[Diagnosis of cryptococcal encephalitis in a patient with mature B-cell lymphoblastic leukemia].

Fungal meningoencephalitides are one of the most menacing infectious complications in hematologic cancer patients in the presence of myelotoxic agranulocytosis. Due to diagnostic difficulties, mortality in these cases can be as high as 100%. The causative agent of cryptococcosis is Cryptococcus neoformans; damage to the brain arachnoid membranes and substance is diagnosed in 70-90% of cases. Unlike bacterial meningitis, the meningeal symptoms typical of cryptococcal meningoencephalitis are not characteristic. The paper gives a case of successful treatment for cryptococcal meningoencephalitis in the presence of agranulocytosis, the diagnosis of which is based on the detection of abnormal MR signal foci by magnetic resonance imaging and identification of the cryptococcal antigen-glucuronoxylomannan in spinal fluid.

[Early computed tomography signs in diagnosis of some pulmonary mycoses in myelotoxic agranulocytosis].

AIM: To characterize minimal CT signs of initial pulmonary lesion in candidomycosis and invasive aspergillesis of the lungs. MATERIAL AND METHODS: A multislice computer tomograph Light Speed+ (GE) was used to examine 67 patients with hematological malignancy in the condition of myelotoxic agranulocytosis (MTA). A CT picture considered as early presentation of fungal lesion of the lungs was seen in 25 (37%) of 67 patients. This diagnosis was made basing on the symptom of bronchiolyte manifesting roentgenologically as a "tree in the kidneys". RESULTS: Eleven (16%) patients in the condition of MTA for 5-7 days had clinical pulmonary symptoms accompanied with fungal lesion of the upper respiratory tract and a positive reaction to mannan, a candida antigen, signs of diffuse bronchiolyte. In 14 (21%) patients bronchiolyte symptom was detected in some lobules or segments on MTA day 5-12 and was not associated with pulmonary symptoms and an elevated level of Aspergillus antigen - galactomannan in the blood. A "halo" symptom accompanied with a high concentration of Aspergillus antigen was found in 7 (10%) patients untreated with antifungal drugs at the site of local bronchiolitis. CONCLUSION: A principal differential-diagnostic sign of bronchiolytis in candidomycosis and aspergillesis of the lungs as shown by multislice computed tomography and high resolution computed tomography is the pattern of its distribution. In candidomycosis bronchiolytis is subtotal or total, with small amount of liquid (> 100 ml) in the pleural cavities (37% cases). Invasive aspergillesis of the lungs is characterized by lobular or segmental bronchiolitis.

[Efficacy of different chemotherapy programs, indications for surgery and radiotherapy in primary mediastinal B-cell lymphosarcoma].

AIM: To evaluate efficacy of treatment of primary mediastinal B-cell lymphosarcoma (PMBLS). MATERIAL AND METHODS: Fifty nine patients with PMBLD were divided into three groups. Group 1 (n = 15) received 8 courses of CHOP, prevention of neuroleukemia and radiotherapy (RT). Group 2 (n = 8)--4 courses of ProMACE-CytaBOM or 1 course of MACOP-B, prevention of neuroleukemia and RT. Group 3 (n = 36)--2 courses of CHOP and 2-3 courses of ESHAP or 3 courses of DexaBEAM, surgical removal of residual mediastinal tumor (RMT), RT. RESULTS: The number of complete remissions in group 1 and 2 was the same (26 and 25%, respectively). Overall 5-year and event-free survivals in groups 1 and 2 were 52 +/- 5 and 13 +/- 5; 62 +/- 5 and 38 +/- 8%, respectively. In group 3 a complete remission was observed in 89% patients (p = 0.01), overall 5-year and event-free survival reached 88 +/- 8 and 85 +/- 7%, respectively. Removal of RMT in time of tumor size stabilization and partial remission (in 12 of 15 cases) led to a complete remission but in progression of the disease (in 3 cases) appeared ineffective. RT resulted in complete remission in 39 of 53 cases, stabilization of tumor growth was in 3 cases, progression--in 10, recurrence--in 1. RT was ineffective in all 4 cases of partial remission. RT use in stabilization of tumor size induced complete remission only in 1 of 7 cases. CONCLUSION: CHOP program is ineffective in PMBLS. Program ProMACE-CytaBOM or MACOP-B is insignificantly more effective than CHOP. Combined therapy is most effective. Surgery is justified in partial remission and tumor growth arrest. RT is indicated in complete remission to achieve its consolidation.

[Gamma-scintigraphy with Ga-67 citrate in differential diagnosis of residual tumors in lymphogranulomatosis and lymphosarcoma].

AIM: To study informative and diagnostic efficacy of quantitative evaluation of the results of gamma-scintigraphy in patients with lymphogranulomatosis and lymphosarcoma with prevalent mediastinal and pulmonary lesions. MATERIAL AND METHODS: 100 patients with verified lymphogranulematosis were studied: 67 with lymphosarcoma and 33 with mediastinal involvement. The mediastinal tumor monitoring was made before therapy, in complete clinicohematological remission, in progression using a complex of radio-, clinicohematological, histomorphological and radionuclide methods. RESULTS: A comparative analysis of the findings of radiation, radionuclide and histomorphological examinations of the removed residual mediastinal tumor in 10 patients showed that scintigraphic evidence was similar to that of histological findings in most of the examinees. CONCLUSION: A high diagnostic efficacy of a complex of radiation and radionuclide methods with Ga-67 citrate based on estimation of accumulation intensity providing comprehensive information about mediastinal tumor is demonstrated. A comparative analysis was made of the results of radiation, radionuclide and histomorphological examinations of the removed residual lesion of the mediastinum in 10 patients. In most cases, scintigraphic findings coincided with the results of histological studies of biopsies of mediastinal residual lesion.

[Invasive pulmonary aspergillesis].

AIM: To evaluate the results of therapy of invasive pulmonary aspergillesis (IPA) in one medical center from 2000 to 2005. MATERIAL AND METHODS: Diagnosis of IPA was made according to the International criteria. Incidence of verified IPA was 2%, probable--84%, possible--14%. RESULTS: IPA was diagnosed in 50 cases in 49 patients aged 16- 78 years, median 35. Most of the patients consisted of acute leukemia cases (54%). Intensive cytostatic therapy was given in 41% cases. In 54% IPA developed in critical neutropenia, median of duration of which being 29 days (3 to 144 days). 29 patients received glucocorticoid drugs. In diagnosis of IPA Aspergillus spp was isolated in 46% cases (A. fumigatus-59%, A. flavus-29%, A. niger-4%, A-versicolor-4%, in 1 (4%) case identification was not made. Positive antigen Aspergillus was detected in 27 cases. All the patients had pulmonary involvement detected at x-ray or computed tomography. Coincidence of pulmonary lesions seen at x-rays and computer tomograms was only in 30% patients. Cure was achieved in 44%, lethality was 56%. Overall survival in IPA for 90 days was 47%. Amphotericine was effective in 29%. Voriconasol--in 3 of 5 patients, kaspofungin--in 3 of 7. Surgical treatment was given to 4 patients. CONCLUSION: Lethality in IPA for 5 years when basic therapy was amfotericin B reached 56%. Reduction of lethality can be achieved due to early diagnosis of the infection and administration of voriconasol at the initial stage of IPA. It is necessary to conduct multicenter studies to ascertain indications for combined antifungal therapy.

[Potentialities of high-resolution computed tomography in diagnosis of pulmonary lesions after bone marrow transplantation in blood diseases]. / Vozmozhnosti komp'iuternoi tomografii vysokogo razresheniia v diagnostike porazhenii legkikh posle transplantatsii kostnogo mozga pri zabolevaniiakh sistemy krovi.

AIM: To study characteristics of a skialogical picture of pulmonary parenchyma and roentgenomorphological signs of inflammatory changes before and after bone marrow transplantation (BMT); relationship between the data of high-resolution computed tomography (HRCT) and clinical data. MATERIAL AND METHODS: HRCT (computer tomograph of the third generation "Somatom CR-3") was made in fever, changes in physical examination in patients (n = 28) after BMT from November 2001 to January 2003. BMT was made in myelomic disease, lymphogranulomatosis, acute leukemia, chronic myeloid leukemia, lymphosarcoma, autoimmune hemolytic anemia. RESULTS: Twenty four patients were examined before BMT. Of them, 18 patients had roentgenomorphological changes of the parenchyma, primarily, diffuse. Three patients were examined during conditioning, two cases had signs of toxic pulmonitis. One day after allo-BMT all the patients exhibited lowering of densitometric values of pulmonary tissue by 70 HU vs the baseline. Infectious affection of the lungs was diagnosed in 13 cases during day 0-100. From day 100 after allo-BMT 7 recipients were observed. In 6 cases the changes resulted from transplant against host reaction. Infectious affection of pulmonary tissue was observed in 1 case. Characteristic x-ray picture of pulmonary stroma in secondary disease was determined. CONCLUSION: For early diagnosis of pneumonia in myelotoxic agranulocytosis it is necessary to make examination by HRCT before BMT. HRCT of the chest is indicated in even minor changes in the clinical picture. It is necessary to perform a control over water-electrolyte balance and active respiratory exercise in the course of conditioning. Viral pneumonias show the picture of metainflammatory changes for a long time. Fungal pneumonias tend to recurrence at "previous site". HRCT examination of the pulmonary tissue provides more information about pulmonary tissue in patients with secondary disease.

[Invasive aspergillosis in immunocompromised patients]. / Invazivnyi aspergillez u immunokomprometirovannykh bol'nykh.

AIM: To analyse results of treatment of invasive aspergillesis in immunocompromised patients for 2000-2002. MATERIAL AND METHODS: The study was made of patients who, when treated with antibiotics, exhibited foci in the lungs typical for invasive aspergillesis. Aspergillas were detected in the sputum, bronchoalveolar lavage, bronchial wash-ups, aspergilla antigen (galactomannan) was detected in the blood. RESULTS: Invasive aspergillesis was diagnosed in 25 patients. 13 (52%) patients were treated with adjuvant glucocorticoids. 19 (76%) patients had neutropenia. All the patients had fever. Foci in the lungs were in 24 patients. Aspergillas were detected in 15 patients, a positive antigen galactomannan in 7 patients. A. Fumigatus, A flavus, A. Niger occurred in 67, 26.5 and 6.5% patients, respectively. All the patients received amphotericin B (median of the treatment reached 38 days, total dose 880-3500 mg). In 5 patients amphotericin B was replaced for liposomal amphotericin B because of high creatinine. 7 patients continued with itraconasol in a dose 400-600 mg/day. The foci were removed in 3 patients. The cure was achieved in 12 patients, 13 patients, 13 patients died (cause of death--respiratory insufficiency). CONCLUSION: Lethality in invasive aspergillesis in immunocompromised patients remains high--52%. Cultural detection of mycelial fungi was, as a rule, delayed. Early diagnosis of the disease requires monitoring of the aspergilla antigen in the blood and computer tomography of the chest especially in fever persisting in the treatment of wide-spectrum antibiotics.

[Opportunities of delayed densitometry of "late (fixed) contrast" as a test for tumors in residual mediastinal lesion in primary mediastinal lymphosarcoma after polychemotherapy]. / Vozmozhnosti sposoba otsrochennoi densitometrii "pozdnego (fiksirovannogo) kontrasta", primeniaemogo v kachestve testa opukholi v ostatochnom obrazovanii sredosteniia pri pervichnykh mediastinal'nykh limfosarkomakh posle okonchaniia polikhimioterapii.

AIM: To clarify the potential of delayed densitometry of late (fixed) contrast in differentiation between tumor and fibrosis in residual mediastinal lesion (RML). MATERIAL AND METHODS: Computed tomography (computed tomograph of the third generation COMATOM CR-3 made in Germany, SIEMENS) has examined 12 patients with mediastinal lymphosarcomas after polychemotherapy. All of them had a RML 3 to 6 cm in diameter. RESULTS: CT has detected 8 cases of the tumor and 4 cases of fibrosis. The criteria of the tumor were the following: increased RML density shortly after the contrast medium introduction and 30 min after urographine introduction (p < 0.01); RML density 30 min after introduction of contrast medium was higher than above the aorta (p < 0.01). Fibrosis in RML was stated if RML density before, at the high of concentration and after introduction of the contrast medium was the same (p > 0.01); aortic density was significantly higher of RML density at the height of the contrast (p < 0.01). CONCLUSION: The above method differentiates the tumor with fibrosis in RML with maximal probability. This facilitates further choice of therapeutic policy in secondary resistant form of primary mediastinal lymphosarcoma.

[Diagnosis of pulmonary lesions in acute respiratory insufficiency in patients with depressed hemopoiesis]. / Porazheniia lëgkikh pri ostroi dykhatel'noi nedostatochnosti u bol'nykh s depressiiami krovetvoreniia.

AIM: To analyse causes of acute respiratory failure (ARF) and methods of diagnosis of pulmonary lesions in patients with depressed hemopoiesis (DH). MATERIAL AND METHODS: 50 patients with DH and ARF were examined according to the protocol including x-ray, computed tomography, fibrobronchoscopy with bronchoalveolar lavage, cytological, bacteriological, virusological studies of the lavage fluid, biopsy of the lung. The algorithm of the protocol is provided. RESULTS: Sensitivity of the lavage fluid in diagnosis of fungal, bacterial, pneumocystic and cytomegaloviral infections was 84, 78, 93 and 93%, respectively. The cytologic examination of the lavage fluid may detect lung infiltration with blood tumors. In complicated diagnostic cases lung biopsy verified pulmonary lesion but its conduction aggravated the patients' condition. ARF patients with DH, bacterial flora, fungi, cytomegalovirus and pneumocystic infection, pulmonary tumor involvement, pulmonary lesions in ATRA-syndrome, non-infectious lesions of the lungs after bone marrow transplantation were found in 38, 18, 40, 18, 8 and 4% of cases, respectively. CONCLUSION: DH patients with ARF should be examined by the protocol including both non-invasive and invasive diagnostic methods. Accurate diagnosis of ARF causes is the basic reserve in the treatment of such patients.

[Preoperative embolization of the splenic artery in patients with blood system diseases]. / Predoperatsionnaia émbolizatsiia selezenochnoi arterii u bol'nykh s zabolevaniiami sistemy krovi.

AIM: To develop and introduce X-ray endovascular preocclusion of the splenic artery in general surgical patients with different forms of cytopenias as preparation for further surgical treatment. MATERIALS AND METHODS: Data on 12 splenic arterial occlusions in patients with different diseases of the blood system. RESULTS: Despite the severity of the underlying process, the use of X-ray endovascular preocclusion of the splenic artery in patients with different hematological diseases made it possible to make the so-called bloodless splenectomy on short notice, then a required cavitary operation or in the immediate postembolization period if there were emergency indications or some time later if the patient's status allowed. CONCLUSION: When patients with blood system diseases attended by thrombocytopenia, anemia, leukopenia are indicated to have surgical treatment of some contaminant diseases, it is necessary to perform X-ray endovascular splenic arterial occlusion at the first stage, then make a major intervention when blood parameters have improved.

[Clinical manifestations, diagnosis and course of Pneumocystis carinii pneumonia in patients with hematologic diseases]. / Klinicheskie proiavleniia, diagnostika i techenie pnevmotsistnoi pnevmonii u bol'nykh s zabolevaniiami sistemy krovi.

AIM: To characterize clinical, diagnostic and course features of pneumonia caused by Pneumocystis carinii (PC) in hematologic inpatients. MATERIALS AND METHODS: 27 patients with blood diseases were studied. 22 of them had acute respiratory insufficiency and 5 had unclear lung affection. The data from bronchoalveolar lavage (BAL), lung biopsy, serum tests for IgG, IgM anti-PC-antibodies were used for diagnosis of PC-pneumonia. RESULTS: PC-pneumonia was diagnosed in 8 of 27 patients. Clinical manifestations characteristic for PC-pneumonia were not found. In 5 patients the diagnosis was made on the evidence provided by BAL. Lymphocyte count in BAL was elevated to 27.7 +/- 8.7%. Open biopsy of the lung and transbronchial biopsy diagnosed PC-pneumonia in 2 and 1 patients, respectively. Previous BAL examinations failed to detect PC-pneumonia in 2 of them. In all the patients PC-pneumonia was associated with another infection (bacterial, cytomegaloviral). Histologically, the picture of the disease was determined by the severity of the lung affection or its complications. 5 of 8 patients failed treatment with trimethoprim-sulphamethoxazole and died. Marked respiratory insufficiency was registered at PC-pneumonia diagnosis in all the lethal cases. CONCLUSION: Clinical and x-ray pictures of PC-pneumonia in hemoblastosis patients are not specific. All such patients with symptoms of lung infection resistant to antibacterial and antifungal therapy should be examined for PC-pneumonia.

[The embolization of the splenic artery in hematologic surgery]. / Embolizatsiia seleznochnoi arterii v gematologicheskoi khirurgii.

The short- and long-term results of embolization of the splenic artery are analyzed in 143 patients with different diseases of the blood system. Two methods of splenic artery occlusion have been examined: one-stage total and staged embolization of the splenic artery. The course of the postembolization period is considered depending on the type of splenic artery occlusion as is the treatment policy for such conditions. The authors hold that transcatheter embolization of the splenic artery required in some diseases of the blood system is, in terms of its clinical effect, an alternative to splenectomy.

[Roentgeno-endovascular prosthetics of the superior vena cava in compression syndrome]. / Rentgenoéndovaskuliarnoe protezirovanie verkhnei poloi veny pri kompressionnom sindrome.

The paper discusses the first Soviet experience of transcatheter intravascular application of endoprosthesis into superior vena cava for compression with paratracheal lymph nodes in a patient suffering Hodgkin's disease. The patient had failed to respond to 3 cycles of combination chemotherapy and 46 Gy of radiation to the mediastinum. Application of the procedure brought the vascular lumen and blood flow to normal which led to regression of compression syndrome. The self-fixing endoprosthesis dilates and forms an interior frame for the vessel thus preventing relapse of compression in case of progression of disease.