Comparison of fungemia caused by Candida and non-Candida rare yeasts: a retrospective study from a tertiary care hospital

Although Candida species are the most common cause of fungemia, non-Candida rare yeasts (NCY) have been increasingly reported worldwide. Although the importance of these yeast infections is recognized, current epidemiological information about these pathogens is limited, and they have variable antifungal susceptibility profiles. In this study, we aimed to evaluate the clinical characteristics for fungemia caused by NCY by comparing with candidemia. The episodes of NCY fungemia between January 2011 and August 2023 were retrospectively evaluated in terms of clinical characteristics, predisposing factor, and outcome. In addition, a candidemia group, including patients in the same period was conducted for comparison. Antifungal susceptibility tests were performed according to the reference method. A total of 85 patients with fungemia episodes were included: 25 with NCY fungemia and 60 with candidemia. Fluconazole had high minimal inhibitory concentration (MIC) values against almost all NCY isolates. The MIC values for voriconazole, posaconazole, and amphotericin B were ≤ 2 µg/ml, and for caspofungin and anidulafungin were ≥ 1 µg/ml against most of isolates. Hematological malignancies, immunosuppressive therapy, neutropenia and prolonged neutropenia, polymicrobial bacteremia/fungemia, preexposure to antifungal drugs, and breakthrough fungemia were associated with NCY fungemia, whereas intensive care unit admission, diabetes mellitus, urinary catheters, and total parenteral nutrition were associated with candidemia. In conclusion, the majority of fungemia due to NCY species was the problem, particularly in hematology units and patients with hematological malignancy. Preexposure to antifungal drugs likely causes a change in the epidemiology of fungemia in favor of non-albicans Candida and/or NCY.

A Novel Finding of an HLA Allele's and a Haplotype's Relationship with SARS-CoV-2 Vaccine-Associated Subacute Thyroiditis

Subacute thyroiditis (SAT) is a thyroid disease associated with viral infections. Its relationship with major histocompatibility complex (MHC) antigens was shown before. SAT cases triggered by different types of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have been reported. In this study, human leukocyte antigen (HLA) genotypes of 27 SAT patients (13 vaccine-associated (V-SAT) and 14 non-SARS-CoV-2-infection non-vaccine-associated (non-V-SAT)) were compared with those of 362 healthy donors. HLA analyses were performed with low-resolution DNA-based sequence-specific oligonucleotide or sequence-specific primer methods. Statistical analyses were performed using IBM SPSS Statistics 25 and Stata/MP 14.1 with the hapipf function. Allele and haplotype frequencies were estimated by PyPop and gene[RATE] tool programs. The allele frequencies of HLA-A*11, HLA-B*35, and HLA-C*04 were higher in the patient groups. Both the allele frequency of HLA-A*11 and the haplotype frequency of A*11-B*35-C*04 were higher in the V-SAT group. The A*11-B*35-C*04 haplotype, including all three loci of MHC class I genes, is shown to be associated with the disease for the first time, especially in the V-SAT group. This finding will contribute to a better understanding of the etiopathogenesis of vaccine-associated SAT and the role of HLA genotypes in the functioning mechanisms of the SARS-CoV-2 vaccines.

An Anomaly with Potential as a New Prognostic Marker in CLL with del(13q): Gain of 16p13.3

Deletion 13q [del(13q)] is a favorable prognostic marker if it is detected as a sole abnormality in chronic lymphocytic leukemia (CLL). However the clinical courses of cases with isolated del(13q) are quite heterogeneous. In our study, we investigated copy number variations (CNVs), loss of heterozygosity (LOH), and the size of del(13q) in 30 CLL patients with isolated del(13q). We used CGH+SNP microarrays in order to understand the cause of this clinical heterogeneity. We detected del(13q) in 28/30 CLL cases. The size of the deletion varied from 0.34 to 28.81 Mb, and there was no clinical effect of the deletion size. We found new prognostic markers, especially the gain of 16p13.3. These markers have statistically significant associations with short time to first treatment and advanced disease stage. Detecting both CNVs and LOH at the same time is an advantageous feature of aCGH+SNP. However, it is very challenging for the array analysis to detect mosaic anomalies. Therefore, it is very important to confirm the results by FISH. In our study, we detected approximately 9% mosaic del(13q) by microarray. In addition, the gain of 16p13.3 may affect the disease prognosis in CLL. However, additional studies with more patients are needed to confirm these results.

A Real-life Turkish Experience of Venetoclax Treatment in High-risk Myelodysplastic Syndrome and Acute Myeloid Leukemia

INTRODUCTION

Venetoclax is a selective B-cell lymphoma 2 (BCL2) inhibitor, which is approved to treat elderly patients with newly diagnosed acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) in combination with either low-dose cytarabine (ARA-C) or hypomethylating agents. We aimed to collect and share data among the efficacy and safety of venetoclax both as a monotherapy or in combination with other drugs used to treat high-risk MDS or AML.

MATERIALS AND METHODS

A total of 60 patients with a median age of 67 (30-83) years from 14 different centers were included in the final analysis. Thirty (50%) of the patients were women; 6 (10%) of the 60 patients were diagnosed with high-risk MDS and the remaining were diagnosed with AML.

RESULTS

The best objective response rate (complete remission [CR], complete remission with incomplete hematological recovery (CRi), morphological leukemia-free state [MLFS], partial response [PR]) was 35% in the entire cohort. Best responses achieved during venetoclax per patient number were as follows: 7 CR, 1 CRi, 8 MLFS, 5 PR, and stable disease. Median overall survival achieved with venetoclax was 5 months in patients who relapsed and not achieved in patients who were initially treated with venetoclax. Nearly all patients (86.7%) had experienced a grade 2 or more hematologic toxicity. Some 36.7% of these patients had received granulocyte colony stimulating factor (GCSF) support. Infection, mainly pneumonia (26.7%), was the leading nonhematologic toxicity, and fatigue, diarrhea, and skin reactions were the others reported.

CONCLUSION

Our real-life data support the use of venetoclax in patients with both newly diagnosed and relapsed high-risk MDS and AML.

Use of rotational thromboelastometry for a global screening of coagulation profile in patients of myeloproliferative neoplasms

Chronic myeloproliferative neoplasms (MPN) are clonal disorders of hematopoietic stem/progenitor cell characterized by thrombohemorrhagic complications and a tendency to transform into acute leukemia. The pathogenesis of thrombosis in MPN is complex and results from a multifaceted interplay of clinical and disease-related factors. Rotational thromboelastometry (ROTEM) provides the complete and rapid information about all stages of the coagulation process. Here, we assess ROTEM parameters as a screening of coagulation profile in patients with MPNs. In particular, higher mean maximum clot firmness values were found in Essential thrombocythemia and Polycythemia vera patients when compared to healthy controls. Rotational thromboelastometry may be able to detect MPN patients who are susceptible to thrombotic and/or hemorrhagic complications. The predictive value of ROTEM for thrombosis remains to be established to classify subsets of patients at prominent risk who may benefit from prophylaxis with antithrombotic drugs.

Circulating endothelial cells in Behçet's disease: is there a relationship with vascular involvement?

OBJECTIVES

Circulating endothelial cells (CEC) are identified in conditions with vascular damage such as systemic vasculitis. Our aim was to investigate if EPC, CEC, and/or its subgroups activated CEC (aCEC) or resting CEC (rCEC) related with vascular involvement in Behçet's disease (BD).

METHODS

In total 60 patients were included in this study, divided into 4 groups: 1) Behçet patients with a history of vascular involvement: vascular BD; 2) Behçet patients with mucocutaneus involvement: mucocutaneus BD; 3) patients with history of thrombosis due to other causes: thrombosis; 4) 20 healthy controls were also included: control group. Percentages of CEC, aCEC, rCEC and EPCs in peripheral blood mononuclear cells were measured by flow cytometry.

RESULTS

CEC (3.75 (1.80-7.20), 1.80 (0.70-3.53), 3.50 (1.83-7.23), 2.45 (1.28- 4.60)) and aCEC (2.40 (1.28-4.28), 1.10 (0.77-2.20), 3.15 (1.48-7.20), 3.20 (1.15-9.80) levels were did not show a statistically significant difference between groups (p:0.077 and p:0.054, respectively). EPC and rCEC levels were higher in vascular BD and thrombosis groups than mucocutaneus BD and control groups (EPC:10.5 (7.20-18.3), 11.6 (7.30-20.9) vs. 7.15 (5.55-8.25), 10.2 (5.93-18.6), rCEC: 5.35 (3.13-7.90), 6.45 (4.60-10.8) vs. 4.95 (3.05-7.55), 3.40 (1.88-4.30), p:0.042 and p:0.007, respectively).

CONCLUSIONS

CEC, EPC, aCEC and rCEC may have role in the assessment of vascular involvement in BD. Longitudinal studies would be needed to identify the utility of these cells for the follow up and risk stratification of BD patients with vascular involvement for recurrences or identify BD patients at risk of vascular involvement.

Complete Resolution of the Left Ventricular Pedunculated Thrombus with Tirofiban Infusion in a Patient with Severe Left Ventricular Dysfunction

A 28-year-old man was admitted with symptoms of heart failure. Echocardiography revealed severe left ventricular dysfunction, apical aneurysm, and a 40 × 11 mm sized mobile thrombus attached to apical septum with a narrow stalk. The patient had anterior myocardial infarction two years ago. Heparin infusion was started at 1000 IU/hour for 48 hours. There was no detected change on the size of the thrombus. Surgery recommended to the patient was refused by him because of the procedural risks. Tirofiban infusion was started. Repeat echocardiography showed significant reduction in thrombus size after 24 hours, and complete resolution of the thrombus after 48 hours. To our knowledge, this is the first case with left ventricular mobile thrombus treated successfully with tirofiban infusion.

Hepatitis B Virus Reactivation under Treatment with Nilotinib

Hepatitis B virus (HBV) reactivation with imatinib, a tyrosine kinase inhibitor, has been reported in chronic myeloid leukemia. Nilotinib is a more potent second generation tyrosine kinase inhibitor and it inhibits the Src-family kinase LCK and hamper proliferation and function of CD8 (+) T lymphocytes. CD8 (+) T lymphocytes are the main cellular subset responsible for viral clearance in patients with HBV infection. We report a case of HBV reactivation under treatment with nilotinib. Fatal HBV reactivation is not usually related to death in chronic myeloid leukemia patients who have an expectation of longevity with well-tolerated oral drugs. Thus, screening for latent chronic HBV infections including assessment of hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc antibody) and antibody to hepatitis B surface antigen (anti-HBs), especially at countries with intermediate and high prevalence of HBsAg is warranted. Treatment with nucleoside analogs and close monitoring may be life-saving in this context.

TWO CASES WITH DIFFERENT EPILEPSY TYPE AND DYSMORPHIC FEATURES ASSOCIATED WITH 17q21.31 MICRODELETION SYNDROME

The 17q21.31 microdeletion syndrome is characterized by intellectual disability, epilepsy, facial dysmorphism and friendly behavior. Recently, KANSLJ gene has been considered as a major causal gene for this phenotype. Here we report on two Turkish patients with different seizure types and additional dysmorphic features associated with 17q21.31 microdeletion syndrome. A 4 year-old female patient with generalized tonic-clonic seizures, mild mental retardation, dysmorphic features and friendly behavior and a 14 years-old female with intractable epilepsy, different dysmorphic features, severe mental and motor retardation and self-mutilation were evaluated by array-based comparative genomic hybridization (microarray CGH). Array CGH identified 17q21.31 microdeletion that contains MAP7 CRHR1, KANSLI, PLEKHMI genes in case I and CRHR1, PLEKHM but not KANSLJgenes in case 2. To the best of our knowledge this is the first report of a patient with the 17q21.31 microdeletion which does not encompass KANSLI gene. These data imply another gene or genes causing similar phenotype in this patient.

Peripheral blood regulatory T cell levels are correlated with some poor prognostic markers in newly diagnosed lymphoma patients

BACKGROUND

Regulatory T cells (Tregs) are a specialized subpopulation of CD4+ T cells which maintain the immune system homeostasis. They may increase during cancer progression and have been correlated with a worse prognosis in many malignancies. However, the role of Treg cells in lymphoma is debated.

METHODS

In this study, we assessed the peripheral blood levels of CD4+ CD25+ FOXP3+ Tregs in newly diagnosed patients with lymphoma and tried to find a relationship with patient characteristics. Twenty one patients with Hodgkin lymphoma (HL), 40 patients with non Hodgkin lymphoma (NHL) and 30 healthy sex matched controls were included in the study. Analysis were done by 3-color flow cytometry and only helper T cells were selected directly using CD4perCP as a gating strategy.

RESULTS

In HL group; there was a positive correlation with IPS, CRP, LDH and negative correlation with albumin, absolute lymphocyte count. Tregs were higher in male HL patients. In NHL group; there was a positive correlation with stage, IPI, CRP, LDH and a negative correlation with albumin ve absolute lymphocyte count.

CONCLUSIONS

There is a relationship between peripheral blood Treg levels and some poor prognostic parameters in newly diagnosed lymphoma patients. This relationship suggests a possible prognostic role of Tregs in lymphoma. Further research is needed in determining how to use Tregs as a prognostic factor. © 2015 International Clinical Cytometry Society.

The effect of clinical characteristics on the performance of galactomannan and PCR for the diagnosis of invasive aspergillosis in febrile neutropenic patients

Rapid diagnosis and early treatment of invasive aspergillosis is crucial for the management of the patients with haematological malignancy. We evaluated 358 sera from 78 febrile neutropenic episodes in patient with invasive aspergillosis (IA) (one proven, 17 probable, and 60 possible) and 83 episodes in patients with no IA according to the EORTC/MSG criteria. Patient's specimens were tested by Mycassay Aspergillus PCR (first commercial real-time PCR test) and in house real-time PCR to investigate the presence of Aspergillus DNA, and by ELISA for detect the galactomannan (GM) antigen. We systematically investigated the medical background that can be effective on the test results. The hospitalisation period was longer in proven/probable episodes when compared with no IA (P = 0.001) and possible episodes. With regard to duration of neutropenia, the differences between both proven/probable with no IA (P = 0.023) and possible with no IA (P = 0.002) were highly significant. Similarly, the rates of T cell suppressant therapy in group proven/probable and possible episodes were significantly higher than in no IA (P = 0.005). There are significant differences in the performance of GM and PCR-based tests among studies, and standardisation is required. Therefore, it can be useful to determine the effective factors on these tests. The use of larger volume of sera improved the performance of real-time PCR for detection of Aspergillus DNA in high-risk adult patients in the present study. Some host factors such as duration of neutropenia and administration of T cell suppressants related to the development of IA.

Utility of flow cytometric κ and λ light chain analysis of peripheral blood

PURPOSE

Monoclonality in the peripheral blood can be shown by flow cytometric analysis of kappa (κ) and lambda (λ) light chain ratio of B lymphocytes. We aimed to show the utility of this method in patients with unknown causes of lymphadenopathy and/or splenomegaly.

METHODS

This method was performed in 81 adult patients with undefined causes of lymphadenopathy and splenomegaly.

RESULTS

18 (22%) of these patients had clonality and all of them were diagnosed as B cell lymphoma later. None of the patients with benign causes had clonality in the peripheral blood. We could not find any relationship between presence of clonality and type and stage of lymphoma and bone marrow involvement.

CONCLUSION

This method is easy to perform, cheap and non-invasive and yet it can give valuable information about the malignant nature of a suspected disease. If there is a sign of clonality in the peripheral blood, more invasive diagnostic procedures should be performed rather than watch and wait.

The role of flow cytometry in the diagnosis of non- Hodgkin's lymphoma, Hodgkin's lymphoma, granulomatous inflammation and reactive lymph node specimens

PURPOSE

In this study we aimed to compare the flow cytometry (FC) results of patients with B cell lymphoma, T cell lymphoma, Hodgkin's lymphoma, granulomatous inflammation and reactive lymph node and investigate the role of FC in malignant or non malignant conditions.

METHODS

Ninety patients were divided into 5 groups according to histopathology results. Patients were compared according to cytokeratin and positivity percentage of the following surface markers: CD45, CD19, CD5, CD19-CD5, CD4, CD8, CD3,CD16-CD56, CD10, CD10-CD19, CD23, CD20, CD4-CD8, CD3-CD16-56, CD30, CD38, kappa and lambda light chains, CD20-CD23. Patients were also compared according to the intensity of the expression (exp) of same markers. ROC curve analysis was performed for CD19+ cell percentage, CD38 exp, kappa/lambda and lambda/kappa ratios.

RESULTS

1) Kappa/lambda and lambda/kappa ratios can distinguish B cell lymphoma from T cell lymphoma, Hodgkin's lymphoma, granulomatous inflammation and reactive lymph node; 2) CD19+ cell percentage can distinguish T cell lymphoma from Hodgkin's lymphoma, granulomatous inflammation and reactive lymph node; 3) CD38 exp can partly distinguish B cell lymphoma from T cell lymphoma, Hodgkin's lymphoma, granulomatous inflammation and reactive lymph node and T cell lymphoma from granulomatous inflammation, T cell lymphoma from reactive lymph node, Hodgkin's lymphoma from reactive lymph node.

CONCLUSION

Flow cytometry has a role in distinguishing lymphomas from non malignant lesions.

Central nervous system relapse in a patient with acute promyelocytic leukaemia: does the risk stratification matter?

Extramedullary relapse is an uncommon complication of acute promyelocytic leukaemia (APL). The most common site of extramedullary relapse is the central nervous system (CNS), and the majority of CNS relapses occur in patients with high-risk disease in which white blood cell count at presentation is greater than 10×10(3)/μL. The best management of such patients is still controversial. We describe a 47-year-old man with APL who developed two CNS relapses which were diagnosed through the presence of t(15;17)(q22;q21) on PCR of the cerebrospinal fluid (CSF), despite presenting initially with intermediate-risk disease. We conclude that the intermediate risk group is very heterogeneous and these patients sometimes may behave like high-risk patients. Also, clinicians should take into account symptoms that can be related to CNS relapse in patients with APL and consider lumbar puncture even if radiological imaging does not reveal anything.

Thrombelastographic evaluation of the influence of 2-RBC apheresis on donor's coagulation system

Rotation thrombelastogram (ROTEM®/TEG®) assays allow rapid global assessment of hemostatic function using whole blood. Since published data about the effects of automated red cell collection on coagulation system are scarce, we aimed to investigate the effects of 2-RBC apheresis on donor's coagulation system using ROTEM® assays. In INTEM assay, CFT was significantly shortened 24h after apheresis compared with baseline value (p<0.05) and MCF was significantly prolonged immediately after apheresis and 24h after apheresis compared with baseline value (p<0.05 and p<0.01, respectively). In EXTEM assay, CFT was significantly prolonged immediately after apheresis and 24h after apheresis compared with baseline value (p=0.001 and p<0.001, respectively) and MCF was significantly prolonged 24h after apheresis compared with baseline value (p<0,001). Our results demonstrate thromboelastographic signs of hypercoagulability in donors undergoing 2-RBC apheresis.

Effect of hypericin on the ADAMTS-9 and ADAMTS-8 gene expression in MCF7 breast cancer cells

AIM

To investigate the effects of hypericin which is obtained from the plant Hypericum perforatum on the expression and the regulation of ADAMTS8 and ADAMTS9 genes in MCF7 breast cancer cells and on the viability of these cells.

MATERIALS AND METHODS

MCF7 cells were cultured and were separately exposed to 2, 10 and 50 µl/mL of hypericin. After 24 hours, RNA was isolated from these cells and converted to cDNA. The expression levels of ADAMTS8 and ADAMTS9 genes were evaluated using the Reverse Transcription Polymerase Chain Reaction. XTT (2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide, disodium salt) cell viability assay was used to determine cytotoxicity.

RESULTS

ADAMTS9 expression in MCF7 cells were increased 1.8 and 3.6 fold with the use of 2 and 10 µl/mL of hypericin, respectively; and decreased 0.7 fold with the use of 50 µl/mL of hypericin. There was no significant change in the ADAMTS8 expression. Rapid cell death was observed in the cancer cells when hypericin was used at a dose of ≥ 50 µl/mL.

CONCLUSIONS

The increase in ADAMTS9 expression can be a useful factor in the prevention of possible metastasis in breast cancer and for the occurrence of a tumor suppressive effect. Hypericin increases the expression of ADAMTS9, therefore, it may show its antitumoral and antiapoptotic effects by means of ADAMTS9.

Cardiac and pulmonary thrombosis during multidrug treatment in an idiopathic thrombocytopenic purpura patient

Glucocorticosteroids, intravenous immunoglobulins, vincristine, danazol, and eltrombopag are used in refractory chronic idiopathic thrombocytopenic purpura (ITP). All those treatment modalities are susceptible for thrombosis generation. There is an increased risk of thrombosis in the diseases' natural course. The case we present is a resistant chronic ITP patient who developed pulmonary and intracardiac thrombosis during multidrug treatment. Risk of concomitant usage of drugs and rapid increase in platelet count are discussed.

Can thrombelastography be a new tool to assess bleeding risk in patients with idiopathic thrombocytopenic purpura?

Thrombelastography (TEG) analyses the status of blood coagulation including abnormalities associated with low platelet count. The aim of this study was to investigate the changes in TEG parameters in idiopathic thrombocytopenic purpura (ITP) patients. Thirty nine patients with ITP (platelet count < 100 × 103  µl⁻¹) were included in the study. Age-matched 17 patients with thrombocytopenia due to chemotherapy were selected as a control group. Platelet count was positively correlated with maximum clot formation (MCF) in INTEM (r = 0.716, p < 0.001) and MCF in EXTEM (r = 0.679, p < 0.001); negatively correlated with clot formation time (CFT) in INTEM (r = -0.755, p < 0.001) and CFT in EXTEM (r = -0.585, p < 0.001) in ITP patients. Platelet count was positively correlated with MCF in INTEM (r = 0.776, p < 0.001) and MCF in EXTEM (r = 0.878, p < 0.001); negatively correlated with CFT in INTEM (r = -0.627, p < 0.001) in control group. Receiver operating characteristic curves to describe the critical platelet count and fibrinogen level that affect MCF revealed 31 × 103 µl⁻¹ and 375 mg dl⁻¹ as cut-off values, respectively. In conclusion, ROTEM determines the contribution of fibrinogen and platelets to clot strength in patients with ITP. MCF appears to be the most important TEG parameter in predicting bleeding in ITP patients that makes TEG superior to other hemostatic tests.

Lack of B-RAF mutations in head and neck squamous cell carcinoma

B-RAF is one of the most commonly mutated oncogenes in human cancer. However, the mutation status of B-RAF has not been established completely in HNSCC. We have analysed the mutation status of the kinase domain of the B-RAF gene (exons 11 and 15) in 91 Japanese HNSCC patients as well as 12 HNSCC cell lines. DNA was extracted and amplified by PCR. Mutations were then analysed by SSCP mutation detection method. Since V600EB-RAF constitutes 90 % of the mutations identified in B-RAF in human cancers, we also used MASA analysis to specifically detect this mutation in exon 15 of B-RAF. Using both methods, no mutation was found in both exon 11 and 15 in all patients and cell lines. Mu tations are absent or rare in the kinase domain of B-RAF in Japanese HNSCC. However, more studies are still needed to determine its usefulness as a target for molecular therapy in these patients.

Deletion mapping of chromosome 4q22-35 and identification of four frequently deleted regions in head and neck cancers

Head and neck squamous cell carcinoma (HNSCC) is a diverse group of cancers that are frequently aggressive in their biologic behavior. Inactivation of tumor suppressor gene (TSG) is one of the most critical steps leading to HNSCC. Loss of heterozygosity analysis is very sensitive method for the detection of frequent allelic loss in a chromosomal locus. This method has been considered as an important evidence for the localization of TSGs. We analyzed loss of heterozygosity (LOH) at chromosome 4q22-35 region by using 14 polymorphic microsatellite markers in 83 matched normal and HNSCC tissues. LOH was detected at least in one location in 71 of 83 (86%) tumor tissues. Frequent deletions were detected at the location of microsatellite markers, D4S2909 (46%), D4S2623 (51%), D4S406 (48%), D4S1644 (45%) and D4S2979 (40%). Four different frequently deleted regions at 4q22, 4q25, 4q31 and 4q34-35 were observed. These regions include several putative TSGs such as Caspase-6, SMARCAD1, SMARCA5, SAP30 and ING2. Further molecular analysis of each gene should be performed to clarify their roles in head and neck squamous cell carcinogenesis.