Kaposi's sarcoma following allogeneic hematopoietic stem cell transplantation for chronic myelogenous leukemia

Unlike solid organ transplantation, Kaposi's sarcoma (KS) occurs rarely following hematopoietic stem cell transplantation (HSCT). In fact, only 5 cases of KS have been reported after allogeneic or autologous HSCT. The usual treatment combines a substantial decrease in, or elimination of, immunosuppressive therapy along with local measures such as surgical excision, cryotherapy or radiation therapy. A 46-year-old woman with chronic myelogenous leukemia who had received an allogeneic HSCT previously from an HLA-identical sibling, presented on day +814 with human herpes virus-8-associated KS involving her left lower extremity. She had been on continuous immunosuppressive therapy since her transplant because of chronic graft-versus-host disease. The intensity of immunosuppressive therapy was decreased once a diagnosis of KS had been established. However, the nodular lesions continued to progress in size and number. Therefore, a course of irradiation was administered to sites of bulk disease on her legs. Furthermore, thalidomide was initiated along with a topical retinoid, alitretinoin 0.1% gel applied twice daily to the nonirradiated lesions. This approach yielded a partial response in both irradiated and nonirradiated lesions over the course of the following 7 months. Both thalidomide and alitretinoin 0.1% gel appear to be beneficial in HSCT-associated KS and exhibit tolerable side effects.

Idiopathic pneumonia syndrome following myeloablative chemotherapy and autologous transplantation

OBJECTIVE

To report the outcome as well as the clinical, radiographic, and pathologic features of idiopathic pneumonia syndrome (IPS) following autologous peripheral blood stem cell transplantation (aPBSCT).

CLINICAL FINDINGS

A total of 271 patients with a variety of underlying malignancies received busulfan-containing myeloablative chemotherapy prior to aPBSCT; none of these patients received total body irradiation. Ten individuals developed IPS, with a median time of onset of 102 days after stem cell infusion. The major clinical and radiographic findings included an acute or subacute onset of dyspnea, cough, hypoxemia, and bilateral or unilateral infiltrates with or without pleural effusion. Pathologic findings consisted mainly of diffuse interstitial pneumonitis, organizing alveolitis, and cellular atypia. Nine patients diagnosed with IPS were treated with high doses of glucocorticoids parenterally. Despite heroic measures, eight patients died of IPS. The two remaining individuals recovered without experiencing significant long-term pulmonary sequelae.

DISCUSSION

Chronic low-dose busulfan therapy results in lung injury in 4-6% of patients after several years of treatment and once the cumulative dosage begins to approach 3g. High-dose, short-course busulfan (16 mg/kg)-containing conditioning chemotherapy prior to aPBSCT can also be complicated by IPS. IPS differs from lung damage due to chronic busulfan therapy by its earlier onset, an acute or subacute rather than indolent presentation, characteristic clinical and radiographic features, and lack of multinucleated giant cells on pathologic review. The pathophysiology of IPS secondary to high-dose busulfan-containing myeloablative regimens is not known, but cell-mediated immune reactions and release of cytokines may contribute to the lung injury. Mortality is high (80%) despite the use of heroic measures, including mechanical ventilation. Some patients, however, can respond to high doses of parenteral corticosteroid therapy.

CONCLUSIONS

IPS following high-dose, short-course busulfan-containing regimens exhibits unique clinical, radiographic, and pathologic features that differ from lung damage characteristic of chronic, low-dose busulfan therapy. Mortality from this complication is 80%, but some patients survive without long-term pulmonary sequelae following early treatment with glucocorticoids.

Early human occupation of the Red Sea coast of Eritrea during the last interglacial

The geographical origin of modern humans is the subject of ongoing scientific debate. The 'multiregional evolution' hypothesis argues that modern humans evolved semi-independently in Europe, Asia and Africa between 100,000 and 40,000 years ago, whereas the 'out of Africa' hypothesis contends that modern humans evolved in Africa between 200 and 100 kyr ago, migrating to Eurasia at some later time. Direct palaeontological, archaeological and biological evidence is necessary to resolve this debate. Here we report the discovery of early Middle Stone Age artefacts in an emerged reef terrace on the Red Sea coast of Eritrea, which we date to the last interglacial (about 125 kyr ago) using U-Th mass spectrometry techniques on fossil corals. The geological setting of these artefacts shows that early humans occupied coastal areas and exploited near-shore marine food resources in East Africa by this time. Together with similar, tentatively dated discoveries from South Africa this is the earliest well-dated evidence for human adaptation to a coastal marine environment, heralding an expansion in the range and complexity of human behaviour from one end of Africa to the other. This new, wide-spread adaptive strategy may, in part, signal the onset of modern human behaviour, which supports an African origin for modern humans by 125 kyr ago.

Incidence and outcome of vancomycin-resistant enterococcal bacteremia following autologous peripheral blood stem cell transplantation

A retrospective evaluation of 321 consecutive recipients of high-dose chemotherapy (HDC) and autologous peripheral blood stem cell transplantation (PBSCT) was conducted to ascertain the incidence and outcome of vancomycin-resistant enterococcal (VRE) bacteremia. Ten patients developed VRE bacteremia at a median of 6 days following PBSCT. Nine isolates were Enterococcus faecium and one was E. faecalis. The median duration of bacteremia was 5 days. The central venous catheter was removed in seven individuals. Nine patients were treated with a variety of antimicrobial agents including quinupristin-dalfopristin, chloramphenicol, doxycycline, oral bacitracin, co-trimoxazole, and nitrofurantoin. Bacteremia resolved without adverse sequelae in seven patients. Two individuals who died of other causes had persistent or relapsed bacteremia at the time of death. An additional patient suffered multiple relapses of VRE bacteremia and died as a result of VRE endocarditis 605 days following PBSCT. Mortality as a direct result of VRE bacteremia was 10% in this series. The optimal type and duration of treatment of VRE bacteremia has not been clearly defined. Therefore, we perform weekly stool surveillance cultures for VRE in our hospitalized transplant population and apply strict barrier precautions in those individuals in whom stool colonization has been identified. Furthermore, the empiric use of vancomycin has been restricted. Bone Marrow Transplantation (2000) 25, 147-152.

Dose-intense paclitaxel, etoposide and cyclophosphamide: a safe and active regimen for tumor cytoreduction and stem cell mobilization in metastatic breast cancer

Patients with metastatic breast cancer in complete remission are the ones most likely to have an improved outcome with subsequent high-dose chemotherapy and autologous peripheral blood stem cell transplantation (HDC-PBSCT). Peripheral blood stem cells are usually procured following mobilization with single agent chemotherapy and colony-stimulating factor support. We utilized a dose-intense regimen of paclitaxel 200 mg/m2 i.v., etoposide 60 mg/kg i.v., and cyclophosphamide 3 g/m2 i.v. (TEC) followed by daily administration of granulocyte colony-stimulating factor. The aim was not only to mobilize stem cells but also to achieve optimal tumor cytoreduction prior to HDC/PBSCT. One hundred consecutive patients with metastatic breast cancer received 257 cycles of TEC between March 1994 and June 1997, with the aim of collecting 5 x 106 CD34-positive cells/kg usually following the second cycle of chemotherapy. Patient characteristics included a median age of 45 years, a median of two organ systems involved by disease, a median of two prior chemotherapy regimens and eight prior chemotherapy cycles, and a median interval of 8 months from diagnosis of metastases to first cycle of TEC. There were 61 febrile episodes during neutropenia and 13 of these were associated with bacteremia or fungemia. Mortality rate was 1%. An adequate number of stem cells was collected in 90% of patients. The overall response rate of the tumor was 58.8% with 23.7% complete responders among 97 evaluable patients. Multivariate analysis demonstrated chemosensitivity to the most recent standard chemotherapy regimen administered for metastatic disease, an ECOG performance score of 0 as opposed to 1, 2 or 3, and involvement by disease of only one organ system as significant variables for achieving a complete remission with TEC. This novel dose-intense regimen was safe and well tolerated, highly active against metastatic breast cancer, and capable of excellent stem cell mobilization. Bone Marrow Transplantation (2000) 25, 123-130.

Hemolytic transfusion reaction due to anti-Tc(a)

BACKGROUND

Anti-Tc(a) detects a high-incidence antigen in the Cromer blood group system. Cromer system antibodies have not usually been associated with hemolytic transfusion reactions or hemolytic disease of the newborn.

CASE REPORT

Anti-Tc(a) (initially identified in the patient's serum in 1982) was not detected when she was admitted to the hospital with upper gastrointestinal. bleeding. Three units of red cells were administered. The patient was discharged, but was readmitted to the hospital after her hemoglobin fell to 7.1 g per dL. Antibody detection tests remained negative and three additional units were transfused. Over the next 7 days, her hemoglobin steadily fell to 5.5 g per dL. The level of lactate dehydrogenase rose to 1257, the plasma hemoglobin rose to >16 mg per dL, and the haptoglobin decreased to <6 mg per dL. Five days after transfusion, her direct antiglobulin test was weakly reactive with complement-specific antiglobulin reagents. Eluates were nonreactive. Anti-Tc(a) was detected in her serum; no other antibodies were detected. Differential typing failed to detect any circulating Tc(a+) red cells. The antibody was strongly reactive in a monocyte monolayer assay.

CONCLUSION

Although Cromer system antibodies have generally not been proven to be clinically significant in transfusion therapy, the destruction of red cells from six units of transfused Tc(a+) red cells in this patient indicates that anti-Tc(a) may have destructive potential in some patients.

Cytomegalovirus viremia, viruria and disease after autologous peripheral blood stem cell transplantation: no need for surveillance

A retrospective evaluation of 200 consecutive recipients of autologous peripheral blood stem cell transplantation (PBSCT) was conducted to ascertain the incidence, risk factors, clinical features, complications, and outcome of cytomegalovirus (CMV) infection. A total of 26 patients (13%) developed CMV viremia (n = 5), DNAemia (n = 3), viruria (n = 18) and/or disease (n = 3) at a median of 45 days following stem cell infusion. None of the patients underwent surveillance testing for CMV. A diagnosis was established by culture and polymerase chain reaction of blood, urine or other tissue samples submitted when patients exhibited clinical features suggestive of CMV infection. Cytomegalovirus seropositivity prior to transplantation was the only statistically significant risk factor predicting subsequent identification of CMV (P < 0.001). The symptoms were severe enough in 23 patients to warrant treatment with intravenous ganciclovir. Three patients developed CMV disease; two developed fatal CMV pneumonia and one developed CMV gastritis which responded to antiviral treatment. Clinical signs and symptoms as well as viremia and viruria resolved with (20 patients) and without (three patients) treatment in the remaining individuals. All instances of CMV viremia, DNAemia, viruria and disease occurred within 3 months of stem cell infusion. These results demonstrate that CMV is a common pathogen after autologous PBSCT and may result in fatality in rare instances. Surveillance programs appear to be neither useful nor cost-effective. Diagnostic evaluation should be performed only in patients exhibiting suspicious clinical features and antiviral chemotherapy should be administered for persistent and severe signs and symptoms.

Incidence and outcome of Clostridium difficile infection following autologous peripheral blood stem cell transplantation

A retrospective evaluation of 200 consecutive recipients of autologous peripheral blood stem cell transplantation (PBSCT) was conducted to ascertain the incidence and outcome of infection with Clostridium difficile. The diagnosis was confirmed in 14 patients with diarrhea (15 episodes) at a median of 33 days after stem cell infusion. Five patients were neutropenic at the time of diagnosis. Every individual had adverse known risk factors such as recent or current use of antibiotic, corticosteroid and antiviral therapy, recent administration of myeloablative chemotherapy and numerous, prolonged periods of hospitalization. Diarrhea, frequently hemorrhagic, was the most common presenting feature along with fever, abdominal cramps and abdominal distention. Diagnosis was established by the stool-cytotoxin test. Response to standard treatment with oral vancomycin or metronidazole was prompt despite the presence of several adverse prognostic features in these patients. There was only one instance of relapse which was also treated successfully. Several transplant-related variables such as age, sex, underlying malignancy, myelo-ablative regimen, duration of neutropenia, and prophylactic use of oral ampicillin underwent statistical analysis but failed to be predictive of C. difficile infection in such a setting. Finally, C. difficile is not uncommon after autologous PBSCT and must be included in the differential diagnosis in any such patient with diarrhea.

Varicella zoster virus infection associated with high-dose chemotherapy and autologous stem-cell rescue

A retrospective evaluation of 215 consecutive recipients of high-dose chemotherapy (HDC) and autologous stem cell rescue (ASCR) was conducted to ascertain the incidence, temporal course, and outcome of varicella zoster virus (VZV) infection. Herpes zoster was identified in 40 individuals at a median of 69 days following ASCR. Six of these cases occurred at a median of 33 days prior to ASCR but following the initiation of high doses of stem cell mobilization chemotherapy. Twenty-five percent of patients demonstrated cutaneous or systemic dissemination and 32.5% required medical intervention for post-herpetic neuralgia. All except two individuals received antiviral chemotherapy. One patient with active VZV infection died of multiorgan failure 39 days after ASCR. Multivariate analysis of risk factors disclosed the significance of prophylactic acyclovir use in Herpes simplex virus seropositive individuals in reducing the risk of VZV infection. Moreover, the use of busulfan, thiotepa and carboplatin as the conditioning chemotherapy regimen was associated with an increased risk of subsequent VZV infection. The incidence of VZV reactivation after HDC and ASCR is similar to that observed following bone marrow transplantation but has an earlier onset. This may be related to an earlier induction of immunosuppression by stem cell mobilization chemotherapy administered prior to ASCR. We demonstrated a marked reduction in the proliferative and synthetic capacities of peripheral blood mononuclear cells obtained prior to and following stem cell mobilizing chemotherapy. Moreover, greater than 80% of VZV infections occurred within 6 months following ASCR and late cases were seldom observed compared to allogeneic and autologous bone marrow transplantation. The role of antiviral chemoprophylaxis during the period of maximum immunocompromise needs to be studied further in the HDC-ASCR setting.

Regional thrombolysis with urokinase for central venous catheter-related thrombosis in patients undergoing high-dose chemotherapy with autologous blood stem cell rescue

Fifty-one of 300 patients undergoing high-dose chemotherapy with (n = 245) or without (n = 55) autologous stem cell rescue developed central venous catheter-related thrombosis diagnosed by Doppler sonography or contrast venography. Eighteen of these individuals underwent regional thrombolysis defined as the infusion of urokinase into a superficial vein of the ipsilateral upper extremity in a dose not sufficient to produce systemic fibrinolysis by laboratory criteria. Urokinase was administered at a dose of 75,000-150,000 U/hour for 24 to 96 hours and contrast venography was performed to assess response. All individuals had a partial or complete resolution of clinical signs and symptoms. Fifty percent of patients also achieved a partial radiographic response defined as clot lysis with irregular canalization of the vein. Therapeutic doses of heparin for 5 to 7 days and warfarin for at least 3 months were commenced at the conclusion of urokinase therapy. Twelve catheters were salvaged and utilized subsequently until no longer required. Six catheters were removed because of poor catheter function or rethrombosis. The median interval from diagnosis of the thrombus until extraction of the 12 salvaged catheters was 3 months (range 1-8 months). Only a single patient who developed gastrointestinal bleeding required discontinuation of urokinase. Regional thrombolysis is safe, easy to administer, effective in many instances, less costly than the doses of antifibrinolytic agents required to induce systemic fibrinolysis, and should be considered in patients receiving high-dose chemotherapy with autologous stem cell rescue who develop central venous catheter-related thrombosis.

Climate and vegetation history of the midcontinent from 75 to 25 ka: A speleothem record from crevice cave, missouri, USA

Four Missouri stalagmites yield consistent overlapping records of oxygen and carbon isotopic changes and provide a climate and vegetation history with submillennial resolution from 75 to 25 thousand years ago (ka). The thorium-230-dated records reveal that between 75 and 55 ka, the midcontinental climate oscillated on millennial time scales between cold and warm, and vegetation alternated among forest, savanna, and prairie. Temperatures were highest and prairie vegetation peaked between 59 and 55 ka. Climate cooled and forest replaced grassland at 55 ka, when global ice sheets began to build during the early part of Marine Oxygen Isotope Stage 3.

Acanthamoeba meningoencephalitis following autologous peripheral stem cell transplantation

Amoebic meningoencephalitis is an unusual complication of bone marrow transplantation. We report a case of Acanthamoeba meningoencephalitis in a patient with non-Hodgkin's lymphoma after autologous stem cell transplantation. Leg weakness, fever and urinary retention developed 69 days following transplantation. The patient then developed fever, generalized tonic clonic seizure, rapid deterioration of mental functions and hypercapneic respiratory failure. Magnetic resonance imaging demonstrated a ring enhancing lesion at the level of the thoracic spines 11 and 12. Examination of the cerebrospinal fluid revealed pleocytosis. Despite empiric therapy with broad-spectrum antimicrobial agents, the patient's condition worsened and she died 11 days following admission. Autopsy findings revealed a subacute meningoencephalitis secondary to Acanthamoeba culbertsoni.

Deep-Sea coral evidence for rapid change in ventilation of the deep north atlantic 15,400 years Ago

Coupled radiocarbon and thorium-230 dates from benthic coral species reveal that the ventilation rate of the North Atlantic upper deep water varied greatly during the last deglaciation. Radiocarbon ages in several corals of the same age, 15.41 +/- 0.17 thousand years, and nearly the same depth, 1800 meters, in the western North Atlantic Ocean increased by as much as 670 years during the 30- to 160-year life spans of the samples. Cadmium/calcium ratios in one coral imply that the nutrient content of these deep waters also increased. Our data show that the deep ocean changed on decadal-centennial time scales during rapid changes in the surface ocean and the atmosphere.

Protactinium-231 and thorium-230 abundances and high scavenging rates in the western arctic ocean

The Canadian Basin of the Arctic Ocean, largely ice covered and isolated from deep contact with the more dynamic Eurasian Basin by the Lomonosov Ridge, has historically been considered an area of low productivity and particle flux and sluggish circulation. High-sensitivity mass-spectrometric measurements of the naturally occurring radionuclides protactinium-231 and thorium-230 in the deep Canada Basin and on the adjacent shelf indicate high particle fluxes and scavenging rates in this region. The thorium-232 data suggest that offshore advection of particulate material from the shelves contributes to scavenging of reactive materials in areas of permanent ice cover.

Streptococcus viridans bacteremia following autologous peripheral blood stem cell transplantation

A retrospective evaluation of 200 consecutive recipients of autologous peripheral blood stem cell transplantation was conducted to ascertain the incidence and outcome of Streptococcus viridans bacteremia as well as to determine the role of prophylactic ampicillin therapy in the peri-transplant setting. Viridans streptococci were isolated from the blood of 35 individuals at a median of 6 days (range 2-8 days) following stem cell infusion. The most common isolates were S. sanguis and S. mitis. All patients received ciprofloxacin orally during the peri-transplant period. Additionally, 79 patients received oral ampicillin prophylactically against gram-positive cocci. Although none of the patients suffered a fatal outcome, three individuals developed respiratory compromise requiring mechanical ventilation. Female sex proved to be the only independent risk factor for viridans streptococcal bacteremia (P=0.04). The shorter duration of neutropenia observed after stem cell transplantation did not impact on the incidence of S. viridans infections. Moreover, the prophylactic use of ampicillin failed to decrease the incidence of viridans sepsis and selected out organisms that were resistant to beta-lactam antibiotics.

Protactinium-231 Dating of Carbonates by Thermal Ionization Mass Spectrometry: Implications for Quaternary Climate Change

Measurement of protactinium-231 (231Pa) in carbonates by thermal ionization mass spectroscopy yields 231Pa ages that are more than 10 times more precise than those determined by decay counting. Carbonates between 10 and 250,000 years old can now be dated with 231Pa methods. Barbados corals that have identical 231Pa and thorium-230 (230Th) ages indicate that the timing of sea level change over parts of the last glacial cycle is consistent with the predictions of the Astronomical Theory. Two Devils Hole calcite subsamples record identical 231Pa and 230Th ages, suggesting that the chronology of this climate record is accurate.

Stomatococcus mucilaginosus meningitis in a patient with multiple myeloma following autologous stem cell transplantation

Bacterial meningitis is an unusual complication of bone marrow transplantation. We report a case of Stomatococcus mucilaginosus meningitis in a patient with multiple myeloma shortly after an autologous peripheral blood stem cell transplant. The infection resolved with a combination of intravenous penicillin G and chloramphenicol, and intrathecal vancomycin.

When community resources fail. Assisting the frightened or angry parent

The failure to receive expected community services or specialized in-home medical care can be upsetting for some parents. This article is designed to help pediatricians interpret inappropriate family behaviors and to therapeutically defuse verbal anger, unrealistic expectations, and unfounded fears.