Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Case Series with Review of the Literature

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder, and eculizumab and ravulizumab are its two approved therapies. Only few case series/reports have reported the outcomes of pregnancies in patients with PNH despite the increased risk of thrombosis. Similarly, there is limited knowledge regarding the effect of the approved treatments on conception and pregnancy outcomes. Here, we report the first series of pregnancies in PNH patients from the Middle Eastern region from our tertiary care hospital. Ten pregnancies in four females after diagnosis with PNH were identified. In terms of PNH management, only eculizumab was used, as the safety of ravulizumab use in pregnancies has not yet been established. In the antepartum period, the patients had variable symptoms that ranged from mild symptoms including epistaxis, tea-colored urine and vaginal bleeding to life-threatening vessel thrombosis. Further, red blood cell and platelet transfusions were required because of bleeding and hemolysis in four pregnancies. The pregnancy outcomes varied, but based on these, the safety of eculizumab use during pregnancy remained inconclusive. The postpartum period was complicated in one case by portal vein thrombosis and was managed accordingly. In conclusion, pregnant females with PNH are at an increased risk for complications due to PNH, and thus experienced hematologists and obstetricians should be involved jointly in their care.

Pattern of psychiatric illnesses among long-stay patients at Mental Health Hospital, Taif, Saudi Arabia: a 10-year retrospective study

To identify the pattern and determinants of psychiatric illness and the predictors of long stay among long-stay patients at the Mental Health Hospital, Taif, Saudi Arabia, we examined a total of 430 records of patients who had been admitted during the period January 1999-January 2009 and had stayed for > 9 months. More than half these patients had a history of drug addiction (60.7%). The majority were diagnosed with schizophrenia (88.8%) and mental retardation was reported in 17.7%. Personality disorders and epilepsy were diagnosed in 3.7% and 1.9% of the participants respectively. The mean duration of hospital stay was 6.16 (standard deviation 2.32; range 1-10) years. Multivariate logistic regression analysis showed that patients diagnosed with schizophrenia accompanied by mental retardation, those with lower education levels, and those with a history of co-morbid chronic diseases stayed for more than 2 years.

The Wilms' tumor antigen is a novel target for human CD4+ regulatory T cells: implications for immunotherapy

Compelling evidences indicate a key role for regulatory T cells (T(reg)) on the host response to cancer. The Wilms' tumor antigen (WT1) is overexpressed in several human leukemias and thus considered as promising target for development of leukemia vaccine. However, recent studies indicated that the generation of effective WT1-specific cytotoxic T cells can be largely affected by the presence of T(regs). We have generated T-cell lines and clones that specifically recognized a WT1-84 (RYFKLSHLQMHSRKH) peptide in an HLA-DRB1*0402-restricted manner. Importantly, they recognized HLA-DRB1*04-matched fresh leukemic cells expressing the WT1 antigen. These clones exerted a T helper 2 cytokine profile, had a CD4(+)CD25(+)Foxp3(+)GITR(+)CD127(-) T(reg) phenotype, and significantly inhibited the proliferative activity of allogeneic T cells independently of cell contact. Priming of alloreactive T cells in the presence of T(regs) strongly inhibited the expansion of natural killer (NK), NK T, and CD8(+) T cells and had an inhibitory effect on NK/NK T cytotoxic activity but not on CD8(+) T cells. Furthermore, priming of T cells with the WT1-126 HLA-A0201-restricted peptide in the presence of T(regs) strongly inhibited the induction of anti-WT1-126 CD8(+) CTL responses as evidenced by both very low cytotoxic activity and IFN-gamma production. Moreover, these T(reg) clones specifically produced granzyme B and selectively induced apoptosis in WT1-84-pulsed autologous antigen-presenting cells but not in apoptotic-resistant DR4-matched leukemic cells. Importantly, we have also detected anti-WT1-84 interleukin-5(+)/granzyme B(+)/Foxp3(+) CD4(+) T(regs) in five of eight HLA-DR4(+) acute myeloid leukemia patients. Collectively, our in vitro and in vivo findings strongly suggest important implications for the clinical manipulation of T(regs) in cancer patients.

Vascular events associated with alpha interferon therapy

Alpha Interferon (IFN) is a biological agent used for the therapy of an increasing number of diseases, either as an established effective therapeutic tool or in the context of clinical trials. The use of IFN may be complicated by serious adverse reactions. We describe here the clinical course of a variety of vasculopathic complications in association with IFN-therapy in 12 patients with the diagnosis of chronic myeloid leukemia and 1 patient with malignant melanoma treated at our institute. Vascular manifestations in these patients include Raynaud's phenomena, digital ulcerations and gangrene, pulmonary vasculitis, pulmonary hypertension and thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). These reactions occurred after 3 months to 3 years of 3-10 million units (MU) daily IFN therapy. Concomitant administration of hydroxyurea (HU) was noted in 5 patients. Discontinuation of IFN and initiation of immunosuppressive therapy brought about a complete resolution or arrested progression of these reactions. IFN-therapy may be complicated by severe vasculopathic/vasospastic complications that usually improve after its discontinuation. Possible underlying mechanisms for these complications are discussed. The early diagnosis of these complications may be vital and IFN should be immediately discontinued when early signs of these complications become evident.

Prostatic carcinoma: a nutritional disease? Conflicting data from the Kingdom of Saudi Arabia

PURPOSE

The incidence of prostate cancer in Saudi Arabia has been reported to be low at 1.4 to 2.1/100,000 person-years. We prospectively evaluated the true incidence of this disease and its association with dietary factors.

MATERIALS AND METHODS

From 1994 to 1997 inclusive Saudi men older than 50 years treated at our institution for various presenting symptoms and diseases were randomly selected from various departments. They were examined prospectively with digital rectal examination, and total and free prostate specific antigen measurement. Transrectal ultrasound and prostatic biopsy were performed when either test was abnormal. Nutrition questionnaires and detailed interviews with a nutritionist were completed to assess the type of diet, and amount of saturated and polyunsaturated fat consumption of patients with prostatic carcinoma and controls.

RESULTS

For the 2,270 Saudi men screened we noted an incidence of 3.1/100,000 person-years. Our nutritional survey revealed that recent fat consumption was greater than 120 gm. per person daily, of which about 40% was from meat and dairy products. Saturated fat comprised about 50% of the total fat intake. There was no difference in the amount of fat in the diet of men with and without prostatic carcinoma.

CONCLUSIONS

The incidence of prostatic carcinoma in the Kingdom of Saudi Arabia is low despite a high saturated fat diet in recent years. This finding contradicts most western clinical studies, which indicate a positive association of a high fat diet with prostatic carcinoma.

Deep Vein Thrombosis

Initially, patients with deep vein thrombosis (DVT) should be treated with a 5- to 7-day course of heparin or low-molecular-weight heparin (LMWH). They can be administered LMWH as outpatients. Patients with extensive iliofemoral thrombosis, major pulmonary embolism, or concomitant medical illness, and those at high risk for bleeding, should be treated as inpatients. Thrombolytic therapy may be considered for patients with extensive iliofemoral thrombosis if there is no contraindication to the use of thrombolytic drugs. Oral anticoagulants can be started within 24 hours of the initiation of heparin or LMWH. Warfarin is started at a dose of 5 mg, and subsequent doses are given in amounts sufficient to achieve an international normalized ratio of 2.0 to 3.0. Inferior vena caval filters should be considered for patients with overt bleeding or for those at high risk for hemorrhage. Warfarin can be used for secondary prophylaxis in most patients. Patients in whom there are contraindications to the use of oral anticoagulants and patients in whom recurrent venous thromboembolism (VTE) develops while they are receiving therapeutic doses of warfarin can be safely and effectively treated with LMWH. Patients with idiopathic DVT should be treated with anticoagulants for at least 6 months. Those with calf DVT or proximal DVT that complicates surgery or medical illness can be treated with anticoagulants for 6 weeks and 3 months, respectively, provided that there are no ongoing risk factors for recurrent VTE. Oral anticoagulants are teratogenic and should be avoided by patients who are pregnant; unfractionated heparin or LMWH are safe alternatives. Unfractionated heparin, LMWH, and oral anticoagulants can be safely administered to nursing mothers.

Granulocyte-macrophage colony-stimulating factor-associated histiocytosis and capillary-leak syndrome following autologous bone marrow transplantation: two case reports and a review of the literature

Bone marrow (BM) histiocystosis in association with the administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) is a rare phenomenon with few published cases. We report two cases of BM histiocystosis in patients with Hodgkin's disease treated with GM-CSF after autologous bone marrow transplantation. Both patients also developed clinical features of capillary leak syndrome, another rare complication of GM-CSF administration. GM-CSF-induced histiocystosis should now be considered in the differential diagnosis of delayed engraftment post-autotransplant.