The effect of thymectomy on myasthenia gravis, thrombocytopenia, and granulocytopenia associated with thymoma: report of a case.

We report the case of a 47-year-old woman with thymoma who developed myasthenia gravis, thrombocytopenia, and granulocytopenia, simultaneously, the concurrent association of these four disorders being extremely rare. Thymectomy was performed, and, during the post-thymectomy course, there were surprising findings concerning the recovery of not only the myasthenia gravis but also of the hematologic disorders. Immediately after thymectomy, the myasthenic symptoms completely disappeared, and the granulocyte and platelet counts recovered to within the normal range within a few days. The laboratory data revealed no difference between pre- and post-thymectomy in the release of cytokines (tumor necrosis factor; TNF, interleukin; IL-2, and IL-6), anti-acetylcholine receptor antibody, or platelet-associated IgG. On the other hand, the serum level of anti-neutrophil cytoplasmic antibody (p-ANCA), against the myeloperoxidase of the granulocytes was dramatically decreased, after thymectomy, showing a significant correlation with the granulocyte count. According to our survey of the literature, this is the first report to show that the removal of a thymoma led to the dramatic resolution not only of myasthenia gravis but also of other associated diseases. It is possible that p-ANCA may be regulated by thymoma, thus causing severe granulocytopenia.

Treatment of malignant glioma with high dose intra-arterial ACNU and autologous bone marrow transplantation--case report.

A 44-year-old female with malignant astrocytoma received subtotal removal and high dose (200 mg/m2) intra-arterial 1-(4-amino-2-methyl-5-pyrimidinyl)methyl-3-(2- chloroethyl)-3-nitrosourea hydrochloride (ACNU) with autologous bone marrow transplantation. Tumor remission with minimal bone marrow suppression was achieved. However, she developed severe encephalopathy and computed tomographic scans revealed a low-density area at the ACNU delivery site. She received glycerol solution to treat the brain edema and recovered completely from the encephalopathy. Intra-arterial ACNU exceeding 200 mg/m2 possibly causes neurotoxicity.

Typhlitis: selective surgical management.

Typhlitis is a neutropenic enterocolitis of varying severity. Its incidence is increasing, particularly in patients with acute myelogenous leukemia undergoing high dose cytosine arabinoside chemotherapy. The onset is heralded by prodromal fever, watery or bloody diarrhea, abdominal distension, and nausea during the phase of severe neutropenia. The symptoms may then localize to the right lower quadrant with an associated increase in systemic toxicity. The diagnosis can be confirmed in these and other less specific cases by serial reexamination and abdominal radiographs, ultrasonography, computerized tomograms, or radionucleotide scans. The mainstay of management is complete bowel rest with nasogastric suction and total parenteral nutrition. Broad-spectrum combination antibiotics are essential, as is the avoidance of laxatives or antidiarrheal agents. Granulocyte support may be helpful. Patients with a history of nonspecific gastrointestinal complaints or of true typhlitis, successfully managed nonoperatively, should have prophylactic bowel rest and total parenteral nutrition instituted at the beginning of further chemotherapy. Patients with ongoing severe systemic sepsis who do not respond to chemotherapy and those with overt perforation, obstruction, massive hemorrhage, or abscess formation require surgical intervention. All necrotic material must be resected, usually by a right hemicolectomy, ileostomy, and mucous fistula. Divided ileostomy for less severe cases may be useful. Failure to remove the necrotic focus in these severely immunocompromised patients is fatal. With adequate recognition of typhlitis and its precipitating factors, the incidence of complications can be reduced through prevention and timely surgical intervention. Although typhlitis developed in a quarter of our acute myeloblastic leukemia patients, use of this combined approach was successful in all cases.

Peritoneal lavage as an aid in the surgical management of neutropenic colitis.

Neutropenic colitis is a severe, often devastating complication of acute leukemia. The diagnosis can be difficult as the symptoms are often those of the leukemia itself or of the therapy being rendered. These anemic, thrombocytopenic, and severely immunosuppressed patients present great operative risks. Distinction between the surgical and nonsurgical abdomen can be a challenge for even the most experienced surgeon. Peritoneal lavage may serve as a means to help in this differentiation.