Irreversible neurological defects in the lower extremities after haploidentical stem cell transplantation: possible association with nelarabine.

Severe peripheral neuropathy and myelopathy are rare complications after stem cell transplantation (SCT). In our institution, seven patients of precursor T lymphoblastic leukemia/lymphoma without the central nervous involvement who had been treated by nelarabine to control their diseases received SCT from HLA-haploidentical familial donor (HLA-haploidentical SCT) with the conditioning regimen including high-dose cytarabine (HDAC). Three of evaluable six patients developed irreversible paresthesia and muscle weakness in both lower extremities after neutrophil engraftment. The results of nerve conduction studies and short latency somatosensory evoked potentials suggested axonal neuropathy of both lower extremities in all three patients and myelopathy in two patients. Negative findings of PET-CT, and analyses of repeated cerebrospinal fluid samples and the bone marrow also indicated that tumor involvement was improbable. In all three patients, the symptoms worsened or persisted despite administration of corticosteroid and intravenous immunoglobulin. The high frequency of the neurological symptoms in our patients previously treated by nelarabine strongly suggested the association of the nelarabine use. Furthermore, the HLA-haploidentical SCT setting and the use of a potentially neurotoxic agent, HDAC might augment the neurotoxicity of nelarabine. It may be desirable that HLA-haploidentical SCT candidates avoid receiving nelarabine.

[Alleviation of carotid sinus syncope and removal of cardiac pacing after regression of cervical malignant lymphoma].

A 68-year-old man developed a rapidly-growing right cervical tumor, a biopsy of which allowed for the diagnosis of diffuse large B-cell lymphoma, not otherwise specified. Magnetic resonance imaging demonstrated a right cervical mass lesion of 80 mm in diameter that extended from the medial region of the parotid gland to the posterior region of the neck. While undergoing a chest X-ray in an upright position, he lost consciousness and briefly fell. A transient loss of consciousness recurred while changing his position on the bed, and an electrocardiogram at that time revealed sinus arrest of a seven second duration. This syncope was considered to be a carotid sinus syncope (CSS) induced by the compression of the carotid sinus by his cervical bulky lymphoma. Temporary cardiac pacing was immediately started and rituximab was administered. Three days later, CHOP therapy was started. As his cervical tumor rapidly shrank, the frequency of sensed sinus arrests decreased to zero per day by day 9 of CHOP therapy, resulting into the removal of the pacemaker. In certain cases with CSS due to cervical lymphoma, cardiac pacing, if needed at the onset, is considered to become removable early after chemotherapy in association with tumor shrinkage.

[A case of intravascular malignant lymphoma with initial progressive non-specific neurological symptoms].

A 79-year-old woman was admitted to a nearby hospital for seven days due to low-grade fever, loss of appetite and general fatigue. She was diagnosed with normal condition and discharged. She was admitted to our hospital one week later with disturbed consciousness. Laboratory findings upon admission revealed anemia, elevated alanine amino transferase, elevated total birirubin and thrombocytopenia. Abdominal CT demonstrated multiple low intensity lesions in the liver. Enhanced brain CT revealed multiple lesions with increased signal intensity lesions in the white matter and cortex. The value of soluble IL-2 receptor antibody was 16,000U/ml. Intravascular lymphoma was suspected because of brain CT finding and IL-2 receptor antibody titer. Methylprednisolone pulse therapy was started considering her age and general condition, but she was died thirteen days after admission. Postmorten examination revealed widespread intravascular aggregation of malignant lymphoma cells in the liver, spleen, bone marrow, bladder, ovary and stomach indicating a diagnosis of an Asian variant of intravascular large B cell lymphoma (AIVL). Neurological abnormalities are not usually associated with AIVL, but this patient had rare AIVL presenting with initial progressive nonspecific neurological symptoms.

Retrievable Inferior Vena Cava Filter and Catheter Directed Thrombolysis (CDT) for Treating a 19-year-old Man with Acute Myeloid Leukemia Complicated by Deep Vein Thrombosis (DVT): A Case Report.

Here, we report a case of a 19-year-old man with acute myeloid leukemia complicated by deep vein thrombosis (DVT) in which we placed a retrievable inferior vena cava (IVC) filter during catheter directed thrombolysis (CDT). We were able to retrieve the IVC filter after a successful CDT and concluded that the use of this filter might be efficacious and better than an indwelling IVC filter that is associated with long-term risks. A retrievable filter and CDT should be considered in patients who are at transient risk for phlebemphraxis and require placement of a filter.

Thrombo-occlusion of inferior vena cava filter in a patient with polycythemia vera.

This is a case of a thrombo-occlusion occurring below an inferior vena cava (IVC) filter inserted in a patient with polycythemia vera and deep vein thrombosis. The patient was a 48-year-old man with polycythemia vera and a chief complaint of swelling, redness, and bursting pain in his right leg. After admission, contrast-enhanced computed tomography scanning demonstrated a pulmonary artery thrombus and deep vein thrombosis. We inserted a Gunther tulip vena cava filter on day 1 for the prevention of pulmonary embolism (PE), and started anticoagulation therapy based on the guideline of the Japanese Circulation Society for DVT. In addition to intravenous anticoagulants, we started therapeutic phlebotomy to improve the hypercoagulability state. On day 4, our patient complained of back pain caused by thrombo-occlusion below the IVC filter, despite the anticoagulation therapy and two therapeutic phlebotomies. From this case, we concluded it is important to lower hemoglobin level and hematocrit as early as possible for IVC-filter-insertion in patients with polycythemia vera.

A atrial flutter consisted of two different conduction pathways.

The patient is a 64-year-old male who had been implanted with a DDD-pacemaker for sick sinus syndrome in 2003. In January 2006, he experienced palpitations and visited a local hospital on the second day of occurrence. After an electrocardiography (ECG) revealed atrial flutter (AFL) during palpitation, which was resistant to administered verapamil, the patient was admitted to our hospital for curative treatment. Electrophysiological study revealed a common AFL (AFL1) initiated by atrial burst pacing. We performed isthmus radiofrequency (RF) ablation against AFL1 successfully, after which another common AFL (AFL2) with differing atrial rate was detected. A second ablation operation with standard catheterization techniques was successful, suggesting that two pathways with differing conduction times existed.

A congenital absence of the pericardium diagnosed by echocardiography.

A 29-year-old man visited our office after experiencing palpitations at night. The electrocardiogram revealed premature ventricular contractions (PVCs), and he was admitted to our hospital for further tests. The echocardiography revealed paradoxical motion of the interventricular septum. After considering results from a previous cardiac catheter test, we suspected that the patient may have a congenital absence of the pericardium. A CT scan and magnetic resonance imaging were inconclusive, but through echocardiography and ECG performed during three positional changes we diagnosed a congenital absence of the pericardium.