[Diffuse large B-cell lymphoma expressing high-level glyceraldehyde 3-phosphate dehydrogenase complicated with hypoglycemia].

A 69-year-old male patient was referred to our hospital for further examination of hypoglycemia, splenomegaly, and para-aortic lymphadenopathy. The patient was diagnosed with diffuse large B-cell lymphoma (DLBCL) by para-aortic lymph node biopsy. Hypoglycemia was refractory to glucose supplementation but improved shortly after chemotherapy. This situation suggested that hypoglycemia was caused by lymphoma. We compared the expression levels of glyceraldehyde 3-phosphate dehydrogenase, a glycolytic enzyme whose expression is positively correlated with the glycolytic activity of cells, between the current case and two cases of DLBCL without hypoglycemia to explore the possibility that hypoglycemia was due to intense glucose consumption by lymphoma cells through their high glycolytic activity. Results revealed substantially higher expression levels of glyceraldehyde 3-phosphate dehydrogenase in the current case than in DLBCL without hypoglycemia, suggesting that the glycolytic pathway was enhanced in the current case. These results implied that intense glucose consumption by lymphoma cells through their high glycolytic activity causes hypoglycemia.

Novel prognostic index based on hemoglobin level and platelet count for diffuse large B-cell lymphoma, not otherwise specified in the R-CHOP era.

The international prognostic index (IPI) is a broadly utilized clinical tool to aid in predicting the prognosis of patients with aggressive non-Hodgkin's lymphomas (NHL). However, since this score was developed before the development of rituximab, and the introduction of combined rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) (R-CHOP) therapy for NHL has dramatically improved clinical outcomes, the IPI may be inadequate to assess prognosis in the R-CHOP era. In the present study, we assessed the utility of hemoglobin (Hb) level and platelet count to predict prognosis in diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS), the largest category of aggressive NHL. A total of 89 patients newly diagnosed with nodal DLBCL, NOS and treated with R-CHOP therapy were included. The blood count results at diagnosis were statistically analyzed. Available biopsy specimens were immunostained for interleukin (IL)-6. Hb levels lower than 120 g/L (p = 0.0133) and platelet counts lower than 135 × 109/L (p = 0.0233) were associated with worse overall survival (OS). Based on those levels as cutoff values, a hemoglobin-platelet (HP) index was calculated by assigning 1 point for an Hb level or a platelet count lower than the cutoff. The patients were divided into three groups based on the HP index: high, with a score of 2 (n = 8); intermediate, with a score of 1 (n = 39); and low, with a score of 0 (n = 42). A higher HP index was associated with worse OS (p = 0.0055). Patients with IL-6-positive tumors had significantly lower Hb levels than those with IL-6-negative tumors (p = 0.0264), suggesting that abnormal production of IL-6 by lymphoma cells is associated with anemia. On the other hand, there was no association between the platelet counts and the IL-6 expression in the lymphoma cells. In a multivariate analysis, the HP index predicted OS rate independently of the IPI. Since the HP index is based on inexpensive and broadly available laboratory values, we believe that this index will have great utility in clinical practice, and the addition of this index to IPI could more precisely predict prognosis.

[Sudden death associated with myocardial damage caused by microthrombi in a patient with thrombotic thrombocytopenic purpura].

We describe a 35-year-old woman with Down's syndrome who was admitted to a clinic with anorexia and vomiting. Since laboratory findings showed anemia (Hb 7.4 g/dl) and thrombocytopenia (0.5 × 104/µl), she was transferred to our hospital for treatment. Further laboratory examinations revealed schistocytes, LDH elevation, and a negative Coombs' test. Thrombotic thrombocytopenic purpura (TTP) was suspected. Plasma exchange (PEX) and prednisolone administration were thus immediately initiated. Prior to these treatments, ADAMTS13 activity was less than 5% and inhibitors were detected at a level of 0.8 Bethesda U/ml. Although her platelet count had risen to 13.0 × 104/µl by day 6 (post 4 sessions of PEX), it had decreased to 1.8 × 104/µl on day 7. Despite ongoing PEX, thrombocytopenia persisted. On day 21, she suddenly died. Autopsy findings revealed no evidence of myocardial necrosis or coronary artery thrombosis. Extensive microthrombi were, however, detected in precapillary arterioles, capillaries, and post-capillary venules of the heart. Therefore, this patient's sudden death was clinically suspected to have been caused by cardiomyopathy, which had produced cardiogenic shock.

A case-control study of bronchiolitis obliterans syndrome following allogeneic hematopoietic stem cell transplantation.

Bronchiolitis obliterans syndrome (BOS) is a significant complication after allogeneic hematopoietic stem cell transplantation (HSCT). However, the pathogenesis and risks for the development of BOS have remained unclear. Therefore, a case-control study was conducted to investigate the risk factors for the development of BOS, which included the largest number of BOS cases; 196 patients with BOS were identified and compared with 1960 control recipients. The following were identified as significantly higher risk factors for the development of BOS: female recipients (OR 1.47, P = 0.019), ABO-mismatch HSCT (minor mismatch, OR 1.67, P = 0.015; major mismatch, OR 1.73, P = 0.012; bidirectional mismatch, OR 1.96, P = 0.018), busulfan+cyclophosphamide-based myeloablative conditioning (OR 1.74, P = 0.016), and acute graft-versus-host disease (GVHD) involving the skin (OR 1.55, P = 0.011). On the other hand, the risk for the development of BOS was significantly lower in patients receiving cord blood transplantation (OR 0.26, P = 0.0011). With respect to other target organs of chronic GVHD, ocular involvement was significantly associated with BOS (OR 2.53, P < 0.001). Prospective studies are required to elucidate the risk factors for the development of BOS, and future investigations should focus on finding a prophylactic approach against BOS based on these findings.

[Analysis of high-risk multiple myeloma patients treated with high-dose chemotherapy].

Although high-dose chemotherapy supported by autologous peripheral blood stem cell transplantation (auto-PBSCT) is the standard approach for younger patients with multiple myeloma, some of them still show a poor prognosis. We attempted to define a high-risk group among 32 patients who received auto-PBSCT between August 2000 and July 2007 in our hospital. In conventional metaphase cytogenetics (G-banding), chromosome abnormalities (CA), hypodiploidy, and 13 or 13q deletion (Gd13) were noted in 27.6, 17.2, and 19.4% of patients, respectively. In a FISH study, del(17p) (Fd17p) and t(4;14) were noted in 12.5 and 9.4% of patients, respectively. Prognostic analyses of patients with these abnormal chromosomes revealed that those with CA, hypodiploidy, Gd13, and t(4;14) showed a poorer survival at 3 years compared to those without them: 42.9 vs. 95.2% (p=0.0072), 25.0 vs. 91.5% (p=0.0056), and 40.0 vs. 91.8% (p=0.0245), 0 vs. 89.3% (p<.0001), respectively. When we defined patients showing at least one of CA, hypodiploidy, Gd13, Fd17p, and t(4;14) as a "high-risk group", they showed a poorer overall (23.9 vs. 106.1 mo., p=0.0011) and progression-free (13.5 vs. 25.6 mo., p=0.0095) survival compared to a non-high-risk group. This study indicated that chromosome analysis has a prognostic value in patients with multiple myeloma receiving auto-PBSCT.

Combinations of cytogenetics and international scoring system can predict poor prognosis in multiple myeloma after high-dose chemotherapy and autologous stem cell transplantation.

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a standard therapy for newly diagnosed multiple myeloma. Combinations of recently proposed prognostic factors such as cytogenetics and international scoring system (ISS) may be useful to predict prognosis after ASCT. This study evaluated 60 consecutive patients who underwent ASCT in four institutes. The median age of patients was 57 years old. Cytogenetic analyses of bone marrow at diagnosis detected metaphase abnormalities in 9 of 51 patients and interphase abnormalities in six of 35 patients (17p13 deletion, t(4;14) and t(14;16)). Seventeen patients had ISS stage 3 at diagnosis. Twenty-five patients who had any of these risk factors were defined as high risk. All patients were conditioned with high-dose melphalan. With a median follow-up of 3.4 years, overall survival and event-free survival at 3 years were significantly worse in high-risk patients (48% vs. 97%; P = 0.0005 and 16% vs. 37%; P = 0.038, respectively) despite the higher CR plus VGPR rate among high-risk patients. In addition, survival at 1 year after progression was significantly worse in high-risk patients despite salvage chemotherapy containing thalidomide (32% vs. 100%, P = 0.0001). Combinations of cytogenetics and ISS could readily predict prognosis. Quality of response is a poor surrogate marker for ultimate outcome. High-risk patients may need more effective treatment.

The Difference Between Movement and Self-Recognition in Children Performing the Standing Long Jump.

This study examined the relationship between the recognition of movement and actual movement during the standing long jump. A total of 11 healthy elementary school children from 10 to 11 years of age participated in this study. Participants conducted standing long jumps (the target movement) after receiving video instruction. They were then tested on their recognition of the target movement according to an image. A total of 12 markers were then attached to each participant to measure the actual movements taken during subsequent performances of the target movement. They were then tested on the recognition of their own movements (a self-evaluation). The results were as follows: maximum shoulder angle was observed prior to each jump; this became successively lower in the image review, actual movement, and self-evaluation procedures. Knee flexion angle successively decreased in the actual, target, self-evaluation, and image movements during the railway crossing procedure. While jumping, the maximum shoulder angle was significantly larger in the target movement than the actual (P < .01) movement, but the actual movement was significantly lower than the image (P < .001) and self-evaluation (P < .001) movements. The angle between the perpendicular from the acromion and the line segment connecting the acromion to the lateral malleolus successively decreased in the target, image, self-evaluation, and actual movements. Thus, there were obvious points at which it was either easier or more difficult for subjects to recognize movements. Points of relative ease and difficulty were also identified during performance of the target movement.

Tumor necrosis factor- and interleukin-6-producing high-grade B-cell lymphoma, not otherwise specified in the pleura.

A 65-year-old man was admitted to our hospital with left-sided chest and back pain and dyspnea. Computed tomography demonstrated a marked circumferential left pleural thickening. A thoracoscopic pleural biopsy led to a diagnosis of high-grade B-cell lymphoma, not otherwise specified (HGBL, NOS). Lymphoma cells were positive for tumor necrosis factor (TNF) and interleukin-6. This is the first case report of TNF- and IL-6-producing aggressive HGBL, NOS in the pleura, in which radiological findings mimicked pleural mesothelioma. The aggressive tumor progression in the present case may have been caused by abnormal cytokine production from lymphoma cells.

[Frequency and prognostic value of chromosome abnormalities in multiple myeloma].

Chromosomal aberrations have been shown to significantly affect survival in multiple myeloma (MM), but few cytogenetic analyses among Japanese MM patients have been reported. Using a commercial laboratory, we performed interphase fluorescent in situ hybridization (FISH), as well as a conventional metaphase cytogenetic study (G-banding), among 106 of 131 patients between April 1997 and February 2007. Karyotype abnormalities were found in 21.2% (21 of 99 patients). Del(13q), del(17p), del(11q), t(11;14) and t(4;14) were detected by FISH in 36.0% (31/86), 24.7% (19/77), 7.6% (5/64), 18.2% (12/66) and 10.4% (7/67) of patients, respectively. The prevalence of abnormalities detected by G-banding was lower than that reported in European countries, but when compared with FISH studies, no difference was observed. Prognostic analyses of patients with these abnormal chromosomes revealed that those with abnormal karyotype and del(13q), t(4;14), as detected by FISH, had significantly poorer survival. This study suggests that the prevalence of chromosome abnormalities among Japanese patients is similar to that for European populations, and that chromosome studies by G-banding and FISH are essential to predict survival.

[Efficacy and safety of induction chemotherapy consisting of anthracycline for 3 days and cytarabine for 7 days in elderly patients with acute myeloid leukemia].

Optimal therapeutic strategy for elderly patients with acute myeloid leukemia has not been established. We retrospectively reviewed the medical records of 24 patients who underwent induction chemotherapy, consisting of anthracycline for 3 days and cytarabine for 7 days. Regimens of induction therapy included cytarabine and daunorubicin (n=19), cytarabine and idarubicine (n=3), enocitabine and daunorubicin (n=2). Eleven patients (45.8%) achieved complete remission (CR). Three patients (12.5%) died without relapse or of progression underlying diseases. Of the 11 patients who achieved CR, 9 received consolidation therapy. The median survival was 11.2 months, and the median of event-free survival and overall survival in the patients who achieved CR was 9.4 months and 21.6 months, respectively. This study indicated that induction chemotherapy which consisted of anthracycline for 3 days and cytarabine for 7 days is effective and safe for elderly patients with acute myeloid leukemia.

A multicenter phase 2 study of empirical low-dose liposomal amphotericin B in patients with refractory febrile neutropenia.

Invasive fungal infection (IFI) is a major life-threatening problem encountered by patients with hematological malignancies receiving intensive chemotherapy. Empirical antifungal agents are therefore important. Despite the availability of antifungal agents for such situations, the optimal agents and administration methods remain unclear. We conducted a prospective phase 2 study of empirical 1 mg/kg/day liposomal amphotericin B (L-AMB) in 80 patients receiving intensive chemotherapy for hematological malignancies. All enrolled patients were high-risk and had recurrent prolonged febrile neutropenia despite having received broad-spectrum antibacterial therapy for at least 72 hours. Fifty-three patients (66.3 %) achieved the primary endpoint of successful treatment, thus exceeding the predefined threshold success rate. No patients developed IFI. The treatment completion rate was 73.8 %, and only two cases ceased treatment because of adverse events. The most frequent events were reversible electrolyte abnormalities. We consider low-dose L-AMB to provide comparable efficacy and improved safety and cost-effectiveness when compared with other empirical antifungal therapies. Additional large-scale randomized studies are needed to determine the clinical usefulness of L-AMB relative to other empirical antifungal therapies.

Recurrent intramural hematoma of the small intestine in a severe hemophilia A patient with a high titer of factor VIII inhibitor: a case report and review of the literature.

A 17-year-old man with severe hemophilia A (factor VIII <1%) developed intermittent left upper quadrant pain. He had a high titer of factor VIII inhibitor (1024 Bethesda units/mL) and was diagnosed with intramural hematoma of the jejunum. He was managed conservatively with activated prothrombin complex concentrate (APCC), resulting in the resolution of symptoms. He developed recurrent intramural hematoma of the small intestine over the next 54 months, and was successfully treated with APCC. This case highlights a rare clinical manifestation in hemophilia patients, and also indicates the effectiveness of APCC instead of exploratory surgery for intramural hematoma. Cases of intramural hematoma of the gastrointestinal tract among hemophilia patients are also reviewed.

High titer of ADAMTS13 inhibitor associated with thrombotic microangiopathy of the gut and skeletal muscle after allogeneic hematopoietic stem cell transplantation.

Transplantation-associated thrombotic microangiopathy (TMA) is one of the main complications after hematopoietic stem cell transplantation (HSCT). At the time of onset of gut TMA, a patient developed a high titer of an inhibitor of the non-immunoglobulin G type to ADAMTS13, which physiologically hydrolyzes von Willebrand factor to control spontaneous intravascular thrombus formation. The patient developed symptoms of myositis, a disorder that has occasionally been reported to manifest after HSCT and to resemble some idiopathic autoimmune diseases. However, a muscle biopsy specimen presented pathologic findings of TMA, including microvascular platelet thrombus formation, without inflammatory lymphocyte infiltration. ADAMTS13 activities returned to normal after steroid treatment, and the improvement of TMA symptoms followed. This patient appears to represent a rare case of post-HSCT TMA associated with the development of an ADAMTS13 inhibitor.

Classic polyarteritis nodosa presenting rare clinical manifestations in a patient with hemophilia A.

A 35-year-old patient with hemophilia A presented with rapidly progressive polyarteritis nodosa (PAN). He had been infected with hepatitis B virus (HBV) by repeated transfusion and was positive for hepatitis B surface antigen but negative for hepatitis B surface antibody. The patient presented symptoms of acute epididymitis followed by emergency admission because of acute appendicitis. On day 7 of admission, he complained of severe back pain, and computerized tomography (CT) showed massive perirenal hematoma. On day 49, mild monoplegia in the left arm suddenly developed, and CT and magnetic resonance imaging revealed multiple cerebral infarctions. Factor VIII replacement therapy was attenuated; however, cerebral infarction was progressive and extended throughout the cerebral hemispheres. He was diagnosed with classic polyarteritis nodosa (cPAN), and pulse methylprednisolone was continued. The patient died of supratentorial herniation, and autopsy revealed that vasculitis associated with intimal thickening was present in the liver, pancreas, intestine, kidneys, and larger-sized cerebral arteries. The development of cPAN appeared to have originated from chronic HBV infection, and this is the first report of cPAN in hemophilia patients. Concomitant hemorrhagic and thrombotic manifestations of cPAN are hardly treatable in patients with coagulation disorders, and the current case may represent a rare transfusion-related complication in hemophilia patients.

Shifts in morphology and diet of non-native sticklebacks introduced into Japanese crater lakes.

An increasing number of exotic animals are causing ecological problems. Therefore, for better ecosystem management, it is important to understand how exotic species colonize and adapt to novel environments. The threespine sticklebacks (Gasterosteus aculeatus) can be a good vertebrate model system to explore the ecological and genetic mechanisms of adaptation not only in natural populations, but also in non-native populations. Although morphological changes have been documented in several introduced populations of stickleback, little is known about the dietary changes during colonization into novel environments. Here, we investigated the morphological and dietary changes of exotic threespine stickleback populations introduced into three Japanese crater lakes (Lake Towada, Lake Kussharo, and Lake Shikotsu). Sticklebacks were introduced into the crater lakes likely along with salmonids transplanted for aquaculture. The stickleback population in Lake Kussharo had multiple mitochondrial haplotypes and had larger phenotypic variances than other crater lake stickleback populations that had only one mitochondrial haplotype. Compilation of historical data on the morphology and stomach contents of the Lake Towada stickleback population showed that substantial shifts in body size and stomach contents occurred after colonization. Some of these changes may be related to an outbreak of the Schistocephalus parasite. These results suggest that sticklebacks can change their morphology and trophic ecology when they colonize novel environments. Therefore, extreme care should be taken when salmonids are transported between watersheds for aquaculture and that long-term monitoring of exotic species is essential for ecosystem management. In addition, further genetic studies on phenotypic changes in crater lake sticklebacks would help elucidate the genetic mechanisms underlying the adaptation of exotic fishes to novel environments.

Prediction of clinical outcome in patients with idiopathic thrombocytopenic purpura by evaluating bone marrow clot CD20+ B lymphocytes and morphological changes of megakaryocytes.

The pathology of B-lymphocytes in the bone marrow of patients with idiopathic thrombocytopenic purpura (ITP) has not been well described, even though B-lymphocytes may be involved in the etiology of ITP. We retrospectively reviewed the medical records of 73 ITP patients between January 1997 and June 2005 with platelet counts of < 50 x 10(9)/L. Bone marrow clots were available for pathological review in 56 patients who were classified into 3 groups based on the results of the bone marrow clot examination : Group A (21 patients) had increased CD20+ lymphocytes (> or =1% of nucleated cells) and megakaryocytes with morphologic changes ; Group B (21 patients) had morphologic changes but no increase in CD20+ lymphocytes ; and Group C (14 patients) had neither morphologic changes nor increased CD20+ lymphocytes. Multivariate analysis showed that, compared to Group A, Group B had a significant prognostic factor (p = 0.04 ; odds ratio, 6.65 ; 95% confidence interval, 1.09 to 40.54) for achieving complete response, while Group C had a significant prognostic factor for any treatment response (p = 0.04 ; odds ratio, 14.26 ; 95% confidence interval, 1.08 to 188.02). Thus, ITP patients can be classified with different clinical outcomes based on immunohistopathological examination of bone marrow clots.

Identification of amino acid residues essential for heparin binding by the A1 domain of human von Willebrand factor.

Platelet adhesion is mediated by von Willebrand factor (VWF) that binds platelet glycoprotein Ib (GPIb). Previous observations suggested that heparin competitively inhibits the binding of VWF to GPIb and may down-regulate platelet adhesion. We performed charged-to-alanine scanning mutagenesis of domain A1 and studied dose-dependent binding to heparin-Sepharose beads. Mutations at Lys1362 and Arg1395, at which the GPIb binding was markedly decreased, showed 41% and 42% binding, respectively. Clustered mutations in the segments 1332KDRKR1336 and 1405KKKK1408, which have been proposed as heparin binding sequences, showed 72% and 52% binding, respectively. However, single alanine substitutions within these clusters showed normal binding. Our findings suggest that heparin may inhibit the binding of VWF to GPIb by interacting with GPIb binding and interpret why some hemorrhagic complications of heparin therapy are not predictable based on techniques for monitoring the conventional anticoagulant effects of heparin.

Identification of protein Salpha gene mutations including four novel mutations in eight unrelated patients with protein S deficiency.

Eight distinct and potentially causative mutations were identified in eight unrelated Japanese patients with protein S (PS) deficiency, by direct DNA sequencing of the protein Salpha (PSalpha) gene-specific polymerase chain reaction products of all 15 exons and exon/intron boundaries. There were five missense mutations, including two novel mutations (Cys80Tyr and Arg314His), and three showed a major impact on the expected gene products: novel mutations of a 5-bp deletion (delCTCTG887:Cys206Stop) and a nonsense mutation (Glu208Stop), as well as a previously reported splice site (exon 10 +5 A-->G) mutation. One of the patients showed compound heterozygosity for delCTCTG887 and 732A-->G. Investigation for the cosegregation state of these two mutations with PS deficiency in the patient's family suggested that the delCTCTG887 mutation was responsible for the abnormal phenotype and that the 732A-->G (Lys155Glu) mutation did not appear to play a key role. However, we also identified the same 732A-->G (Lys155Glu) mutation in an unrelated patient with apparent PS deficiency with severe pulmonary embolism, and found that this mutation seemed to cosegregate with a PS-deficient state in her family members. These data implied that unknown factor(s) other than the 732A-->G mutation itself might influence phenotypic expression of PS status in different individuals.