Pathogenesis, prevalence, and prognostic significance of cytopenias in chronic lymphocytic leukemia (CLL): a retrospective comparative study of 213 patients from a national CLL database of 1,518 cases.

Utilizing the database of the Israeli CLL Study Group, we investigated the prevalence and prognostic significance of anemia and thrombocytopenia in patients with chronic lymphocytic leukemia (CLL). Of 1,477 patients, 113 had anemia and thrombocytopenia associated with "infiltrative" marrow failure, median survival of 41 and 86 months, respectively. Autoimmune cytopenias were diagnosed in 100 patients, autoimmune hemolytic anemia (AIHA) in 80, and immune thrombocytopenia (ITP) in 31, while 11 had both co-existent. Median survival of patients with AIHA and ITP, from CLL diagnosis, was 96 and 137 months, respectively, but 29 and 75 months from onset of cytopenia. Patients with AIHA from the time of CLL diagnosis had a significantly shorter survival than those without anemia (p < .0001). Survival was similar for patients with AIHA or anemia due to "infiltrative" bone marrow failure (p = .44). The presence of positive antiglobulin test even without hemolysis was associated with worse outcome. Overall survival of patients with ITP and those without cytopenias (p = 0.94) were similar. In conclusion, laboratory or clinical evidence of AIHA has a significant negative impact on the survival of patients with CLL. Outcome for cases with ITP and patients without cytopenias was similar.

Cell surface expression of CD25 antigen (surface IL-2 receptor α-chain) is not a prognostic marker in chronic lymphocytic leukemia: results of a retrospective study of 281 patients.

Using the database of the Israeli CLL Study Group, we investigated the incidence and prognostic significance of CD25 expression on the surface of lymphocytic leukemia cells. Strong CD25 expression was found in 46 (16.4 %) of 281 tested cases and was correlated with the presence of splenomegaly (p = 0.04), expression of CD38 antigen (p = 0.001), and FMC-7 (p = 0.04). Age, gender, Binet stage, circulating lymphocyte count, presence of anemia or thrombocytopenia, atypical cell morphology, serum beta 2-microglobulin level, and ZAP-70 expression did not differ in patients with or without cell surface CD25. There was no correlation between CD25 expression and time to first treatment or overall survival. CD25 expression does not appear to be a prognostic factor in CLL.

Survival trends among 1,325 patients with chronic lymphocytic leukemia seen over the past 40 years in Israel.

In the light of recent data showing survival improvement of patients with chronic lymphocytic leukemia (CLL), we investigated clinical characteristics and survival patterns of patients with CLL over the last 40 years in Israel. Demographic and clinical data collected in the database of the Israeli CLL Study Group were analyzed. Of the 1,325 patients, 221 were diagnosed during the time period 1968-1989, 456 during 1990-1999, and 639 during 2000-2010. There was shift toward older age (median, 71 vs. 68 vs. 66 years) and a higher proportion of patients at Binet stage A at diagnosis (77.6% vs. 66.7% vs. 60.3%) in the more recent time periods. Median survival for the entire cohort was 10.9 years; 12.2 years for patients diagnosed at Binet stage A, 8.5 years for stage B, and 6.4 years for stage C patients. Older age, high-beta 2-microglobulin level, and expression of ZAP-70 predicted shorter survival. There were no apparent changes over time regarding gender, age or different clinical stages. Young patients with Binet stage A had lower life expectancy than the general population; but, in older ages, the survival rates were comparable. There were increased proportions of CLL patients diagnosed in early stages, and, at older age, during the last decades, however, survival rates according to sex, age, or stage remained stable. CLL continues to be an incurable disease affecting survival even in patients diagnosed at early stages. Survival benefit shown in recent trials using chemoimmunotherapy has still to be proven in wider general practice.

Clinical significance of serologic markers related to red blood cell autoantibodies production after red blood cell transfusion-severe autoimmune hemolytic anemia occurring after transfusion and alloimmunization: successful treatment with rituximab.

BACKGROUND: The association of autoantibody formation with blood transfusion was previously noted. Severe autoimmune hemolytic anemia (AIHA) diagnosed after red blood cell (RBC) transfusion determined us to undertake this study and investigate the incidence and clinical significance of autoantibodies occurring after transfusion by a retrospective review of blood bank and medical records. STUDY DESIGN AND METHODS: We report a lymphoma patient who developed severe autohemolysis after blood transfusion and alloantibody production. The hemolysis was refractory to steroids and chemotherapy and ceased after rituximab. We also retrospectively assessed the blood bank records for a 2-year period to identify the patients who developed autoantibodies after blood transfusion and examined laboratory, clinical features, and outcome. RESULTS: From January 2005 through December 2006, 375 direct antiglobulin tests (DATs) and 3409 indirect antiglobulin tests (IATs) were found to be positive. Thirty-eight patients with positive DATs and IATs had demonstrable RBC warm-type autoantibodies occurring after blood transfusion; 27 of them had also one or more alloantibodies. Clinical and laboratory signs of hemolysis were absent in all patients (except the case reported). In another 5 patients alloantibodies were retrieved from RBC eluate and serum without evidence of autoantibodies; therefore, a delayed serologic transfusion reaction was diagnosed. CONCLUSION: RBC autoantibodies are quite commonly found after blood transfusion. Nevertheless, clinically significant AIHA is a rare but at times a life-threatening phenomenon. We describe a first case of successful treatment with rituximab of refractory posttransfusion AIHA. Rituximab must be further evaluated for this indication.

Post-transfusion purpura: a challenging diagnosis.

BACKGROUND: Post-transfusion purpura is a rare syndrome characterized by severe thrombocytopenia and bleeding caused by alloimunization to human platelet specific antigens following a blood component transfusion. The suggested incidence is 1:50,000-100,000 transfusions, most often occurring in multiparous women. The diagnosis is not easy because these patients, who are often critically ill or post-surgery, have alternative explanations for thrombocytopenia such as infection, drugs, etc. OBJECTIVES: To describe patients with initially misdiagnosed PTP and to emphasize the diagnostic pitfalls of this disorder. PATIENTS AND RESULTS: During a period of 11 years we diagnosed six patients with PTP, four women and two men. The incidence of PTP was approximately 1:24,000 blood components transfused. We present the detailed clinical course of three of the six patients in whom the diagnosis was particularly challenging. The patients were initially misdiagnosed as having heparin-induced thrombocytopenia, systemic lupus erythematosus complicated by autoimmune thrombocytopenia, and disseminated intravascular coagulation. A history of recent blood transfusion raised the suspicion of PTP and the diagnosis was confirmed by appropriate laboratory workup. CONCLUSIONS: PTP seems to be more frequent than previously described. The diagnosis should be considered in the evaluation of life-threatening thrombocytopenia in both men and women with a recent history of blood transfusion.

HTLV-1 associated adult T-cell leukemia/lymphoma in Israel: report of two patients of Romanian origin.

Human T-lymphotropic virus type 1 (HTLV-1) was the first human oncovirus isolated by Gallo et al. in 1980 and established as an etiological agent for adult T-cell leukemia/ lymphoma (ATL). Although more than 15 million individuals are infected by HTLV-1 through the world, the spread of the virus is highly endemic. The HTLV-1 infection is prevailing in southwestern Japan, inter-tropical Africa, Central and South America. In Kyushu district, Japan, the seroprevalence reaches >30% in the adult population. In the US, Europe and the Middle East the HTLV-1 infection is very rare, and cases of ATL have been reported sporadically. We describe here acute ATL in two patients of Jewish- Romanian origin. The epidemiological anamnesis and screening indicate that both patients acquired the HTLV-1 from their mothers leaving in Romania.

Cytokine release by activated T-cells in large granular lymphocytic leukemia associated with autoimmune disorders.

INTRODUCTION: Patients with T-cell large granular lymphocytic leukemia (T-LGLL) have a high incidence of autoimmune disorders. The pathogenesis of associated T-LGLL and autoimmune abnormalities is not clear. In this study we have investigated the role of cytokines in the development of immune complications in LGLL. PATIENTS AND METHODS: We studied clinical and laboratory features of 15 patients diagnosed with T-LGLL. The patients had various autoimmune disturbances: persistent neutropenia, immune thrombocytopenia, pure red-cell aplasia, Hashimoto's thyroiditis, sicca syndrome, systemic lupus erythemathosus, systemic scleroderma. The T-LGLL cells obtained from these patients were activated by phytohemagglutinin and incubated for 3 days. Using ELISA technique we analysed the release of sIL-2R, IL-4, IL-6, IL-8, IL-10, IL-12 and TNF-alpha in the supernatant. RESULTS: Cytokine analysis of supernatants obtained from the LGLL T cells stimulated with PHA revealed increased sIL-2R production in 40% (six patients), TNF-alpha - in 47% (seven patients), IL-6 - in 67% (10 patients), IL-10 - in 47% (seven) and IL-8 - in 60% (nine) of patients. Levels of IL-4 and IL-12 were not elevated compared to controls. No correlation was found between LGL count, CD4 versus CD8 expansion, or in the clinical findings of the patients and cytokine release in vitro. CONCLUSION: Our findings showing the potential of LGLL cells for cytokine release in vitro suggests that these cells may play a major role in the immune disturbances observed in large granular lymphocytic leukemia accompanied by autoimmunity features.

Polyclonal reactive peripheral blood plasmacytosis mimicking plasma cell leukemia in a patient with Staphylococcal sepsis.

A 41-year-old man presented with rhabdomyolysis and sepsis while the peripheral blood smear showed a pseudo-leukemic picture of plasma cells. After starting supportive therapy, the morphologic finding disappeared within 24 h.

Conventional dose fludarabine-based regimens are effective but have excessive toxicity in elderly patients with refractory chronic lymphocytic leukemia.

The best approach to elderly patients with relapsing chronic lymphocytic leukemia (CLL) or disease refractory to conventional therapy with alkylating agents has not yet been established. Fludarabine and its combination with mitoxantrone and/or cyclophosphamide, which is the most effective treatment in younger patients, has not been extensively utilized in the elderly CLL. Here we report our results with fludarabine-based chemotherapy in 32 previously treated patients over the age of 65 years. The overall response rate was 59% with no complete remission, 3 nodular partial remissions and 16 partial remissions. The median time to progression of disease was 7 months. Only 10 patients completed the entire treatment program, because of poor compliance due to toxicity. Eight patients developed neutropenic fever, 14 severe bacterial infections and 2 patients showed progressive encephalopathy. For comparison, in a younger group of patients with refractory CLL (< 65 years), 38 of 50 patients completed the treatment plan, and the ORR was 80% (10 CR, 11 PR-nodular, 19 PR) with a median response of 12 months. Neutropenic fever was diagnosed in 10 and severe bacterial infection in 4 patients. In conclusion, fludarabine-based chemotherapy is effective for refractory CLL, however, excessive toxicity such as severe infections and neurological complications, do not allow completion of treatment in the majority of the elderly patients. Because maintenance of a good quality of life should be the main goal in the elderly CLL population, dose reduction of fludarabine and the appropriate use of myeloid growth factors and prophylactic antibiotics appear mandatory in this group of patients.

Can a rare form of myasthenia gravis shed additional light on disease mechanisms?

A healthy 43-year-old physician developed gradually progressive and fluctuating fatigable muscle weakness involving ocular, limb, bulbar and respiratory muscles, with episodic acute respiratory failure, eventually necessitating intermittent non-invasive respiratory support (NIV). A mild short episode occurred 15 years earlier with complete resolution. Electromyography (EMG) studies and acetylcholine receptor (AchR) antibodies were repeatedly non-diagnostic. The diagnosis of myasthenia gravis (MG) was finally confirmed by direct measurement of diaphragmatic strength using magnetic nerve stimulation providing clear cut evidence of significant fatigable weakness and the demonstration of muscle-specific kinase (MuSK) serum antibodies using a novel cell-based assay. The cluster of several atypical features and lack of response to commonly used treatment modalities prompted a search for a unifying mechanism and better understanding of the underlying pathophysiology. Review of the literature suggested a possible impairment of excitation-contraction coupling with malfunction of a signaling protein downstream to the AchR, without an accompanying impairment of electrical transmission. This postulated mechanism, resulting in a disturbance of calcium signaling, explained the unusual features in this patient's illness and led to treatment with salbutamol and ephedrine and to significant symptomatic improvement not achieved by any other treatment.

Vincristine-loaded platelet infusion for treatment of refractory autoimmune hemolytic anemia and chronic immune thrombocytopenia: rethinking old cures.

We report our experience with vincristine-loaded platelet infusion in patients with refractory immune thrombocytopenia (ITP), autoimmune hemolytic anemia (AIHA), and Evans syndrome. Ten patients with symptomatic thrombocytopenia and/ or hemolytic anemia who failed to respond to two to six different treatment modalities, including corticosteroids and splenectomy, were treated with infusion of vincristine-loaded platelets. Platelets were harvested by plateletpheresis from a healthy ABO compatible blood donor and incubated with 5 mg vincristine. Excess of vincristine was removed, and platelets were resuspended in 50 ml plasma and infused over 30 min. All 10 patients responded, and 6 of them achieved complete remission. The response was prompt, occurring 3-8 days after vincristine-loaded platelet infusion. Two patients with AIHA are still in remission 9 and 8 years posttreatment with no maintenance treatment. Three ITP patients achieved persisted partial response for 6 years, 5 years, and 11 months; in the remaining 5 patients the response lasted for 2-5 months. No side effects were seen. Our results suggest that this inexpensive and well-tolerated treatment modality may be a useful approach in patients with ITP and AIHA refractory to primary therapy.

New sporadic case of congenital dyserythropoietic anemia type III in an aged woman: detailed description of ultrastructural findings.

We describe a new case of congenital dyserythropoietic anemia (CDA) type III. This least common type of CDA was diagnosed at the age of 59 in a 70-year-old woman who suffered from a young age from mild macrocytic anemia, while the long follow up since diagnosis documented a benign clinical course. No family history of blood diseases was obtained and no anemia was documented in the medical records of any of her four children. The bone marrow (BM) examination on light microscopy revealed a severe erythroid hyperplasia with the presence of giant multinucleated erythroblasts. Ultrastructural examination of the BM disclosed the presence of many large multinucleated erythroblasts bearing a variety of ultrastructural findings: nuclear clefts, autophagic vacuoles, iron-loaded mitochondria, and intracytoplasmic myelin figures. In addition, extensive hyperlobulation of the nucleus and partial loss of nuclear membrane with "spilling" of nuclear material to the adjacent cytoplasm was also noted in some of the erythroblasts. These last two findings have not been previously described in CDA III.

Acute basophilic leukaemia: eight unsuspected new cases diagnosed by electron microscopy.

We report eight new patients with de novo acute basophilic leukaemia (ABL) diagnosed by electron microscopy (EM) in 184 patients with poorly differentiated AML who were selected for ultrastructural analysis between the years 1989 and 2002. Morphology by light microscopy, cytochemistry, immunophenotyping and cytogenetics did not enable an accurate diagnosis in any of these patients. In almost all the patients, the blasts showed reactivity for HLA-DR and CD34. EM studies demonstrated the presence of basophilic granules in the leukaemic blasts. These granules were membrane bound and their contents varied in appearance from uniformly electron dense to partially speckled or electron lucent. Theta granules were present in only three patients and no mast-cell type granules were observed. By light microscopy, the myeloperoxidase reaction was positive in three patients in an unusual coarse granular pattern. Ultrastructural demonstration of peroxidase in the granules, nuclear membrane and profiles of endoplasmic reticulum was observed in all eight patients. The reaction in the granules showed a particular speckled pattern. The outcome was unfavourable in six of our eight patients. As a definitive diagnosis of ABL may be made only by EM, we suggest including such studies as an integral part of the diagnostic work-up of acute leukaemia cases that lack differentiation markers.

T-gamma large granular lymphocyte leukemia associated with amegakaryocytic thrombocytopenic purpura, Sjögren's syndrome, and polyglandular autoimmune syndrome type II, with subsequent development of pure red cell aplasia.

We present a female patient with T-gamma LGL leukemia, who was followed for the last 20 years. Over these years she developed several autoimmune disorders, including Sjögren's syndrome, Hashimoto's thyroiditis, premature ovarian failure (compatible with type II autoimmune polyglandular syndrome), amegakaryocytic thrombocytopenic purpura, and finally pure red cell aplasia. PCR analysis confirmed rearrangement for TCR gamma. This case emphasizes the complex association of LGL leukemia with autoimmune disorders.