Antiparasitic and disease-modifying activity of Nyctanthes arbor-tristis Linn. in malaria: An exploratory clinical study.

BACKGROUND: An unceasing threat of drug resistance continuously poses demand for new antimalarial drugs. A scientific assessment of traditionally used antimalarial plants through reverse pharmacology is crucial for a fast track drug discovery. An Ayurvedic plant Nyctanthes arbor-tristis Linn. - (Parijat) is being used in clinical practice and had shown antimalarial activity, with a parasite clearance in 76.6% of 120 patients, in an earlier clinical study. OBJECTIVE: To further explore antimalarial potential of the plant through additional objective markers. MATERIALS AND METHODS: An open-labelled observational study was conducted at M.A. Podar Hospital - Ayurveda (MAPH-A) after ethics committee approval. Administration of a paste of 5 fresh leaves, thrice a day for a week was a standard practice for management of malaria at MAPH-A. Clinical activity of N. arbor-tristis was evaluated by monitoring pyrexia, parasitemia and morbidity score (MS) in twenty patients. In addition, immune and biochemical markers and organ functions were monitored for objective markers of response. Student's paired-'t' test was applied to assess statistical significance. RESULTS: Ten out of 20 patients showed both fever and parasite clearance, which was confirmed by polymerase chain reaction. Remaining ten patients had persistent but decreasing parasitemia. Four of them needed chloroquine as a fail-safe procedure. Irrespective of the degree of parasitemia all the patients showed decrease in MS. There was also an increase in platelet count and normalization of plasma lactic acid. There was a good clinical tolerability and an improvement in organ function. The inflammatory cytokines showed a reduction; particularly in TNF-α within a day. CONCLUSIONS: At the given dosage, N. arbor-tristis showed disease-modifying activity; early clinical recovery with a decline of TNF-α and a gradual parasite clearance. Further studies with a standardised formulation for dose-searching and optimizing the treatment schedule are needed in a larger sample size. CLINICAL TRIAL REGISTRATION NO: The process of trial registration had not begun when the study was conducted in 2000.

Double minute chromosomes in acute myeloid leukemia, myelodysplastic syndromes, and chronic myelomonocytic leukemia are associated with micronuclei, MYC or MLL amplification, and complex karyotype.

Double minute chromosomes (dmin) are small, paired chromatin bodies that lack a centromere and represent a form of extrachromosomal gene amplification. Dmin are rare in myeloid neoplasms and are generally associated with a poor prognosis. Most studies of dmin in myeloid neoplasms are case reports or small series. In the current study, we present the clinicopathologic and cytogenetic features of 22 patients with myeloid neoplasms harboring dmin. These neoplasms included acute myeloid leukemia (AML) (n = 18), myelodysplastic syndrome (MDS) (n = 3), and chronic myelomonocytic leukemia (CMML) (n = 1). The AML cases consisted of AML with myelodysplasia-related changes (n = 13) and therapy-related AML (n = 5). Dmin were detected in initial pre-therapy samples in 14 patients with AML or CMML; they were acquired during the disease course in 8 patients who had AML or MDS. The presence of dmin was associated with micronuclei (18/18; 100%), complex karyotype (17/22; 77.3%), and amplification of MYC (12/16; 75%) or MLL (4/16; 25%). Immunohistochemical staining for MYC performed on bone marrow core biopsy or clot sections revealed increased MYC protein in all 19 cases tested. Except for one patient, most patients failed to respond to risk-adapted chemotherapies. At last follow up, all patients had died of disease after a median of 5 months following dmin detection. In conclusion, dmin in myeloid neoplasms commonly harbor MYC or MLL gene amplification and manifest as micronuclei within leukemic blasts. Dmin are often associated with myelodysplasia or therapy-related disease, and complex karyotypes.

Waldenström macroglobulinemia: a review of the entity and its differential diagnosis.

The definition of Waldenström macroglobulinemia (WM), originally described in 1944, has been refined substantially over time. The current fourth edition of the World Health Organization of lymphoid neoplasms, in large part, adopted criteria proposed for WM at a consensus conference in 2002. WM is defined as lymphoplasmacytic lymphoma involving the bone marrow associated with a serum immunoglobulin (Ig) M paraprotein of any concentration. Morphologically, WM is composed of a variable mixture of lymphocytes, plasmacytoid lymphocytes, and plasma cells. Immunophenotypically, the neoplastic cells express monotypic IgM and light chain: B lymphocytes express pan-B-cell antigens and surface Ig are usually negative for CD5 and CD10; and plasma cells are typically positive for CD138, CD38, CD45, cytoplasmic Ig, and CD19 (in a substantial subset of cases). The putative cell of origin of WM is a postantigen selected memory B-cell that has undergone somatic hypermutation. The most common cytogenetic abnormality in WM is del(6q), usually in the region 6q23-24.3, present in 40% to 50% of cases. IGH gene translocations are rare and recurrent chromosomal translocations or gene aberrations have not been identified in WM. Here, we provide a historical perspective of WM, review clinical and pathologic aspects of the disease as it is currently defined, and discuss some practical issues in the differential diagnosis of WM that pathologists encounter in the signout of cases.

Myelodysplastic syndromes arising in patients with germline TP53 mutation and Li-Fraumeni syndrome.

CONTEXT: Li-Fraumeni syndrome (LFS), characterized by predisposition to early onset of a variety of malignancies, is usually associated with germline mutation of the tumor-suppressor gene, TP53. Mutation carriers are at increased risk of multiple primary tumors, many of which arise in previous radiation-therapy sites. In patients with LFS, acute myeloid leukemia is uncommon and myelodysplastic syndrome (MDS) is rare. OBJECTIVE: To evaluate the morphologic, cytogenetic, and molecular diagnostic findings of 3 unique cases of MDS arising in patients with germline TP53 mutation, 2 with classic LFS. DESIGN: We searched the Li-Fraumeni Syndrome Registry in the Department of Genetics at the University of Texas M. D. Anderson Cancer Center (Houston, Texas) and identified 3 patients with documented germline TP53 mutations or LFS who had developed MDS during a period of 6 years (2000-2005). The clinical, cytogenetic, and molecular diagnostic data and bone marrow aspirate smears and biopsies on all patients were reviewed. Immunohistochemical staining with antibody to p53 was also performed. RESULTS: Two patients met the criteria for classic LFS; one had no history of malignancy in first-degree relatives. The MDS followed chemotherapy and radiation therapy and progressed to acute myeloid leukemia in 2 patients. Cytogenetic analysis demonstrated chromosome 5 abnormalities in a complex karyotype in all cases. Two patients died, one of acute myeloid leukemia and one with glioblastoma multiforme, MDS, and persistent pancytopenia. CONCLUSIONS: Patients with LFS may develop MDS, which is most likely therapy-related and is associated with cytogenetic markers of poor prognosis.

Angioimmunoblastic T-cell lymphoma in bone marrow: a morphologic and immunophenotypic study.

Angioimmunoblastic T-cell lymphoma is known to frequently involve bone marrow. However, the histologic and immunophenotypic features of angioimmunoblastic T-cell lymphoma at this site are poorly defined. We assessed 27 bone marrow specimens involved by angioimmunoblastic T-cell lymphoma from 20 patients. Histologically, bone marrow involvement was predominantly multifocal (74%) and exhibited a nodular pattern (78%), often associated with other patterns. Using immunohistochemistry, programed death-1 and CD10 were expressed by atypical lymphocytes in 17 (85%) of 20 and 5 (18.5%) of 27 specimens, respectively. CXCL13 was not expressed by atypical lymphocytes in all cases but did stain stromal cells consistent with follicular dendritic cells in 1 case. BCL-6 as a single antibody was difficult to interpret because many normal bone marrow cells are dimly positive, but BCL-6/CD3 dual staining highlighted BCL-6+ T-cells in all cases assessed. Antibodies specific for CD21 and CD35 did not highlight follicular dendritic cells in any biopsy specimens. Flow cytometry immunophenotyping revealed a CD3+CD10+ T-cell population in 2 (25%) of 8 cases assessed. We conclude that the recognition and classification of angioimmunoblastic T-cell lymphoma in bone marrow are made difficult by the uncommon expression of CD10 (25%), rarity of follicular dendritic cells, and lack of CXCL13 expression at this site. This is most likely attributable to the very different microenvironment of the bone marrow relative to lymph nodes and, in particular, the absence of follicles in bone marrow. By contrast, programed death-1 immunohistochemical staining and double labeling using antibodies specific for BCL-6 and CD3 were helpful in appreciating the follicular T-helper cell immunophenotype of angioimmunoblastic T-cell lymphoma.

Anaplastic large cell lymphoma involving the breast: a clinicopathologic study of 6 cases and review of the literature.

CONTEXT: Lymphomas involving the breast are rare, and most cases are of B-cell lineage; T-cell neoplasms represent less than 10% of all breast lymphomas. OBJECTIVE: To define the clinicopathologic spectrum of anaplastic large cell lymphomas (ALCLs) involving the breast. DESIGN: Six cases of ALCL involving the breast were identified at a single institution during 21 years. The clinicopathologic and immunophenotypic features are presented, and the literature is reviewed. RESULTS: All patients were women, with a median age of 52 years. There were 4 anaplastic lymphoma kinase- negative (ALK(-)) ALCL cases; 3 of these neoplasms developed around breast implants. Two patients with ALK(-) ALCL had a history of cutaneous ALCL. There were 2 ALK(+) ALCLs; both patients had stage IV disease. Histologically, all neoplasms were composed of large anaplastic cells that were uniformly CD30(+) and expressed markers of T-cell lineage. Four patients with adequate follow-up are alive, with a mean of 4.1 years (range, 1.5-9 years) after diagnosis of the breast tumor. Included in this group are 2 patients with ALK(-) ALCL associated with breast implants who were alive 4 years and 9 years after diagnosis. CONCLUSIONS: Including the 6 cases we describe, a total of 21 cases of ALCL involving the breast are reported. Fifteen cases, all ALK(-), were associated with breast implants, suggesting a possible pathogenetic relationship, and associated with an excellent prognosis. Patients with cutaneous ALCL can subsequently develop ALK(-) ALCL involving the breast, and these tumors can be associated with breast implants.

Embryonal rhabdomyosarcoma of the uterine cervix in a 41-year-old woman treated with radical hysterectomy and adjuvant chemotherapy.

BACKGROUND: Cervical embryonal rhabdomyosarcoma (ERMS) mostly affects young girls. The current treatment protocols are based on trials done on patients under 21 years old. ERMS in women over 40 is rare, and studies on treatment and outcome are limited. CASE: We report a case of a 41 year-old woman with cervical ERMS who was treated with radical hysterectomy followed by chemotherapy. She is currently disease-free. CONCLUSION: Cervical ERMS in women over the age of 40 can be treated using protocols established for the pediatric population.

Lymphomas involving the breast: a study of 106 cases comparing localized and disseminated neoplasms.

Lymphomas involving the breast account for approximately 2% of extranodal and <1% of all non-Hodgkin lymphomas. Our aim in this study was to classify breast lymphomas using the World Health Organization classification and then compare this classification with clinical, histologic, and radiologic findings as well as survival. The study group included 106 patients with breast lymphoma (105 women and 1 man). The neoplasms were divided into 2 groups based on extent of disease at initial diagnosis: localized disease (n=50) and disseminated disease (n=56). The follow-up period ranged from 4 to 252 months (median, 49 mo). Almost all (97%) patients presented with a palpable breast mass or masses. In the localized group, diffuse large B-cell lymphoma (DLBCL) was most frequent (n=32, 64%). In the disseminated group, follicular lymphoma was most frequent and exclusive to this group (P=0.0004). Mucosa-associated lymphoid tissue lymphomas occurred in both groups without a significant difference in frequency. A variety of other types of B-cell and T-cell non-Hodgkin lymphomas and classical Hodgkin lymphoma involved the breast at much lower frequency; most of these neoplasms involved the breast as part of disseminated disease. The clinical presentation correlated with radiologic findings: localized lymphomas presented as solitary masses, whereas disseminated lymphomas commonly presented as multifocal masses. There was a significant difference in the disease-free survival between patients with localized and disseminated DLBCL (P=0.003). In the disseminated group, patients with DLBCL had a worse disease-free survival compared with patients with mucosa-associated lymphoid tissue lymphoma or follicular lymphoma (P=0.01).

Multiple myeloma and immunosecretory disorders: an update.

The immunosecretory disorders are a diverse group of diseases associated with proliferation of an abnormal clone of immunoglobulin (Ig)-synthesizing, terminally differentiated B cells. These disorders include multiple myeloma (MM) and its variants, plasmacytoma, Waldenstrom macroglobulinemia, monoclonal gammopathy of undetermined significance, and monoclonal Ig deposition diseases, the latter including primary amyloidosis and nonamyloidotic types. These disorders are histologically composed of plasma cells, or plasmacytoid cells which produce Ig that is synthesized and usually secreted and can be deposited in some diseases. The Ig can be complete or can be composed of either heavy or light chains and is termed M-(monoclonal) protein. In MM, this proliferation overwhelms the normal cellular counterparts that synthesize and secrete appropriate levels of Ig. Immunosecretory disorders have been classified in multiple schemes, mostly morphologic, to such a degree that the classification of these entities has become a challenge to pathologists. The World Health Organization classification in 2001 was helpful because it provided specific clinicopathologic criteria for diagnosis. However, terms such as "progressive" disease were not well defined. In 2003, the International Myeloma Group defined MM as a disease with related organ and tissue injury, serving to better explain progressive in terms of deterioration of organ (renal, bone, and bone marrow) function over time. Therefore, modern classification of immunosecretory diseases is based on integration of clinical, morphologic, laboratory, radiographic, and biologic (including molecular) parameters, which we review here.

Ischemia modified albumin, a marker of acute ischemic events: a pilot study.

Ischemia modified albumin (IMA) is a relatively new marker for evaluating patients with cardiac ischemia. Data are emerging on its potential role in non-cardiac ischemic events. In this pilot study we evaluated the utility of IMA in diagnosing acute coronary syndromes (ACS), assessed its role in the diagnosis of non-cardiac ischemia, and correlated its efficacy with troponin T (TnT). Serum levels of IMA were measured in 89 sequential patients who presented to the emergency room with chest pain for which serum TnT was ordered. The patients were classified into 4 groups based on their IMA and TnT results and discharge diagnoses. The data were analyzed with Fischer's exact test. Multivariate logistic regression analysis relating acute coronary syndrome (ACS) to the combination of TnT and IMA was also performed. The results showed that IMA was a useful marker for the diagnosis of ACS. There was a significant relationship between TnT and IMA (p = 0.032), suggesting that both these biomarkers added significant information about the presence of ACS (p = 0.028) and may be useful for triage of patients who present to the emergency room with chest pain. Serum IMA was also increased in a small proportion of patients with symptoms of stroke, suggesting that it should be considered a marker of acute ischemic events and not specific for cardiac ischemia.

Pathologic evaluation of cryoprobe-assisted lumpectomy for breast cancer.

Cryoprobe-assisted lumpectomy is a relatively new technique that converts nonpalpable carcinomas into well-defined, palpable ones by creating an ice ball under ultrasonographic guidance, thus eliminating the need for preoperative needle localization. We evaluated the effect of cryoprobe-induced freezing on tumor tissue, peritumoral tissue, and margin status in 6 cases of cryoprobe-assisted lumpectomy performed for infiltrating ductal carcinoma. Immunohistochemical stains for estrogen and progesterone receptors and the proliferation marker Ki-67 were performed on 4 cases and results compared with those of the pretreatment biopsy specimens. Although it was possible to recognize the tumor as infiltrating carcinoma in all cases, the alteration in tumor morphology interfered with tumor grading, distinguishing in situ and invasive components, and assessment of mitoses and lymphovascular invasion. The expression of estrogen and progesterone receptors was greatly reduced, whereas the Ki-67 staining was not significantly different when compared with pretreatment biopsy specimens. The "cryoprobe effect" did not interfere with evaluation of the margins and surrounding breast tissue.

A case of primary unilateral adrenal Burkitt-like large cell lymphoma presenting as adrenal insufficiency.

Primary adrenal lymphoma is extraordinarily rare, in comparison with secondary adrenal involvement by non-Hodgkin lymphoma. Although higher-resolution imaging techniques have enhanced detection of adrenal masses, biopsy or excision is often needed for definitive diagnosis. Percutaneous computed tomography-guided fine needle aspiration has great diagnostic value in the workup of adrenal masses, but is limited by sampling error and artifacts. Primary adrenal lymphoma most commonly manifests with diffuse large B-cell morphology. Burkitt-like large cell lymphoma morphology has been previously reported only once, to our knowledge. We report an 80-year-old man presenting with unilateral primary adrenal lymphoma showing Burkitt-like morphology and adrenal insufficiency. Fine needle aspiration yielded a dispersed population of monomorphic, medium to large cells suggestive of lymphoma. Although dispersed cell populations cytologically favor lymphoma, metastatic poorly differentiated carcinoma and adrenal cortical carcinoma can manifest similarly. Integrated histological, immunohistochemical, and flow cytometric immunophenotyping would provide an accurate and definitive diagnosis. We review the literature and discuss important issues with regard to diagnosis.

MALT1 gene rearrangements and NF-kappaB activation involving p65 and p50 are absent or rare in primary MALT lymphomas of the breast.

Mucosa associated lymphoid tissue (MALT) lymphomas arising in the breast are uncommon and few cases have been assessed for MALT lymphoma-associated translocations, BCL-10 expression, or NF-kappaB activation. In this study, we analyzed eight cases of primary breast MALT lymphoma. We also included 14 cases of primary breast diffuse large B-cell lymphoma since some of these may represent transformation of MALT lymphoma, known to occur at extra-mammary MALT sites. All cases were assessed for MALT1 gene rearrangements by fluorescence in situ hybridization (FISH). Using immunohistochemical methods, all cases were assessed for BCL-10, and subsets were assessed for NF-kappaB p65 and p50. None of the cases had MALT1 gene rearrangements by FISH. Of eight MALT lymphomas, BCL-10 was positive in seven (88%), with moderate nuclear and cytoplasmic staining in six, and a weak cytoplasmic staining in one. NF-kappaB p65 (n=8) and p50 (n=5) were negative or showed only cytoplasmic staining (ie inactivated) in all cases. Of 14 diffuse large B-cell lymphoma cases, BCL-10 was positive in 12 (87%), with weak-to-moderate cytoplasmic staining in 10, weak cytoplasmic and focally nuclear staining in one, and a moderate-to-strong nuclear and cytoplasmic staining in one. NF-kappaB p65 (n=11) showed cytoplasmic staining in all cases, whereas p50 (n=8) showed nuclear positivity (ie activated) in two (25%) cases. We conclude that MALT1 gene rearrangements are absent or rare in primary breast MALT lymphoma and diffuse large B-cell lymphoma. In MALT lymphomas, the moderate BCL-10 nuclear expression in six neoplasms is inconsistent with the FISH results, suggesting that BCL-10 immunostaining overestimates the frequency of MALT1 gene rearrangements. We also could not demonstrate NF-kappaB activation using nuclear staining for p65 and p50. In contrast, breast diffuse large B-cell lymphomas are heterogeneous. Weak cytoplasmic BCL-10 staining in most cases and evidence of NF-kappaB p50 activation in a subset differs from breast MALT lymphomas.

Extra-adrenal myelolipoma in the renal hilum: a case report and review of the literature.

Myelolipoma most commonly arises in the adrenal gland. Extra-adrenal myelolipomas are rare; to our knowledge, approximately 37 previous cases have been reported. We report a myelolipoma presenting as a localized mass in perirenal adipose tissue juxtaposed to the renal hilum in a 65-year-old Caucasian man who presented with back pain, weight loss, hematuria, and flank pain. The most likely diagnostic considerations were pyelonephritis or primary renal malignancy. However, histology revealed mainly mature adipose tissue along with multiple scattered islands of hematopoietic precursor cells. Representation of all the three hematopoietic cell lineages (granulocytic, erythroid, and megakaryocytic) was present. Perirenal masses such as morphologically identified myelolipomas are rarely, if ever, considered in differential diagnosis. The purpose of this report is to elicit consideration of extra-adrenal myelolipoma when formulating a differential diagnosis for perirenal and retroperitoneal tumors. Although primary and secondary malignant retroperitoneal tumors are much more common and aggressive neoplasms, establishing the correct diagnosis has important therapeutic and prognostic implications.

Plasmodium DNA fluoresces with berberine: a novel approach for diagnosis of malarial parasites.

The key to reducing mortality and morbidity associated with malaria is rapid diagnosis and early, effective therapy. Berberine, a plant alkaloid, has been used for fluorescent staining of the Y chromosome. We evaluated whether berberine can be used for staining of malarial parasites in 40 selected peripheral blood smears from patients with clinical symptoms of malaria; smears were evaluated with OptiMal (DiaMed, Miami, FL) and Giemsa stain. Twenty were positive with both OptiMal and Giemsa (Plasmodium vivax, 14; Plasmodium falciparum, 6); 10 were negative with both. The remainder were positive by OptiMal but negative by Giemsa and, therefore, were classified as equivocal. All slides were processed simultaneously, stained with berberine, and read under a fluorescent microscope. P vivax and P falciparum DNA fluoresced with berberine. The positives and negatives by berberine concurred with the Giemsa staining. Of the 10 equivocal smears, 5 were confirmed positive by berberine. Gametocytes were easily identifiable. This test has high sensitivity and high positive predictive value and, once standardized, can be used as a potential screening and diagnostic tool.

Case report: atypical presentation of anti-Rg(a).

The Rodgers (Rg(a)) antigen is a plasma protein that binds to the red blood cell (RBC) membrane. About 2 to 3% of the transfusion-recipient white population lacks the antigen and can produce anti-Rg(a) antibody. We report the case of a 70-yr-old man who presented with a medical history of hairy cell leukemia and profound pancytopenia that required RBC and platelet (PLT) transfusions. The patient had received 2 units of RBCs and 4 PLT concentrate pools. He was typed as O Rh(D) positive, with positive reactions in all 3-screen cells using the polyethylene glycol (PEG) indirect antiglobulin test/IAT (anti-IgG). Three antibody identification panels were performed, which all proved to be negative. A direct antiglobulin test and an auto-control were run, which were also negative. Since further investigations were needed, the patient's blood sample was sent to a reference laboratory where anti-Rg(a) was identified. Since the percentage of antigen-positive cells in the red cell panel was low, crossmatch compatible units of RBCs were transfused with no discernible immediate or delayed transfusion reaction. This report should alert hospital transfusion service personnel to recognize that, although the panel cells are usually reliable for antibody identification purposes, they may not have the antigens that are present on the screening cells.

Acute lymphoblastic leukemic transformation in a patient with chronic idiopathic myelofibrosis and paroxysmal nocturnal hemoglobinuria: a case report and review of the literature.

Leukemic transformation of chronic idiopathic myelofibrosis (CIMF) to acute lymphoblastic leukemia (ALL) is rare. We report a case of a patient with CIMF who developed paroxysmal nocturnal hemoglobinuria (PNH) 2 years after initial presentation. His disease eventually transformed to ALL of precursor B-cell type. In that CIMF and PNH are clonal stem cell disorders with different pathogeneses, there may be an association between them. However, leukemic transformation is a rare sequel of both disorders. Coexistence of CIMF and PNH and subsequent transformation to ALL have, to our knowledge, never been previously reported in the world literature. The simultaneous presentation of CIMF and PNH, complicated by the rare sequela of leukemic transformation, raises important issues with regard to diagnosis and treatment.