Acute rhabdomyolysis following administration of high-dose cyclophosphamide: case report

Rhabdomyolysis is an unusual complication of hematopoietic stem cell transplantation (HSCT). Cyclophosphamide has been one of the key drugs in the most common preparative regimen for HSCT. We present here a rare case of acute rhabdomyolysis following administration of high-dose cyclophosphamide. A 47-year-old woman with adult T-cell leukemia in remission was treated with high-dose cyclophosphamide as a preparative regimen for allogeneic bone marrow transplantation. Nineteen hours later, general convulsions and acidosis suddenly occurred. Levels of serum creatine kinase (skeletal muscle type), myoglobin, and aldolase were markedly elevated to 32870 IU/l, 640 ng/ml, and 240.3 IU/l, respectively. Rhabdomyolysis caused by high-dose cyclophosphamide was diagnosed, and the preparative chemotherapy was discontinued. Subsequently, her muscular signs and symptoms improved, and the results of laboratory examinations returned to normal after 2 weeks. She had previously been treated with conventional doses of cyclophosphamide, doxorubicin, vincristine, and prednisolone without evidence of rhabdomyolysis. Acute rhabdomyolysis may be an adverse effect specific to high-dose cyclophosphamide therapy.

[Two cases of bronchus-associated lymphoid tissue lymphoma]

We report 2 cases of bronchus-associated lymphoid tissue lymphoma (BALT lymphoma), which is a rare disease. Patient 1 was a 76-year-old woman with a chief complaint of cough. Since plain chest radiography revealed an abnormal shadow in the hilum of the lung, she visited our hospital. Patient 2 was a 56-year-old man, who had been diagnosed as having pseudolymphoma at a medical check-up in a local hospital. During follow-up, however, he was referred to our hospital because of enlarged tumors and chest pain. In both patients, bronchofiberscopy demonstrated submucosal tumors and biopsy samples showed formation of lymphoepithelial lesions by centrocyte-like cells with a B-cell staining pattern. The patients were therefore diagnosed as having BALT lymphoma. Both received CEOP-E treatment, which improved the clinical symptoms but did not result in complete remission. The patients have been followed up after discontinuation of the medication. The progress of the disease has been slow, and both patients are alive as of September 2001.

Blastic NK-cell lymphoma/leukemia with T-cell receptor gamma rearrangement

A 79-year-old Japanese man was admitted to our hospital with dyspnea in June 1999. Physical examination revealed general exanthema, hepatosplenomegaly, and lymphadenopathy. Increased numbers of abnormal cells were observed in peripheral blood; these cells were of lymphoblastic morphology with high nuclear/cytoplasm ratios and few azurophilic granules. Immunophenotypic analysis revealed positivity for CD2, CD4, CD56, and HLA-DR, and negativity for CD3, CD13, CD16, CD33, CD34, and T cell receptor (TCR). On genotypic analysis, TCRgamma chain was rearranged, but neither the TCRbeta chain nor TCRdelta chain. Despite an initial good response to chemotherapy the disease relapsed in the early stage, and the patient died 6 months after diagnosis.

A centrifuge-less plasma separation method from whole blood anticoagulated with EDTA-2K for the use of clinical laboratory tests

In the modern medical laboratory system, simple and rapid processing of specimens are required. In the current system with the transportation line, its centrifugation part would disturb smooth flow of the testing because it needs much time for the centrifugation. To solve the problems, a serum separation method was tried for the whole blood specimen using poly-L-lysine, concanavalin A and phyto-hemoagglutinin. Ploy-L-lysine with molecular weight 130,000 to 210,000 in a final concentration of 0.1% could accelerate blood sedimentation, although its supernatant contaminated platelets. Concanavalin and phytohemoagulutinin could accelerate the sedimentation and obtained plasma, but the method could yield enough amount of supernatant by 1 hour standing. As the purpose of this study is to develop a centrifugeless method, a sieve method using a steel mesh and a magnet was applied to the mixture of EDTA blood, red-cell adhesives and thrombin. The method was unique to separate plasma, but the yield was not so high and chemistry data were not fitted with serum data in some of tests. Thus, the trial would be a new technology, but it was judged that some further improvement will be needed technically.

Selective activation of p38 mitogen-activated protein kinase cascade in human neutrophils stimulated by IL-1beta

We investigated activation of mitogen-activated protein kinase (MAPK) subtype cascades in human neutrophils stimulated by IL-1beta. IL-1beta induced phosphorylation and activation of p38 MAPK and phosphorylation of MAPK kinase-3/6 (MKK3/6). Maximal activation of p38 MAPK was obtained by stimulation of cells with 300 U/ml IL-1beta for 10 min. Extracellular signal-regulated kinase (ERK) was faintly phosphorylated and c-Jun N-terminal kinase (JNK) was not phosphorylated by IL-1beta. IL-1beta primed neutrophils for enhanced release of superoxide (O(2)(-)) stimulated by FMLP in parallel with increased phosphorylation of p38 MAPK. IL-1beta also induced O(2)(-) release and up-regulation of CD11b and CD15, and both responses were inhibited by SB203580 (p38 MAPK inhibitor), suggesting that p38 MAPK activation mediates IL-1beta-induced O(2)(-) release and up-regulation of CD11b and CD15. Combined stimulation of neutrophils with IL-1beta and G-CSF, a selective activator of the ERK cascade, resulted in the additive effects when the priming effect and phosphorylation of p38 MAPK and ERK were assessed. IL-1beta induced phosphorylation of ERK and JNK as well as p38 MAPK in human endothelial cells. These findings suggest that 1) in human neutrophils the MKK3/6-p38 MAPK cascade is selectively activated by IL-1beta and activation of this cascade mediates IL-1beta-induced O(2)(-) release and up-regulation of CD11b and CD15, and 2) the IL-1R-p38 MAPK pathway and the G-CSF receptor-ERK pathway work independently for activation of neutrophils.

Effects of inhaled corticosteroid and short courses of oral corticosteroids on bone mineral density in asthmatic patients : a 4-year longitudinal study

BACKGROUND

It is not certain whether inhaled corticosteroid (ICS) therapy reduces bone mineral density (BMD) in asthmatic patients. In addition, the potential risk of osteoporosis associated with the rescue use of short courses of oral corticosteroids (SC-OCS) is unclear.

OBJECTIVE

To evaluate the effect of inhaled beclomethasone dipropionate (BDP) and SC-OCS on BMD in asthmatic patients.

DESIGN

A 4-year longitudinal study.

METHOD

Lumbar BMD was measured twice by dual-energy x-ray absorptiometry at a mean (+/- SD) interval of 4.2 +/- 0.1 years in 35 asthmatic adults (15 men and 20 postmenopausal women; mean age at the second evaluation, 60.6 +/- 11.5 years) who had been treated with BDP and SC-OCS.

RESULTS

The average period of BDP treatment was 7.7 +/- 2.2 years (range, 4.8 to 13.0 years) at the second evaluation. During the study period, the daily dose of BDP was 765 +/- 389 microg (range, 100 to 1,730 microg), and the frequency of SC-OCS was 1.9 +/- 2.7 courses per year (range, 0.0 to 8.9 courses per year). As a whole, lumbar BMD was unchanged during the course of the study, whereas the Z score (ie, the percentage of normal value predicted from age and sex) increased significantly. Changes in BMD and Z scores in patients receiving high doses of BDP (ie, > 1,000 microg/d; n = 9) were not significantly different from those of patients receiving lower doses (ie, <or= 1,000 microg/d; n = 26). However, patients receiving frequent SC-OCS (ie, > 2.5 courses per year; n = 9) showed a significantly greater loss in BMD and Z score compared with those receiving sporadic courses (ie, <or= 2.5 courses per year; n = 26) (p = 0.002 and p = 0.035, respectively).

CONCLUSIONS

ICS therapy per se does not affect BMD, whereas frequent SC-OCS may do so.

New enzymatic method for determining D-arabinitol in serum

A new reagent has been developed to determine D-arabinitol. This utilizes D-arabinitol 2-oxidoreductase derived from Bacillus sp. with high stability, and water-soluble tetrazolium salt, that can detect NADH with high sensitivity. Since this enzyme does not react to D-mannitol, elimination of D-mannitol is unnecessary. Thus, this is a much simpler process than currently available with commercial kits use D-arabinitol 4-oxidoreductase. The within-run and between-run precisions (CV) were 2.4-6.9% and 3.1-8.7%, respectively, whilst the correlation (r) between the results obtained with our proposed method (y) and those obtained with the commercial "Arabinitec-auto" kit (x) was 0.964 (y = 1.02x + 0.933 mumol/l; n = 69). However, some samples deviated remarkably from correlation in both methods. Our analyzing accuracy is satisfactory in clinical application, as it does not miss positive sample over cut-off value. We are refining this method by investigating why some specimens are apart from correlation significantly.

Chemical diversity in lipopeptide antifungal antibiotics

In the course of screening for antifungal antibiotics, we have discovered a novel series of lipopeptide compounds structurally related to, but highly superior to, echinocandin B in terms of their water solubility due to the presence of a sulfate residue. These compounds, WF11899s, WF738s, WF14573s, WF16616 and WF22210, and their derivatives have diversity in their nuclear structures and acyl side chains. The producing strains were classified into two groups, the Coleomycetes group and the Hyphomycetes group. Compound FK463, a derivative of WF11899A, is currently in Phase 3 clinical development as a novel antifungal antibiotic.

Apoptosis and thymidylate synthase inductions by 5-fluorouracil in gastric cancer cells with or without p53 mutation

We studied apoptosis and thymidylate synthase (TS) inductions by 5-fluorouracil (5-FU) in gastric cancer cells with wild-type p53 (MKN-45 and MKN-74) and with mutated p53 (MKN-28 and KATO-III). Apoptotic inductions in MKN-45 and MKN-74 were stronger than those in MKN-28 and KATO-III, suggesting that wild-type p53 may contribute to the induction of apoptosis. After continuous exposure to 0.1 microg/ml of 5-FU for 96 h, no TS induction was obtained in KATO-III, while approximately twice the amount of TS was observed compared to non-treatment cells in MKN-45, MKN-74, and MKN-28. The results of immunohistochemical staining for TS and p53 showed no relation between these two protein expressions in endoscopic biopsy specimens of 25 patients with advanced gastric cancer. These results indicated that p53 status may not play a pivotal role in regulating TS expression. We found no significantly different effects of 5-FU between intermittent (repeat of 24-h continuous infusion and 24-h drug-free) and continuous treatments in either MKN-28 or stem cells (CD34+ hematopoietic progenitor cells) when the same area under the time-concentration curve of 5-FU was administered. The TS induction in MKN-28 cells by intermittent treatment was significantly higher than that by continuous treatment; however, most TSs in both types of 5-FU treatment cells were of the inactive form, i.e., TS bound to FdUMP, a 5-FU metabolite. Therefore, neither intermittent nor continuous treatment appears to induce 5-FU resistance related to the level of increment free TS. In conclusion, our observations suggested that p53 mutation may be associated with apoptotic induction by 5-FU; however, p53 status may not strongly affect TS induction by 5-FU. Intermittent treatment can be replaced with continuous treatment without causing 5-FU resistance.

[Roles of clinical laboratory monitoring in bone marrow and peripheral blood stem cell transplantation]

Hematopoietic stem cell transplantation(HSCT) increase the chances of cure of many hematological malignancy. The clinical laboratory plays a major role in support of HSCT. Both transplantation-specific laboratory test(tissue typing, assessment of graft viability/rejection, evaluation of minimal residual disease, and measurement of immunosuppressive drugs) and routine clinical laboratory tests(biochemical, hematological, serological, urinary, bacteriological, and physiological examinations) are significant. Hematopoietic stem cells(HSC) are usually assessed as CD34+ cells, while immature cells determined by automated hematology analyzers can simply evaluate HCS. These automated immature cell counts are earlier markers of engraftment following transplantation than the traditional indicators(neutrophils and platelets). After transplantation, infections, regimen-related toxicities, graft-versus host disease, veno-occlusive disease, and thrombotic microangiopathy are the serious complications, which are causes of expected mortality and morbidity in HSCT. Clinical laboratory monitoring may contribute early diagnosis and treatment of the complications, resulting in prevention of the adverse events.

Tissue factor pathway inhibitor as a universal anticoagulant for use in clinical laboratory tests

Tissue factor pathway inhibitor (TFPI) is a protease inhibitor of extrinsic coagulation. The present study investigates the possibility of utilizing TFPI as a universal anticoagulant in clinical laboratory tests. The optimal concentration of TFPI for use in clinical laboratory tests was found to be 1 microl TFPI/ml blood (100 mmol TFPI/ml blood); the subsequent analyses were conducted at this concentration. In hematological tests, complete blood cell count and differential white blood cell count were done with an automatic blood analyzer. The results except for platelet and white blood cell counts were similar for ethylenediaminetetraacetic acid (EDTA)-treated and TFPI-treated samples. The effects of TFPI on platelet count were more pronounced when blood samples were stored at 4 degrees C than at room temperature. The effects of TFPI on cell morphology were evaluated by spreading blood samples into thin films and applying a Giemsa stain. The results showed that TFPI did not alter the morphology of blood cells. An automatic biochemical analyzer performed seventeen basic biochemical tests on serum samples and TFPI-treated plasma samples. The results of seventeen tests were comparable between TFPI-treated samples and EDTA-treated samples. The prothrombin time for TFPI-treated plasma samples was longer than that for citrated plasma samples. Nonetheless, in activated partial thromboplastin time tests, the addition of the reagent caused turbidity and partial coagulation, thus demonstrating that TFPI is not suitable for this assay. These findings suggest that although some tests cannot be performed with TFPI, this compound may be useful as a universal anticoagulant in the future.

Primary refractoriness to platelet transfusion caused by Nak(a) antibody alone

BACKGROUND AND OBJECTIVES

Anti-Nak(a), a platelet-specific antibody, occasionally causes platelet-transfusion refractoriness (PTR) together with human leucocyte antigen (HLA) antibodies. Anti-Nak(a) usually appears after frequent platelet transfusions or pregnancy. We report the first case of PTR caused by anti-Nak(a) alone.

MATERIALS AND METHODS

A 19-year-old male patient with testicular tumour showed PTR when receiving his first transfusion of platelets. Screening for platelet antigens and platelet antibodies revealed that he had type I CD36 (Nak(a)) deficiency and that anti-Nak(a), but not anti-HLA, was present before he received his first transfusion.

RESULTS

The transfusion of Nak(a)-negative, but HLA non-selected, platelets was effective in raising the platelet count.

CONCLUSION

Clinically significant Nak(a) antibody was present as naturally occurring antibody in a platelet glycoprotein IV (CD36)-negative non-transfused male patient.

Bone resorption associated with uncoupling of osteoclastic and osteoblastic activities in adult T cell leukemia with hypercalcemia: case report

A 64-year-old woman with adult T cell leukemia (ATL) was admitted to our hospital with severe hypercalcemia. The serum calcium level was elevated to 14.9 mg/dl. Biochemical parameters for bone formation including serum osteocalcin (bone Gla protein, BGP) and alkaline phosphatase (ALP) were normal. The serum levels of tartrate-resistant acid phosphatase (TRAP), a parameter for bone resorption, were increased (4.6 KAU). The serum level of parathyroid hormone-related protein (PTHrP) was elevated (343 pmol/l). The cytokines with stimulatory effects on bone resorption, such as interleukin (IL)-1alpha, IL-1beta, IL-6, and tumor necrosis factor-alpha, were not detected. Serum Ca levels, PTHrP levels, and TRAP levels decreased with the decrease in ATL cells after chemotherapy, while serum BGP levels and ALP levels increased. On the 29th hospital day, ATL cells began to increase again. Then serum PTHrP levels, Ca levels, and TRAP levels increased, while serum BGP levels and ALP levels decreased. A marked excessive bone resorption with suppressed bone formation (uncoupling) occurred in this patient. The ATL cells produced not only PTHrP but also IL-1alpha and IL-1beta. These results suggest that PTHrP may act as a humoral factor and IL-1 may act as a local factor in bone metabolism of ATL patients.

Nodal gamma/delta T cell lymphoma in complete remission following allogeneic bone marrow transplantation from an HLA-matched unrelated donor

Gamma/delta T cell lymphoma is very rare, and usually occurs as an extranodal tumor. We describe the case of a 16-year-old Japanese man with an unusual nodal gamma/delta T cell lymphoma with generalized lymphadenopathy and bone marrow involvement. No tumor involvement was observed in the liver, spleen, or nasal cavity. Examination for surface antigens on lymphoma cells revealed a unique phenotype, positive for CD3 and T cell receptor (TCR) gamma/delta, but negative for CD2. Genotypic analysis revealed the tumor to be of monoclonal origin and characterized by TCR gamma-chain gene rearrangement, but there was no rearrangement of the TCR beta-chain gene. Our patient's tumor responded to combination chemotherapy and subsequent allogeneic bone marrow transplantation from an HLA-matched unrelated donor. He has remained well and free of disease for 35 months.

Virus-associated hemophagocytic syndrome due to rubella virus and varicella-zoster virus dual infection in patient with adult idiopathic thrombocytopenic purpura

A 26-year-old woman with idiopathic thrombocytopenic purpura (ITP) was admitted to our hospital because of fever and rash. Blood tests revealed thrombocytopenia, liver dysfunction, coagulopathy, and hyperferritinemia. Bone marrow examination revealed many atypical lymphocytes and some histiocytes with hemophagocytosis. On admission she was diagnosed with rubella virus-associated hemophagocytic syndrome (VHAS), but on laboratory examination, she was seropositive for varicella-zoster virus (VZV)-IgM as well as rubella virus-IgM. She was therefore diagnosed with dual infection by rubella virus and VZV. Her simultaneous rubella virus and VZV infection may have been related to the VAHS pathogenesis. She was treated with prednisolone and gamma globulin therapy and recovered completely.

Clinical significance of simultaneous measurement of reticulated platelets and large platelets in idiopathic thrombocytopenic purpura

Frequencies of reticulated platelets (RP) and large platelets (LP) among circulating platelets can now be simultaneously determined using the R-3000 automated reticulocyte counter (Sysmex, Kobe, Japan) equipped with special software. We measured frequencies of RP and LP in patients with idiopathic thrombocytopenic purpura (ITP. acute type n = 5; chronic type n = 39), and healthy normal controls (n = 20). In ITP patients, the platelet-associated IgG (PAIgG) level was also determined. Both RP and LP were significantly higher in chronic ITP patients than those in normal volunteers, and interestingly, the LP in acute ITP was significantly lower than that in chronic ITP although there was no significant difference in RP between acute and chronic ITP. Furthermore, we analyzed the changes in both RP and LP during the clinical course of ITP to monitor the therapeutic effect in 2 patients. An elevation of RP with a steep slope prior to a decrease in the platelet count level was observed. The RP significantly correlated with the PAIgG level. Simultaneous measurement of RP and LP may be helpful for the diagnosis of chronic ITP, for the differentiation of acute from chronic type and for the control of the efficacy of management in ITP, since RP seems to reflect the disease activity of ITP.

[CD13- and CD33-negative acute myelocytic leukemia (FAB classification; M2) with morphological changes and CD13 expression on recurrence]

A 42-year-old man was diagnosed as having acute myelocytic leukemia in July 1998. The leukemic cells tended to be differentiated, and on the basis of positive peroxidase staining, this case was considered to be AML (M2) according to the FAB classification. t(8;21)(q22;q22) chromosomal abnormality was observed, but surface antigen analysis revealed no expression of either CD13 or CD33, a finding characteristic of myelocytic leukemia. Combination chemotherapy resulted in complete remission, and allogeneic bone marrow transplantation was performed with donor cells from the patient's sister. Unfortunately, however, the patient died about 18 months after the onset of leukemia. Comparison of the findings at recurrence with those at initial diagnosis revealed morphological changes in non-differentiated immature cells (AML-M1) and CD13 surface antigen expression. This was considered to be a rare case of AML with neither CD13 nor CD33 expression at onset, but with CD13 expression at recurrence.