[Successful treatment with rituximab in a patient with refractory thrombotic thrombocytopenic purpura refractory to plasma exchange].

We report a patient with refractory idiopathic thrombotic thrombocytopenic purpura (TTP) who was successfully treated with rituximab. A 50-year-old woman was referred to our hospital with progressive psychoneurotic symptoms, hemolytic anemia and thrombocytopenia. The diagnosis of TTP was confirmed by the absence of ADAMTS13 activity with the presence of circulating ADAMTS13 inhibitor. High-dose steroid therapy and plasma exchange were performed. Despite 21 sessions of plasma exchange, however, there was no remarkable improvement. We then administered rituximab. Fifteen days after the first infusion of rituximab, she achieved complete remission and ADAMTS13 activity increased up to 14%. The patient has remained in remission for more than 9 months.

Lymphoplasmacytic Lymphoma Presenting with Diarrhea and Joint Pain Which was Successfully Diagnosed by an MYD88 Mutation Analysis.

A 55-year-old man presented to our department with diarrhea, weight loss, fatigability, and polyarthralgia. Blood tests revealed elevated soluble interleukin-2 receptor levels and IgG-type M protein positivity, without any findings that were suggestive of collagen disease. After computed tomography (CT) detected enlarged lymph nodes in the abdominal para-aortic region, lymphoma was suspected. CT-guided needle biopsy of the lymph node did not help to achieve a definitive diagnosis; however, a bone marrow test showed the pathological features of B-cell lymphoma. A genetic examination detected a MYD88 L265P mutation; the mutation analysis was valuable in diagnosing lymphoplasmacytic lymphoma in a IgM-type M protein-negative patient.

Clinicopathological features of cryptococcal lymphadenitis and a review of literature.

Cryptococcosis is an invasive fungal infection in immunocompromised patients. The clinicopathological characteristics of cryptococcal lymphadenitis are not well known. We analyzed three cases of cryptococcal lymphadenitis and compared their characteristics with those in previous reports. Two patients were human immunodeficiency virus (HIV) carriers, and one patient was a human T-cell leukemia virus type-1 (HTLV-1) carrier. The age of the HTLV-1 carrier with cryptococcosis was much higher than that of the HIV-1 carriers. CD4-positive cell counts in peripheral blood were 5.8/µL (Case 1) and 79.9/µL (Case 2) in the HIV carriers and 3285/µL in the HTLV-1 carrier (Case 3). According to flow cytometric analysis of the lymph nodes of Cases 1, 2, and 3, 50.0%, 87.1%, and 85.9%, respectively, of the T-cells were CD3; 9.8%, 16.3%, and 75.8%, respectively, were CD4; and 35.5%, 77.3%, and 10.2%, respectively, were CD8. Cryptococcus neoformans was detected in tissue culture in all patients. Although gelatinous lesions and numerous fungal cocci were observed in the two HIV patients, the granuloma formation was small. Gelatinous formation and granuloma formation were observed in the HTLV-1 carrier. Necrosis was observed in all cases. In previous reports, granuloma formation, epithelioid cells, and necrotic lesions were observed in most cases. Most of the patients were also immunosuppressed. However, no HTLV-1 carrier was detected. In conclusion, lymphadenopathy in a HTLV-1 carrier may suggest the presence of cryptococcal lymphadenitis. The frequency of cryptococcosis in HTVL-1 carriers may increase with increase in the long-term survival rate of HTLV-1 carriers.

A retrospective cohort study of venous thromboembolism(VTE) in 1035 Japanese myeloma patients treated with thalidomide; lower incidence without statistically significant association between specific risk factors and development of VTE and effects of thromboprophylaxis with aspirin and warfarin.

BACKGROUND: Rate of thalidomide-related VTE and risk factors in Japanese myeloma patients are not clear and effects of thromboprophylaxis remain controvertial. PATIENTS AND METHODS: We retrospectively analyzed a cohort data of registered Japanese myeloma patients treated with thalidomide-based regimens between 2009 and 2010. Primary endpoint was rate of symptomatic VTE. Secondary endpoints were associations between VTE and clinical factors including age, gender, disease characteristics and duration, history of VTE, immobilization, comorbidities, treatment regimens, and laboratory parameters of Hb, leukocyte, platelet and FDP or D-dimer level, and effects of thromboprophylaxis with aspirin or warfarin. Statistical analysis was performed by Fischer's exact test and Cochran-Mantel-Haenszel test to control for confounders, and t test for dichotomous and continuous variables, respectively. RESULTS: 1035 refractory or relapsed myeloma patients were followed up for a median of 112days(range 2-311days), and 14 (1.4%) developed VTE with a median treatment of 31days (range 9-134days) with thalidomide. Treatments with or without other agents lead to similar rates of VTE, 1.7% and 1.1%, respectively (p=0.43) and no specific clinical factors influenced development of VTE. Thromboprophylaxis with aspirin or warfarin did not reduce risk of VTE; VTE with or without aspirin: 1.4% and 1.3% (p=1.00), and warfarin: 2.4% and 1.3% (0.31), respectively. CONCLUSIONS: Rate of VTE is low in Japanese myeloma patients treated with thalidomide. Risk factors and effects of thromboprophylaxis with aspirin or warfarin are not apparent, however, controlled randomized studies of larger scale are needed for statistically valid conclusion.