Von Willebrand Factor and Mitral Valve Prolapse

The levels of von Willebrand factor (vWF: Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (<80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p <0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 ± 30% versus 100 ± 23%, p <0.001). In those with MVP and congestive heart failure secondary to ruptured chordae tendineae, however, the mean level of vWF:Ag was not significantly different from control values (95 ± 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF: Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF: Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

Accelerated phase of chronic myeloid leukemia presenting with hypercalcemia and a mediastinal mass

A patient with chronic myeloid leukemia developed hypercalcemia as a presenting sign of the accelerated phase of the disease. Ultrasound of the neck showed a large hypodense mass connected to the thyroid gland, which was thought to be a parathyroid tumor and the cause of the hypercalcemia. Histology of the surgically removed mass revealed a chloroma. The patient's course was complicated by respiratory failure and metastatic calcinosis of the lung, an unusual finding in hypercalcemia of short duration.

Activated protein C resistance (factor V Leiden) associated with thrombosis in pregnancy

OBJECTIVE

Our purpose was to evaluate activated protein C resistance phenotype and genotype among patients with thrombosis during pregnancy and the puerperium.

STUDY DESIGN

This observational study was conducted prospectively during a 2-year period (July 1993 to June 1995) in a preselected population. All patients admitted to our high-risk pregnancy unit with a diagnosis of deep vein thrombosis, pulmonary emboli, transient ischemic attack, and cerebrovascular accident during pregnancy and the puerperium were included. Prothrombin time, partial thromboplastin time, fibrinogen levels, protein C, protein S, antithrombin III, functional test for activated protein C resistance, and factor V Leiden mutation by polymerase chain reaction were performed on each patient.

RESULTS

Fifteen patients were included. Seven (46.6%) patients were positive for activated protein C resistance (factor V Leiden). All other coagulation studies were negative for all patients. All patients with activated protein C resistance had a venous thrombotic event, deep vein thrombosis, or pulmonary emboli, and only one had a cerebrovascular accident on the basis of sagittal sinus thrombosis. Only two of the activated protein C resistance-negative patients had venous thrombosis (pulmonary emboli). The remaining six patients had transient ischemic attacks or cerebrovascular accidents. For the subgroup with venous thrombosis during pregnancy and the puerperium, the incidence of activated protein C resistance (factor V Leiden) was 78%.

CONCLUSION

This study demonstrates the incidence of factor V Leiden in a selected population in whom thrombotic events developed during pregnancy and the puerperium. This small-scale study provides justification for a large cohort study that will identify women with factor V Leiden and determine their risk for thrombosis during pregnancy and the puerperium. We believe that factor V Leiden should be evaluated in conjunction with thrombotic events in the pregnant woman.

Occurrence of Parkinson's syndrome in type I Gaucher disease

Gaucher disease, the most prevalent glycolipid storage disorder, is classically subdivided into types according to the presence or absence of neurological involvement. Type I has hitherto been considered non-neuronopathic. We present six cases and a review of the literature of Parkinsonian symptoms in type I Gaucher disease patients. The hallmark of this atypical Parkinsonian syndrome is a relatively severe clinical course with early appearance of neurological signs in the 4th to 6th decade of life, aggressive progression of the signs and refractoriness to conventional anti-Parkinson therapy. We discuss the implications of these findings in the light of enzyme replacement therapy for Gaucher disease.

Interferon-alpha-2b with VMCP for induction in multiple myeloma: the Israel Myeloma Cooperative Group experience

In 1988, a prospective, randomized multicenter study was initiated to determine the efficacy of a combined induction regimen with recombinant interferon-alpha-2b (IFN-alpha) and maintenance with IFN-alpha on the response and survival rates in multiple myeloma (MM) patients. Induction therapy consisted of VMCP (vincristine, melphalan, cyclophosphamide, prednisone), randomized to combine IFN-alpha at a dose of 2 x 10(6) U, 5 days per week throughout the induction period of 12 months. Patients who achieved plateau phase were subsequently randomized again between IFN alpha maintenance (2 x 10(6) U, 3 days a week) for 12 months and no maintenance therapy. Of the previously untreated patients, 84 were initially randomized for induction therapy, and 31 for the maintenance phase with IFN-alpha. Results of the cohort median survival, based on the intention to treat, have shown that those on the VMCP/IFN-alpha arm had a median survival of 53 months, compared with patients on the VMCP induction arm who a median survival of 26 months (P = 0.052). The median survival of stage 3 evaluable patients who were on the VMCP/IFN induction arm was 43 months, and 13 months for patients treated by VMCP alone (P = 0.008). No significant difference in survival was detected among patients in partial remission (after induction) who had a second IFN-alpha randomization at the plateau phase. Hematologic toxicity, mild to moderate fever, and fatigue were more common in the VMCP/IFN induction arm. The results show that VMCP/IFN is a well-tolerated treatment regimen, and is superior to VMCP for patients with stage 3 myeloma.

Treatment of Hodgkin's disease at a local hospital

It is unclear whether patients with Hodgkin's disease can be adequately treated at local hospitals. From 1978 through 1991, 40 patients with Hodgkin's disease were treated at the Carmel Medical Center. Disease-free survival was 36/40 (90%) and 19/23 (83%) after 3 and 10 years follow-up, respectively. These results are comparable to those reported by tertiary cancer centers. We conclude that adequate treatment for patient's with Hodgkin's disease can be given at local hospitals. Further studies are warranted to determine if our results can be extrapolated to other local hospitals.

Kidney conservation by delayed contralateral autotransplantation in a case of retroperitoneal lymphoma involving the ureter

Large-cell retroperitoneal lymphoma was partially resected including a long segment of ureter. The proximal end of the ureter was clipped during surgery. A percutaneous nephrostomy was inserted after 48 h. Adjuvant chemotherapy was then delivered and the kidney was autotransplanted to the contralateral iliac fossa. Salvage of a hydronephrotic functioning kidney by nephrostomy and delayed contralateral autotransplantation in a case of huge retroperitoneal tumor involving the ureter has not, to the best of our knowledge, been described previously. This might suggest a reasonable approach for young patients with large retroperitoneal tumors involving long segments of the ureter. Autotransplantation was performed only after a disease-free status was confirmed following chemotherapy.

Fulminant bilateral cerebellar syndrome in a patient with chronic lymphocytic leukemia

A 55 year old patient with chronic lymphocytic leukemia (CLL) and long-standing excessive lymphocytosis developed a rapidly progressive neurological syndrome. Differential diagnosis focused on two rate neurological complications in this disease: direct brain infiltration by leukemic cells versus progressive multifocal leukoencephalopathy (PML). Tissue diagnosis was not available. Two cerebro-spinal fluid examinations performed during the presence of the acute neurological symptoms were normal. Computed tomography (CT) showed low density lesions without enhancement and no mass effect within the left cerebellum. Magnetic resonance imaging scan (MRI) demonstrated multiple hyperintense areas in the brain stem, right and left cerebellum and right capsula interna, suggestive of demyelinative process. In our opinion these findings were compatible with the diagnosis of PML, but biopsy was not performed. Because of the different therapeutic approach in these two conditions, we feel that tissue diagnosis is warranted in patients with CLL who develop a rapidly progressive central nervous system complication in the presence of normal CSF.

Erythropoietin-independent colonies of red blood cells and leukocytosis in a worker exposed to low levels of benzene

BACKGROUND

Exposure to high levels of benzene commonly results in the suppression of hemopoiesis, although cases of leukocytosis and leukocytosis with thrombocytosis have been reported. No hematologic abnormalities have generally been found with exposure to low levels of benzene.

METHODS

A pipe fitter exposed to low levels of benzene (time-weighted average 0.9 ppm) developed leukocytosis. His blood counts and growth of erythroid burst forming units (BFU-E) was followed with and without the addition of erythropoietin.

RESULTS

Erythropoietin-independent BFU-E colonies were increased to 40 per 4 x 10(4) cells (normal < 3 per 4 x 10(4) cells). Both the leukocyte count and the number of erythropoietin-independent BFU-E colonies decreased when exposure to benzene was terminated. On reexposure the white blood count again increased. After the work was terminated, the white blood count returned to normal, as did the number of erythropoietin-independent BFU-E colonies, over a period of 12 months.

CONCLUSIONS

Our findings suggest that even low levels of benzene can result in perturbations of the hemopoietic system. Further studies are warranted to determine whether these findings are idiosyncratic, coincidental, or a more general phenomenon.

Soluble factors from peripheral blood T-cells of patients with polycythemia vera stimulate normal BFU-E

T cells and monocytes from patients with polycythemia vera (PV) were isolated and grown in culture. The conditioned medium was tested for the presence of soluble factors that promote proliferation of erythroid colonies from the blood of healthy donors. We show that T cells from all 14 PV patients that were examined secrete factor/s that stimulate the proliferation of erythroid burst-forming units (BFU-E) in the absence of an external source of erythropoietin and BPA. Addition of cyclosporin A to the culture did not inhibit the production of this activity. The conditioned medium from monocytes of PV patients can also stimulate normal BFU-E but to a much lesser extent than T-cell conditioned medium. Such stimulation was not observed with control T cells or monocytes. We observed that the fraction of DR-positive T cells was significantly higher in PV patients comparing to normal. These results suggest that PV patients possess an abnormally high level of circulating activated T cells which may in turn be the source of the putative factor that facilitates uncontrolled erythroid differentiation.

High incidence of myeloproliferative disorders in Ashkenazi Jews in northern Israel

We have analysed epidemiological parameters in 339 patients with myeloproliferative disorders (MPD) diagnosed in northern Israel between 1975 and 1989 as having polycythemia vera (191 patients), agnogenic myeloid metaplasia (AMM) (113) and essential thrombocythemia (ET) (36). Mean average annual incidence was 11.4 per 1 million residents for polycythemia vera, 6.5 for AMM and 2.1 for ET. For all three diseases the average annual incidence increased with age and was 10 times higher in patients over 65 years compared to those less under the age of 45 years. Four percent of all patients had relatives with MPD. Incidence of MPD in Jews was 10 fold higher than expected compared to Arabs and this difference was noted for all 3 diseases. The incidence in Ashkenazi Jews originating from eastern and central Europe, was 10 and 20 folds higher than in Sephardic Jews and Arabs respectively. Mean age at diagnosis of MPD in Arabs and Sephardic Jews was lower than in Ashkenazi Jews (52 and 56 years compared to 64 years P < 0.05). Likewise, mean age at diagnosis was lower in the 11.5% of MPD patients with prior exposure to biological or chemical hazards compared to unexposed individuals (58 years versus 63 years, P < 0.02). These data demonstrate a cluster of MPD in Ashkenazi Jews in northern Israel and emphasize the importance of genetic predisposition possibly interacting with acquired factors in the pathogenesis of these disorders.

Increased spontaneous secretion of IL-6 from B cells of patients with B chronic lymphatic leukaemia (B-CLL) and autoimmunity

We studied B cells from 18 patients with B-CLL, six of them with autoimmune haemolytic anaemia, for spontaneous secretion of IL-6. Our aim was to determine whether the increased incidence of autoimmune disease found in B-CLL patients is associated with enhanced spontaneous IL-6 secretion. IL-6 was measured by the effect of B cell supernatants on the proliferation of an IL-6 dependent plasmacytoma cell line T1165. The highest IL-6 values (7.4 +/- 1.8 U/ml) were measured in supernatants derived on day 3 of culture from lymphocytes of the six patients with B-CLL and concomitant autoimmune disease. The maximal IL-6 values for 10 patients with B-CLL only were 2.8 +/- 0.3 U/ml and for 10 age-matched controls, 0.8 +/- 0.3 U/ml (P less than 0.01, each group compared with the other). We conclude that there is an association between B-CLL, autoimmune disease and the spontaneous in vitro secretion of IL-6. Further studies are needed to determine whether the IL-6 secretion plays a role in the pathogenesis of autoimmune disease in patients with B-CLL.

Evidence for the existence of circulating monoclonal B-lymphocytes in multiple myeloma patients

Multiple myeloma is characterized by the proliferation of a single clone of plasma cells producing a homogeneous immunoglobulin fraction. In this disease, plasma cells home essentially in the bone marrow. However, controversy exists whether peripheral blood B-lymphocytes in patients with multiple myeloma (MM) are part of the malignant clone. We investigated clonal immunoglobulin gene rearrangement (IgGR) in T-cell-depleted peripheral blood mononuclear cells as well as in bone marrow of these patients. Seven out of 17 MM patients demonstrated an identical IgGR in bone marrow and peripheral mononuclear cells, these patients were in an active stage of the disease. In nine patients in plateau phase, clonal IgGR could not be detected in peripheral blood. Peripheral mononuclear cells from ten patients with monoclonal gammopathies of undetermined significance (MGUS) were also examined and no IgGR was detected. The existence of monoclonal B-lymphocytes in the circulation of patients with MM suggests a mechanism whereby the malignant clone homes in the bone marrow through peripheral blood. These findings may also be used for the evaluation of patients with active myeloma and the determination of plateau phase.

Multiple myeloma in the geriatric patient

Consecutive patients with multiple myeloma were studied. The clinical characteristics and survival of 17 patients aged 75 years or more were compared to 42 patients younger than 75 years of age. Of the patients older than 75 years, 14/17 (82%) died in less than 12 months compared to only 11/42 (26%) of those under 75 years old (P less than 0.001). Multivariate analysis showed that both age and hemoglobin were significant predictors of survival (P less than 0.012 and P less than 0.002, respectively) explaining 34.6% of the variance (r = 0.588, P less than 0.000), whereas the extent of bone lesions, the presence of more than 50% plasma cells in the bone marrow, the amount of serum monoclonal protein, functional class, and the Salmon and Durie staging system did not significantly add to the analysis. We conclude that the factors that best predict prognosis are hemoglobin levels and age at presentation. Different approaches including more appropriate chemotherapeutic regimes and comprehensive geriatric assessment with improved supportive treatment need to be developed for the geriatric patient with multiple myeloma.

Concomitant effect of 2'-deoxycoformycin on natural killer cell activity and tumour cell sensitivity to lysis in hairy cell leukaemia--discordant effects of alpha interferon

The effects of 2'-deoxycoformycin (dCF) and alpha interferon (IFN-alpha) on natural killer (NK) cell-enriched fractions and hairy cell (HC) targets from three patients with HC leukaemia (HCL) were investigated. There was no significant increase in NK activity when either the HC targets or NK-enriched cells were preincubated with dCF. However, preincubation of both HC and NK cells with dCF resulted in increased NK activity. Culture of enriched NK cells with IFN-alpha enhanced their activity. However, preincubation of HC targets with this drug in the presence or absence of dCF resulted in a protective effect. Maximal NK activity towards HCL was obtained when the target tumour cells were separately precultured with dCF and the NK-enriched effectors precultured with dCF + IFN-alpha. The effect of dCF and IFN-alpha was also measured using the standard K562 cells as targets for NK activity. dCF enhanced NK activity following preculture of both effector and target K562 cells, but IFN-alpha did not reduce K562 cell susceptibility to NK lysis as it did for HC cells. Our findings suggest that (a) dCF and IFN-alpha, which are used to treat HC, could function via activation of NK cells, (b) effects on both effector and tumour target cells should be taken into account, and (c) caution should be exercised in extrapolating the effects of NK-cell activity against K562 cells to those on HC targets.

Effect of adherent cells on the regulation of BFU-E in patients with myeloproliferative disease

The interaction between adherent cells and red cell progenitors from peripheral blood of patients with polycythemia vera (PV), essential thrombocytosis (ET), and healthy controls was studied. Various combinations of adherent and nonadherent cells were co-cultured in a semisolid system. Adherent cells from controls, when added at low concentrations, stimulated BFU-E proliferation, whereas high concentrations (40% of total cells in the culture) caused a significant decrease in the number of BFU-E colonies in 6/8 PV patients, 4/4 ET patients, and 8/12 controls. On the other hand, low and high concentrations of adherent cells from both patients with PV and ET caused a significant increase in BFU-E from either patients or controls. Moreover, adherent cells from these patients induced endogenous BFU-E proliferation (independent of erythropoietin) in nonadherent cells of 12/12 normal controls. The results show that BFU-E from patients with PV and ET are sensitive to suppression by normal adherent cells. On the other hand, adherent cells from these patients possess stimulatory activity on BFU-E from peripheral blood at all concentrations and are devoid of the inhibitory activity. This suggests a possible defect in the functioning of adherent cells in PV and ET patients which may contribute to the abnormal regulation of hematopoiesis in these disorders.

Antithrombin III levels in preeclampsia

Antithrombin III (AT-III) activity was measured and compared in 29 patients with preeclampsia and 31 women with normal pregnancies. AT-III levels were 83 +/- 25% in preeclamptic patients with greater than 5 g/l proteinuria compared with 102 +/- 11% in the controls. Less severe proteinuria was not associated with decreased AT-III levels. Multivariate analysis revealed that the duration of pregnancy and the degree of proteinuria had an independent negative effect on AT-III levels. AT-III activity correlated poorly with platelet counts and blood pressure measurements. We conclude that urinary loss appears to be the major mechanisms of lower AT-III levels observed in our patients with preeclampsia.

The mean leukocyte myeloperoxidase index in hematological patients

A Technicon H-1 hematologic analyzer was used to measure the mean leukocyte myeloperoxidase (MPX) in 160 patients seen in a hematology clinic. The normal range was -15 to +10, which included 95% of 300 consecutive hospitalized patients. No abnormalities in the MPX were found in 35 patients with beta-thalassemia minor, 8 with iron deficiency, 14 with myeloproliferative disorders, 17 with autoimmune disorders, and 37 patients with lymphoma in complete remission. On the other hand 36% (10/28) of lymphoma patients with active disease either at diagnosis or relapse had a MPX of greater than 10 compared to only 2.3% (7/300) in hospitalized patients (P less than 0.001). Increased levels of MPX were found primarily in patients with non-Hodgkin's lymphoma (NHL) of intermediate or high grades, or Hodgkin's disease [56% (9/16) compared to only 8.3% (1/12) in those with low grade NHLs, P less than 0.05]. The MPX levels returned to normal after successful treatment. Of the various chemotherapeutic agents used, only hydroxyurea led to a consistent elevation of the MPX. The authors conclude that MPX is commonly increased in patients with lymphoma and in those receiving hydroxyurea. Further studies are required to determine if the MPX is a sensitive test for relapse in patients with lymphomas who had an elevated pretreatment value.

Decreased natural killer (NK) activity in patients with myeloproliferative disorders

Natural killer (NK) cell number and activity were measured in 26 patients with myeloproliferative disorders and the results were compared with 16 age-matched control patients. The percent of Leu-11b-positive cells was 11% +/- 3% in the patients, compared with 12% +/- 4% in the control patients. Ten of 26 patients, however, had NK activity lower than all of the control values at three different effector to target cell ratios (E:T) (P less than 0.005). The values of those patients with low unstimulated NK activity remained low despite stimulation with interleukin-2 (IL-2) or alpha-interferon (alpha-IFN), whereas the values of those patients with normal unstimulated activity responded to IL-2 and alpha-IFN like the control patients. Three of the ten patients with low NK activity had a history of malignant neoplasms. None of the 16 patients with normal NK activity had a history of malignant neoplasms (P less than 0.05). We conclude that patients with myeloproliferative disorders frequently have low endogenous NK cell activity in vitro. The dysfunction of the NK system appears to be intrinsic because the relative number of NK cells was similar to control values and the response to stimulation with IL-2 and alpha-IFN was suboptimal. There may be a relationship between low NK activity and the development of malignant disease in such patients.

Increase in the suppressor-inducer T cell subset in multiple myeloma and monoclonal gammopathy of undetermined significance

The expression of CD4 (helper-inducer), CD8 (suppressor-cytotoxic) and CD4 subpopulations (2H4 and 4B4) were studied in patients with multiple myeloma, monoclonal gammopathy of undetermined significance (MGUS) and in healthy controls. The percentages of CD4+ cells and CD8+ cells among total T cells were not different between the three groups studied. However the percentage of CD4+ cells of the suppressor-inducer type (CD4 + 2H4 +) was 53 +/- 9% in patients with MGUS, and 51 +/- 9% in those with MM, compared to 46 +/- 5 in the controls (P = 0.033 and P = 0.07 respectively). A significant negative correlation between serum polyclonal IgM and the percentage of CD4 + 2H4 + cells was found in patients with MM but not in those with MGUS. No difference was found in the percentage of CD4 + 4B4 + (helper CD4+ cells) between the various groups. These findings suggest that the elevation of the suppressor-inducer subset occurs prior to clinical manifestations of MM, perhaps as an immune response to the malignant clone. The existence of elevated proportions of CD4 suppressor-inducer cells was associated with the hypogammaglobulinaemia observed in patients with MM. Since no hypogammaglobulinaemia was present in those with MGUS, additional factors are needed to explain the influence of the CD4 + 2H4 + cells on the production of immunoglobulins.

Von Willebrand factor and mitral valve prolapse

The levels of von Willebrand factor (vWF:Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (less than 80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p less than 0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 +/- 30% versus 100 +/- 23%, p less than 0.001). In those with MVP and congestive heart failure secondary to rupture chordae tendineae, however, the mean level of vWF: Ag was not significantly different from control values (95 +/- 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF:Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF:Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

T-cells of multiple myeloma patients triggered by the autologous mixed lymphocyte reaction suppress polyclonal immunoglobulin synthesis

To elucidate the possible role of T-cells of patients with multiple myeloma (MM) in the suppression of polyclonal immunoglobulin synthesis. T-cells with and without prior activation by the autologous mixed lymphocyte reaction (AMLR) were added to normal immunoglobulin (Ig)-secreting cultures. The suppression induced by AMLR-activated T-cells from patients with MM was compared to that induced by AMLR-activated T-cells from apparently normal controls. The addition of 10% unstimulated autologous T-cells from patients with MM resulted in minimal suppression of IgG synthesis (87 +/- 19% of baseline values for patients and 115 +/- 21% for controls, no significant difference). The suppression sharply increased when T-cells were preactivated by AMLR and then added in the same concentration to the IgG-secreting cultures (38 + 12% of baseline values for patients compared to 106 + 14% for controls, P less than 0.05). AMLR cultures were performed in the presence of adherent monocytes and after their depletion. The T-cell suppressor effect on normal IgG synthesis was unchanged after monocyte depletion. T-cells preactivated in the AMLR from patients with MM sharply suppress in vitro polyclonal IgG synthesis, and the activation of these suppressor T-cells is not dependent on the presence of monocytes.

Bone marrow biopsy in multiple myeloma: a clinical pathological study

Forty-two bone marrow aspirates and biopsies during follow-up examinations from patients with multiple myeloma were reviewed to determine whether the results correlate with the clinical state of the patient at the time of examination. The percentage of plasma cells on biopsy and aspiration, cytological immaturity, patterns of plasma cell infiltration, and the presence or absence of multiple lymphoid nodules and marked fibrosis were cross-tabulated with clinical parameters (hemoglobin levels, osteolytic lesions, and renal function). Hemoglobin levels less than 10 g/dl were more frequent in those with greater than 70% plasma cells on either aspiration or biopsy (P less than 0.05). A nodular histological pattern on biopsy, however, had a higher correlation with hemoglobin levels less than 10 g/dl, and serum creatinine levels greater than 2 mg/dl, than did plasma cell number. The presence of lymphoid nodules correlated with less lytic bone lesions. The degree of fibrosis and plasma cell immaturity did not correlate with any of the clinical parameters. Our findings suggest that reports on bone biopsies should include in addition to the number of plasma cells, the pattern of plasma cell infiltration and the presence or absence of multiple lymphoid nodules.

Discordant effect of interferon on natural killer activity and tumor cell sensitivity to lysis in hairy cell leukemia

We studied the action of alpha-interferon (IFN) and interleukin-2 (IL-2) on natural killer (NK)-rich fractions and autologous tumor cells from two patients with hairy cell leukemia (HCL). The addition of IFN or IL-2 to the NK-rich fractions resulted in a significant increase in NK activity against the autologous tumor cells. This stimulatory effect was blocked if the target hairy cells (HCs) were preincubated with either IFN or IL-2. Pretreatment of the HCs with anti-Tac antibody entirely prevented the blocking effect of IL-2 and partially the blocking effect of IFN. One patient was treated with recombinant alpha c-IFN. After 2 months there was a dramatic reduction in the number of HCs in the peripheral blood coincident with the loss of the protection effect of IFN against NK lysis of the patient's HCs. NK activity against autologous tumor cells correlated poorly with that against the K562 cell line. We conclude that there is a discordant effect of IFN and IL-2 on NK activity and HC sensitivity to lysis. The Tac receptor appears to play a role in this sensitivity. Caution should be exercised in extrapolating the effects of NK activity against K562 cells to those on HC targets.

Primary hepatic lymphoma presenting as symptomatic immune thrombocytopenic purpura

A 33-year old Arabian man presented with idiopathic thrombocytopenic purpura that did not respond to steroid treatment or splenectomy. A routine liver scan performed after splenectomy showed a large mass in the liver. Four years later, massive gastrointestinal bleeding led to an emergency laparotomy, which revealed well-differentiated lymphocytic lymphoma extending from the liver to the fundus and lesser curvature of the stomach. A partial gastrectomy was performed. With chemotherapy the liver mass resolved and the platelet counts have normalized for the past 30 months.

Monocyte produced burst-promoting activity after stimulation with lymphokine

Normal monocytes were stimulated by lymphokine(s) from a homogenous population of malignant T cells of the helper phenotype (OKT 3+/4+/6-/8-/11+). The resultant monocyte-conditioned medium after stimulation with T cell-conditioned medium (M-CM+) was assayed for burst-promoting activity. The number of burst-forming units-erythriod (BFU-E) in methylcellulose cultures of normal human nonadherent peripheral blood cells increased by nearly threefold in the presence of 5% M-CM+. This activity was lost after the conditioned medium was boiled for 20 min. The addition of 5% conditioned medium (CM) from unstimulated monocytes did not significantly increase BFU-E proliferation. We conclude that lymphokine(s) from malignant T cells of the helper phenotype stimulate normal monocytes to produce a heat-sensitive monokine that increases BFU-E proliferation.

Reduced natural killer activity in patients with Fanconi's anemia and in family members

Natural killer (NK) activity was measured in the peripheral blood of a family with Fanconi's anemia (FA) and compared to normal controls. One of two children with FA, and 6 of 11 family members had reduced NK activity (less than 30% with an E:T ratio of 25:1) compared to none of 40 controls (p less than 0.001). On retesting 5 of 8 family members and both children with FA had reduced endogenous NK activity compared to 0 of 5 controls (p less than 0.02). The number of NK cells determined by Leu 11b antibody was not reduced in any of the family members. Augmentation with interleukin-2 (IL-2) and alpha interferon (IFN) in those with low endogenous activity was variable. Three demonstrated no response to the 2 immunomodulators, while the 4 others increased to low normal levels. We conclude that some patients with FA and their apparently healthy relatives have reduced NK activity, which appears to be secondary to an intrinsic cell defect.

MR imaging in myelofibrosis

Two patients with myelofibrosis demonstrated decreased signal intensity from the bone marrow due to replacement of marrow fat with fibrosis and cellular elements.

The von Willebrand factor in myocardial infarction and unstable angina: a kinetic study

Recent studies have demonstrated elevations of von Willebrand Factor following acute myocardial infarction (AMI). In order to determine if this parameter may serve as a marker for AMI, we tested the blood levels of vWF and Factor VIII:C in 28 patients with AMI, 9 patients with unstable angina, 7 patients with atypical chest pain, and 25 healthy volunteers. The level of ristocetin cofactor activity of vWF was between 70 and 144% in the control group. In patients with AMI, the mean level of this activity was 175% on the first day following infarction, rose to a peak of 270% on the fifth and sixth days, and was still significantly greater than normal in all patients on the 14th day. The vWF:Ag level closely paralleled the rise of ristocetin cofactor activity of vWF, with a peak of 336% on day 5. FVIII:C was not significantly changed. No significant elevation of vWF was observed in patients with unstable angina. The ristocetin cofactor activity of vWF and vWF:Ag thus are sensitive biochemical indicators for recent AMI, and may serve as useful markers for up to 14 days following infarction, when the traditional enzymes have returned to normal levels.

Discrimination between iron deficiency and heterozygous beta-thalassemia in children

The authors studied 119 children with microcytic anemia who were selected by lack of response to a month's treatment with oral iron. Family studies and retesting after further treatment with iron were done in all cases to ensure accurate diagnosis. Seventy-five cases of beta-thalassemia minor (BTM) and 40 cases of iron deficiency were identified. In all 75 cases of BTM, at least one parent had a mean cell volume (MCV) less than 79 microns. In 35 of 40 children with iron deficiency, the MCV of both parents was normal. In contrast, Hb A2 was normal in 15% (11 of 75) of children with BTM, until they received additional treatment with oral iron. The authors conclude that in children with microcytic anemia unresponsive to a month's treatment with oral iron, the MCV of the parents is superior to Hb A2 in discriminating between iron deficiency and heterozygous beta-thalassemia. Repeated testing after additional treatment with oral iron may be needed to ensure accurate diagnosis.

Hodgkin disease: malignancy, inflammation and abnormal immunity

The effect of Hodgkin disease cells on the surrounding environment is complex. In the light of recent findings on growth factors and oncogenes a hypothesis on Hodgkin disease is presented. The interrelation of three main features of Hodgkin disease: malignancy, inflammation and abnormal immunity may be explained by the local secretion of platelet-derived growth factor like substances and interleukin-1 like substances by malignant Hodgkin disease cells.

A subpopulation of suppressor cells in Richter's syndrome with both monocytic and T-lymphocytic characteristics

We evaluated T-lymphocyte functions in the peripheral blood of a patient with B-cell chronic lymphocytic leukemia after transformation to large cell lymphoma (Richter's syndrome). A subpopulation of E-rosette adherent cells were found with T-lymphocytic surface markers (OKT3+/8+/4+), monocytic characteristics (latex ingestion, nonspecific esterase staining), and suppressor activity. In contrast to the patient's nonadherent T-cells, this subpopulation suppressed PHA proliferation of autologous lymphocytes, pokeweed mitogen (PWM)-induced proliferation of normal non-T cells, and a mixed lymphocyte reaction. Further studies are warranted in patients with Richter's syndrome, in order to determine the frequency and significance of our findings.

Acquired factor X and antithrombin III deficiency in a patient with primary amyloidosis and nephrotic syndrome

A 45-year-old man with primary amyloidosis was initially seen with nephrotic syndrome. Factor X was found to be 5% and antithrombin III (AT III) 45% of normal plasma values. During an 11-month period, despite severe factor X deficiency, the patient did not have any bleeding complications. He developed progressive renal failure and AT III levels increased to normal, at which time he developed severe bleeding complications. These findings suggest a protective role of AT III deficiency against bleeding in a patient with severe factor X deficiency.

Altered transcription of an oncogene in chronic myeloid leukaemia

The oncogene abl, which resides on chromosome 9, is translocated to chromosome 22 as part of the Philadelphia (Ph1) chromosome. Leukaemic cells from 5 of 6 patients with chronic myelogenous leukaemia (CML) and the Ph1 chromosome were found to contain a new 8 kb abl RNA transcript. This finding raises the possibility that the abl oncogene is directly involved in the development of CML. It is suggested that the abl gene's expression is altered by the DNA rearrangement in the translocation.

Factor XI deficiency in an Arab Moslem family in Israel

An arab moslem family with members affected by PTA deficiency is described. 3 children were found to have major deficiency, factor XI procoagulant activity being 3, 3 and 4 units/dl. 8 members, including parents, paternal grandparents and 4 siblings, were found to have minor deficiency of factor XI (40 to 68 units/dl). Assays of immunoreactive material in 4 members corresponded to the level of procoagulant activity. In this family, gene expression is autosomal recessive. The only bleeding episode reported was haematuria in the propositus. No other spontaneous, post-trauma or post-operative bleeding was noted. The PTA deficiency was reported until now, mainly in ashkenazi jews. This family is the first case of PTA deficiency ever reported in arab moslems.

Normal bone marrow as a source of granulocytes for transfusion

A method for obtaining granulocytes for transfusion by direct aspiration of bone marrow from normal donors is described. The bone marrow is the major storage reserve for granulocytes with as many as 60 times more granulocytes than in the peripheral blood. With current methods of leukapheresis from peripheral blood, steroids, hydroxyethyl starch, and anticoagulants are given to the donor and his processed blood is returned. Bone marrow aspiration spares the donor such treatment. In addition, no costly machine is necessary and the whole procedure takes less than 2 hours. Due to minimum manipulation, cell viability is not impaired. Furthermore, some committed granulocyte stem cells, as well as nonmature granulocytes, are transfused. These cells have the potential to mature to efficient phagocytes in the patient's circulation.

Ferritin deposits in peripheral blood lymphocytes of Hodgkin's disease patients

In view of the reported associations of Hodgkin's disease and ferritin, an electron microscopic study of the peripheral blood lymphocytes of these patients was done. In 5 out of the 6 patients studied intracellular ferritin deposits were seen. No such deposits were seen in the lymphocytes of healthy subjects or in those of a patient with beta-thalassemia. The lymphocyte ferritin accumulation in Hodgkin's disease can arise either from increased synthesis or from phagocytosis.

Selective splenectomy in Hodgkin's disease, stages I and II. Results of treatment

Sixty-three patients with Hodgkin's disease, in stages I or II, asymptomatic (A) or symptomatic (B), were diagnosed and followed at the Chaim Sheba Medical Center from 1969 to 1976. Only 14 were staged pathologically. Until 1971, the patients received mantle or "inverted Y" therapy only; thereafter, an extended field that included mantle, upper abdomen and spleen irradiation was given. Symptomatic patients, as well as patients with extranodal involvement, received MOPP chemotherapy (nitrogen mustard, vincristine, procarbazine and prednisone) after termination of radiotherapy. Of 51 patients who were in stage IA or IIA, six relapsed 20 to 43 months after irradiation. Three had a pelvic recurrence; two of them were surgically staged. Thus, in only 1 of 51 patients could staging laparotomy possibly have detected pelvic disease and resulted in different therapy. Our results suggest that total nodal irradiation and staging laparotomy are not mandatory in stages IA and IIA of Hodgkin's disease. The group of 12 symptomatic patients is too small to allow us to draw definite conclusions as to the role of staging laparotomy and adjuvant chemotherapy. However, in view of the high relapse rate in the upstaged symptomatic patients, it seems that chemotherapy should be given to these patients.

Hodgkin's disease of the lung

The clinical and radiological findings in 16 patients with Hodgkin's disease involving the lung are reviewed. Lung involvement was evident at initial presentation in 11 patients and appeared during the course of the disease in five patients. All the patients had hilar as well as mediastinal lymphadenopathy; most of them--14 of 16--had the nodular sclerosis type of the disease. Patients with these combined findings are apparently more likely to develop lung lesions. Seven of the 11 patients with lung involvement at presentation were symptomatic and received combined chemotherapy in addition to radiotherapy. The lung lesions responded completely in 10 of the 11 patients, and in one they cleared slowly after more than a year of treatment. The question remains open as to whether an asymptomatic patient in the high-risk group, as described above, should receive either adjuvant chemotherapy or radiation therapy to the lung on the prophylactic basis. Our own policy is to add chemotherapy as an adjuvant to female patients and to males who have children.

Clinical and laboratory aspects of disseminated intravascular coagulation (DIC): a study of 118 cases

The medical records of 118 cases who met laboratory criteria of DIC were studied. The most frequent etiologies were: Generalized infection (39.8%), trauma (16.9%), malignancy (6.8%) and surgical cases (6.8%). The main clinical manifestations which appeared to be related solely to DIC were (in a decreasing order of frequency): Bleeding (64.4%), renal dysfunction (24.6%), liver dysfunction (18.6%), respiratory dysfunction (16.1%), shock (14.4%), thromboembolic phenonmena (6.8%) and central nervous system involvement (1.7%). In 26 patients none of these manifestations were observed. In patients with infection, liver and renal dysfunction were frequent and respiratory dysfunction rare, whereas in trauma cases, liver and renal dysfunctions were rare and respiratory dysfunction frequent. This variability indicates that the clinical manifestations are affected not only by the process of intravascular coagulation but also by the underlying clinical disorders. The most impaired coagulation tests were prothrombin time, partial thromboplastin time, platelet count and thrombin time. The degree of abnormality of these coagulation tests was found to be related to the extensiveness of organ involvement. The mortality (overall 54.7%) increased independently with age, with the number of clinical manifestations and with the degree of abnormality of the above-mentioned four most impaired coagulation tests. In addition, older patients were more likely to have an increased number of clinical manifestations and more impaired coagulation tests. Mortality was similar in the various etiologies except for trauma patients in whom it was lower (30%).