Lindane (Kwell)-induced aplastic anemia.

Numerous toxic exposures have been implicated in causing aplastic anemia. Thirteen cases of aplastic anemia and 5 cases of other blood dyscrasias, eg, red blood cell aplasia and thrombocytopenia, associated with lindane, have been reported in the literature. However, aplastic anemia secondary to the scabicidal product (lindane [Kwell]) has not been documented, to our knowledge. We present the case of a 21-year-old man with a diagnosis of aplastic anemia, known prolonged exposure to lindane, and documented elevated serum lindane levels. His clinical course is described as well as various defects are explored for the aplasia.

The effects of interleukin-1 beta and tumor necrosis factor-alpha on in vitro colony formation by human hematopoietic progenitor cells exposed to doxorubicin or hydroquinone.

Previous studies have shown that treatment of bone marrow (BM) cells with interleukin-1 beta (IL-1 beta) or tumor necrosis factor-alpha (TNF-alpha) can protect hematopoietic progenitor cells (HPC) from the toxic effects of 4-hydroperoxycyclophosphamide (4HC) or gamma-irradiation. Since doxorubicin (DX) and hydroquinone (HQ) may inhibit hematopoiesis through mechanisms similar to 4HC and gamma-irradiation, it was of interest to determine whether IL-1 beta or TNF-alpha could protect HPC from DX and HQ as well. Bone marrow mononuclear cells (BMMNC) or purified HPC (pHPC) were exposed to 50 ng/mL IL-1 beta or 25 ng/mL TNF-alpha alone or in combination with DX or HQ for 22 hours at physiological O2 partial pressure and temperature. The cells were washed free of the cytokines and toxicants and plated in cytokine-containing semisolid medium. Under these concurrent cytokine +/- toxicant treatment conditions, neither IL-1 beta nor TNF-alpha significantly affected progenitor cell frequencies (assessed as CFU-C) or lineage commitment compared with the medium-treated controls. Treatment with either 100 nM DX or 30 microM HQ, however, reduced CFU-C frequencies by approximately 70%. When BMMNC were used, treatment with neither IL-1 beta nor TNF-alpha consistently protected CFU-C from either DX or HQ. In contrast, using pHPC, IL-1 beta or TNF-alpha treatment conferred nearly two-fold protection of CFU-C from DX in all donors tested. TNF-alpha protected CFU-C from HQ using pHPC from all but one donor, while IL-1 beta did not protect CFU-C from HQ. Using phPC, maximum protection of CFU-C from DX was reached at IL-1 beta or TNF-alpha concentrations above 10 ng/mL or 1 ng/mL, respectively. Treatment of pHPC with TNF-alpha for at least 8 hours was necessary before significant protection from DX could be detected. Therefore, we conclude that IL-1 beta and TNF-alpha can act directly on human HPC to protect them from the inhibitory effects of DX and that, to a lesser extent, TNF-alpha can directly protect HPC from HQ.

Granulocytic sarcoma: three unusual patients.

This report describes three unusual patients with lesions due to myeloblasts. In one instance, the patient presented with massive adenopathy. The second patient had bone lesions and a pathologic fracture. The third patient, with myelodysplasia, had diffuse skin lesions infiltrated with myeloblasts. These cases fit the diagnostic category of granulocytic sarcoma. Granulocytic sarcoma is a tumor of immature myeloid cells that may involve any site in the body but that most commonly affects the skin, soft tissues, lymph nodes, bone, and periosteum. Lesions can predate leukemia or occur late in an established chronic granulocytic leukemia or acute granulocytic leukemia. The most common presentation occurs late in the course of acute granulocytic leukemia or in chronic granulocytic leukemia as a herald to blastic transformation. Therapy for localized lesions is radiotherapy, which produces prompt shrinkage of the lesions but relapse occurs subsequently. Systemic chemotherapy also produces satisfactory clinical results. In all instances, therapy can only be considered palliative since virtually all patients have a short survival following the appearance of an extramedullary myeloblastic lesion. Recognition of this pathologic entity at an early stage may give us information on the best management for these patients.

Monocyte nonspecific esterase. Enzymologic characterization of a neutral serine esterase associated with myeloid cells.

Monocytes contain a characteristic, prominent set of membrane-bound nonspecific esterases with a slightly acid isoelectric point. These esterases are also detected at modest levels in some granulocyte preparations. They are not apparent in lymphocytes. Among 18 fresh myeloid leukemias and myeloid leukemia cell lines, those of subtypes M4 (myelomonocytic) and M5 (monocytic) were strongly positive; some of subtypes M1-M3 (granulocytic) were moderately positive. The esterases were not detected among 32 fresh lymphoid leukemias and lymphoid leukemia and lymphoblast cell lines. The membrane-bound monocyte esterases, solubilized by treatment of monocyte preparations with nonionic detergent, were resolved by ion-exchange chromatography. The monocyte species account for 80-95% of the total nonspecific esterase activity of monocytes. The resolved enzymes behave as neutral serine carboxyl esterases and are highly sensitive to inhibition by diisopropylfluorophosphate (DFP) and also by sodium fluoride. Similar analysis of a lymphocyte preparation yielded no detectable monocyte esterases, but yielded numerous other forms which were generally resistant to inhibition by DFP and NaF. These nonspecific esterases are also present at background levels in monocytes. The resolution and characterization of the membrane-bound serine esterases from monocytes demonstrates the basis for the well-known cytochemistry of monocytes. The results are also crucial to the development of an immunologic surface marker test for myeloid cells and the study of monocyte membrane physiology.

Blastic transformation of hairy cell leukemia.

OBJECTIVE: To report blastic transformation of hairy cell leukemia, an uncommon lymphoproliferative disorder of B-cell lineage. DESIGN: Routine histology, cytochemistry, and ultrastructural analysis were used to study this case. Immunoperoxidase studies for leukocyte common antigen (CD45), pan B-cell marker L26 (CD20), and hairy cell leukemia marker DBA.44 were performed. In addition, cell surface marker analysis for CD19, CD20, CD5, CD25, CD11c, and kappa and lambda light chains by flow cytometry was performed. RESULTS: The patient presented with typical clinical, morphologic, cytochemical, immunophenotypic, and ultrastructural features of hairy cell leukemia. Following splenectomy and prior to institution of any other therapy, he developed a blastic lymphoproliferative malignancy with loss of tartrate-resistant acid phosphatase activity, expression of cell surface markers CD11c and CD25, and immunoreactivity for DBA.44. CONCLUSION: We believe this to be the first report of such a transformation and recommend that the differential diagnosis of blastic transformation of chronic lymphoproliferative disorders include such a possibility.

Location and type of mutation in the LIS1 gene do not predict phenotypic severity.

BACKGROUND: Lissencephaly is a neuronal migration disorder leading to absent or reduced gyration and a broadened but poorly organized cortex. The most common form of lissencephaly is isolated, referred as classic or type 1 lissencephaly. Type 1 lissencephaly is mostly associated with a heterozygous deletion of the entire LIS1 gene, whereas intragenic heterozygous LIS1 mutations or hemizygous DCX mutations in males are less common. METHODS: Eighteen unrelated patients with type 1 lissencephaly were clinically and genetically assessed. In addition, patients with subcortical band heterotopia (n = 1) or lissencephaly with cerebellar hypoplasia (n = 2) were included. RESULTS: Fourteen new and seven previously described LIS1 mutations were identified. We observed nine truncating mutations (nonsense, n = 2; frameshift, n = 7), six splice site mutations, five missense mutations, and one in-frame deletion. Somatic mosaicism was assumed in three patients with partial subcortical band heterotopia in the occipital-parietal lobes or mild pachygyria. We report three mutations in exon 11, including a frameshift which extends the LIS1 protein, leading to type 1 lissencephaly and illustrating the functional importance of the WD domains at the C terminus. Furthermore, we present two patients with novel LIS1 mutations in exon 10 associated with lissencephaly with cerebellar hypoplasia type a. CONCLUSION: In contrast to previous reports, our data suggest that neither type nor position of intragenic mutations in the LIS1 gene allows an unambiguous prediction of the phenotypic severity. Furthermore, patients presenting with mild cerebral malformations such as subcortical band heterotopia or cerebellar hypoplasia should be considered for genetic analysis of the LIS1 gene.

IgM cold-warm hemolysins in infectious mononucleosis.

A patient with infectious mononucleosis and immune hemolytic anemia is described. The hemolysis was mediated by the temporary appearance of both a serum IgM anti-i cold agglutinin and an increase of red blood cell i antigen. The cold agglutinin had a high titer, low thermal amplitude and cold-warm hemolytic activity.

In vitro effects of hydroquinone, benzoquinone, and doxorubicin on mouse and human bone marrow cells at physiological oxygen partial pressure.

A comparative study was undertaken in order to assess the hematotoxic effects of hydroquinone (HQ), 1,4-benzoquinone (BQ), and doxorubicin (DX) on mouse and human bone marrow (BM) cells. Initial experiments indicated that the inhibitory effects of near-ambient pO2 and HQ on granulocyte/macrophage colony-stimulating factor (GM-CSF)-induced colony formation were additive. Thus, subsequent experiments were done under conditions of continuous toxicant exposure in complete medium at physiological temperature and O2 partial pressure. Viability was measured 24 hr after exposure, and at the concentrations tested, HQ was less cytotoxic than BQ. DX did not exhibit significant cytotoxicity at the concentrations used. Both HQ and BQ were slightly more cytotoxic to mouse BM cells than to human BM cells. Dose-response analyses of HQ, BQ, or DX inhibition of GM-CSF-induced proliferative and colony-forming responses indicated that murine GM progenitors were significantly less sensitive to HQ than to the majority of myeloid BM cells that proliferated in response to GM-CSF. This preferential resistance of GM progenitors to HQ was not observed when human BM cells were used. HQ was somewhat more inhibitory to human than to mouse GM-CSF responses. Inhibition of GM-CSF-induced responses by BQ correlated closely with cytotoxicity, and DX was 1000-fold more inhibitory to GM-CSF-induced proliferative and colony-forming responses than either HQ or BQ. Again, DX appeared to be slightly more inhibitory to human BM cells than to mouse BM cells. Purified human hematopoietic progenitor cells (HPCs) were also used in the dose-response analyses of HQ, BQ, or DX inhibition of GM-CSF-induced proliferative and colony-forming responses. Inhibition of GM-CSF-induced HPC responses by HQ, BQ, and DX was very similar to that obtained when BM mononuclear cells were used, suggesting that the human HPC is a target for the direct effects of HQ, BQ, and DX.

Platelet transfusion reaction associated with interdonor HLA incompatibility.

An HLA-compatible platelet transfusion was followed by chills, fever, and severe respiratory distress in a multitransfused patient with chronic lymphocytic leukemia. During the previous 7 days the patient had received blood products without incident, including 8 units of red blood cells (RBC), 24 units of pooled random donor platelet concentrates, and five HLA-compatible platelet pheresis products. The patient had no demonstrable RBC, HLA lymphocytotoxic, platelet or granulocyte antibodies. The platelet donor, a multiparous female, had no granulocyte or RBC antibodies but had lymphocytotoxic antibodies against HLA-A2 CREG (cross-reacting group A2, A28, A23, A24) which reacted not with lymphocytes of the patient but with lymphocytes of the donor whose RBC were transfused 24 h prior to the platelet transfusion reaction and whose HLA type is A23, A24; B44, B57. No RBC donors had HLA lymphocytotoxic, granulocyte, or platelet antibodies against the platelet donor. The patient received three subsequent platelet transfusions from the same donor after removal of the antibody-laden plasma with no adverse reaction. These data suggest an interdonor reaction caused by the presence of cells from the RBC donor received by the patient 24 h prior to the transfusion of donor lymphocytotoxic antibody to HLA-A2 CREG antigens.

Enzymologic classification of acute leukemias: nonspecific esterase markers distinguish myeloid and lymphoid varieties.

Nonspecific esterase zymograms of purified leukemic cells from a case of acute myelomonocytic leukemia (AMML) and from a case of acute non-B, non-T lymphocytic leukemia (ALL) were produced by isoelectric focusing and staining with alpha-naphthyl acetate (alpha NA) or alpha-naphthyl butyrate (alpha NB) substrate. A "myeloid" zymogram was found with AMML cells, which closely matched control monocyte and granulocyte zymograms. On the other hand, nonspecific esterase of ALL showed a striking departure from the zymogram pattern of control B lymphocytes and T lymphocytes. An intense reactivity with a very low isoelectric point accounted for most of the ALL nonspecific esterase activity. No corresponding reactivity or relatively small amounts thereof were seen in other zymograms. Conversely, few of the isoenzymes that were prominent in zymograms of control lymphocytes were apparent above trace levels in ALL zymograms. Thus, zymogram analysis of nonspecific esterases clearly differentiated the myeloid leukemia from the lymphoid leukemia and provided a potential marker for each. The AMML cells appeared well enough differentiated with respect to nonspecific esterases as to be similar to mature cells of like lineage. It is plausible that the ALL cells, however, were arrested at an earlier stage of esterase expression as reflected by the associated atypical species.

Nonspecific esterase of B lymphocytes from a case of chronic lymhocytic leukemia and of normal T lymphocytes: similar constellations of isoenzymes.

Lymphocytes from a case of B-cell chronic lymphocytic leukemia (CLL) were obtained in a highly purified state from a therapeutic leukapheresis preparation. The CLL lymphocytes showed a fine, scattered, granular pattern of nonspecific esterase cytochemical reactivity with either alpha-naphthyl acetate (alpha NA) or alpha-naphthyl butyrate (alpha NB) substrate as opposed to the more focal pattern of control (T) lymphocytes. Nonspecific esterase of CLL lymphocytes and normal control lymphocytes was equally resistant to inhibition by fluoride ion. Extractable nonspecific esterases from the CLL lymphocytes and from purified normal T lymphocytes were indistinguishable in regard to specific activity, substrate specificity, pH optima, and zymogram profiles on polyacrylamide gel electrophoresis at pH 9.5 and pH 4.0. Zymograms of alpha NA esterase and alpha NB esterase prepared by isoelectric focusing were also similar, with no unequivocal differences. These results are consistent with recent reports that B lymphocytes contain detectable nonspecific esterase and suggest that the B lymphocytes from this case of CLL contained a constellation of isoenzymes similar to that of normal T lymphocytes. This is interpreted as a reflection of the close kinship of these cells.

A patient with the inability to maintain in vivo levels of bound cobalamin (Cbl) and manifestations of tissue deficiency of Cbl.

A 39-year-old woman presented with mild anemia, glossitis, an increased MCV, a low serum cobalamin (Cbl) (vitamin B12), mild tissue deficiency of Cbl, but with neither malabsorption of Cbl, impaired intake, nor deficiency of or inactivity of transcobalamin II (TC II). Because of a persistently low holo-TC II (TC II carrying Cbl as the circulating complex of TC II-Cbl), much of the evaluation was focused on the patient's TC II. Her TC II promoted the uptake of Cbl, reacted with anti-TC II, and bound Cbl in vitro. A test dose of 200 micrograms of cyanocobalamin (CN-Cbl) i.m. increased her holo TC II to levels higher than those in healthy persons, but with a much more abrupt fall to a subnormal level. Two milligrams of CN-Cbl i.m. followed by 100 micrograms i.m. monthly failed to maintain normal amounts of circulating TC II-Cbl or to overcome the tissue deficiency of Cbl. One milligram i.m. weekly or daily p.o. corrected both. The low holo TC II was considered to be responsible for the clinical expression and may have been primary to the reduced amounts of total and holo R binder of Cbl in the circulation. This study of a newly recognized defect points out the need for circulating holo TC II, a rational use of pharmacologic amounts of Cbl, and a possible interrelationship between TC II and the R binder of Cbl.

Kinetic properties of tartrate-resistant acid phosphatase isolated from human spleen with leukemic reticuloendotheliosis.

The tartrate-resistant acid phosphatase was isolated from the spleen of a patient with leukemic reticuloendotheliosis. The unique characteristic of the enzyme is its similar reactivity toward p-nitrophenylphosphate, inorganic pyrophosphate ADP, and ATP. When ATP was incubated with the enzyme, the initial products were ADP and inorganic phosphate. The kinetic data confirmed that these substrates were hydrolyzed by the same enzyme. This type of substrate specificity is clearly different from acid phosphatase and pyrophosphatases previously described in the literature.

Gynaecological and obstetrical morbidity in women with type I von Willebrand disease: results of a patient survey.

Type 1 von Willebrand disease (vWD) is generally regarded clinically as 'mild' and the obstetrical-gynaecological features have not been fully described. We administered a patient questionnaire and provider survey of the medical and quality of life aspects of childbirth and menstruation to 99 type 1 vWD patients and compared the patients presently menstruating (n=81) to a cohort of 150 menstruating females in the general population. The following measurements had a statistically higher proportion in the vWD group: number of tampons/towels used for a typical menstrual cycle (P=0. 002); percentage reporting that clothes are stained by menses (P = 0. 001); past or present history of anaemia (P = 0.001); childbirth-related bleeding (P=0.001); and childbirth-related bleeding necessitating RBC transfusion (P=0.002). Quality of life assessment of the impact of menses in both of the above cohorts was measured by a Likert scale using seven quality of life parameters. Compared to the control group, the vWD patients had a significantly higher score, with P-values of < 0.0001 for each parameter. Hormonal interventions for menorrhagia in the vWD patients were < or = 50% effective. Menorrhagia resulted in red blood cell transfusions in 6% of patients, dilatation and curettage in 17% and hysterectomy in 13%. Despite the common connotation of type 1 vWD as clinically 'mild', childbirth and the monthly challenge to haemostasis presented by menstruation result in a substantial degree of morbidity in females with type 1 vWD. These results support the rationale for ongoing international efforts to increase awareness of vWD as a cause for menorrhagia and to improve the quality of life in females with known vWD.

Prolonged unmaintained remission after intensive consolidation therapy in adult acute nonlymphocytic leukemia.

Thirty-five adults with acute nonlymphocytic leukemia who were in complete remission after initial induction therapy received a single course of high-dose cytarabine and amsacrine as consolidation therapy. No further therapy was administered. Despite substantial toxicity, the median duration of disease-free survival was 12 months, and 30% of patients are projected to be alive in continuous complete remission at 3 years. A single course of intensive postremission chemotherapy provides long-term disease-free survival in the absence of any further treatment.

The substantial impact of von Willebrand disease on menstruation.

von Willebrand disease (vWd) is the most common of all congenital bleeding disorders with an estimated prevalence of 1-3% in the general population. However, the gynecological complications have not been thoroughly described.Objective: To compare the clinical and quality of life aspects of vWd in menstruating women in relation to a cohort of menstruating women in the general population.Methods: A patient questionnaire and provider survey of the medical and quality of life aspects of menstruation was administered to 81 menstruating vWd patients registered at four geographically linked Hemophilia Treatment Centers. The questionnaire was also administered to 150 menstruating women volunteers that comprised a control group used to determine normal coagulation levels in menstruating women. We assessed the impact on quality of life of menses in both of the cohorts by a Likert scale of 1-10 with 10 being "most significant impact" using 7 quality of life parameters with those comparisons by Wilcoxon rank sum test.Results: 88% of the vWd patients (pts) had type I vWd, the remaining Type II or unknown. The mean age of the vWd patients was 31.6 +/- 10.3; the mean age of the control group was 35.5 +/- 7.6. The following comparisons were made using chi(2) and Wilcoxon rank sum test:Conclusions: vWd markedly diminishes the quality of life during menses. This observation warrants efforts to reduce the attendant morbidities of vWd in menstruating women.