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Liebregts T, Lueck C, Mohring A, Riße J, Tzalavras A. [Cancer patients in the emergency department]. Med Klin Intensivmed Notfmed 2024; 119:3-9. [PMID: 37659989 DOI: 10.1007/s00063-023-01055-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/26/2023] [Accepted: 07/24/2023] [Indexed: 09/04/2023]
Abstract
A growing number of patients are living with cancer or have a history of cancer leading to increasing adverse effects of treatment or disease necessitating emergency department (ED) consultation. Long-term cancer survivors are at higher risk of comorbidities causing a substantial increase in health care resource utilization. The most frequent reasons for cancer-related ED visits are dyspnea, fever, pain, gastrointestinal or neurological symptoms leading to high hospital and intensive care unit admission rates. Acute respiratory failure in cancer patients necessitates timely diagnostic testing, whereby computed tomography is superior to chest X‑ray. Delay in intensive care unit (ICU) admission or mechanical ventilation increases mortality. Febrile neutropenia is an emergency with urgent need for antibiotic treatment. Treatment of neutropenic and nonneutropenic patients with sepsis does not differ. Cardiovascular disease is now the second leading cause of long-term morbidity and mortality among cancer survivors. Immunotherapy can lead to substantial and in some patients life-threatening complications that may not easily be recognized in the ED. Cancer-specific emergencies such as leukostasis, tumorlysis or hypercalcemia rarely present to ED and require interdisciplinary care. The constantly growing cancer population is likely to increase ED utilization. Knowledge about cancer treatment and disease-associated complications is crucial for emergency physicians. Palliative care education should secure appropriate end-of-life care avoiding futile interventions.
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Affiliation(s)
- Tobias Liebregts
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Catherina Lueck
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Annemarie Mohring
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Joachim Riße
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Asterios Tzalavras
- Klinik für Hämatologie und Stammzelltransplantation, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
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2
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Heger JM, Böll B, Naendrup JH, Simon F, Gräf CM, Hallek M, Shimabukuro-Vornhagen A, Kochanek M, Eichenauer DA, Garcia Borrega J. Hyperleukocytosis in patients with acute myeloid leukemia admitted to the intensive care unit: a single-center retrospective analysis. Leuk Res 2023; 132:107352. [PMID: 37423072 DOI: 10.1016/j.leukres.2023.107352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
A relevant proportion of patients with acute myeloid leukemia (AML) presenting with hyperleukocytosis are admitted to the intensive care unit (ICU). However, data on characteristics and outcomes of these patients are limited. We therefore conducted a single-center retrospective analysis including 69 consecutive AML patients with a white blood cell (WBC) count > 100.000/µl who had been treated on the ICU between 2011 and 2020. The median age was 63 years (range: 14-87 years). Males accounted for the majority of cases (n = 43; 62.3%). Mechanical ventilation (MV), renal replacement therapy and the use of vasopressors were necessary in 34.8%, 8.7% and 40.6% of patients, respectively. Cardiopulmonary resuscitation was performed in 15.9% of patients. The ICU, hospital, 90-day and 1-year survival rates were 53.6%, 43.5%, 42% and 30.4%, respectively. Age (p = 0.002), SOFA score (p < 0.001) and MV (p < 0.001) were independently associated with a reduced survival probability. A score comprising the factors age > 70 years, lactate dehydrogenase level > 1500 U/l, WBC count > 150.000/µl, elevated lactate level and SOFA score > 7 allowed the discrimination of 3 distinct risk groups (low-risk: 0-1 points, intermediate-risk: 2 points, high-risk: 3-5 points) with regard to survival (p < 0.0001). Taken together, the present analysis indicates that more than two-thirds of AML patients with hyperleukocytosis treated on the ICU die within 1 year. However, outcomes vary considerably depending on the presence of risk factors.
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Affiliation(s)
- Jan-Michel Heger
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Boris Böll
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Jan-Hendrik Naendrup
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Florian Simon
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Claus Moritz Gräf
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Michael Hallek
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Alexander Shimabukuro-Vornhagen
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Matthias Kochanek
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Dennis A Eichenauer
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.
| | - Jorge Garcia Borrega
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
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3
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Jeon WJ, Dalal S, Moon JH, Joung B, Nguyen M, Castillo D, Hudson J, Park K, Raghavan R, Akhtari M, Patel A. Leukostasis With Isolated Central Nervous System Involvement in Chronic Phase of Chronic Myelogenous Leukemia. J Hematol 2023; 12:187-196. [PMID: 37692864 PMCID: PMC10482607 DOI: 10.14740/jh1150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/11/2023] [Indexed: 09/12/2023] Open
Abstract
Chronic myelogenous leukemia (CML) is a hematologic malignancy with unique significance to the field of hematology and oncology, specifically due to the development of tyrosine kinase inhibitors (TKIs). CML often presents with nonspecific symptoms, and the quality of life in patients with CML has drastically improved as a result of TKIs. However, complications of CML including the risk of transforming into life-threatening blast crises continue to exist. Further, as most patients are asymptomatic in the chronic phase, patients often present with serious complications associated with noncompliance to TKIs. For example, central nervous system (CNS) manifestations of CML have been reported, both as the initial presentation of undiagnosed CML and as known complication of uncontrolled CML. Hyperleukocytosis is a manifestation of uncontrolled CML and leukostasis is a complication, occurring in cases of acute myeloid leukemia (AML). Here we present a rare case of leukostasis in a patient with known CML presenting on computed tomography (CT) as intracranial masses in the chronic phase. Our goal is to discuss this rare case of leukostasis in adult CML and describe its management.
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Affiliation(s)
- Won Jin Jeon
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Suhani Dalal
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Jin Hyun Moon
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Bowon Joung
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Michael Nguyen
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Dani Castillo
- Division of Medical Oncology, City of Hope, Duarte, CA, USA
| | - Jessica Hudson
- Division of Anatomic and Surgical Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kiwon Park
- Department of Pharmacy, Loma Linda University, Loma Linda, CA, USA
| | - Ravi Raghavan
- Division of Anatomic and Surgical Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Mojtaba Akhtari
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ami Patel
- Division of Medical Oncology/Hematology, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
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Ersayoğlu İ, Yazıcı Özkaya P, Metin H, Hekimci H, Zararcı K, Yılmaz Karapınar D, Karapınar B. A rare complication of leukostasis with AML M4 patient: Microcirculatory dysfunction of upper extremities. Transfus Apher Sci 2023; 62:103717. [PMID: 37173209 DOI: 10.1016/j.transci.2023.103717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/15/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In children with acute myeloid leukemia, the incidence of hyperleukocytosis is 5-33%. Patients with AML and hyperleukocytosis have a higher early mortality rate than patients with nonhyperleukocytic AML because of the increased risk of severe pulmonary and neurologic complications. Leukapheresis provides rapid cytoreduction and reduces early mortality rates. CASE PRESENTATION In this report, we present a case with microcirculatory failure of upper extremities as a rare symptom of hyperleukocytic AML M4 at initial presentation. CONCLUSIONS Early diagnosis and treatment of patients with AML admitted to emergency services with these symptoms is too important to prevent from loss of extremities. Most of the complications of hyperleukocytosis can be reversible with early treatment.
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Affiliation(s)
- İrem Ersayoğlu
- Ege University Medical School, Children's Hospital Pediatric Intensive Care Unit, İzmir, Turkey.
| | - Pınar Yazıcı Özkaya
- Ege University Medical School, Children's Hospital Pediatric Intensive Care Unit, İzmir, Turkey.
| | - Hamdi Metin
- Ege University Medical School, Children's Hospital Pediatric Intensive Care Unit, İzmir, Turkey.
| | - Hamiyet Hekimci
- Ege University Medical School, Children's Hospital Pediatric Hematology, İzmir, Turkey.
| | - Kazım Zararcı
- Ege University Medical School, Children's Hospital Pediatric Intensive Care Unit, İzmir, Turkey.
| | | | - Bülent Karapınar
- Ege University Medical School, Children's Hospital Pediatric Intensive Care Unit, İzmir, Turkey.
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5
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Cerrano M, Chevret S, Raffoux E, Rabian F, Sébert M, Valade S, Itzykson R, Lemiale V, Adès L, Boissel N, Dombret H, Azoulay E, Lengliné E. Benefits of dexamethasone on early outcomes in patients with acute myeloid leukemia with hyperleukocytosis: a propensity score matched analysis. Ann Hematol 2023; 102:761-768. [PMID: 36773040 PMCID: PMC9919741 DOI: 10.1007/s00277-023-05119-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
Hyperleukocytosis is associated with a significant early mortality rate in patients with acute myeloid leukemia (AML). To date, no controlled trial has ever evaluated a strategy to reduce this risk, and the initial management of these patients remains heterogeneous worldwide. The aim of the present study was to evaluate the influence of a short course of intravenous dexamethasone on the early outcomes of patients with hyperleukocytic AML with white blood cell (WBC) count above 50 × 109/L. Clinical and biological data of all consecutive patients (1997-2017) eligible for intensive chemotherapy from a single center were retrospectively collected. A total of 251 patients with a median age of 51 years and a median WBC count of 120 × 109/L were included, 95 of whom received dexamethasone. Patients treated with dexamethasone had higher WBC count and a more severe disease compared with those who did not, and they presented more often with leukostasis and hypoxemia, resulting in a more frequent need for life-sustaining therapies (p < 0.001). To account for these imbalances, patients were compared after adjusting for a propensity score, which included all variables with a prognostic influence in the overall cohort. In the matched cohort, dexamethasone was associated with lower early death (OR = 0.34, p = 0.0026) and induction failure rate (OR = 0.44, p = 0.02) and better overall survival (HR = 0.60, p = 0.011), with no impact on relapse risk (cHR = 0.73, p = 0.39). The overall survival benefit was confirmed among all tested subgroups. This study suggests that dexamethasone administration is safe and associated with a lower risk of induction mortality in patients with hyperleukocytic AML and deserves prospective evaluation.
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Affiliation(s)
- Marco Cerrano
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France.,Department of Oncology, Division of Haematology, AOU Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Sylvie Chevret
- Service de Biostatistique Et Information Médicale, Hôpital Saint-Louis, Paris, France
| | - Emmanuel Raffoux
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France
| | - Florence Rabian
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France
| | - Marie Sébert
- Hématologie Seniors, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France.,INSERM U944, Université de Paris, Paris, France
| | - Sandrine Valade
- Medical Intensive Care Unit, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| | - Raphael Itzykson
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France.,INSERM U944, Université de Paris, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| | - Lionel Adès
- Hématologie Seniors, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France.,INSERM U944, Université de Paris, Paris, France
| | - Nicolas Boissel
- Hématologie Adolescents Et Jeunes Adultes, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| | - Hervé Dombret
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France.,INSERM U944, Université de Paris, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| | - Etienne Lengliné
- Hématologie Adulte, Hôpital Saint-Louis, APHP, Université Paris Diderot, 1 Avenue Claude Vellefaux 75010, Paris, France.
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Ashraf M, Naseeruddin G, Zahra SG, Sultan KA, Kamboh UA, Manzoor M, Farooq M, Ahmad M, Ashraf N. Intracerebral hemorrhage as the first symptomatic manifestation of chronic myeloid leukemia (chronic phase): A case report and literature review. Surg Neurol Int 2023; 14:5. [PMID: 36751457 PMCID: PMC9899481 DOI: 10.25259/sni_897_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/27/2022] [Indexed: 01/08/2023] Open
Abstract
Background Chronic myeloid leukemia (CML) is mostly asymptomatic at diagnosis. Intracerebral hemorrhage (ICH), as the first presentation of CML in its chronic phase (CP) has only once been reported in the literature. In addition, CML (CP) patients developing ICH are equally rare, with only eight cases reported. ICH is more commonly associated with CML progressing to its end stage (accelerated phase [AP] and blast crisis [BC]). The pathophysiology of ICH in CML-CP is postulated to be due to leukostasis, unlike in the CML-AP/BC, where thrombocytopenia and coagulopathy are the underlying mechanisms. This case adds to the scarce literature on a rare and challenging complication of ICH in CML-CP, especially as these patients tend to rebleed and management is uncertain. Case Description A 22-year-old male presented with a 2-week history of headaches and vomiting, associated with a 1-week history of the left-sided weakness. Initial blood work revealed hyperleukocytosis. The patient was investigated for CML with intracranial involvement. During his stay, his Glasgow coma score (GCS) dropped (from 14 to 11), prompting an urgent CT scan which revealed a large resolving ICH with perifocal edema and midline shift. A decompressive hemicraniectomy with expansion duraplasty was performed to alleviate the mass effect and reduce intracranial pressure. Three hours postoperatively, the patient developed an extradural hematoma which needed prompt evacuation. A postoperative CT revealed an improved midline shift, and after 7 days, his GCS improved to 15, and he began oncological treatment. Neurological symptoms were experienced by our patient at presentation with hyperleukocytosis on full blood count, which may implicate leukostasis as an underlying mechanism. Conclusion Even in the CP, CML patients presenting with mild neurological symptoms should be investigated to exclude intracranial bleeds. As these patients tend to rebleed, they should be conservatively managed unless there is a need to alleviate intracranial pressure.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom,,Corresponding author: Mohammad Ashraf, Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom.
| | - Ghulam Naseeruddin
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Shah Gul Zahra
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Mehwish Manzoor
- Department of Oncology, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Minaam Farooq
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Manzoor Ahmad
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
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7
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Gitto L, Mehta R, Mirchia K, Ramos C, Tawil M, Serinelli S. Sudden death due to leukostasis in a subject with undiagnosed chronic lymphocytic leukemia. Forensic Sci Med Pathol 2021. [PMID: 34415512 DOI: 10.1007/s12024-021-00406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
Sudden death due to leukostasis and lymphocyte thrombi in patients with chronic hematologic malignancies is rare. Leukostasis is characterized by highly elevated leukemic cell count and decreased tissue perfusion symptoms, leading to severe complications and even death. Chronic lymphocytic leukemia (CLL) is a chronic lymphoproliferative disorder that shows a highly heterogeneous clinical course, ranging from indolent form to very aggressive disease. Due to its low metabolic and mitotic rate, there is a lower incidence of clinically significant leukostasis in patients with CLL. Two main theories have been proposed in the development of leukostasis: (1) increased blood viscosity due to large leukemic cell populations; (2) high metabolic activity and cytokine production by leukemic cells. Both mechanisms lead to local hypoxic damage.We present a case of a 70-year-old man who died suddenly in the absence of symptoms. Autopsy and histology examinations revealed findings consistent with CLL and diffuse leukostasis involving the major organs' vessels.In the presence of gross and/or microscopic findings suggesting a potential hematologic malignancy, undiagnosed or relapsing hematologic malignancies should be considered in the differential diagnosis of sudden deaths.
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Abstract
Mounting evidence suggests that immunological mechanisms play a fundamental role in the pathogenesis of diabetic retinopathy (DR) and diabetic macular edema (DME). Upregulation of cytokines and other proinflammatory mediators leading to persistent low-grade inflammation is believed to actively contribute to the DR-associated damage to the retinal vasculature, inducing breakdown of the blood-retinal barrier, subsequent macular edema formation, and promotion of retinal neovascularization. This review summarizes the current knowledge of the biological processes providing an inflammatory basis for DR and DME. In addition, emerging therapeutic approaches targeting inflammation are discussed, including blockade of angiopoietin 2 and other molecular targets such as interleukin (IL)-6, IL-1β, plasma kallikrein, and integrins.
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Affiliation(s)
- Marina Mesquida
- Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain.
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070, Basel, Switzerland.
| | - Faye Drawnel
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070, Basel, Switzerland
| | - Sascha Fauser
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070, Basel, Switzerland
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Abstract
Emergency providers are likely to encounter patients with acute and chronic leukemias. In some cases, the first presentation to the emergency department may be for symptoms related to blast crisis and leukostasis. Making a timely diagnosis and consulting a hematologist can be life saving. Presenting symptoms are caused by complications of bone marrow infiltration and hyperleukocytosis with white blood cell counts over 100,000. Presentations may include fatigue (anemia), bleeding (thrombocytopenia), shortness of breath, and/or neurologic symptoms owing to hyperleukocytosis and subsequent leukostasis. Treatment of symptomatic cases involves induction chemotherapy and/or leukapheresis. Asymptomatic hyperleukocytosis can be treated with hydroxyurea.
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Affiliation(s)
- Geremiha Emerson
- Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, 760 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210, USA.
| | - Colin G Kaide
- Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, 760 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210, USA
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Ibrahim AS, Saleh H, El-Shafey M, Hussein KA, El-Masry K, Baban B, Sheibani N, Wang MH, Tawfik A, Al-Shabrawey M. Targeting of 12/15-Lipoxygenase in retinal endothelial cells, but not in monocytes/macrophages, attenuates high glucose-induced retinal leukostasis. Biochim Biophys Acta Mol Cell Biol Lipids 2017; 1862:636-45. [PMID: 28351645 DOI: 10.1016/j.bbalip.2017.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/27/2017] [Accepted: 03/24/2017] [Indexed: 11/22/2022]
Abstract
AIMS Our previous studies have established a role for 12/15-lipoxygenase (LO) in mediating the inflammatory response in diabetic retinopathy (DR). However, the extent at which the local or systemic induction of 12/15-LO activity involved is unclear. Thus, the current study aimed to characterize the relative contribution of retinal endothelial versus monocytic/macrophagic 12/15-LO to inflammatory responses in DR. MATERIALS & METHODS We first generated a clustered heat map for circulating bioactive lipid metabolites in the plasma of streptozotocin (STZ)-induced diabetic mice using liquid chromatography coupled with mass-spectrometry (LC-MS) to evaluate changes in circulating 12/15-LO activity. This was followed by comparing the in vitro mouse endothelium-leukocytes interaction between leukocytes isolated from 12/15-LO knockout (KO) versus those isolated from wild type (WT) mice using the myeloperoxidase (MPO) assay. Finally, we examined the effects of knocking down or inhibiting endothelial 12/15-LO on diabetes-induced endothelial cell activation and ICAM-1 expression. RESULTS Analysis of plasma bioactive lipids' heat map revealed that the activity of circulating 12/15-LO was not altered by diabetes as evident by no significant changes in the plasma levels of major metabolites derived from 12/15-lipoxygenation of different PUFAs, including linoleic acid (13-HODE), arachidonic acid (12- and 15- HETEs), eicosapentaenoic acid (12- and 15- HEPEs), or docosahexaenoic acid (17-HDoHE). Moreover, leukocytes from 12/15-LO KO mice displayed a similar increase in adhesion to high glucose (HG)-activated endothelial cells as do leukocytes from WT mice. Furthermore, abundant proteins of 12-LO and 15-LO were detected in human retinal endothelial cells (HRECs), while it was undetected (15-LO) or hardly detectable (12-LO) in human monocyte-like U937 cells. Inhibition or knock down of endothelial 12/15-LO in HRECs blocked HG-induced expression of ICAM-1, a well-known identified important molecule for leukocyte adhesion in DR. CONCLUSION Our data support that endothelial, rather than monocytic/macrophagic, 12/15-LO has a critical role in hyperglycemia-induced ICAM-1 expression, leukocyte adhesion, and subsequent local retinal barrier dysfunction. This may facilitate the development of more precisely targeted treatment strategies for DR.
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Ye EA, Liu L, Jiang Y, Jan J, Gaddipati S, Suvas S, Steinle JJ. miR-15a/16 reduces retinal leukostasis through decreased pro-inflammatory signaling. J Neuroinflammation 2016; 13:305. [PMID: 27931222 PMCID: PMC5146897 DOI: 10.1186/s12974-016-0771-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/02/2016] [Indexed: 11/24/2022] Open
Abstract
Background Hyperglycemia is a significant risk factor for diabetic retinopathy and induces increased inflammatory responses and retinal leukostasis, as well as vascular damage. Although there is an increasing amount of evidence that miRNA may be involved in the regulation in the pathology of diabetic retinopathy, the mechanisms by which miRNA mediate cellular responses to control onset and progression of diabetic retinopathy are still unclear. The purpose of our study was to investigate the hypothesis that miR-15a/16 inhibit pro-inflammatory signaling to reduce retinal leukostasis. Methods We generated conditional knockout mice in which miR-15a/16 are eliminated in vascular endothelial cells. For the in vitro work, human retinal endothelial cells (REC) were cultured in normal (5 mM) glucose or transferred to high glucose medium (25 mM) for 3 days. Transfection was performed on REC in high glucose with miRNA mimic (hsa-miR-15a-5p, hsa-miR-16-5p). Statistical analyses were done using unpaired Student t test with two-tailed p value. p < 0.05 was considered significant. Data are presented as mean ± SEM. Results We demonstrated that high glucose conditions decreased expression of miR-15a/16 in cultured REC. Overexpression of miR-15a/16 with the mimic significantly decreased pro-inflammatory signaling of IL-1β, TNFα, and NF-κB in REC. In vivo data demonstrated that the loss of miR-15a/16 in vascular cells led to increased retinal leukostasis and CD45 levels, together with upregulated levels of IL-1β, TNFα, and NF-κB. Conclusions The data indicate that miR-15a/16 play significant roles in reducing retinal leukostasis, potentially through inhibition of inflammatory cellular signaling. Therefore, we suggest that miR-15a/16 offer a novel potential target for the inhibition of inflammatory mediators in diabetic retinopathy. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0771-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eun-Ah Ye
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA
| | - Li Liu
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA
| | - Youde Jiang
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA
| | - Jenny Jan
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA
| | - Subhash Gaddipati
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA
| | - Susmit Suvas
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA.,Ophthalmology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA.,Immunology and Microbiology, Wayne State University, Detroit, MI, USA
| | - Jena J Steinle
- Department of Anatomy and Cell Biology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA. .,Ophthalmology, Wayne State University, 9314 Scott Hall, Detroit, MI, 48202, USA.
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Zhang HT, Shi K, Baskota A, Zhou FL, Chen YX, Tian HM. Silybin reduces obliterated retinal capillaries in experimental diabetic retinopathy in rats. Eur J Pharmacol 2014; 740:233-9. [PMID: 25066112 DOI: 10.1016/j.ejphar.2014.07.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 02/06/2023]
Abstract
Silybin has been previously reported to possess anti-inflammatory properties, raising the possibility that it may reduce vascular damage in diabetic retinopathy. Present study was designed to investigate this potential effect of silybin and its underlying mechanisms in experimental diabetic retinopathy. Diabetes was induced with streptozotocin (STZ) plus high-fat diet in Sprague-Dawley rats, and silybin was administrated for 22 weeks after the induction of diabetes. Histochemical and immunofluorescence techniques were used to assess the obliterated retinal capillaries, leukostasis, and level of retinal intercellular adhesion molecule-1 (ICAM-1). Western blot was performed to quantitate the expression of retinal ICAM-1. Results showed that silybin treatment significantly prevented the development of obliterated retinal capillaries in diabetes, compared with vehicle treatment. In addition, leukostasis and level of the retinal ICAM-1 were found to decrease considerably in silybin-treated diabetic groups. In conclusion, these results indicate that silybin reduces obliterated retinal capillaries in experimental diabetes, and the recovered retinal vascular leukostasis and level of ICAM-1 at least partly contributes to the preventive effect of silybin.
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Affiliation(s)
- Hong-Tao Zhang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China
| | - Kai Shi
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China
| | - Attit Baskota
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China
| | - Fang-Li Zhou
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China
| | - Ya-Xi Chen
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China
| | - Hao-Ming Tian
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Sichuan, Chengdu 610041, PR China.
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DiNardo CD, Tang G, Pemmaraju N, Wang SA, Pike A, Garcia-Manero G, Cortes J, Bueso-Ramos C, Kantarjian HM. Acute myeloid leukemia with t(10;11): a pathological entity with distinct clinical presentation. Clin Lymphoma Myeloma Leuk 2015; 15:47-51. [PMID: 25081372 DOI: 10.1016/j.clml.2014.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Acute myeloid leukemias with MLL rearrangements are frequently associated with myelomonocytic and monoblastic/monocytic morphology, with an increased risk of leukocytosis and leukostasis-related complications. Yet, little is known regarding the clinical presentation of adult AML patients with MLL translocations based on the specific translocation partner. PATIENTS AND METHODS Two recent AML cases with t(10;11)(p12;q23) translocations are detailed, with their shared presenting symptoms highlighted, followed by a review of the current literature. RESULTS The specific t(10;11)(p12;q23) MLL translocation is a rare recurrent translocation partner, most commonly seen in pediatric and young adult AML. A high incidence of early morbidity from leukocytosis-related complications are frequently seen, including diffuse intravascular coagulation and tumor lysis syndrome with multiorgan system failure, even without a true leukocytosis. CONCLUSION With prompt therapy and intensive supportive care first remissions are frequently attained, however, patients have a high risk of relapse, extramedullary disease, and poor long-term outcomes.
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De Santis GC, Oliveira LC, Ramos AF, da Silva NDF, Falcão RP. Pathologic rupture of the spleen in a patient with acute myelogenous leukemia and leukostasis. Rev Bras Hematol Hemoter 2014; 36:290-2. [PMID: 25031169 PMCID: PMC4207916 DOI: 10.1016/j.bjhh.2014.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/14/2014] [Indexed: 11/26/2022] Open
Abstract
Rupture of the spleen can be classified as spontaneous, traumatic, or pathologic. Pathologic rupture has been reported in infectious diseases such as infectious mononucleosis, and hematologic malignancies such as acute and chronic leukemias. Splenomegaly is considered the most relevant factor that predisposes to splenic rupture. A 66-year-old man with acute myeloid leukemia evolved from an unclassified myeloproliferative neoplasm, complaining of fatigue and mild upper left abdominal pain. He was pale and presented fever and tachypnea. Laboratory analyses showed hemoglobin 8.3g/dL, white blood cell count 278×10(9)/L, platelet count 367×10(9)/L, activated partial thromboplastin time (aPTT) ratio 2.10, and international normalized ratio (INR) 1.60. A blood smear showed 62% of myeloblasts. The immunophenotype of the blasts was positive for CD117, HLA-DR, CD13, CD56, CD64, CD11c and CD14. Lactate dehydrogenase was 2384U/L and creatinine 2.4mg/dL (normal range: 0.7-1.6mg/dL). Two sessions of leukapheresis were performed. At the end of the second session, the patient presented hemodynamic instability that culminated in circulatory shock and death. The post-mortem examination revealed infiltration of the vessels of the lungs, heart, and liver, and massive infiltration of the spleen by leukemic blasts. Blood volume in the peritoneal cavity was 500mL. Acute leukemia is a rare cause of splenic rupture. Male gender, old age and splenomegaly are factors associated with this condition. As the patient had leukostasis, we hypothesize that this, associated with other factors such as lung and heart leukemic infiltration, had a role in inducing splenic rupture. Finally, we do not believe that leukapheresis in itself contributed to splenic rupture, as it is essentially atraumatic.
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Algharras AA, Mamourian A, Coyne T, Mohan S. Leukostasis in an Adult with AML Presenting as Multiple High Attenuation Brain Masses on CT. J Clin Diagn Res 2014; 7:3020-2. [PMID: 24551717 DOI: 10.7860/jcdr/2013/6638.3893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/20/2013] [Indexed: 11/24/2022]
Abstract
Acute myeloid leukemia (AML) is a hematologic malignancy that can present with central nervous system (CNS) symptoms. Neurological symptoms may result from the local accumulation of malignant cells in or near the brain (chloroma), infection, hemorrhage, or infarcts from leukostasis. Leukostasisis a syndrome that can include brain infarction due hyperviscosity of blood with vascular occlusion but CNS involvement is rarely encountered in adults. We report an unusual case of leukostasis in an adult who presented with multiple high attenuation intracranial masses on CT. While initially thought to represent chloromasthey proved to be hemorrhagic infarcts secondary toleukostasis on open brain biopsy. This condition is under-reported in the radiology literature and only rarely biopsy proven. We review in this paper the pathological, CT and MRI findings of leukostasis in order to increase awareness of this uncommon entity and facilitate diagnosis.
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Affiliation(s)
| | - Alexander Mamourian
- Professor, Department of Radiology, Hospital of the University of Pennsylvania , USA
| | - Thomas Coyne
- Forensic Pathology Fellow, Department of Miami-Dade Medical Examiner, Number One on Bob Hope Rd., Miami, Fl 33136
| | - Suyash Mohan
- Assistant Professor, Department of Radiology, Hospital of the University of Pennsylvania , USA
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Oberoi S, Lehrnbecher T, Phillips B, Hitzler J, Ethier MC, Beyene J, Sung L. Leukapheresis and low-dose chemotherapy do not reduce early mortality in acute myeloid leukemia hyperleukocytosis: a systematic review and meta-analysis. Leuk Res 2014; 38:460-8. [PMID: 24472688 DOI: 10.1016/j.leukres.2014.01.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/02/2014] [Accepted: 01/04/2014] [Indexed: 11/25/2022]
Abstract
The role of leukapheresis and low-dose chemotherapy is unclear in decreasing early mortality in acute myeloid leukemia (AML) patients with hyperleukocytosis. This systematic review was conducted to describe early mortality (deaths during first induction) in patients with AML with an initial white blood count≥100×10(9)L(-1) stratified by the approach to leukapheresis and hydroxyurea/low-dose chemotherapy. Twenty-one studies were included. Weighted mean early deaths rate (20 studies, 1354 patients) was 20.1% (95% confidence interval 15.0-25.1). Neither leukapheresis strategy (p=0.67) nor hydroxyurea/low-dose chemotherapy (p=0.23) influenced the early death rate. Early mortality related to hyperleukocytosis in AML is not influenced by universal or selected use of leukapheresis or hydroxyurea/low-dose chemotherapy.
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Affiliation(s)
- Sapna Oberoi
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Bob Phillips
- Leeds General Infirmary, Leeds Teaching Hospitals, NHS Trust, Leeds, UK; Centre for Reviews and Dissemination, University of York, York, UK
| | - Johann Hitzler
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Marie-Chantal Ethier
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Joseph Beyene
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada; Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.
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Abcouwer SF. Neural inflammation and the microglial response in diabetic retinopathy. J Ocul Biol Dis Infor 2011; 4:25-33. [PMID: 23614055 DOI: 10.1007/s12177-012-9086-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/16/2012] [Indexed: 01/27/2023] Open
Abstract
This chapter reviews the function of microglia and their potential roles in neural inflammation and pathological changes during diabetic retinopathy.
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