Recurrent acute renal failure complicating IgG warm-type autoimmune intravascular haemolysis

A 44-year-old woman experienced recurrent episodes of massive intravascular haemolysis complicated by acute oliguric renal failure over a period of 22 years. The haemolysis was induced by IgG warm type autoantibody and complement and responded to corticosteroid therapy. The renal failure was treated effectively by dialysis. To our knowledge, such a life long occurrence of recurrent intravascular haemolysis induced by IgG warm type autoantibodies together with renal failure has not been reported before.

Isolated bone marrow non-Hodgkin's lymphoma. Report of two cases and literature review

We report two patients with isolated bone marrow non-Hodgkin's lymphoma and we review the additional 23 cases thus far described. Bicytopenia or pancytopenia and an elevated erythrocyte sedimentation rate were universally present. Some 84% of the patients manifested fever of unknown origin (FUO), 64% constitutional symptoms, 48% hepatomegaly, and 52% splenomegaly. Of the variety of therapeutic protocols used, corticosteroids, alone or in combination, appeared to be the most effective. Survival ranged from 1 week to 4.5 years. Early diagnosis would avoid unnecessary work-up in patients with FUO and enable optimization of therapy.

Fatal haemoptysis induced by invasive pulmonary aspergillosis in patients with acute leukaemia during bone marrow and clinical remission: report of two cases and review of the literature

We describe two patients with acute leukaemia who died of massive haemoptysis caused by invasive pulmonary aspergillosis (IPA). The fatal event occurred during the period of bone marrow remission which followed chemotherapy-induced neutropenia. This is a rare complication. We were able to find additional 17 similar cases in the English literature, which we review. Clinically, the picture consisted of unremitting fever with profound and prolonged neutropenia, cough and dyspnoea. Both our patients were treated with broad-spectrum antibiotics, fluconazole and amphotericin B. An upper lobe infiltrate in one case, and a progressive pleural effusion in the other, were late findings on chest radiographs during the period of bone marrow recovery. Both patients succumbed to sudden massive haemoptysis during the period of bone marrow and clinical improvement. In conclusion, patients with acute non-lymphoid leukaemia are at significant risk for IPA-induced fatal haemoptysis during bone marrow and clinical remission. A high index of suspicion should be sustained throughout the entire clinical course. In view of the potential fatal outcome, aggressive diagnostic and treatment efforts are mandatory.

Molecular alterations in the TP53 gene of peripheral blood cells of patients with chronic myeloid leukemia

The TP53 gene has been extensively studied in patients with chronic myeloid leukemia (CML), both in chronic phase and in blast crisis. Mutations in the gene were found in up to 30% of the patients, especially among those in blast crisis. We report the results of an analysis of 29 blood samples from CML patients: 8 samples from chronic phase patients, 8 from patients in the accelerated phase, and 13 from patients in blast crisis. By using genomic DNA, we sequenced PCR products of the coding exons and most introns of the TP53 gene, finding genetic changes in 30% of the blast crisis samples and 12% in chronic phase. All mutations were found in introns and were previously unreported. Immunocytochemical studies revealed accumulation of TP53 in blood cells of samples both from chronic phase and blast crisis patients. Since these samples had no TP53 mutations, we believe that wild type TP53 accumulates in blood cells of CML patients. Our results, therefore, indicate that molecular changes in coding regions of the TP53 gene are rare. The significance of the abundance of intronic changes should be investigated further. Accumulation of wild type TP53 in CML cells may indicate an additional mechanism involving this gene in the pathogenesis of this disease.

Enhanced generation of monocyte tissue factor and increased plasma prothrombin fragment1+2 levels in patients with polycythemia vera: mechanism of activation of blood coagulation

Polycythemia vera (PV) is associated with a high incidence of thrombosis. The association of apparent and secondary polycythemia with thrombosis is not clear. It was suggested that activation of the coagulation system contributes to thrombus formation in PV. However, the mechanism of activation is unknown. Monocytes generate a potent tissue factor (TF) upon stimulation with various substances, which is involved in thrombus formation in various disorders. Therefore, we studied the possibility that the factor is involved in the activation of coagulation and thrombus formation also in PV. Unstimulated peripheral blood mononuclear cells (PBMC) from each of the different types of polycythemia expressed weak TF activity (2 U) and antigen (41.4 to 52.9 pg/ml), which were similar to normal controls. Following stimulation with endotoxin, PBMC from normal controls and from apparent and secondary polycythemia showed a 3.9- to 4.5-fold increase in TF, while cells from PV showed a 21-fold increase (P<0.001). Similar levels were generated by PBMC after treatment of PV and at the spent phase. TF was generated by monocytes but not by lymphocytes. Plasma prothrombin fragment1+2 (F1+2) levels, assayed at the same time, were significantly higher in PV (2.46 nm) compared to normals and apparent and secondary polycythemia (0.22 to 0.32 nm), and were in a significant correlation with monocyte TF activity and antigen levels (r = 0.77, 0.87). The high levels of F1+2 confirm that the coagulation system is activated in PV. The increased capacity of monocytes to generate TF may be responsible for the activation of the coagulation system and thrombus formation. The hypercoagulability state that is induced by this mechanism suggests that long-life oral anticoagulation should be considered once thrombosis has been developed in PV.

Unusual bleeding manifestations of amyloidosis in patients with multiple myeloma

We describe two patients who developed severe haemorrhagic complications. One manifested massive vaginal bleeding and the second haemopericardium with cardiac tamponade. In both cases histopathological examination showed subendothelial deposits of amyloid. Since other local and systemic causes of the haemorrhagic complications were excluded the bleeding was most probably due to amyloid angiopathy. Therefore, amyloid angiopathy should be considered in the differential diagnosis of bleeding in patients with amyloidosis associated with multiple myeloma.

Immunological profile changes following perioperative autologous vs. homologous blood transfusion in oncologic patients

To determine the effect of perioperative blood transfusion on immunological parameters, T cells, T-cell subsets, and concanavalin A-induced suppression were measured in 25 patients with colorectal and breast cancer. During the operation, 15 patients received autologous blood and 10 patients had homologous transfusion. The immunological status was again determined after curative surgery. Before surgery, normal percentage of T lymphocytes, decreased ratios of helper/suppressor cells, and impaired con A-induced suppression were found. Following the operation, the helper and suppressor cell percentages reversed to normal, whereas the con A-induced suppression remained impaired. This change was significantly more pronounced in patients who received autologous blood transfusion than in the other group. Autotransfusion has an impact on immune parameters that might prove less detrimental to the clinical outcome in oncologic surgery than homologous transfusion.

Folic acid deficiency, megaloblastic anemia and peripheral polyneuropathy due to oral contraceptives

A 34-year-old woman developed megaloblastic anemia and peripheral polyneuropathy following the use of oral contraceptives for 4 years. Low levels of folic acid and vitamin B12 were found. Both the complete recovery after therapy with the vitamins, and the absence of other causes of vitamin B12 and folate deficiency, suggest that the vitamin deficiencies were caused by the oral contraceptives and resulted in the rare combination of megaloblastic anemia and polyneuropathy. The poor response to vitamin B12 alone, and the development of anemia and polyneuropathy 4 months after cessation of vitamin B12 therapy suggest that folate deficiency was the primary problem.

Clinical manifestations and laboratory findings in patients with lupus anticoagulants

Clinical and laboratory features were evaluated in 48 patients with lupus anticoagulants and the efficiency of three different assays in the detection of lupus anticoagulants was compared. The diagnosis of lupus anticoagulants was based on a prolonged activated partial thromboplastin test not corrected in a mixture of 1:1 with normal plasma and lack of specific inhibitors against coagulation factors. Platelet neutralization procedure was positive for lupus anticoagulants in 98% of the patients, tissue thromboplastin inhibition ratio in 79%, and kaolin clotting time index in 77%. At least one of the assays was positive in 100% of the cases. The largest minority of the patients (31%) suffered from systemic lupus erythematosus. The others had a variety of non-immunological disorders. In the 13 patients who had been operated on, only 1 with renal failure developed hemorrhagic complications after renal biopsy due to thrombocytopathy. The incidence of recurrent spontaneous miscarriage, immune thrombocytopenia and positive direct antiglobulin test, anti-nuclear and anti-DNA antibodies and VDRL was significantly higher in patients with lupus anticoagulants and systemic lupus erythematosus compared to patients with lupus anticoagulants but without systemic lupus erythematosus.

Gaucher's disease associated with chronic lymphocytic leukaemia

The association of Gaucher's disease with chronic lymphocytic leukaemia (CLL) is very rare. To our knowledge only five cases have been reported (Chang-Lo, Yam & Rubenstone 1967; Chang-Lo et al. 1975; Fox et al. 1984; Lee 1982; Mark, Dominguez & Rywlin 1982). We report a patient with this association, the CLL had been diagnosed 12 years after the demonstration of Gaucher's disease.

Functions of polymorphonuclear (PMN) leukocytes of patients with lymphoproliferative diseases

PMN leukocytes from untreated patients with multiple myeloma (MM), Hodgkin's disease (HD) and non-Hodgkin lymphoma (NHL) were studied in vitro for their phagocytic and chemotactic function. Alkaline phosphatase score and the reduction of nitroblue tetrazolium (NBT) in these leukocytes were also determined. Most of the functions of PMN leukocytes from untreated patients with MM were impaired, compared to control leukocytes, while those from patients with HD and NHL were impaired only in their chemotactic response to casein and endotoxin-activated serum (EAS).