage.

Anticonvulsant-induced marrow suppression and immune thrombocytopenia

Phenytoin and carbamazepine are rarely associated with serious hematologic side effects but can include impairment of either humoral or cell-mediated immunity. We describe a patient who developed severe granulocytopenia while taking phenytoin. The phenytoin was replaced by carbamazepine and the patient subsequently developed erythroid hypoplasia, neutropenia and persistent thrombocytopenia. In vitro studies demonstrated a phenytoin-dependent antigranulocyte antibody directly implicating phenytoin in the leukopenia. An extremely high titre of platelet-associated IgG was found which was independent of the presence of carbamazepine. Autoantibodies directed against the patient's red cells, granulocytes and lymphocytes were also demonstrated. In vitro marrow culture studies failed to detect cellular or humoral inhibitors and were suggestive of a stem cell defect. These studies indicate that anticonvulsant therapy can result in sustained humoral abnormalities as well as in nonimmune mediated marrow suppression.

Magnetic resonance imaging for monitoring relapse of acute myeloid leukemia

Magnetic resonance provides a non-invasive tool for monitoring normal and leukemic bone marrow. Measurements of the T1 relaxation times are elevated in acute myelogenous leukemia. However, interpatient variability diminishes the usefulness of MR measurements for diagnosing leukemia. In following the time course of individual patients, T1 relaxation time measurements appear to give an early and sensitive indication of leukemic relapse after remission and this may serve a clinical role in the management of leukemia by reducing the regularity of necessary marrow aspirates and biopsies.

Idiopathic small airways pathology in patients with graft-versus-host disease following allogeneic bone marrow transplantation

In a retrospective analysis (July 1979 to March 1984) of 120 allogeneic adult bone marrow transplant recipients, we identified seven patients with small-airway disease for whom no microbiologic agent was detected. Six had pulmonary function studies demonstrating air flow obstruction. Five of the seven patients had an open-lung biopsy showing pathologic changes within small airways; these varied from early bronchiolar wall damage to bronchiolitis obliterans. The inflammatory cell infiltrate was peribronchiolar, and consisted of polymorphonuclear leukocytes and lymphocytes in varying proportions. Three of the seven patients recovered following increased immunosuppressive therapy; the other four died. Because all seven patients had acute and chronic graft-versus-host disease, in the absence of any identifiable pathogen, we postulate that small-airway damage represents one of the facets of graft-versus host-disease. An additional analysis of 26 patients with respiratory symptomatology and available histologic material supports the hypothesis that small-airway disease in bone marrow transplant patients represents a risk factor for the subsequent development of respiratory opportunistic infections.

Autoantibody analysis of patients with graft versus host disease

The sera of 26 patients with graft versus host disease (GVHD) were analyzed for the presence of autoantibodies. Because the clinical spectrum of GVHD resembles some of the systemic collagen vascular diseases, particular attention was given to antinuclear antibodies and autoantibodies directed against saline soluble cellular antigens. 39% (10/26) of the patients had a positive ANA at a titer of greater than or equal to 1/80. Antibodies to double-stranded DNA were demonstrated in 4 sera (15%), to smooth muscle in 9 (41%) and to nucleoli in 6 (22%). Three sera had precipitating antibodies to saline extracts of rabbit thymus and/or bovine spleen. None of these precipitins showed lines of identity with known autoantibody systems. High titers of ANA were correlated with a previous diagnosis of acute lymphoblastic leukemia and multiple autoantibodies correlated with the severity of GVHD.

[Vertebrobasilar insufficiency of prenatal origin: a case report]

The case of a newborn presenting from birth with arthrogryposis multiplex congenita resting mainly on the legs, severe hypotonia, consciousness anomalies, clonic fits, recurrent apnea and bradycardia, absent sucking and swallowing is described. At the age 4 months a further episode of apnea and bradycardia was followed by death. The neuropathologic analysis disclosed a number of bilateral, cystic and symmetric infarcts in the thalamus and hypothalamus, spreading caudally to the tegmentum of the mesencephalon and the pons. Such distribution of lesions does suggest a vascular topography, i.e. in the territories supplied by branches of the vertebro-basilar arteries. There was light clinical and neuropathological evidence of prenatal occurrence of the vascular injuries, possibly at the end of the 7th month by a defective arterial perfusion of the fetus due to protracted menaces of premature birth. We would outline the existence and frequency of the thalamic and dorsal brain stem necrotic involvement by acute anoxia-ischemia occurring in the third trimester of gestation or at birth, and the relative peculiarity of their clinical picture.

Therapy-related leukemia and myelodysplasia in small-cell lung cancer. Report of a case and results of morphologic, cytogenetic, and bone marrow culture studies in long-term survivors

The bone marrow of 11 patients with small-cell lung cancer, who survived more than two years following combined-modality therapy, was subjected to morphologic, cytogenetic, and bone marrow culture studies. One patient, after a prodrome of anemia and thrombocytopenia, developed acute leukemia 60 months after the start of chemotherapy. Four months before frank leukemia developed, bone marrow culture studies showed a marked inability to form colonies. Cytogenetic studies demonstrated an abnormal clone of cells that included the deletion of the long arm of chromosome 5. No morphologic abnormalities were noted in the bone marrow of any other long-term survivor; however, the mean corpuscular volume of peripheral red blood cells was greater than normal in three of four patients who remain alive and disease free. In one of these patients marrow culture studies also failed to grow colonies. The other patients showed a decreased ability to form multilineage colonies and colonies of the granulocyte-macrophage lineage in vitro compared with a control population. All patients showed some degree of aneuploidy on cytogenetic analysis; in two cases approximately 50% of cells were aneuploid. However, no clonal abnormality was detected in any patient. Follow-up for the development of secondary acute leukemia and other long-term complications continues in these patients.

Heterogeneity of human peripheral blood eosinophil-type colonies: evidence for a common basophil-eosinophil progenitor

We have recently shown that a proportion of previously designated human eosinophil "(Eo)-type" colonies in methylcellulose contain basophils and histamine (Denburg et al Blood 61:775, 1983). In the present studies, individual Eo-type colonies have been analyzed by cell morphology as well as by biochemical assays for histamine, Charcot-Leyden crystal protein (CLC), and eosinophil granule major basic protein (MBP). Clonal origin of single Eo-type colonies was confirmed by G6PD isoenzyme analysis. Morphological observations of such colonies revealed the existence of two distinct colony types: (1) Eo type containing 100% basophils and (2) Eo type containing mixtures of basophils and eosinophils, including cells with mixed basophil-eosinophil granulation. Histamine was not detected in pure, mature peripheral blood eosinophils. Immunofluorescent studies demonstrated bright staining for CLC and MBP in 95% +/- 3% of cells in Eo-type colonies but only in 5% +/- 4% of cells in GM-type colonies. Radioimmunoassay for MBP was positive in 5/9 Eo-type and 0/10 neutrophil-macrophage ("GM-type") colonies, with a mean level (nanogram/colony) of 11.6 +/- 4.2 per Eo-type colony; four of the latter colonies were doubly positive for both histamine and MBP. These and previous findings point out the morphological and biochemical heterogeneity of peripheral blood Eo-type colonies and provide direct evidence for the existence of a common, circulating basophil-eosinophil progenitor.

Molecularly cloned and expressed murine T-cell gene product is biologically similar to interleukin-3

Clonal lines of mouse inducer ly1+ly2- inducer T-lymphocytes that depend for growth upon interleukin-2 have been demonstrated to produce a factor that stimulates colony formation by bone marrow granulocyte-macrophage (GM-CFUc) progenitor cells and replication of factor-dependent mast cell/basophil and multipotential hematopoietic cell lines in vitro. The molecularly cloned and expressed gene product for this growth factor demonstrates the following activities in vitro: using fresh bone marrow or purified subpopulations of nonadherent cells from murine continuous bone marrow cultures as target cells: stimulation of colony formation by GM-CFUc, mast cell progenitor cells, multipotential granulocyte/erythroid/megakaryocyte/macrophage progenitor cells (CFU-GEMM) colonies, erythroid progenitor cells forming macroscopic bursts (BFUe), and megakaryocyte progenitor cells (CFU-mega). The gene product also supports growth of previously reported mast cell growth-factor-dependent cell lines and several classes of interleukin-3 (IL-3)-dependent hematopoietic progenitor cell lines that are multipotential (neutrophil/basophil/eosinophil or neutrophil/basophil/erythroid); or committed to granulocyte-macrophage, or mast cell/basophil differentiation. The gene product does not detectably support replication of IL-2-dependent murine T-cell lines. The biologic activity of the gene product was inhibited greater than or equal to 90% by rabbit antisera prepared against purified interleukin-3. The data indicate that this T-cell derived lymphokine gene product is biologically very similar to interleukin-3.

Clonal origin of human basophil/mast cells from circulating multipotent hemopoietic progenitors

The origin of the human basophil/mast cell lineage from a pluripotent hematopoietic stem cell has been surmised but never demonstrated. By examining individual hemopoietic colonies in methylcellulose under inverted microscopy and using histochemical stains in conjunction with single-colony histamine assays, we have previously identified basophil/mast cell progenitors in human peripheral blood. We now report that a large proportion of normal human peripheral blood mixed granuloerythropoietic (GEMM) colonies contain histamine, in contrast to a significantly lower frequency of histamine positivity among normal neutrophil-macrophage, eosinophil, erythroid, macrophage, or megakaryocyte colonies. Morphological observations confirmed the presence of basophil/mast cells in the majority of GEMM colonies. In our work, the clonal derivation of basophils/mast cells from circulating multipotent (CFU-GEMM) hemopoietic stem cells was formally demonstrated, using combined histamine and G6PD isoenzyme analysis of single colonies grown in methylcellulose from a normal G6PD heterozygote.

Production of colony-stimulating factor(s) for granulocyte-macrophage and multipotential (granulocyte/erythroid/megakaryocyte/macrophage) hematopoietic progenitor cells (CFU-GEMM) by clonal lines of human IL-2-dependent T-lymphocytes

Human T-lymphocyte lines that were selected for recognition of HLA-DR6 antigen and were dependent for growth in vitro on an added source of interleukin-2 (IL-2) were derived from the peripheral blood of normal individuals. Each was tested for production of a lymphokine(s) with properties of granulocyte-macrophage colony-stimulating factor (GM-CSF) using as target cells nonadherent cells from human long-term bone marrow cultures (LTBMC) or fresh marrow. Each of eight T-lymphocyte lines that were OKT3, OKT4, and HLA-DR positive produced GM-CSF that stimulated colony formation by both LTBMC cells and fresh marrow. Individually examined single-cell-derived bone marrow colonies growing in T-cell GM-CSF contained peroxidase-positive neutrophils, and macrophage-monocytes (GM-CFUc). Supernatant from a single-cell-derived T-cell clonal line designated F1 stimulated formation of granulocyte-macrophage colonies, megakaryocyte colonies, macroscopic erythroid bursts, and multipotential colonies containing erythroid cells, megakaryocytes, neutrophilic and eosinophilic granulocytes, and monocyte-macrophages (CFU-GEMM) in the presence of added erythropoietin. These data indicate that human IL-2-responsive T-lymphocytes produce lymphokine(s) that stimulate proliferation of primitive as well as committed hematopoietic stem cells, and implicate human T-lymphocytes in regulation of human multipotential hematopoietic stem cells in vivo.

Acute lymphoblastic leukemia. Possible origin from a mediastinal germ cell tumor

The case of acute lymphoblastic leukemia developing shortly after the diagnosis and treatment of a mediastinal germ cell tumor, is reported. The close temporal relationship of these two rare diseases and the presence of a population of mononuclear cells with features of lymphoblasts in the resected germ cell tumor, suggest that the leukemic process originated from the mediastinal tumor.