The PARN, TOE1, and USB1 RNA deadenylases and their roles in non-coding RNA regulation

The levels of non-coding RNAs (ncRNAs) are regulated by transcription, RNA processing, and RNA degradation pathways. One mechanism for the degradation of ncRNAs involves the addition of oligo(A) tails by non-canonical poly(A) polymerases, which then recruit processive sequence-independent 3' to 5' exonucleases for RNA degradation. This pathway of decay is also regulated by three 3' to 5' exoribonucleases, USB1, PARN, and TOE1, which remove oligo(A) tails and thereby can protect ncRNAs from decay in a manner analogous to the deubiquitination of proteins. Loss-of-function mutations in these genes lead to premature degradation of some ncRNAs and lead to specific human diseases such as Poikiloderma with Neutropenia (PN) for USB1, Dyskeratosis Congenita (DC) for PARN and Pontocerebellar Hypoplasia type 7 (PCH7) for TOE1. Herein, we review the biochemical properties of USB1, PARN, and TOE1, how they modulate ncRNA levels, and their roles in human diseases.

Impaired myelopoiesis in congenital neutropenia: insights into clonal and malignant hematopoiesis

A common feature of both congenital and acquired forms of bone marrow failure is an increased risk of developing acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). Indeed, the development of MDS or AML is now the major cause of mortality in patients with congenital neutropenia. Thus, there is a pressing clinical need to develop better strategies to prevent, diagnose early, and treat MDS/AML in patients with congenital neutropenia and other bone marrow failure syndromes. Here, we discuss recent data characterizing clonal hematopoiesis and progression to myeloid malignancy in congenital neutropenia, focusing on severe congenital neutropenia (SCN) and Shwachman-Diamond syndrome. We summarize recent studies showing excellent outcomes after allogenic hematopoietic stem cell transplantation for many (but not all) patients with congenital neutropenia, including patients with SCN with active myeloid malignancy who underwent transplantation. Finally, we discuss how these new data inform the current clinical management of patients with congenital neutropenia.

Diagnosis and therapeutic decision-making for the neutropenic patient

Determining the cause of a low neutrophil count in a pediatric or adult patient is essential for the hematologist's clinical decision-making. Fundamental to this diagnostic process is establishing the presence or lack of a mature neutrophil storage pool, as absence places the patient at higher risk for infection and the need for supportive care measures. Many diagnostic tests, eg, a peripheral blood smear and bone marrow biopsy, remain important tools, but greater understanding of the diversity of neutropenic disorders has added new emphasis on evaluating for immune disorders and genetic testing. In this article, a structure is provided to assess patients based on the mechanism of neutropenia and to prioritize testing based on patient age and hypothesized pathophysiology. Common medical quandaries including fever management, need for growth factor support, risk of malignant transformation, and curative options in congenital neutropenia are reviewed to guide medical decision-making in neutropenic patients.

Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department

Central venous oxygen saturation (ScvO₂) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO₂ and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO₂ was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO₂ was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO₂ showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO₂ to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO₂ < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO₂ to risk stratify cancer patients presenting to the ED.

Response of an oscillatory differential delay equation to a periodic stimulus

Periodic hematological diseases such as cyclical neutropenia or cyclical thrombocytopenia, with their characteristic oscillations of circulating neutrophils or platelets, may pose grave problems for patients. Likewise, periodically administered chemotherapy has the unintended side effect of establishing periodic fluctuations in circulating white cells, red cell precursors and/or platelets. These fluctuations, either spontaneous or induced, often have serious consequences for the patient (e.g. neutropenia, anemia, or thrombocytopenia respectively) which exogenously administered cytokines can partially correct. The question of when and how to administer these drugs is a difficult one for clinicians and not easily answered. In this paper we use a simple model consisting of a delay differential equation with a piecewise linear nonlinearity, that has a periodic solution, to model the effect of a periodic disease or periodic chemotherapy. We then examine the response of this toy model to both single and periodic perturbations, meant to mimic the drug administration, as a function of the drug dose and the duration and frequency of its administration to best determine how to avoid side effects.

Episodes of fever in neutropenia in pediatric patients with cancer in Bern, Switzerland, 1993-2012

Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop complications, integrated into clinical decision rules, would allow for risk-stratified treatment of FN. This retrospective, single center cohort study in pediatric patients diagnosed with cancer before 17 years, covered two decades, 1993 to 2012. In total, 703 FN episodes in 291 patients with chemotherapy (maximum per patient, 9) were reported here. Twenty-nine characteristics of FN were collected: 6 were patient- and cancer-related, 8 were characteristics of history, 8 of clinical examination, and 7 laboratory results in peripheral blood, all known at FN diagnosis. In total 28 FN outcomes were assessed: 8 described treatment of FN, 6 described microbiologically defined infections (MDI), 4 clinically defined infections, 4 were additional clinical composite outcomes, and 6 outcomes were related to discharge. These data can mainly be used to study FN characteristics and their association with outcomes over time and between centers, and for derivation and external validation of clinical decision rules.

Mutation, drift and selection in single-driver hematologic malignancy: Example of secondary myelodysplastic syndrome following treatment of inherited neutropenia

Cancer development is driven by series of events involving mutations, which may become fixed in a tumor via genetic drift and selection. This process usually includes a limited number of driver (advantageous) mutations and a greater number of passenger (neutral or mildly deleterious) mutations. We focus on a real-world leukemia model evolving on the background of a germline mutation. Severe congenital neutropenia (SCN) evolves to secondary myelodysplastic syndrome (sMDS) and/or secondary acute myeloid leukemia (sAML) in 30–40%. The majority of SCN cases are due to a germline ELANE mutation. Acquired mutations in CSF3R occur in >70% sMDS/sAML associated with SCN. Hypotheses underlying our model are: an ELANE mutation causes SCN; CSF3R mutations occur spontaneously at a low rate; in fetal life, hematopoietic stem and progenitor cells expands quickly, resulting in a high probability of several tens to several hundreds of cells with CSF3R truncation mutations; therapeutic granulocyte colony-stimulating factor (G-CSF) administration early in life exerts a strong selective pressure, providing mutants with a growth advantage. Applying population genetics theory, we propose a novel two-phase model of disease development from SCN to sMDS. In Phase 1, hematopoietic tissues expand and produce tens to hundreds of stem cells with the CSF3R truncation mutation. Phase 2 occurs postnatally through adult stages with bone marrow production of granulocyte precursors and positive selection of mutants due to chronic G-CSF therapy to reverse the severe neutropenia. We predict the existence of the pool of cells with the mutated truncated receptor before G-CSF treatment begins. The model does not require increase in mutation rate under G-CSF treatment and agrees with age distribution of sMDS onset and clinical sequencing data.

Cancer develops by multistep acquisition of mutations in a progenitor cell and its daughter cells. Severe congenital neutropenia (SCN) manifests itself through an inability to produce enough granulocytes to prevent infections. SCN commonly results from a germline ELANE mutation. Large doses of the blood growth factor granulocyte colony-stimulating factor (G-CSF) rescue granulocyte production. However, SCN frequently transforms to a myeloid malignancy, commonly associated with a somatic mutation in CSF3R, the gene encoding the G-CSF Receptor. We built a mathematical model of evolution for CSF3R mutation starting with bone marrow expansion at the fetal development stage and continuing with postnatal competition between normal and malignant bone marrow cells. We employ tools of probability theory such as multitype branching processes and Moran models modified to account for expansion of hematopoiesis during human development. With realistic coefficients, we obtain agreement with the age range at which malignancy arises in patients. In addition, our model predicts the existence of a pool of cells with mutated CSF3R before G-CSF treatment begins. Our findings may be clinically applied to intervene more effectively and selectively in SCN patients.

White blood cell subpopulation changes and prevalence of neutropenia among Arab diabetic patients attending Dasman Diabetes Institute in Kuwait

BACKGROUND

The effects of diabetes mellitus on the differential white blood cell count are not widely studied in the Arab populations. The objective of this cross-sectional, retrospective study is to assess the influence of chronic diabetes mellitus on white blood cell counts, absolute neutrophil (ANC) and lymphocyte counts (ALC) as well as the prevalence of benign ethnic neutropenia among Arabs attending the Dasman Diabetes Institute (DDI) in Kuwait.

METHODS AND FINDINGS

1,580 out of 5,200 patients registered in the DDI database qualified for our study. Age, gender, HbA1c and creatinine levels, estimated glomerular filtration rate as well as average WBC, ANC and ALC levels, presence of diabetes-associated complications and anti-diabetic medications were analyzed. Our results showed the mean value of the WBC was 7.6 ± 1.93 x 109/L (95% CI: 2.95-17.15). The mean ANC was 4.3 x 109/L (95% CI: 0.97-10.40) and mean ALC was 2.5 x 109/L (95% CI: 0.29-10.80). Neutropenia (ANC: <1.5 x 109/L) was detected in fifteen patients (0.94%). Six patients (0.4%) fulfilled the definition of lymphopenia (ALC < 1 x109/L). Patients with an HbA1c ≥ 7% and those taking at least 3 anti-diabetic medications showed higher values for ANC and ALC. Patients with diabetes-associated neuropathy or nephropathy displayed higher mean ANC values. Our study was limited by overrepresentation of patients over 50 years old compared to those under 50 as well as selection bias given its retrospective nature.

CONCLUSIONS

Our study showed that patients with poorly controlled diabetes displayed higher ANC and ALC levels. In addition, patients with DM-associated complications showed higher ANC levels. This finding would suggest that DM exerts a pro-inflammatory influence on differential WBC counts. Our study also showed that the prevalence of benign ethnic neutropenia was lower than previously reported in other studies.

Hematologic manifestations of babesiosis

BACKGROUND

Babesiosis, a zoonotic parasitic infection transmitted by the Ixodes tick, has become an emerging health problem in humans that is attracting attention worldwide. Most cases of human babesiosis are reported in the United States and Europe. The disease is caused by the protozoa of the genus Babesia, which invade human erythrocytes and lyse them causing a febrile hemolytic anemia. The infection is usually asymptomatic or self-limited in the immunocompetent host, or follows a persistent, relapsing, and/or life threatening course with multi-organ failure, mainly in the splenectomized or immunosuppressed patients. Hematologic manifestations of the disease are common. They can range from mild anemia, to severe pancytopenia, splenic rupture, disseminated intravascular coagulopathy (DIC), or even hemophagocytic lymphohistiocytosis (HLH).

CASE PRESENTATION

A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. Blood smear revealed intraerythrocytic Babesia, which was confirmed by PCR. Bone marrow biopsy was remarkable for dyserythropoiesis, suggesting possible HLH, supported by other blood workup meeting HLH-2004 trial criteria.

CONCLUSION

Human babesiosis is an increasing healthcare problem in the United States that is being diagnosed more often nowadays. We presented a case of HLH triggered by Babesia microti that was treated successfully. Also, we presented the hematologic manifestations of this disease along with their pathophysiologies.

Psychometric Properties of the Functional Assessment of Cancer Therapy-Neutropenia in Asian Cancer Patients With Chemotherapy-Induced Neutropenia

CONTEXT

The Functional Assessment of Cancer Therapy-Neutropenia (FACT-N) is a neutropenia-specific questionnaire to assess patients' health-related quality of life.

OBJECTIVES

This study aimed to examine the psychometric properties of FACT-N among cancer patients with chemotherapy-induced neutropenia (CIN).

METHODS

This prospective, cross-sectional study included multiethnic Asian cancer patients. Patients completed the questionnaires within seven days after diagnosed with CIN. Eligible patients completed either the English or Chinese version of the EuroQol 5-Dimensions (EQ-5D) and the FACT-N once, according to their language preference. The reliability was evaluated by using Cronbach alpha (α). The known-group validity was assessed based on patient's Eastern Cooperative Oncology Group performance status, neutropenia grade, and experience of fever. The convergent validity was evaluated by contrasting the FACT-N subscales with the EQ-5D domains. Multiple linear regression models were performed to compare the FACT-N total scores between the two language versions.

RESULTS

A total of 276 eligible patients (200 English speaking and 76 Chinese speaking) were included in this study. Internal consistencies within the FACT-N subscales were satisfactory (Cronbach α = 0.71-0.85), except for the flu-like symptoms subscale (Cronbach α = 0.67). For known-group validity, the FACT-N total score could differentiate patients according to their Eastern Cooperative Oncology Group performance status (P < 0.001), neutropenia grade (P = 0.028), and experience of fever (P < 0.001). The correlations between the FACT-N subscales and their hypothesized constructs in EQ-5D domains were weak to moderate (|r| = 0.15-0.44). The measurement equivalence between the English and Chinese versions was established for the FACT-N total scores.

CONCLUSION

The FACT-N is a valid and reliable instrument to be used in clinical practice to evaluate the health-related quality of life among multiethnic Asian patients with CIN.

Anemia and Neutropenia in Copper-Deficient Patients: A Report of Two Cases and Literature Review

Copper deficiency is an uncommon, but treatable cause of hematologic abnormalities. We present and describe two interesting cases in this report. The first case was a 37-year-old man with history of short bowel syndrome and long-term total parenteral nutrition (TPN) presenting with pancytopenia and chronic symmetrical polyarthritis that resembled rheumatoid arthritis. The second case was a 64-year-old man with malabsorption from Cronkhite-Canada Syndrome (CCS) and history of subtotal gastrectomy presenting with macrocytic anemia and neutropenia. Bone marrow examination in both cases revealed cytoplasmic vacuolization of myeloid and erythroid precursors. After copper supplementation was initiated, hematological abnormalities and arthritis were significantly improved. We encourage clinicians to recognize early and identify copper deficiency in patients who have unexplained cytopenia, especially if there is history of upper gastrointestinal tract surgery, malabsorption, or long-term TPN.

Is chronic neutropenia always a benign disease? Evidences from a 5-year prospective study

AIM

To evaluate infections and oncohematologic evolution in adult patients with chronic idiopathic and autoimmune neutropenia in a prospective study.

PATIENTS AND METHODS

76 consecutive patients were enrolled from September 2008 to April 2012. Complete blood counts and clinical evaluation were performed at enrolment, at month 3, 6, and then every 6 months. Anti-neutrophil antibodies were tested by GIFT method.

RESULTS

Patients (49 chronic idiopathic- and 27 autoimmune neutropenia) were followed for a median of 5 years (range 24-84 months). At enrolment, neutropenia was mild in 44 patients (median neutrophils 1.27×10(3)/μL), moderate in 23 (median 0.8×10(3)/μL), and severe in 9 (median 0.4×10(3)/μL). Neutrophil counts showed a great inter-subject but no intra-subject variability, with lower values in autoimmune neutropenia, in males, and in MGUS cases. Over time, no grade >3 infections occurred; 13/49 chronic idiopathic and 6/27 autoimmune neutropenia patients experienced a grade 2 event, irrespective of mean and nadir neutrophil values. Bone marrow evaluation at enrolment showed reduced cellularity in 23% of cases, and dyserythropoietic features in 55%, with no definite hematologic diagnosis. During the follow-up, 5 cases were diagnosed with NK expansion, 4 with hairy cell leukemia, and 3 with myelodysplasia (1 myelomonocytic leukemia, 1 refractory cytopenia with unilineage dysplasia, and 1 multilineage dysplasia), with a median time to evolution of 30 months.

CONCLUSION

Chronic idiopathic and autoimmune neutropenia, although usually benign, deserve hematological follow-up with a bone marrow evaluation at diagnosis and a re-evaluation in the presence of worsening neutropenia, appearance of additional cytopenias, and lymphocytosis.

Full-Arch Rehabilitation of a Patient With Cyclic Neutropenia

The purpose of this report is to discuss the treatment of a patient with cyclic neutropenia. This patient presented with flared teeth, thin alveolar bone, and mobile teeth. A staged approach was used to remove her teeth, augment the bone, use immediate fixed provisional to determine the type of final prostheses, and ultimately to use cone-shaped overdenture attachments to retain her final prostheses. The result was rehabilitation of the patient with esthetic full-arch fixed-removable dentures with no adverse sequelae in this patient with this systemic disease.

A phase I dose-escalation study of lenalidomide in combination with gemcitabine in patients with advanced pancreatic cancer

Purpose

Lenalidomide have both immunomodulatory and anti-angiogenic properties which could confer anti-cancer effects. The aim of this study was to assess the feasibility of combining lenalidomide with the standard treatment gemcitabine in pancreatic cancer patients with advanced disease.

Patients and Methods

Eligible patients had locally advanced or metastatic adenocarcinoma of the pancreas. Patients received lenalidomide days 1–21 orally and gemcitabine 1000 mg/m2 intravenously (days 1, 8 and 15), each 28 day cycle. Three cohorts of lenalidomide were examined (Cohort I = 15 mg, Cohort II = 20 mg and Cohort III = 25 mg daily). The maximum tolerated dose (MTD) of lenalidomide given in combination with gemcitabine was defined as the highest dose level at which no more than one out of four (25%) subjects experiences a dose-limiting toxicity (DLT). Patients should also be able to receive daily low molecular weight heparin (LMWH) (e.g. dalteparin 5000 IU s.c. daily) as a prophylactic anticoagulant for venous thromboembolic events (VTEs). Twelve patients (n = 4, n = 3 and n = 5 in cohort I, II and III, respectively) were enrolled in this study.

Results

Median duration of treatment was 11 weeks (range 1–66), and median number of treatment cycles were three (range 1–14). The only DLT was a cardiac failure grade 3 in cohort III. Frequent treatment-related adverse events (AEs) (all grades) included neutropenia, leucopenia and fatigue (83% each, but there was no febrile neutropenia); thrombocytopenia (75%); dermatological toxicity (75%); diarrhea and nausea (42% each); and neuropathy (42%).

Discussion

This phase I study demonstrates the feasibility of the combination of lenalidomide and gemcitabine as first-line treatment in patients with advanced pancreatic cancer. The tolerability profile demonstrated in the dose escalation schedule of lenalidomide suggests the dosing of lenalidomide to be 25 mg daily on days 1–21 with standard dosing of gemcitabine and merits further evaluation in a phase II trial.

Trial Registration

ClinicalTrials.gov NCT01547260

[Pathophysiology and diagnosis of cancer patients with febrile neutropenia]

Exogenous pyrogens induce several cytokines which activate immune responses, and produce fever. In Japan, febrile neutropenia is defined as having an axillary temperature of>37. 5°C, and neutropenia showing an absolute neutrophil count (ANC)of<500 cells/mL or an ANC that is expected to reduce to<500 cells/mL during the next 48 hours. Signs and symptoms of inflammation are often attenuated or absent in neutropenic patients. Therefore, careful physical examination is required to detect subtle symptoms and signs of infection. As an initial assessment, laboratory tests should include the following: a ) complete blood cell count with differential leukocyte count and platelet count, b ) measurement of serum levels of creatinine, electrolytes, and hepatic transaminase enzymes, c ) serologic assay for fungal infection, and d ) at least 2 sets of blood cultures. Radiographical approaches are also important for detecting the focus of infection. Proper risk classification should be performed using the Multinational Association for Supportive Care in Cancer(MASCC)scoring system to distinguish high-risk and low-risk patients with febrile neutropenia.

The importance of supportive care in optimizing treatment outcomes of patients with advanced prostate cancer

Optimal oncologic care of older men with prostate cancer, including effective prevention and management of the disease and treatment side effects (so-called best supportive care measures) can prolong survival, improve quality of life, and reduce depressive symptoms. In addition, the proportion of treatment discontinuations can be reduced through early reporting and management of side effects. Pharmacologic care may be offered to manage the side effects of androgen-deprivation therapy and chemotherapy, which may include hot flashes, febrile neutropenia, fatigue, and diarrhea. Nonpharmacologic care (e.g., physical exercise, acupuncture, relaxation) has also been shown to benefit patients. At the Georges Pompidou European Hospital, the Program of Optimization of Chemotherapy Administration has demonstrated that improved outpatient follow-up by supportive care measures can reduce the occurrence of chemotherapy-related side effects, reduce cancellations and modifications of treatment, reduce chemotherapy wastage, and reduce the length of stay in the outpatient unit. The importance of supportive care measures to optimize management and outcomes of older men with advanced prostate cancer should not be overlooked.

Herpetic gingivostomatitis with severe hepatitis in a previously healthy child

A previously healthy boy aged 9 years and 11 months was admitted due to herpetic gingivostomatitis with poor intake. He also had fever, neutropenia, and elevated serum aminotransferase level (> 1000 IU/mL). Prolonged prothrombin time, mild gastrointestinal hemorrhage and transient decreased conscious level were noted during hospital days 2 and 3. Intravenous acyclovir therapy commenced on hospital day 2 and his serum aminotransferase level peaked (> 4000 IU/mL) on hospital day 3 and then improved gradually. A throat swab was positive for human herpes simplex virus (HSV)-1, serological test was positive for acute primary HSV-1 infection, and a blood specimen was also strongly positive for HSV-1 by polymerase chain reaction. He received a 14-day course of intravenous acyclovir and recovered uneventfully. Herpetic gingivostomatitis, although mostly benign and self-limited, may be complicated with severe hepatitis, even in immunocompetent hosts.

A case of onycotricodysplasia with intellectual disability, without neutropenia

Onychotrichodysplasia, a rare autosomal recessive disorder, presents with hypoplastic fingernails, trichorrhexis, chronic neutropenia, and psychomotor retardation. Here, we describe a rare presentation of a child with onycotrichodysplasia associated with intellectual disability, but without neutropenia. He had sparse, short, dry, curly hair, dysplastic nails and intellectual disability. In contrast to cases described earlier, our patient had normal neutrophil count.

A canine model of Cohen syndrome: Trapped Neutrophil Syndrome

BACKGROUND

Trapped Neutrophil Syndrome (TNS) is a common autosomal recessive neutropenia in Border collie dogs.

RESULTS

We used a candidate gene approach and linkage analysis to show that the causative gene for TNS is VPS13B. We chose VPS13B as a candidate because of similarities in clinical signs between TNS and Cohen syndrome, in human, such as neutropenia and a typical facial dysmorphism. Linkage analysis using microsatellites close to VPS13B showed positive linkage of the region to TNS. We sequenced each of the 63 exons of VPS13B in affected and control dogs and found that the causative mutation in Border collies is a 4 bp deletion in exon 19 of the largest transcript that results in premature truncation of the protein. Cohen syndrome patients present with mental retardation in 99% of cases, but learning disabilities featured in less than half of TNS affected dogs. It has been implied that loss of the alternate transcript of VPS13B in the human brain utilising an alternate exon, 28, may cause mental retardation. Mice cannot be used to test this hypothesis as they do not express the alternate exon. We show that dogs do express alternate transcripts in the brain utilising an alternate exon homologous to human exon 28.

CONCLUSION

Dogs can be used as a model organism to explore the function of the alternately spliced transcript of VPS13B in the brain. TNS in Border collies is the first animal model for Cohen syndrome and can be used to study the disease aetiology.

Prospective audit of febrile neutropenia management at a tertiary university hospital in Singapore

INTRODUCTION

Febrile neutropenia (FN) remains a major cause of morbidity and mortality in Oncology/Haematology units. We launched a new protocol for FN management that incorporates risk stratification at our institute from October 2008. An audit was performed concurrently to evaluate the protocol and to define the epidemiology of FN locally.

MATERIALS AND METHODS

Case records of all inpatients with FN between October 2008 and June 2009 were reviewed prospectively. Clinical and microbiological characteristics were collated along with outcomes and programme adherence. Statistical testing was performed using Stata 10.1.

RESULTS

There were 178 FN episodes (50 in patients with solid cancers) from 131 patients. Forty-two (23.6%) episodes were classified as high-risk according to MASCC criteria. Initial blood cultures were positive in 49 (27.5%) episodes, of which gram-negative bacilli (GNB) predominated. Overall compliance to the protocol was 56.7%, with the main issue being disinclination to use oral antibiotics as fi rst-line empirical therapy for low-risk episodes. Overall mortality was 7.3% and infection-related mortality was 4.5%. High-risk FN and the presence of central venous catheters were independently associated with bacteraemia on multivariate analysis, but there were no independent predictors of infection-related mortality.

CONCLUSIONS

GNB accounted for the majority of bloodstream infections at our institute, unlike data from developed countries. Uptake of the new FN protocol was satisfactory, although the use of oral antibiotics as fi rst-line empirical therapy can be improved. A better method for predicting infections caused by antibiotic-resistant GNB is urgently required, and antibiotic resistance trends should be monitored to enable the implementation of more appropriate antibiotic regimens over time.

Idiosyncratic drug-induced agranulocytosis: possible mechanisms and management

The incidence of drug-induced neutropenia has not changed in the western hemisphere over the last 30 years. Yet, the drug panorama has changed considerably. This implies that host factors may play an intriguing role for this idiosyncratic reaction. The knowledge as to mechanisms for the reaction has advanced with emerging understanding of neutropoiesis and immune regulation. Nonetheless, it is still remarkably difficult to pinpoint why and how a drug causes this unexpected, severe adverse event in a patient. Patient characteristics, e.g. genetics, appear to be keys for better understanding, predictions and prevention. Am. J. Hematol. 2009. (c) 2009 Wiley-Liss, Inc.

Late-onset neutropenia following RCHOP chemotherapy in diffuse large B-cell lymphoma

Rituximab has been associated with the development of late-onset neutropenia (LON). As only heterogeneous studies have been conducted, its incidence and clinical course remain unclear. We aim to: (1) study the incidence and clinical relevance of WHO grade 3/4 LON in a uniform group of patients with diffuse large B-cell lymphoma (DLBCL) in complete remission following curative rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) chemotherapy; (2) ascertain predictive factors for LON. The 121 eligible patients identified from our prospectively maintained database were followed up for occurrence of WHO grade 3/4 LON. The clinical course of LON was documented, and its relationship with patient- and tumor-related factors was analyzed. With a median follow-up of 883 days (range, 265-1762), 13.2% had developed LON of grade 3/4. The median time to neutrophil nadir was 129 days (range, 39-277). The median time to recovery was 69 days (range, 3-349) and occurred in all except two patients. Only one episode of nonlife threatening bacterial culture-positive urinary tract infection and pulmonary tuberculosis, both occurring in the same patient was documented. Results of Fischer's exact test revealed that age, stage, LDH level, ECOG, marrow involvement, and hematologic parameters did not predict for LON development. WHO grade 3/4 LON is not infrequent in patients with DLBCL receiving RCHOP. Even so, it is reassuring that LON is self-limiting and unassociated with life-threatening infection. A watchful waiting approach is appropriate in majority of patients who develop LON following RCHOP. Am. J. Hematol., 2009. (c) 2009 Wiley-Liss, Inc.

A tool for neutrophil guided dose adaptation in chemotherapy

Chemotherapy dosing in anticancer treatment is a balancing act between achieving concentrations that are effective towards the malignancy and that result in acceptable side-effects. Neutropenia is one major side-effect of many antitumor agents, and is related to an increased risk of infection. A model capable of describing the time-course of myelosuppression from administered drug could be used in individual dose selection. In this paper we describe the transfer of a previously developed semi-mechanistic model for myelosuppression from NONMEM to a dosing tool in MS Excel, with etoposide as an example. The tool proved capable to solve a differential equation system describing the pharmacokinetics and pharmacodynamics, with estimation performance comparable to NONMEM. In the dosing tool the user provides neutrophil measures from a previous treatment course and request for the dose that results in a desired nadir in the upcoming course through a Bayesian estimation procedure.

A syndrome with congenital neutropenia and mutations in G6PC3

BACKGROUND

The main features of severe congenital neutropenia are the onset of severe bacterial infections early in life, a paucity of mature neutrophils, and an increased risk of leukemia. In many patients, the genetic causes of severe congenital neutropenia are unknown.

METHODS

We performed genomewide genotyping and linkage analysis on two consanguineous pedigrees with a total of five children affected with severe congenital neutropenia. Candidate genes from the linkage interval were sequenced. Functional assays and reconstitution experiments were carried out.

RESULTS

All index patients were susceptible to bacterial infections and had very few mature neutrophils in the bone marrow; structural heart defects, urogenital abnormalities, and venous angiectasia on the trunk and extremities were additional features. Linkage analysis of the two index families yielded a combined multipoint lod score of 5.74 on a linkage interval on chromosome 17q21. Sequencing of G6PC3, the candidate gene encoding glucose-6-phosphatase, catalytic subunit 3, revealed a homozygous missense mutation in exon 6 that abolished the enzymatic activity of glucose-6-phosphatase in all affected children in the two families. The patients' neutrophils and fibroblasts had increased susceptibility to apoptosis. The myeloid cells showed evidence of increased endoplasmic reticulum stress and increased activity of glycogen synthase kinase 3beta (GSK-3beta). We identified seven additional, unrelated patients who had severe congenital neutropenia with syndromic features and distinct biallelic mutations in G6PC3.

CONCLUSIONS

Defective function of glucose-6-phosphatase, catalytic subunit 3, underlies a severe congenital neutropenia syndrome associated with cardiac and urogenital malformations.

Cyclic neutropenia in mammals

Cyclic neutropenia (CN) has been well documented in humans and the gray collie. A recent model of the architecture and dynamics of hematopoiesis has been used to provide insights into the mechanism of cycling of this disorder. It provides a link between the cycling period and the cells where the mutated ELA2 is expressed. Assuming that the biologic defect in CN is the same in dogs, and the observation that the structure of hematopoiesis is invariant across mammals, we use allometric scaling techniques to correctly predict the period of cycling in the gray collie and extend it to other mammals from mice to elephants. This work provides additional support for the relevance of animal models to understand disease but cautions that disease dynamics in model animals are different and this has to be taken into consideration when planning experiments.

Development and validation of a multi-dose neutropenic rat thigh infection model using real-time monitoring of Staphylococcus aureus growth in vivo

BACKGROUND

Several animal models have been described using luminescent bacteria for non-invasive, real-time monitoring of infection in mice. In this study, a multidose rat thigh infection model with luminescent Staphylococcus aureus was developed for the evaluation of antibiotic efficacy.

MATERIALS AND METHODS

Bioluminescent imaging and bacterial loads of S. aureus infected rat thighs with or without vancomycin treatment at different time-points post-infection were compared.

RESULTS

Correlation between luminescence and bacterial load was observed based on the dose- and time-dependent activity of vancomycin in the model.

CONCLUSION

While luminescence detection offered the advantage of monitoring an infection in live animals, limitations to this method included reduced sensitivity and a narrow dynamic range, as compared to a traditional tissue culturing method. Real-time luminescence monitoring of infection may be most appropriate for experiments where rapid in vivo assessment of compound efficacy is desired and absolute quantitation of colony forming units in infected tissue is not required.

Successful treatment of refractory immune hemolysis following unrelated cord blood transplant with Campath-1H

Immune-mediated hemolytic anemia is a well-recognized complication of hematopoietic stem cell transplantation. We report on a 6-year-old boy with X-linked adrenoleukodystrophy who developed severe delayed alloimmune hemolytic anemia associated with immune-mediated neutropenia and thrombocytopenia following major ABO incompatible unrelated cord blood transplantation. The patient's cytopenias were refractory to treatment with corticosteroids, cyclosporine, intravenous immune globulin, rituximab, and pentostatin. After one course of Campath-1H his hematologic parameters normalized, suggesting that the compound may be an effective therapy for complex immunohematologic disorders complicating hematopoietic stem cell transplantation. The case also emphasizes the importance of T-cells in transplant associated immune cytopenias.

Serum complement 3 (C3) and complement 4 (C4) level in febrile neutropenia patients at Dr. Kariadi Hospital, Semarang and Dr. Moewardi Hospital, Surakarta

AIM

to identify the serum complement 3 (C3) and complement 4 (C4) level in febrile neutropenia and non-febrile neutropenia patients.

METHODS

this is a cross-sectional prospective study. Samples were collected from patients with febrile neutropenia as sample group and patients with neutropenia but without fever as control. Both groups were tested for serum complement 3 and complement 4 level, and the data were analyzed using student T-test.

RESULTS

from 37 neutropenia patients, 23 were classified as febrile neutropenia group and 14 in non-febrile neutropenia as control group. Total mean neutrophil count was 653.22/ml serum in sample group and 594.36/ml serum in control group (p=0.575). Mean C3 level was 95.74 ug/dl in sample group and 130.00 ug/dl in control group, showing significant difference with p=0.031. The mean serum C4 level was 34.13 ug/ml in sample group and 34.00 ug/dl in control group, the difference is not significant with p=0.98. When sample C3 and C4 data were combined, the total level was 125.61 ug/ml, which was significantly lower than the total C3 and C4 in control group 184.07 ug/dl. (p=0.04).

CONCLUSION

in febrile neutropenia there is significant decrease of serum C3 level compared to non-febrile neutropenia. Serum C4 level in febrile neutropenia group is lower than the non-febrile neutropenia group, but the difference is not significant.

Neutrophil depletion decreases VEGF-induced focal angiogenesis in the mature mouse brain

To explore the role of neutrophil-derived matrix metalloproteinases (MMPs) during angiogenesis in the brain, we hypothesized that transient neutrophil depletion attenuates the angiogenic response to focal hyperstimulation with vascular endothelial growth factor (VEGF). Brain focal angiogenesis was achieved using an adeno-associated virus delivered VEGF (AAV-VEGF) gene transfer in the mature mouse. Four groups of mice underwent AAV vector injection in the brain parenchyma: (1) AAV-LacZ; (2) AAV-VEGF; (3) AAV-VEGF plus anti-polymorphonuclear (PMN) antibody; and (4) AAV-VEGF plus serum. Animals in groups 3 and 4 underwent 4 days of PMN antibody or serum treatment before transfection; treatment was sustained for an additional 14 days. Anti-PMN treatment decreased circulating neutrophils to 9% of baseline (P<0.001). Microvessels in the AAV-VEGF-group increased 25% compared with the AAV-lacZ-transduced group (256+/-15 versus 208+/-16; P<0.05). Anti-PMN treatment attenuated the increase to 10% compared with control serum treatment (234+/-16 versus 255+/-22; P<0.05). Similarly, compared with control serum treatment, anti-PMN treatment also reduced MMP-9 by 50% (2+/-0.9 versus 4+/-1.4; P<0.05) and MPO expression by 25% (2+/-0.8 versus 3+/-0.9; P<0.05); MMP-9 activity correlated with MPO expression (R(2)=0.8, P<0.05). Our study demonstrated that transient depletion of neutrophils suppressed VEGF-induced angiogenesis, indicating that circulating neutrophils contribute to VEGF-induced focal angiogenesis. In addition, brain MMP-9 activity was attenuated after neutrophil depletion, suggesting that neutrophil is an important source of MMP-9.

Rapid cell senescence and apoptosis in lymphocytes and granulocytes and absence of GM-CSF receptor in congenital dysgranulopoietic neutropenia

A girl with congenital dysgranulopoietic neutropenia (CDN) and her non-neutropenic mother with aphthae (A) were investigated. Apoptosis in lymphocytes and granulocytes of both patients (mother A+) were documented by high annexin and electron microscopic morphology. CD11b/CD18 of the daughter's granulocytes ranged between low to normal while that of the mother changed between very low to high levels through A(-) to A(+) periods. In both patients, CD11b/CD18 on lymphocytes were high; GM-CSF receptor was negative; CD4-/CD8- lymphocytes were high and the leukocytes which showed abnormal cell cycle were stained by senescence associated beta-galactosidase. We think that increased apoptosis and rapid cell senescence of leukocytes underlies the pathophysiology of CDN.

G-CSF treatment of canine cyclical neutropenia: A comprehensive mathematical model

OBJECTIVE

To study the effects of different G-CSF temporal treatment schemes using a comprehensive mathematical model of the mammalian hematopoietic system that couples the pharmacokinetics of granulocyte colony-stimulating factor (G-CSF) to the hematopoietic stem cell, neutrophil, platelet, and erythrocyte dynamics.

MATERIALS AND METHODS

Data from cyclical neutropenic (CN) grey collies are used to build an extended model that reproduces the dynamics of circulating blood cells found in laboratory data from the dogs with and without daily G-CSF therapy. The effects of varying the treatment initiation time, and whether injections are given daily, every other day, or every three days, are examined.

RESULTS

The mathematical model is able to reproduce the large variation in data that occurs from one dog to another. Different drug delivery times, with no other changes in the model parameters, can have significant long-term effects on neutrophil numbers. The frequency of drug delivery also has long-term effects on the oscillations.

CONCLUSION

Using a realistic representation of the effects of G-CSF on the tissue-level hematopoietic system, the model matches a wide range of laboratory data. This implies that it would be possible to generate individualized predictions for specific dogs if data were available in real time. The proposed interventions are practical and may reduce the amount of G-CSF required while potentially maintaining or even improving the treatment effects.

LPS responsiveness and neutrophil chemotaxis in vivo require PMN MMP-8 activity

We identify matrix metalloproteinase (MMP)-8, the polymorphonuclear (PMN) leukocyte collagenase, as a critical mediator initiating lipopolysaccharide (LPS)-responsiveness in vivo. PMN infiltration towards LPS is abrogated in Mmp8-null mice. MMP-8 cleaves LPS-induced CXC chemokine (LIX) at Ser(4)-Val(5) and Lys(79)-Arg(80). LIX bioactivity is increased upon N-terminal cleavage, enhancing intracellular calcium mobilization and chemotaxis upon binding its cognate receptor, CXCR2. As there is no difference in PMN chemotaxis in Mmp8-null mice compared with wild-type mice towards synthetic analogues of MMP-8-cleaved LIX, MMP-8 is not essential for extravasation or cell migration in collagenous matrices in vivo. However, with biochemical redundancy between MMPs 1, 2, 9, and 13, which also cleave LIX at position 4 approximately 5, it was surprising to observe such a markedly reduced PMN infiltration towards LPS and LIX in Mmp8-/- mice. This lack of physiological redundancy in vivo identifies MMP-8 as a key mediator in the regulation of innate immunity. Comparable results were found with CXCL8/IL-8 and CXCL5/ENA-78, the human orthologues of LIX. MMP-8 cleaves CXCL8 at Arg(5)-Ser(6) and at Val(7)-Leu(8) in CXCL5 to activate respective chemokines. Hence, rather than collagen, these PMN chemoattractants are important MMP-8 substrates in vivo; PMN-derived MMP-8 cleaves and activates LIX to execute an in cis PMN-controlled feed-forward mechanism to orchestrate the initial inflammatory response and promote LPS responsiveness in tissue.

Thiopental-Induced Neutropenia in Two Patients with Severe Head Trauma

Thiopental has been used for decades in the treatment of refractory intracranial hypertension in patients with traumatic and nontraumatic head injuries. Commonly reported adverse effects include hypotension, hypokalemia, respiratory complications, and hepatic dysfunction. Neutropenia has rarely been reported as an adverse effect of thiopental. We witnessed probable thiopental-induced neutropenia in two patients with traumatic brain injuries who developed increased intracranial hypertension that was refractory to standard therapy. Based on a MEDLINE search of published case reports and literature, we propose two mechanisms by which thiopental-related neutropenia might be explained. The first is inhibition of inflammatory mediator nuclear factor-kappa B (NF-kappa B), leading to granulocyte apoptosis. The second mechanism involves inhibition of calcineurin. Although the precise link between these two mechanisms has not been elucidated, calcineurin is known to regulate NF-kappa B activity. Development of neutropenia does not appear to be correlated with time but may correlate with plasma concentrations of thiopental. The optimum management of drug-induced neutropenia is unclear. The decision to discontinue thiopental in patients who develop neutropenia should be made by weighing the risks versus benefits. Broad-spectrum antibiotics may be required in the presence of fever. The role of hematopoietic growth factors such as granulocyte colony-stimulating factor is not yet defined. Given the adverse infectious consequences of neutropenia, it is essential to closely monitor neutrophil counts in patients receiving thiopental.

Late-onset neutropenia following rituximab results from a hematopoietic lineage competition due to an excessive BAFF-induced B-cell recovery

Rituximab is used in the treatment of lymphoma and autoimmune diseases, for which late-onset neutropenia (LON) were reported. LON-related mechanisms remain unclear. To obtain insights into the mechanisms, we assessed serum, peripheral blood and bone marrow (BM) samples of a patient with LON. Factors classically associated with neutropenia such as anti-neutrophil antibodies, T-LGL, soluble Fas Ligand were not detectable. We then evaluated the kinetics of various cytokines involved in B-cell and granulocyte homeostasis. We found that LON is related to a lack of granulopoiesis in the BM that coincides with a very high level of BAFF, a strong stimulator of B-cell recovery, and hypothesized a hematopoietic lineage competition due to an excessive B-cell recovery in the BM by promotion of B-cell lymphopoiesis over granulopoiesis within common developmental niches. Assessment of serum BAFF levels following rituximab could detect patients at risk of developing LON.

Care of Patients With Neutropenia

Neutropenia can be a significant problem in the oncology setting. Awareness of potential risks, management of neutropenia, and preventive measures guide nurses in providing comprehensive care that can make the difference between life and death.

Severe congenital neutropenia: inheritance and pathophysiology

PURPOSE OF REVIEW

Severe congenital neutropenia is a heterogeneous disorder of hematopoiesis characterized by a maturation arrest of granulopoiesis at the level of promyelocytes with peripheral blood absolute neutrophil counts below 0.5 x 10/l. In this review we summarize our current knowledge on inheritance and pathophysiolgy of congenital neutropenia.

RECENT FINDINGS

There are two major subtypes of congenital neutropenia as judged by inheritance: autosomal dominant trait defined by neutrophil elastase mutations consisting of 60% of patients and autosomal recessive trait comprising approximately 30% of patients. This genetic heterogeneity suggests that several pathologic mechanisms may lead to the same phenotype due to downregulation of common myeloid transcription factors. Lymphoid enhancer-binding factor 1 is the most promising candidate, as its abrogation together with downregulation of lymphoid enhancer-binding factor 1 target genes is compatible with this phenotype. Congenital neutropenia is considered as a preleukemic syndrome, since after 10 years of observation the cumulative incidence for leukemia is 21%. Acquired granulocyte colony-stimulating factor receptor mutations are detected in approximately 80% of congenital neutropenia patients who developed acute myeloid leukemia.

SUMMARY

Congenital neutropenia is a congenital disorder of hematopoiesis inherited by autosomal dominant or recessive traits. Downregulation of lymphoid enhancer-binding factor 1 is involved in the pathophysiology of all congenital neutropenia patients. Congenital neutropenia patients with acquired granulocyte colony-stimulating factor receptor mutations define a group with high risk for development of leukemia.

Effect of neutropenia and treatment delay on the response to antifungal agents in experimental disseminated candidiasis

Disseminated candidiasis is associated with a high rate of morbidity and mortality. The presence of neutrophils and the timely administration of antifungal agents are likely to be critical factors for a favorable therapeutic outcome of this syndrome. The effect of neutropenia on the temporal profile of the burden of Candida albicans in untreated mice and those treated with amphotericin B was determined using a pharmacodynamic model of disseminated candidiasis. A mathematical model was developed to describe the rate and extent of the C. albicans killing attributable to neutrophils and to amphotericin B. The consequences of a delay in the administration of amphotericin B, flucytosine, or micafungin were studied by defining dose-response relationships. Neutrophils caused a logarithmic decline in fungal burden in treated and untreated mice. The combination of amphotericin B and neutrophils resulted in a high rate of Candida killing and a sustained anti-C. albicans effect. In neutropenic mice, 5 mg/kg of body weight of amphotericin B was required to prevent progressive logarithmic growth. An increased delay in drug administration resulted in a reduction in the maximum effect to a point at which no drug effect could be observed. Neutrophils and the timely initiation of antifungal agents are critical determinants in the treatment of experimental disseminated candidiasis.

Efficacy and safety of micafungin in febrile neutropenic patients treated for hematological malignancies

OBJECTIVE

The purpose of this study was to prospectively evaluate the efficacy and safety of micafungin (MCFG) in empirical therapy for febrile neutropenic patients for whom antibiotic therapy was not effective for hematological malignancies.

PATIENTS AND METHODS

Twenty-three hematological patients aged 27-82 years with febrile neutropenia for whom antibiotic therapy was not effective were enrolled in this study and responses to treatment were evaluated.

RESULTS

Treatment success rate was 73.9%. Treatment success rates by primary diagnosis were 77.8% in patients with AML, 50.0% in patients with NHL and 87.5% in patients with other diseases. Moreover, MCFG at a dose of 100 mg or more have a tendency to be effective. One or more adverse events occurred in five (27.7%) of the patients during the study. All of these adverse events were below grade 2 toxicity.

CONCLUSIONS

Although the number of patients studied was limited, MCFG as a monotherapy seems to be effective and safe as an empirical therapy in patients with febrile neutropenia. However, further investigation using large-scale studies is needed. This study demonstrated the clinical efficacy and safety of MCFG in patients with febrile neutropenia and with hematological malignancies.

Pathophysiology of in-vitro induced filaments, spheroplasts and rod-shaped bacteria in neutropenic mice

This study compared the in-vitro properties and in-vivo effects of Escherichia coli filaments, spheroplasts and normal cells in a murine thigh infection model. E. coli was exposed to ceftazidime, meropenem or saline to obtain filaments, spheroplasts or normal bacilli, which were then injected into neutropenic mice. After 24 h, morphology, CFUs, local and circulating endotoxin levels, cytokine levels and mortality were recorded, and correlations between bacterial and host parameters of infection were investigated. Filaments and spheroplasts contained more endotoxin/CFU than controls. Histological studies showed that morphologically altered bacteria changed into rod-shaped cells in the absence of antibiotics. Bacterial spread to the liver was significantly higher in mice challenged with rod-shaped cells, compared with antibiotic-exposed bacteria (p 0.007). Muscle endotoxin levels correlated significantly with circulating interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha, and both pro-inflammatory cytokines were correlated significantly (p 0.011). Despite a tendency toward higher local and systemic concentrations of endotoxin in the filament group, inflammatory responses and survival did not differ between groups. It was concluded that morphologically altered bacteria contain more endotoxin and can regain a rod shape after withdrawal of antibiotics, while non-antibiotic-exposed bacteria show greater spread to the liver. There was a clear intra-individual relationship between local endotoxin, systemic endotoxin, TNF-alpha and IL-6 production, but these parameters did not differ among groups.

A prospective investigation of chemotherapy-induced neutropenia and quality of life

This prospective study of chemotherapy-induced neutropenia (CIN) explored the association between the relative grade of neutropenia and symptom burden and quality of life (QOL). Eighty-four adult cancer patients from nine community oncology centers receiving 1 of 13 myelosuppressive chemotherapies were evaluated at days 0, 4, 7, 9, 11, 14, and 21 of their respective first cycle. Neutropenia grade (grade 3/4 vs grades 0 to 2) was determined by serial absolute neutrophil count (ANC) measures. Measures of patient-reported outcomes included the Rotterdam Symptom Checklist (RSCL), Hospital Anxiety and Depression Scale (HADS), Cancer Care Monitor-Medical Isolation Scale (CCM-MIS), and SF-36. Changes in outcomes from baseline to highest grade of neutropenia were evaluated using mixed model-repeated measures for each of 15 outcomes. Compared with grades 0-2, grade 3/4 neutropenia was associated with greater symptom burden and worse QOL for six measures (P < 0.05). The pattern of differences suggested that measures of symptom distress and social functioning were sensitive to patient changes associated with grade 3/4 neutropenia. Worsening of symptom burden and QOL appears to be associated with severe afebrile neutropenia. A causal relationship between neutropenia and worse symptoms and QOL remains difficult to establish due to the confounding of the effects of neutropenia with other adverse effects of chemotherapy.

Intravenous itraconazole vs. amphotericin B deoxycholate for empirical antifungal therapy in patients with persistent neutropenic fever

BACKGROUND

Amphotericin B dexoycholate is currently the standard empirical antifungal therapy for neutropenic patients with hematologic malignancies and who also have persistent fever that does not respond to antibacterial therapy. The antifungal triazoles offer a potentially safer and effective treatment alternative to Amphotericin B dexoycholate.

METHODS

We assessed the efficacy and safety of intravenous itraconazole, as compared with the efficacy and safety of amphotericin B deoxycholate, as an empirical antifungal therapeutic agent in a matched case-control clinical trial from June 2004 to August 2005.

RESULTS

Efficacy was evaluated in 96 patients (48 received itraconazole and 48 received amphotericin B deoxycholate) and all the patients who received the study drugs were evaluated for safety. The baseline demographic characteristics were well matched. The overall success rates were 47.9% for itraconazole and 43.8% for amphotericin B deoxycholate (% difference: 4.1% [95% confidence interval for the difference: -15.8 to 24]), which fulfilled the statistical criteria for the non-inferiority of itraconazole. The proportions of patients who survived for at least seven days after discontinuation of therapy or who were prematurely discontinued from the study were not significantly different between the two groups. The rates of breakthrough fungal infections and resolution of fever during neutropenia were similar in both groups. More patients who received amphotericin B deoxycholate developed nephrotoxicity, hypokalemia or infusion-related events than did those patients who received itraconazole (nephrotoxicity: 16.7% vs. 1.8%, hypokalemia: 66.7% vs. 24.6%, and infusion-related events: 41.7% vs. 3.5%, respectively).

CONCLUSIONS

Intravenous itraconazole is as effective as amphotericin B deoxycholate and it is generally better tolerated than amphotericin B deoxycholate when it is given as empirical antifungal therapy for Korean patients with persistent neutropenic fever.

Bilateral basal ganglia involvement in a patient with Griscelli syndrome

We report a 6-year-old Iranian boy with silvery-gray hair, eyelashes and the eyebrows who was admitted because of seizures and subsequent stupor. He had previous history of acute hemiparesis at 1 year of age and hepatitis-like syndrome 3 months ago. Microscopic examination of the patient's hair shaft revealed different sized clumps of melanin seen in the center of the shafts. Bone marrow aspiration revealed erythroid hyperplasia and erythrophagocytic cells. Bilateral frontal cortical and subcortical high signal lesions, dirty white matter, high signal areas in the upper pons and in both caudates and lentiform nuclei in T2 WI were the brain MRI findings of the patient. He died in the accelerated phase of Griscelli Syndrome (GS) type 2. To our knowledge we report the first case of GS from Iran.

Oncologic emergencies: diagnosis and treatment

Patients with malignancies are subject to developing a unique set of complications that require emergent evaluation and treatment. With the increasing incidence of cancer in the general population and improved survival, these emergencies will be more frequently encountered. Physicians must be able to recognize these conditions and institute appropriate therapy after a focused initial evaluation. The approach to definitive therapy is commonly multidisciplinary, involving surgeons, radiation oncologists, medical oncologists, and other medical specialists. Prompt interventions can be lifesaving and may spare patients considerable morbidity and pain. In this review, we discuss the diagnosis of and initial therapy for common emergencies in hematology and oncology.