Abrupt cessation of immunosuppression in a patient with persistent acute lymphoblastic leukaemia following allogeneic transplantation.

A 20-year-old man with acute lymphoblastic leukaemia (ALL) in second complete remission underwent sibling donor transplant. Post-transplant there was haematological and immunophenotypic evidence of persisting disease. Cyclosporine was abruptly discontinued and following this the leukaemic clone disappeared. Discontinuation of immunosuppression may be of benefit in leukaemia which persists following transplant.

Hepatitis A immunization in HIV-infected haemophilic patients.

Forty-seven HIV-infected haemophilic patients were entered into a hepatitis A vaccination programme. 10 patients (21%) were lgG seropositive for hepatitis A consistent with past exposure. Of the 37 patients offered vaccination, one refused and 31 completed the vaccination course, 17/13 (55%) seroconverted, nine after the second and eight after the third injection, and 14 patients failed to seroconvert. The CD4 lymphocyte counts immediately prior to vaccination were significantly higher in the patients who developed immunity compared to the nonresponders (median CD4 count in the immune group 380 × 10(6) /1 (range 170-1290), median CD4 count in nonimmune group 110 × 10(6) /1 (range 10-590), P== 0.003). No patient with a CD4 count < 170 × 10(6) /1 seroconverted and five patients with well-preserved CD4 counts also failed to seroconvert. We conclude that HIV-infected haemophilic patients, especially those with more advanced disease, have an impaired response to hepatitis A vaccination. Due to the likely failure of response in patients with CD4 counts < 150 × 10(6) /1, it is reasonable not to include these patients in a hepatitis A vaccination programme.

Outpatient management of DVT using low molecular weight heparin and a hospital outreach service.

In recent years there have been several studies comparing the efficacy and safety of low molecular weight (LMW) and unfractionated heparin for the treatment of deep venous thrombosis (DVT), showing them in the clinical trial setting to be equal in these regards. LMWH has the advantage of once daily subcutaneous injection and daily monitoring of levels is not usually required. This has led many centres to develop outpatient treatment strategies for these patients but evidence for the safety of this approach is scarce. In 1997 we developed a hospital outreach service for the treatment of patients with DVT and, in a retrospective study, have compared the outcome in 172 patients treated at home with 172 age, sex and thrombotic risk factor matched inpatients treated at our institution with unfractionated heparin. Five patients in the home treatment group suffered a haemorrhagic event, compared with six patients in the hospital group. One patient in the home treatment group had a recurrent DVT within the first 3 months of treatment; in the hospital-treated group, six patients had recurrent DVTs and nine developed pulmonary emboli. At 3 months, there were three deaths in the home treatment group, compared with five deaths in the hospital group. There was no difference in re-admission rate at 3 months: 23 in the home treatment group, 24 in the hospital-treated group. Average length of hospital stay for the home-treatment group was 2.1 days and 12 days for the hospital group. Warfarin control was found to be significantly better in those patients treated at home, and only 18% of patients treated in hospital received heparin according to hospital guidelines. In conclusion, outpatient management of patients with DVT using LMWH is as safe as hospitalization and continuous infusion of unfractionated heparin. The complication rate was lower in the home treatment group and, in particular, the incidence of recurrent thrombosis was significantly less in the home treatment group. In addition, warfarin control was better when managed by specialist nurses. Patients expressed a preference for home treatment.

A fourth case of 8p11 myeloproliferative disorder transforming to B-lineage acute lymphoblastic leukaemia. A case report.

A 56-year-old male presented with inguinal lymphadenopathy and leucocytosis (WBC 98 x 10(9)/l). Bone marrow morphology showed myeloid hyperplasia, with eosinophilia. Cytogenetic analysis showed no evidence of the Philadelphia chromosome, and fluorescence in situ hybridisation studies for the BCR/ABL fusion were negative. All cells examined showed the t(8;13)(p11;q12) translocation. Six weeks after presentation, the disease progressed to an acute lymphoblastic leukaemia (ALL). The lymphoblasts were CD19/CD10 dual positive. Cytogenetic analysis again showed the t(8;13) translocation, with no additional abnormalities. There have been at least 14 reported cases of the t(8;13) myeloproliferative disorder to date, of which only 3 transformed to B-lineage ALL: our case is the 4th.