High-throughput simultaneousquantification offive azole anti-fungal agents and one active metabolite in human plasma using ultra-high-performance liquid chromatography coupled to tandem mass spectrometry.

OBJECTIVES: For patients with hematological malignancy, triazole antifungal agents such as fluconazole (FLCZ), itraconazole (ITCZ), voriconazole (VRCZ), posaconazole (PSCZ) and isavuconazole (ISCZ) are often used for prophylaxis of deep mycosis. Since these azoles exhibit large pharmacokinetic variability, dose adjustment by therapeutic drug monitoring is recommended for some azoles. This study aimed to develop and validate a novel method for simultaneous determination of plasma concentrations of FLCZ, ITCZ, VRCZ, PSCZ, ISCZ and ITCZ-OH, an active metabolite of ITCZ, using ultra-high-performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS). DESIGN & METHODS: A high-throughput solid-phase extraction method using 96-well MCX µElution Plate was selected as the pretreatment procedure. RESULTS: The calibration curves for FLCZ, ITCZ, ITCZ-OH, VRCZ, PSCZ and ISCZ showed good linearity (back-calculation of calibrators: relative error ≤ 15% [LLOQ: ≤ 20%]) over wide ranges of 100-100000, 20-20000, 40-40000, 20-20000, 5-5000 and 50-50000 ng/mL, respectively. The validation results of all six drugs fulfilled the criteria of the guidance for bioanalytical method validation of the US Food and Drug Administration for within-batch and batch-to-batch precision and accuracy. The extraction recovery rates were good at ≥ 74.9%, and almost no matrix effects were found for all the drugs. The trough (10 h post-dose in 1 patient on PSCZ) drug concentrations in patients with hematologic malignancy who received oral FLCZ, ITCZ, VRCZ or PSCZ were quantified using the method developed. The measurements for all samples were within the ranges of the calibration curves, demonstrating the feasibility of clinical application of the novel method. CONCLUSIONS: We have succeeded in developing a novel high-throughput method using UHPLC-MS/MS for simultaneous quantification of plasma concentrations of FLCZ, ITCZ, ITCZ-OH, VRCZ, PSCZ and ISCZ.

[Successful treatment with cidofovir for disseminated adenovirus infection accompanied by hemophagocytic syndrome and meningitis in an allogeneic hematopoietic stem cell transplantation recipient].

A 65-year-old woman received bone marrow transplantation from an HLA-DRB1 one locus mismatched donor for high-risk myelodysplastic syndrome. On day 237 after transplantation, she developed recurrent acute gastrointestinal graft-versus-host disease and adenoviral hemorrhagic cystitis. Hence, the methylprednisolone (mPSL) dose was increased to 2 mg/kg, and mesenchymal stem cells were administered. After the dose was tapered, she developed high fever, gross hematuria, and progressive pancytopenia. Then, the serum LDH, ferritin, and hepatobiliary enzyme levels of the patient increased, and hemophagocytosis was observed based on bone marrow examination. The adenovirus DNA level in the plasma was 6.3×106 copies/ml on day 278, and the volume of cerebrospinal fluid increased. Hence, the patient was diagnosed with meningitis and disseminated adenovirus infection. On day 288, cidofovir was administered at a dose of 1 mg/kg three times a week for 8 doses. The mPSL dose was again increased to 2 mg/kg for the treatment of hemophagocytic syndrome. Then, the patient's symptoms gradually improved, and the adenovirus viral load became negative on day 369. Based on the clinical course of our patient, cidofovir is useful for severe adenovirus infection.

Kinetics and clinical significance of human herpesvirus 6 DNA shedding in saliva after allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Little is known about the kinetics and clinical significance of saliva human herpesvirus-6 (HHV-6) DNA after hematopoietic stem cell transplantation (HSCT). METHODS: In this observational study, we quantified HHV-6 DNA in serially collected plasma and saliva from allogeneic HSCT recipients. Associations between the status of salivary HHV-6 DNA and the development of HHV-6 encephalitis, depression, and oral mucosal graft-versus-host disease (GVHD) were retrospectively analyzed. RESULTS: A total of 787 plasma and 434 saliva samples were collected from 56 patients. The cumulative incidence of HHV-6 DNA in plasma and saliva at 60 days after transplantation was 51.8% and 83.9%, respectively. The peak level of salivary HHV-6 DNA was significantly higher in patients who displayed plasma HHV-6 DNA than in those who did not (median, 51,584 copies/mL vs 587 copies/mL; P < .0001). Salivary HHV-6 DNA levels increased after positive plasma HHV-6 DNA was detected and remained high during observation period. Despite the frequent occurrence of positive salivary HHV-6 DNA, no patient developed depression. Positivity of salivary HHV-6 DNA was not significantly associated with the development of HHV-6 encephalitis (P = 1.00, Fisher's exact test) or oral mucosal GVHD (P = .71, Grey's test). No significant relationship between salivary HHV-6 DNA and these diseases was found even when comparing higher HHV-6 DNA loads in saliva. CONCLUSION: Salivary HHV-6 DNA levels increased after HHV-6 DNA was detected in the blood. However, no epidemiological evidence was shown to support a role of salivary HHV-6 in the development of HHV-6 encephalitis, depression, and oral mucosal GVHD.

[Successful delivery after chemotherapy for acute myeloid leukemia diagnosed in the second trimester].

Development of acute myeloid leukemia (AML) during pregnancy is rare, and the available data are limited to small retrospective reports. Currently, no guidelines exist for the management of AML during pregnancy in Japan. A 26-year-old female was diagnosed with AML at 19 weeks of gestation, received chemotherapy with daunorubicin and cytarabine, and achieved complete remission. Following the first consolidation therapy, she gave birth to a 1964-g female infant by cesarean section at 33 weeks of gestation. One week later, she was initiated on the second consolidation therapy; however, she developed a pelvic abscess during neutropenia. She underwent urgent surgery for open drainage and recovered soon after surgery. She has been in complete remission for eight months, and the daughter is healthy. Chemotherapy delivered after the second trimester rarely causes congenital malformations and may not require the termination of pregnancy. The clinical course of the present case suggests that chemotherapy can be performed safely and effectively in pregnant patients with AML after the trimester and babies.

[Philadelphia chromosome-positive acute lymphoblastic leukemia relapsing with an anterior chamber lesion of the eye].

A 48-year-old Filipino woman underwent umbilical cord blood stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia under non-remission status. Left aqueous humor puncture was performed owing to the development of left eye pain and exacerbation of anterior eye chamber inflammation 72 days after the transplantation; this revealed the relapse of leukemia in the anterior chamber. Subsequently, the patient tested positive for peripheral blood minimal residual disease. Therefore, doctors should take note that anterior chamber disease may appear as a non-typical relapse of leukemia.

[Successful treatment of secondary graft failure in a mixed-phenotype acute leukemia patient with haploidentical hematopoietic stem cell transplantation and post-transplant cyclophosphamide administration].

A 38-year-old woman in the first remission of mixed-phenotype acute leukemia underwent unrelated bone marrow transplantation from an HLA-DR-mismatched donor in the host-versus-graft (HVG) direction with myeloablative conditioning. Neutrophil engraftment was achieved and complete donor chimera was obtained on days 21 and 29 after transplantation, respectively. Subsequently, with delayed blood cell recovery, continuous transfusion was needed to replace platelets. In the CD3 peripheral blood chimerism test, the percentage of recipient cells on days 50, 63, and 80 was 27.3%, 90%, and 95% or higher, respectively. With no relapse of leukemia observed on bone marrow examination, secondary graft failure associated with autologous hematopoietic recovery was diagnosed. Bone marrow transplantation from the patient's HLA-haploidentical sister was performed because of graft failure on day 111 after the initial transplant using post-transplant cyclophosphamide (PTCy). Neutrophil engraftment was achieved and complete donor chimera was obtained on days 14 and 21 after the second transplantation, respectively. With no serious complications or acute graft versus host disease, the patient was discharged with symptomatic improvement. According to our results, retransplant using PTCy obtained from an HLA-haploidentical sibling donor is a potential treatment for graft failure.

Administration of antisense DNA for GPR39-1b causes anxiolytic-like responses and appetite loss in rats.

The G protein-coupled receptor 39-b (GPR39-1b) is a splice variant of which is expressed in the central nervous and gastrointestinal systems. Previously, GPR39-1b was proposed to be the receptor for obestatin, but current evidence does not support this hypothesis. The purpose of the present work was to identify the role of GPR39-1b in anxiety and eating behaviors. Antisense oligonucleotides were infused at a constant rate into the cerebral lateral ventricles of rats and their effect on anxiety-like behavior and food intake was monitored. GPR39-1b antisense oligonucleotides produced anxiolytic-like effects in the elevated-plus maze test and in the black and white box test. Antisense oligonucleotides also decreased food intake. These results indicate that inhibition of GPR39-1b induces a decrease in anxiety-related behaviors and disturbs appetite.