Cutaneous large B-cell lymphoma of the leg: presenting initially as mononeuritis multiplex

We report a rare case of primary B-cell lymphoma of the leg presenting with mononeuropathy multiplex. A 79-year-old Chinese woman who was being investigated for mononeuritis multiplex had an incidental finding of indurated erythematous plaques on the breast and left leg. A skin biopsy from the nodular area on the right breast showed a dense and diffuse infiltrate of atypical cells with large, round, hyperchromatic nuclei with prominent nucleoli. These atypical lymphocytes were CD20+, Bcl-2+ and Mum-1+. A diagnosis of diffuse large B-cell lymphoma, leg type involving the breast and leg with extracutaneous involvement, was made. This case highlights the importance of a full systemic and cutaneous examination in patients presenting with progressive, painful peripheral neuropathy.

[Effective combination chemotherapy with rituximab for acute lymphoblastic leukemia with bone relapse after bone marrow transplantation]

A 26-year-old woman with acute lymphoblastic leukemia (ALL) relapsed three times after HLA-matched related bone marrow transplantation. Initially, ALL relapsed in the central nervous system (CNS) 1 year after transplantation. Then, ALL relapsed as a single bone tumor involving the CNS and pelvis 4 years after transplantation. Finally, multiple bone tumors in the pelvis and lumbar bones were found as well as spread to the bone marrow 5 years after transplantation. Bone marrow aspiration also showed ALL relapse. Flow cytometry analyses detected CD20-positive cells in the bone tumor. Though the initial bone tumor was resistant to hyper CVAD, radiation was effective and this patient achieved complete remission. At that time, the total radiation dose had already reached the upper limit. After the third relapse, bone marrow achieved complete remission with the administration of pirarubicin, vincristine, prednisolone, and L-asparaginase (arranged DVP-L), though this combination chemotherapy itself was not effective in multiple bone tumors. Thereafter, arranged DVP-L plus rituximab was administered, which resulted in significant tumor reduction. Biweekly rituximab administration as maintenance therapy has completely prevented the regrowth of bone tumors. Rituximab for relapsed CD20-positive ALL patients after stem cell transplantation could be beneficial.

Therapy of hepatitis C virus-associated glomerulonephritis: current approaches

The most frequent kidney disease associated with chronic hepatitis C virus (HCV) infection is type I membranoproliferative glomerulonephritis (MPGN) in patients with type II mixed cryoglobulinemia. The principal clinical manifestations of glomerular disease in HCV-infected patients are the presence of proteinuria and microscopic hematuria with or without impaired kidney function. Various approaches have been tried for the treatment of HCV-associated glomerulonephritis, including immunosuppressive therapy (corticosteroids and cytotoxic agents), plasma exchange and antiviral agents. Limited data exist regarding antiviral treatment of HCV-associated glomerulonephritis, whereas immunosuppressive agents have been suggested for cryoglobulinemic kidney disease. A recent meta-analysis of controlled clinical trials (CCTs) suggested that standard interferon (IFN) doses were more effective than immunosuppressive agents in lowering proteinuria of patients with HCV-related cryoglobulinemic glomerulonephritis (odds ratio 3.86; 95% confidence interval, 1.44-10.33; p=0.007). However, data for follow-up were not given. Two distinct approaches should be considered for the treatment of HCV-associated cryoglobulinemic glomerulonephritis according to the level of proteinuria and kidney failure. Preliminary studies with rituximab therapy of HCV-related cryoglobulinemic glomerulonephritis have given encouraging results, even if a point of caution is important, because rituximab use may be associated with activation of various infections, including HCV.

Primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue type: case report and review of the literature

A primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) is very rare. We found a solitary mass 27 mm in size in the left lobe of the liver of a 58-year-old Japanese man with a history of hepatitis-C infection. Based on the results of imaging studies, the tumor was diagnosed as a hepatocellular carcinoma (HCC). The left lobe of the liver was lobectomized and microscopic findings showed that the tumor was a hepatic MALT lymphoma, while immunohistochemistry showed it to be positive for CD20 and CD79a. In a fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning (FDG-PET CT) before surgery, the tumor was revealed to have a high standardized uptake value (SUV) for FDG. The patient received chemotherapy after surgery. To the best of our knowledge, 45 cases had been reported with a mean age for all patients of 61.4 years. The pathogenesis remains unclear, although half of the patients had a past history of chronic inflammatory liver disease. Surgical resection was performed in most cases and some patients received postoperative chemotherapy or radiotherapy. The clinicopathologic characteristics and management of this extremely rare disease are also discussed.

Histopathological changes of pancreas in patients with fibrocalculous pancreatopathy

A total of 20 pancreatic biopsy samples taken from Fibrocalculous Pancreatopathy previously known as Fibro Calculus Pancreatic Diabetes (FCPD) patients, a variant of Malnutrition Related Diabetes Mellitus (MRDM) or under 30 young diabetes attending hepatobiliary, surgical and out patient department of Bangladesh Diabetes, Endocrine and Metabolic (BIRDEM) hospital were processed for light microscopic examination. Four samples were subjected to Immunohistochemistry (IHC) staining using antibodies to T cell marker (CD3), B cell marker (CD20), anti apoptotic markers (bcl-2) and tumour suppressor gene marker p53. Light microscopic findings and IHC indicate an immune mediated injury of pancreatic tissue and increased evidence of apoptosis which possibly results in the development of diabetes in these patients.

[Biological treatment of rare inflammatory rheumatic diseases]

The current status of the use of biological medicine in the treatment of adult onset morbus still, Wegeners granulomatosis and systemic lupus erythematosus (SLE) is reviewed. The need for controlled trials is emphasized. Anti-CD20 treatment for SLE patients with kidney involvement and patients with Wegeners granulomatosis seems promising. Anti-TNF and IL1 receptor antagonist can control disease activity in most patients with adult morbus still.

B-cell depletion with rituximab in relapsing-remitting multiple sclerosis

BACKGROUND

There is increasing evidence that B lymphocytes are involved in the pathogenesis of multiple sclerosis, and they may be a therapeutic target. Rituximab, a monoclonal antibody, selectively targets and depletes CD20+ B lymphocytes.

METHODS

In a phase 2, double-blind, 48-week trial involving 104 patients with relapsing-remitting multiple sclerosis, we assigned 69 patients to receive 1000 mg of intravenous rituximab and 35 patients to receive placebo on days 1 and 15. The primary end point was the total count of gadolinium-enhancing lesions detected on magnetic resonance imaging scans of the brain at weeks 12, 16, 20, and 24. Clinical outcomes included safety, the proportion of patients who had relapses, and the annualized rate of relapse.

RESULTS

As compared with patients who received placebo, patients who received rituximab had reduced counts of total gadolinium-enhancing lesions at weeks 12, 16, 20, and 24 (P<0.001) and of total new gadolinium-enhancing lesions over the same period (P<0.001); these results were sustained for 48 weeks (P<0.001). As compared with patients in the placebo group, the proportion of patients in the rituximab group with relapses was significantly reduced at week 24 (14.5% vs. 34.3%, P=0.02) and week 48 (20.3% vs. 40.0%, P=0.04). More patients in the rituximab group than in the placebo group had adverse events within 24 hours after the first infusion, most of which were mild-to-moderate events; after the second infusion, the numbers of events were similar in the two groups.

CONCLUSIONS

A single course of rituximab reduced inflammatory brain lesions and clinical relapses for 48 weeks. This trial was not designed to assess long-term safety or to detect uncommon adverse events. The data provide evidence of B-cell involvement in the pathophysiology of relapsing-remitting multiple sclerosis. (ClinicalTrials.gov number, NCT00097188 [ClinicalTrials.gov].).

Rituximab for the treatment of post-bone marrow transplantation refractory hemolytic anemia in a child with Omenn's syndrome

Omenn's syndrome is a rare severe combined immunodeficiency that kills affected subjects before the end of the first year of life unless patients are treated with bone marrow transplantation (BMT). Unfortunately, post-BMT patients may develop autoimmune diseases, such as autoimmune hemolytic anemia (AIHA), which sometimes fails to respond to standard therapies. Rituximab is a chimeric, human, immunoglobulin G1/k monoclonal antibody specific for the CD20 antigen expressed on the surface of B lymphocytes. Rituximab is currently only labeled for treatment of B-cell lymphoproliferative disorders, such as B-cell non-Hodgkin's lymphoma and follicular lymphoma; however, it is also employed in the treatment of a variety of disorders mediated by auto-antibodies, such as AIHA and transplant-related autoimmune disorders. Herein, we describe the case of a 23-month-old male child with Omenn's syndrome, who had undergone BMT and was successfully treated with rituximab (375 mg/m(2) intravenously, weekly for three times) for refractory post-BMT hemolytic anemia. Our findings evidence that rituximab should be considered for treatment of post-BMT AIHA refractory to traditional therapy also in children with primary immunodeficiencies; furthermore, rituximab might represent a means to obtain remissions without the toxic effects associated with corticosteroid and immunosuppressive agents.

Gastric MALT Lymphoma Presenting as Waldenström's Macroglobulinemia Without Bone Marrow Involvement

We report a case of gastric mucosa-associated lymphoid tissue (MALT) lymphoma with macroglobulinemia in a 59-year-old man who presented with melena. A computed tomography scan of the abdomen showed irregular thickening of the wall of the stomach, and endoscopic examination disclosed enlarged and inflammatory folds of the fundus. Histopathologic examination of gastric samples showed mucosal infiltration by small lymphocytes, which were positive for CD20 and negative for CD10 and CD23, confirming the diagnosis of gastric MALT lymphoma. Serum electrophoresis detected a monoclonal peak and immunoelectrophoresis revealed an immunoglobulin M kappa component. Bone marrow aspirate and biopsy results were normal. The patient received chemotherapy. After treatment, he was in complete remission, and the serum monoclonal component had disappeared. Our observation is uncommon because of important macroglobulinemia occurring in gastric MALT lymphoma without bone marrow involvement.

Two cases of refractory thrombotic thrombocytopenic purpura associated with collagen vascular disease were significantly improved by rituximab treatment

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder of small vessels. TTP is associated with deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, and its inhibitor. Low ADAMTS13 activity is present in most of idiopathic TTP patients. The prognosis of TTP was improved by plasma exchange treatment, which replaces the ADAMTS13 and removes ADAMTS13 inhibitor. However, ADAMTS13 activity is normal in some TTP patients. These are found among the secondary TTP patients associated with collagen disease, hematopoietic stem cell transplantation, malignancy, or drugs. In addition, most of them do not respond to plasma exchange. On the other hand, several reports demonstrated that rituximab, which is an anti-CD20 monoclonal antibody, is effective for refractory TTP cases caused by ADAMTS13 deficiency. It is considered that the effect of rituximab is associated with disappearance of ADAMTS13 inhibitor. However, rituximab therapy was effective for the TTP patients with normal ADAMTS13 activity in our cases. We considered another mechanism of rituximab for TTP cases.

Rituximab as a Treatment Option for Refractory Endogenous Anterior Uveitis

BACKGROUND

To report on anti-CD20 antibody therapy in a patient with uveitis refractive to immunosuppression therapy.

METHODS

Case report with ophthalmoscopic, optical coherence tomography and fluorescein-angiographic findings.

RESULTS

A 49-year-old woman was suffering from bilateral, noninfectious chronic anterior uveitis refractive to corticosteroids and immunosuppressive drugs. Bilateral visual acuity was 20/100 due to cataract and cystoid macular edema (CME). After treatment with rituximab, vision and CME improved, and uveitis was stable until the final visit (follow-up at 12 months).

CONCLUSION

The case report suggests that rituximab may be helpful for selected patients with chronic anterior uveitis refractive to corticosteroids and immunosuppressive medication.

Immunological changes at rectal mucosa in appendectomised subjects and inhabitants of developing countries

AIM

It has been suggested that appendicitis protects against ulcerative colitis. We hypothesize that early poor hygiene protects against ulcerative colitis (UC) and predisposes to appendicitis. Our aim was to elucidate the immunological characteristics of rectal mucosa in two populations protected against UC development: appendectomised subjects and inhabitants of developing countries.

METHODS

this was an age-matched prospective case-control study. Each consecutive individual case appendectomised (group A) was compared to another control from a developing country (group B) and to a control from the general population (group C). Four biopsies from rectal mucosa were taken from all subjects, two for histological and two for histochemical study; specific antibodies were used for T lymphocytes CD3+, CD4+, CD8+ and B lymphocytes CD20+ populations.

RESULTS

Mucosa samples of 45 non-smoker healthy subjects were studied, of which 15 were from group A, 15 from group B and 15 from group C. In appendectomised subjects, the proportion of CD8+ cells was higher than in the control group (p<0.001), but similar to that in B group. The proportion of CD3+ and CD20+ cells was significatively lower than in Ecuadorians, but similar to the control group. In Ecuadorians, the proportion of CD3+ and CD8+ cells was significatively higher than in the control group (p<0.001), and were similar to that of CD20+. There were no significant differences in the proportion of CD4+.

CONCLUSION

Appendectomy and deficient environmental hygiene are associated with an increase of CD8+ T lymphocytes in the rectal mucosa. Moreover, deficient environmental hygiene is associated with an increase of CD3+ and CD8+ lymphocytes. The CD8+ increase is the only common significant alteration in the mucosa of both groups protected against the development of ulcerative colitis, suggesting that the factors causing changes in lamina propria lymphocytes of both groups are different.

Lymphomatoid Keratosis

OBJECTIVE

To provide evidence that lymphomatoid keratosis should be categorized as an epidermotropic subtype of cutaneous lymphoid hyperplasia.

DESIGN

Clinicopathological, immunohistochemical, and molecular biological studies of epidermotropic and dermal bandlike infiltrates of lymphocytes without necrotic keratinocytes, Civatte bodies, or Max-Joseph spaces and solar lentigo or seborrheic keratosis adjacent to the lesion, but with epidermal hyperplastic change (clinically scaly plaque) in cases of lymphomatoid keratosis. Conventional histopathologic study as well as immunohistochemical examinations for CD1a, CD3, CD4, CD8, CD20, and CD79a and S100 protein and genotypic examinations were performed.

SETTING

University departments comprising 2 sections of dermatology and 1 section of pathology.

MAIN OUTCOME MEASURES

Ratio of T to B cells and of CD4(+) to CD8(+) cells, and the phenotype of epidermotropic cells were evaluated. Gene rearrangement of the immunoglobulin heavy chain gene and T-cell receptor (TCR)-beta and TCRgamma genes was also investigated by the polymerase chain reaction method.

RESULTS

Immunohistochemically, epidermotropic CD20(+) and/or CD79a(+) cells were present. In the upper dermal lymphocytic infiltrates, the CD3(+)/CD79a(+) cell ratio ranged from 5:5 to 8:2. The CD4(+)/CD8(+) cell ratio was within normal limits. Rearrangements of the TCRgamma gene were demonstrated in 2 cases and of the TCRbeta gene in 1 case.

CONCLUSIONS

Our results indicate that lymphomatoid keratosis is a clinically benign keratotic lesion but histologically malignant, simulating mycosis fungoides. Immunohistochemical findings showed a reaction pattern in all cases, but genotypical examination showed some clonal dermatoses. Therefore, "lymphomatoid" keratosis should be classed as a pseudolymphoma, namely, a subtype of cutaneous lymphoid hyperplasia with epidermotropism.

Immunotherapy with rituximab/interleukin-2 after autologous stem cell transplantation as treatment for CD20+ non-Hodgkin's lymphoma

BACKGROUND

Relapse of non-Hodgkin's lymphoma (NHL) remains a problem after autologous stem cell transplantation (ASCT). Soon after ASCT, the immune system is not very active, and this immune incompetence could thus result in decreased ability for immune-mediated tumor eradication. The early addition of immunotherapy after ASCT might decrease the incidence of relapse and prolong survival. In an initial phase I/II trial at our center, the immune modulator interleukin-2 (IL-2) increased over baseline natural killer and lymphokine-activated killer activity in vitro. Because rituximab can lyse CD20-bearing cells by antibody-dependent cellular cytotoxicity, adding IL-2 to rituximab might boost its effectiveness. It thus seemed reasonable to study this combination after ASCT. The results of our phase II study are reported herein.

PATIENTS AND METHODS

Twenty patients with CD20+ NHL who had ASCT were treated. The median time to starting therapy was 79 days (range, 49-100 days) after transplantation.

RESULTS

The majority of patients reported grade <or= 2 erythema, induration and pain at IL-2 injection sites, flu-like symptoms, and worsening fatigue. Neutropenia that responded to granulocyte colony-stimulating factor was the most common grade 3/4 toxicity, seen in 45% of patients. There were no treatment-related deaths. Eighteen of 20 patients remain alive in complete remission, with a median follow-up of 55.5 months (range, 17-64 months).

CONCLUSION

Interleukin-2/rituximab can be administered after ASCT with manageable toxicity. A randomized trial is under way to address whether this combination therapy is beneficial to patients with NHL who have had ASCT.

Evidence for a specific crevicular lymphocyte profile in aggressive periodontitis

BACKGROUND AND OBJECTIVE

It is undisputed that the periodontal pocket is a particular region of the host defense that is dominated by polymorphonuclear leukocytes. However, little is known about the lymphocytes in the crevice. It was the aim of this study to analyse the proportions of T cells (CD3+), T-helper cells (CD4+), T-suppressor cells (CD8+), and B cells (CD20+) in the crevice of patients with localized aggressive periodontitis (LAP), generalized aggressive periodontitis (GAP), and generalized chronic periodontitis (CP). The results were compared with those obtained from periodontally healthy controls.

MATERIAL AND METHODS

Crevicular cells were collected according to a previously described method. The lymphocyte subpopulations were analysed by using an indirect immunofluorescence method.

RESULTS

Significant differences were established between the test groups and the controls regarding the mean number of CD8+ lymphocytes (LAP > CP and controls; p < 0.05) and CD20+ lymphocytes (LAP/GAP > CP, p < 0.05 and LAP/GAP > controls; p < 0.001). Significant variations in the CD4+/CD8+ ratio were observed (LAP < controls and GAP < controls; p < 0.01), as well as a correlation between the number of T cells and the degree of inflammation.

CONCLUSION

In the present study, patients with LAP and patients with GAP were found to have increased numbers of crevicular T-suppressor/cytotoxic and B cells. This supports the hypothesis of a changed immune pathology in patients with aggressive periodontitis.

Complete remission in a pancytopenic HIV negative, HHV-8 positive patient with multicentric Castleman’s disease induced with anti-CD20

A 75-year-old woman was diagnosed of MCD plasma cell (PC) variant with B symptoms. Diffuse lymph-node enlargement, splenomegaly and pancytopenia were detected. Induction with Rituximab was made because pancytopenia was present. Actually patient is free of disease. This is the first complete response of MCD published, VIH negative, induced with anti CD20.

Ibritumomab tiuxetan for non-Hodgkin's lymphoma

Targeted radiation therapy, or radioimmunotherapy, has been an important recent advancement in the treatment of patients with B-cell non-Hodgkin's lymphoma (NHL). 90Y ibritumomab tiuxetan comprises the murine monoclonal antibody ibritumomab, the linker chelator tiuxetan and the radiolabeled isotope 90yttrium. 90Y ibritumomab tiuxetan has been demonstrated to be efficacious in the treatment of B-cell NHL. Initial Phase I/II trials established the therapeutic dose of ibritumomab tiuxetan for low-grade NHL to be 0.4 mCi/kg, or 0.3 mCi/kg for patients with mild thrombocytopenia. Currently, there are many ongoing trials of ibritumomab tiuxetan with different dose schedules and intensities, in combination with chemotherapy and with stem cell transplantation, in an attempt to improve response rate and duration and to study its effectiveness in other B-cell lymphomas, including diffuse large B-cell lymphoma and mantle cell lymphoma. Radioimmunotherapy has great promise and the safe incorporation of 90Y ibritumomab tiuxetan into treatment will hopefully result in improved survival for patients with NHL.

Review of clinical radioimmunotherapy

Radioimmunotherapy involves a form of biologically targeted radiopharmaceutical treatment in which a radioactive isotope (typically a short-range, high-energy beta-emitter) is chemically bound to a target-specific monoclonal antibody or fragment. Thus, these radioimmunoconjugates combine the exquisite targeting specificity of the humoral immune system with the known cancer-killing power of high-energy radiotherapy. To date, two radioimmunotherapy agents have been fully approved for commercial use: 90Yttrium ibritumomab tiuxetan and (131)Iodine tositumomab. Both compounds target the CD20 surface molecule found on normal and malignant B cells, and both are medically indicated for the treatment of indolent B-cell lymphoma and related conditions. Clinical results are excellent (20-40% complete response rates and 60-80% overall response rates) and toxicity is typically quite mild. Current research is now attempting to both explore the biology of these compounds and to expand the spectrum of CD20+ diseases that could be treated using either or both of these active agents. Concurrently, work is in progress to achieve the same excellent clinical results using antibodies specific for other, more common epithelial tumors. This work is at an earlier stage than the lymphoma work, partly due to the high innate radiosensitivity of the lymphoid system. Thus, various enhancement methodologies are being explored to increase clinical response rates for these solid tumors, and a number of solid tumor RIT agents are now in early-stage clinical trials. The most likely pattern of use for this field in the next 5 years will probably involve combination or sequential regimens incorporating both radioimmunotherapy and more conventional chemotherapy or external radiotherapy.