[2 cases of neutropenic enteropathy and bone marrow hypoplasia. An association not reported in Mexico]

Neutropenic enterocolitis (NE) is a serious complication in neutropenic patients; it often affects the cecum and the ascending colon. Most cases have been reported in neutropenic patients after chemotherapy for hematologic neoplasms, and some in association with conditions such as rheumatoid arthritis, benign cyclic neutropenia, and solid neoplasms. As far as we know, four cases of NE associated to AA (aplastic anemia, hypoplastic bone marrow) have been previously reported, two of them with autopsy studies. The macroscopic findings in the enterocolonic lesions were not illustrated. We report the first two cases in Mexico. The NE was neither clinically nor radiographically suspected initially, i.e. the morphologic diagnosis of their colonic lesions were amebic colitis in one and edematous ulcerated colitis in the other. Medical treatment without surgery was instituted. Both died. The macroscopic aspect of the enterocolonic lesions in NE associated to aplastic anemia in our two patients was similar to that in NE associated to hematologic neoplasms. In Mexico there is little experience in the clinical, radiographic or morphologic diagnosis of this rare association.

[Results of treatment for severe acquired aplastic anemia in children]

The authors evaluated results of treatment of 106 children with acquired aplastic anemia. The patients were divided into 3 groups depending on the severity of their disease. Thirty-nine patients were classified as very severe, 30 as severe and 37 as non-severe according to the modified Camitta criteria. Among them, 47 children were treated with oxymetholone and prednisolone. In this group 32 died. Antilymphocyte globulin (ALG) was given to 48 patients and 20 received cyclosporin A (CsA). The results obtained by these two methods are nearly the same and 5 year survival was 61% and 59% respectively. Bone marrow was transplanted in only one child, who is still in complete remission. Statistical analysis showed a steady increase in incidence of aplastic anemia in the years 1987-1989, which might coincide with the Czarnobyl explosion. However, further research is required to prove this point.

Identification of a specific HLA class II haplotype strongly associated with susceptibility to cyclosporine-dependent aplastic anemia

Hematopoietic function of some aplastic anemia (AA) patients is dependent on the administration of cyclosporine (CyA). To investigate whether certain HLA class II genes are associated with susceptibility to such CyA-dependent AA, we determined the HLA class II alleles of 59 AA patients treated with CyA. Among 26 patients successfully treated with CyA, 13 required a small dose of CyA to maintain stable hematopoiesis. Of these 13 AA patients, 10 shared an HLA class II haplotype of DRB1*1501-DQA1*0102-DQB1*0602. None of the 13 responders who obtained a sustained remission off CyA therapy possessed this haplotype. In the 10 patients who shared the HLA class II haplotype, single-strand conformation polymorphism analysis of each gene fragment of this haplotype failed to detect a polymorphism in the nucleotide sequence. When the AA patients were assessed for their likelihood to respond to CyA therapy, the response rate in patients with this haplotype (71%) was significantly higher than that of patients with another haplotype associated with HLA-DR2, DRB1*1502-DQA1*0103-DQB1*0601 (36%) and that of patients without HLA-DR2 (35%). These findings indicate that the CyA-dependent response of AA is closely related to an HLA class II haplotype of DRB1*1501-DQA1*0102-DQB1*0602 and suggest that, in AA patients with this haplotype, immune mechanisms play an important role in the pathogenesis of bone marrow failure.

Aplastic anemia after liver transplantation for fulminant liver failure

We determined the incidence and outcome of aplastic anemia among 56 patients who underwent liver transplantation for fulminant liver failure at the University of Nebraska Medical Center between July 1985 and December 1993. Aplastic anemia developed in 6 of 18 (33%) children and 1 of 19 (5%) adults who had fulminant non-A, non-B hepatitis; no cases of aplastic anemia occurred among patients with other causes of fulminant liver failure. None of these patients had evidence of a preexisting hematological disorder or infection with hepatitis C virus (as determined with a second-generation ELISA). Aplastic anemia was diagnosed at a median of 4 wk after the onset of hepatitis, with five cases seen before transplantation. Six patients received antithymocyte globulin to promote remission of aplastic anemia. Three children died (fungal infection in two, intracranial hemorrhage in one)--one at 43, one at 108 and one at 119 days after transplantation--without remission of aplastic anemia. Among the four surviving patients, with median follow-up of 25 mo, complete and partial remission of aplastic anemia have occurred in three and one, respectively. Liver allograft function is stable in all surviving patients. The data demonstrate that aplastic anemia is a common complication among children who undergo liver transplantation for fulminant non-A, non-B hepatitis. It is associated with a high rate of mortality, although most survivors appear to have full hematological recovery.

Immunological recovery after bone marrow transplantation for severe aplastic anaemia: a Brazilian experience

Twenty-nine patients with severe aplastic anaemia (SAA) were submitted to bone marrow transplantation (BMT) and their immunological recovery analysed. Total lymphocyte counts, estimation of B lymphocytes, T lymphocytes and their subsets, natural-killer (NK) activity were performed. Cells with the CD8+ phenotype and NK activity were the first signs of immunological recovery, whereas the CD4+ subset recovered later in patients who suffered from acute graft versus host disease (GvHD) and infections. Acute and chronic GvHD, cirrhosis, rejection and HIV viral infection contributed to the persistence of the profound immunodeficiency status observed after BMT. Our results did not differ greatly from the others and confirmed that BMT may be performed in underdeveloped countries despite the difficulties it might pose.

Surveillance of drug induced diseases in children

A hospital based prospective study on drug induced diseases (DID) in children below 14 years of age was done for a duration of two years. A total number of 20,310 patients were examined in pediatric department during this period, out of which 204 (1.004%) patients were diagnosed as DID. Children with severe reactions were admitted in pediatric ward for in hospital intensive surveillance. The male:female ratio in DID was 1.2:1. DID were most common in neonates (24.51%). Erythmatous maculopapular rashes (67.12%) formed the most common pool of DID in neonates. Thrombophlebitis (41.56%) was most commonly seen in infants above 28 days of life, and in children up to 14 years of age. Out of 204 cases of DID, 9 (4.41%) died. Aplastic anemia was most morbid DID, as all the 7 patients of aplastic anemia died. Chloramphenicol was responsible for all the cases of aplastic anemia. Other two deaths were from erythma multiforme and C.C.F. The most commonly involved drugs, other substances and vaccines were baby powders, massage oils, ampicillin, co-trimoxazole, i.v. infusions (electrolytes and mannitol), DPT and measles vaccines.

Clinical characteristics of children with hereditary hemolytic anemias and aplastic crisis: a 7-year review

We reviewed the clinical courses of children < or = 16 years of age with hereditary hemolytic anemias who were admitted to the University of Mississippi Medical Center for aplastic crisis. Constitutional signs, gastrointestinal complaints, and headache were the most frequent findings. Statistically significant decreases in hemoglobin levels, hematocrit, and reticulocyte counts, but not total white blood cell or platelet counts, were found on admission when compared to other times of determination. For 27 of 49 patients, IgM antibody determinations to human parvovirus (B19) were available, and 15 (56%) had positive values. We conclude that erythroid (but not other) blood cell lines are helpful in establishing a clinical diagnosis, and that both acute and convalescent titers are necessary to assess the immune response to the infection. Physicians should continue to search for agents other than B19 parvovirus in patients in whom B19 antibodies cannot be found.

Bone marrow transplantation in Taiwan: low incidence of acute GVHD in patients with hematologic malignancies and severe aplastic anemia

A total of 116 consecutive patients, including 82 cases of hematologic malignancies and 34 cases of severe aplastic anemia (SAA), were treated by allogeneic bone marrow transplantation (BMT). The conditioning regimens and post-graft immunosuppressive agents were as described by Thomas in Seattle and Santos in Baltimore. The incidence of grades II-IV acute GVHD in patients with hematologic malignancies with a full HLA match, with one locus and with two loci mismatches was 6.3% (4 of 63), 0% (0 of 11) and 37.5% (3 of 8), respectively. None of SAA patients developed grade II-IV acute GVHD. The low incidence of acute GVHD after BMT among Chinese patients may be associated with the use of isolation in laminar airflow rooms and a relatively low level of genetic diversity in histocompatibility antigens. This is an interesting issue for further study.

Bone marrow transplantation in India

Beginning in early 1983, bone marrow transplantation (BMT) facilities in India have undergone slow but steady growth. With about 50% disease-free survival in acute myeloid leukaemia and aplastic anaemia and 90% survival in thalassemia major, the results are encouraging. However, the outcome in chronic myeloid leukemia so far has been poor. There is urgent need for expansion of BMT facilities in India.

Allogeneic bone marrow transplantation in Korea: 1983-92

Between March 1983 and December 1992, we performed 178 allogeneic BMTs for patients with hematopoietic stem cell disorders: 48 acute myelogenous leukemia (AML), 27 acute lymphoblastic leukemia (ALL), 40 chronic myelogenous leukemia (CML), 55 severe aplastic anemia (SAA), 6 myelodysplastic syndrome (MDS), 1 non-Hodgkin's lymphoma and 1 hybrid leukemia. Twenty-five of 48 AML are in disease-free survival (DFS). Fifteen of 27 ALL are in unmaintained remission. Twenty-four of 40 CML are in DFS. Forty-four out of 55 SAA patients are alive and well. Comparing the survival between standard (< or = CR1: 21 of 31 (68%)) and high risk (> or = CR2: 4 of 17 (24%)) AML, our data suggest that the preparative regimen for high risk AML was not potent enough to eradicate the residual disease in advanced AML. Although our cases are limited and the follow-up period is short, the result of ALL (overall: 56%, standard risk (adult < or = CR1, children < or = CR2: 10 of 14 (71%) and high risk (adult > or = CR2, children > CR2): 5 of 13 (38%)) and CML (overall: 60%; CP: 19 of 27 (70%), AP or BC: 5 of 13 (38%)) are promising. The probability of 5 year survival of SAA was 80 +/- 4 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone marrow transplantation in New Zealand. New Zealand Bone Marrow Transplant Study Group

From their initiation in 1979 until the end of 1992, five New Zealand transplant centres have carried out a total of 233 bone marrow transplants, of which 149 were allografts and 84 autografts. The New Zealand Bone Marrow Transplant Study Group aims to coordinate the transplant programmes and maintains a collaborative register of transplants. This report provides a brief overview of transplantation activity within New Zealand and summarises the results.

Bone marrow transplantation in Iran

Seventy-three BMT procedures (42 allogeneic-BMT, 30 autologous-BMT, 1 syngeneic transplant) were undertaken at the Shariati Hospital in Tehran between March 1991 and November 1993. Allogeneic-BMT was performed for thalassaemia major (n = 23), AML in complete remission (n = 3), severe aplastic anaemia (n = 7), CML (n = 7), dyskeratosis congenita (n = 2) and Fanconi anaemia (n = 1). Conditioning regimens comprised busulphan (BU) plus cyclophosphamide (CY) or CY only. Thirty-two (78%) of the 43 patients remain alive 1-34 months after BMT. Twelve patients died: the causes of death were haemorrhagic cystitis (n = 1), CMV pneumonitis (n = 1), GVHD (n = 3), infection (n = 3), rejection (n = 1), VOD (n = 2) and hepatitis (n = 1). Autologous-BMT was performed for patients with AML in CR (n = 16), ALL in CR (n = 9), lymphoma in relapse (n = 3), Ewing sarcoma (n = 1) and multiple myeloma (n = 1). The median age was 18 years. Conditioning regimens were Ara C plus CY, etoposide plus CY and high-dose melphalan. Sixteen (54%) of the 30 patients survive, 14 in continuous complete remission. The causes of death were relapse (AML (n = 7), ALL (n = 4), lymphoma (n = 1)), VOD (n = 1) and infection (n = 1).

Unrelated bone marrow donor registry in Japan: the Central Coordination Committee of the Japan Marrow Donor Foundation. Japan Donor Marrow Program

The Japan Marrow Donor Program (JMDP) was officially funded as of December 1991. The process of donor recruitment has been successful and the registry now has an enrollment of 32,140 Japanese donors with approximately 1200 donors being added monthly. The number of unrelated transplants facilitated through JMDP is increasing and 62 unrelated BMTs have been carried out since January 1993. The unique composition of donor pool of JMDP will be helpful with respect to international cooperation in unrelated BMT.

Bone marrow transplantation in Thailand

In Thailand aplastic anemia and thalassemias as well as leukemias and lymphomas are prevalent. Bone marrow transplantation has been used to cure these patients. The results are more favorable in non-malignant diseases than in hematological malignancies. The incidence of GVHD and CMV infection is low. There are still some unresolved problems, especially lack of personnel, limited facilities and high cost.

EBMT survey on bone marrow transplant activity in Europe: regional differences

In the years 1991 and 1992, 203 teams in 26 European countries performed 11026 BMT procedures: 4841 allografts and 6185 autografts; 10263 (93%) were performed in those 12 countries which did at least 100 transplants in total and five transplants per 1 million inhabitants per year during this 2-year period. Indications for these 10263 BMT were leukemia in 5080 patients (3294 allo-BMT, 1786 auto-BMT), lymphopro-liferative disorders in 3177 patients (329 allo-BMT, 2848 auto-BMT), solid tumors in 1236 patients (18 allogeneic-BMT), 1218 autologous-BMT), aplastic anemia in 305 patients and hemoglobinopathies or inborn errors of disease in 465 patients (456 allogeneic-BMT, 9 autologous-BMT). The proportion of allogeneic- and autologous-BMT, the main indications and the timing (first complete remission versus later stages) were compared between these 12 countries. Differences and similarities can be observed in all three aspects. They underline previously described differences in Europe which can partially be ascribed to different patient populations but may also be caused by divergent medical opinions.

Hematopoietic malignancies and related disorders among benzene-exposed workers in China

Although the relationship between benzene and acute nonlymphocytic leukemia (ANLL) is well established, most of the analytic cohort investigations examining the relationship between benzene and hematologic neoplasms have evaluated only death certificates to validate diagnoses. In a follow-up study of 74,828 benzene-exposed and 35,805 non-exposed workers in China, pathology reports, medical records, and/or histopathologic material were reviewed for all patients with hematopoietic malignancies to ensure correct classification and to provide clinicopathologic descriptions. Eighty-two patients with hematopoietic neoplasms and related disorders were identified among benzene-exposed workers, including 32 cases of acute leukemia, 7--myelodysplastic syndrome (MDS), 9--chronic granulocytic leukemia (CGL), 20--malignant lymphoma or related disorder (ML), 9--aplastic anemia, and 5 others. Among the comparison group, 13 hematologic malignancies were observed, including 6 patients with acute leukemia, 2--CGL, 3--ML, and 2 others. The hematopathologic characteristics of the benzene-exposed ANLL cases resembled those following chemotherapy or radiotherapy. ANLL in workers exposed to benzene may represent a distinct clinicopathologic entity, with characteristics similar to treatment-related ANLL, including a preceding preleukemic phase in some patients. Results in our series, one of the largest to data, also indicate that a greater diversity of hematologic neoplasms is evident among benzene-exposed workers than previously described.

Bone marrow transplantation in Taiwan: an overview

In Taiwan, a country with 21 million people, 388 bone marrow transplants (BMTs), 308 allografts and 80 autografts, were performed in 5 BMT centers from November 1983 to October 1993. The commonest indications were leukemia, aplastic anemia, lymphoma and thalassemia. Campaigns promoting an unrelated marrow donor registry were started in August 1993 and recruited approximately 26,000 volunteers. A peripheral stem cell program is just beginning. The overall results of BMT in Taiwan are comparable to other countries. The complications of BMT are similar to Western series, except that acute GVHD was rarer in one large series; this observation needs further study. A particular indication for allogeneic BMT in Taiwan is thalassemia, accounting for 10% of all patients. Disease-free survival after BMT for thalassemia is 44%; graft rejection is the major cause of treatment failure. Another important issue is the role of hepatitis B virus (HBV) in BMT, since the prevalence of HBV infection in Taiwan is very high (> 90%). Abnormal liver function is currently the most common complication and might be related to HBV. Among nearly 100 allogeneic BMTs with HBV carriers as either donor or recipient, 2 patients (approximately 2%) died of HBV-related hepatic failure. Whether the HBV status of the donor and recipient is an important prognostic factor remains to be defined.

Graft rejection and second bone marrow transplants for acquired aplastic anaemia: a report from the Aplastic Anaemia Working Party of the European Bone Marrow Transplant Group

Six hundred and eighteen patients with acquired aplastic anaemia grafted from an HLA-identical sibling donor between 1976 and 1990 in eight European centres were reported to the Working Party for Severe Aplastic Anaemia (SAA) Registry and were evaluable for analysis of the incidence of graft failure/rejection and the outcome of second bone marrow transplants (BMT). The number of patients experiencing graft rejection declined significantly over the study period from 32% to 8% (p < 0.0001). This coincided with the introduction of cyclosporine to the conditioning regimen for BMT. The graft rejection rate in the post-hepatitis SAA group was significantly lower than in the group with idiopathic SAA (4% vs 20%) (p = 0.001). The use of irradiation in the conditioning regimen significantly reduced the number of patients experiencing graft rejection (7% vs 21%) (p = 0.004). Age, sex and severity of disease did not influence the rate of sustained engraftment. Of the 85 patients experiencing graft rejection, 41 received a second transplant: their survival is 33% vs 8% for patients not transplanted a second time (p = 0.003). The major factor predicting the outcome of second BMT for SAA was the interval from first BMT. Patients receiving a second BMT within 60 days from the first BMT had a significantly poorer outcome.

Severe aplastic anaemia--an aetiological correlation

Over 4 years, 43 cases of severe aplastic anaemia (SAA) were seen. Etiologically 58.1% had idiopathic, 39.5% secondary and 2.3% congenital aplastic, anaemia. Idiopathic SAA was more common in patients between 0-15 years of age, whereas secondary SAA was more frequent in 16-60 years age group. Males were more commonly affected with a male:female ratio of 3.3:1. Amongst 17 cases of secondary SAA, chloramphenicol was responsible for 4, septran for 3, insecticides for 2 and anti-scabitic drugs, anti-diabetic drugs and "kushta from hakeem" in one patient each. Hepatitis associated SAA was suspected in 3 cases.

[Acquired aplastic anemia: a stereological analysis of bone marrow fatty tissue and its clinical correlations]

BACKGROUND

To analyze the changes of the number and size of bone marrow adipocytes in aplastic anaemia. To discover possible clinical and haematological factors which may be associated with predominant expansion of the number or size of adipocytes. To analyze the prognostic value of the adipocyte number and size.

METHODS

The adipose tissue of 25 plastic-embedded bone marrow specimens corresponding to patients with aplastic anaemia was studied stereologically. The correlation study between the results obtained and clinical and haematological data was carried out.

RESULTS

The expansion of the adipose tissue is due to the predominant increase of the adipocyte number in some cases and of the adipocyte size in others. Among different clinical and haematological factors, only a lower age is significantly associated with a predominant increase of adipocyte number. In the prognostic stratification performed according to three different systems, neither the adipocyte number nor the size showed a statistically significant association.

CONCLUSIONS

In the aplastic anaemia, the younger patients expand their bone marrow adipose tissue by increasing predominantly the adipocyte number, whereas in the older patients this occurs by predominantly increasing the adipocyte size (may be due to the decrease in proliferative potential). On the other hand, both the adipocyte number and size lack prognostic significance.

Risk of agranulocytosis and aplastic anemia in relation to history of infectious mononucleosis: a report from the international agranulocytosis and aplastic anemia study

The general objective of this study was to evaluate the risks of agranulocytosis and aplastic anemia in relation to drug use. Other potential risk factors, including history of infectious mononucleosis, were also evaluated. In an international population-based case-control study, cases of agranulocytosis and aplastic anemia and controls, who were patients with selected diagnoses, were identified from the same hospitals. Information on drug use was obtained in a structured interview. Limited information on environmental exposures and on selected items of medical history, including infectious mononucleosis, was also recorded. The possible effects of these factors on the risk of the two blood dyscrasias were evaluated. Relative risks were estimated by stratified analysis and by multiple logistic regression. Among 319 cases of agranulocytosis, 12 patients (4%) gave a history of infectious mononucleosis at least 1 year previously; among 2180 controls the corresponding number was 11 (0.5%) (multivariate relative risk estimate, 6.2; 95% confidence interval, 2.3-17). A nonsignificant elevation in the relative risk was observed for aplastic anemia. The data suggest that infectious mononucleosis may confer a long-term increase in the risk of agranulocytosis. However, the association was an unexpected one, identified in the course of multiple comparisons, and it must be independently confirmed.

Human parvovirus infection in homozygous sickle cell disease

We studied the epidemiology of human parvovirus B19 infection in 308 children with homozygous sickle cell (SS) disease and 239 controls with a normal haemoglobin (AA) genotype followed from birth in a cohort study. Annual serum samples identified the time and frequency of B19 infection, which did not differ between SS and AA children, about 40% of each group developing specific IgG by age 15. B19 infection followed an epidemic pattern similar to that observed for aplastic crises; accounted for all 91 aplastic crises that occurred; and was found in an additional 23 SS patients, of whom 10 showed mild haematological changes and 13 no changes. The magnitude or duration of IgG response did not differ between these groups. No patient had 2 attacks of aplasia and no patient nor control had 2 attacks of B19 infection. Following B19 infection, serial specific IgG concentrations remained high after 5 years in only 45% of SS patients, although the rarity of recurrent aplasia suggests lifelong immunity. B19 infection accounts for most if not all aplastic crises in SS disease, but at least 20% of infections do not result in aplasia. An effective vaccine against B19 might make an important contribution to the management of sickle cell disease.

Epidemiology of aplastic anemia in France: a case-control study. I. Medical history and medication use. The French Cooperative Group for Epidemiological Study of Aplastic Anemia

Aplastic anemia (AA) is a rare, severe disease of mainly unknown origin. Numerous case history reports have incriminated drugs in the etiology of this disease. Because those reports were questionable, a case-control study was conducted in France between 1985 and 1988. Cases selected from the national register were eligible for inclusion when at least two blood lineages were depressed (hemoglobin < or = 10 g/100 mL and reticulocytes < or = 50 x 10(9)/L, granulocytes < or = 1.5 x 10(9)/L, platelets < or = 100 x 10(9)/L) and when the bone marrow biopsy was compatible with the disease. Using a standardized questionnaire, trained investigators interviewed one AA patient and two groups of controls (two hospitalized patients and one neighbor of the AA patient) matched for age, sex, and interviewer. One hundred forty-seven AA patients, 287 hospitalized controls, and 108 neighbors were interviewed. The occurrence of AA was analyzed by matched design with relation to medical history and drug use during the last 5 years, and specifically during the last year. Three times as many AA patients reported having suffered from clinical hepatitis during the last 6 months than either type of control. Similarly, a higher proportion of AA patients reported a history of chronic immune disorder, mainly rheumatoid arthritis (odds ratio of 6.8), and a previous use of gold salts and D-penicillamine in the 5 previous years (odds ratio of 4.9 for each drug). An excess of colchicine and allo/thiopurinol intake in the 5 previous years was observed among the AA patients (odds ratio equal to 4.1 and 3.6, respectively). These results for gold salts, D-penicillamine, and colchicine were confirmed when looking for drug use within the last year. A moderate risk was associated with acetaminophen or salicylate intake during the 5 previous years or during the last year (odds ratio between 1.8 and 2.0). The frequent use of salicylates within the last year was associated with a high risk of AA (odds ratio of 5.0). A high risk was also associated with indolic derivative intake but only when comparing AA patients to neighbor controls. No association could be evidenced with diclofenac intake, whatever the control group. Differences observed with recently published studies suggest that targeted studies on each category of drugs according to the treated pathologies should be initiated.