Transient dyserythropoiesis in repopulated human bone marrow following transplantation: an ultrastructural study

Transmission electron microscopy was used to examine marrow samples from 15 patients with aplastic anaemia or acute leukaemia who had been treated with bone marrow transplantation. There were 11 allogeneic, three syngeneic and one autologous graft. The purpose was to estimate the frequency, type and extent of dyserythropoietic change. Transient dyserythropoietic features were substantiated in all cases. Nuclear changes were present in 12 cases, iron laden mitochondria (sideroachrestic phenomena) in 10 and cytoplasmic contacts and/or connections between red cell precursors in 10. Dyserythropoiesis was most conspicuous in the majority of cases between 14 and 28 d after transplantation but it may persist for over 100 d. No deficit in red cell production was noted and it is proposed that dyserythropoiesis in this circumstance is a physiological rather than a pathological phenomenon.

Fatal airway disease in an adult with chronic graft-versus-host disease

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Tumour lysis syndrome with hypocälcaemia in accelerated chronic granulocytic leukaemia

Tumour lysis syndrome is a well-known complication of lymphoid malignancies, but it has rarely been described in myeloproliferative disorders. A patient is reported with myeloblastic type of accelerated chronic granulocytic leukaemia who developed a tumour lysis syndrome following intensive chemotherapy. The most prominent manifestation of such a syndrome was hypocalcaemia, which was associated with other biochemical alterations, including hyperphosphataemia, hyperuricaemia and renal failure.

Comparative morphology of granulocytes collected by three methods of leukapheresis. A light microscopy and transmission electron microscopy study

The morphology of granulocytes collected by continuous-flow centrifugation (CFC), discontinuous-flow centrifugation (DFC), and continuous-flow filtration (CFF) was investigated in 18 healthy donors by means of light microscopy and transmission electron microscopy. Light microscopy study of semithin sections of granulocytes collected by CFC and DFC showed minimal morphologic abnormalities, compared to granulocytes procured by CFF. Ultrastructural study of granulocytes procured by CFF showed more conspicuous qualitative and quantitative abnormalities (the most prominent being "microvilli," degranulation, and bazarre chromatin) than in granulocytes obtained by the other two methods. Controls showed that the bulk of CFF-cell abnormalities was due to the "tapping" of the filters. Factors such as the mechanical compression (plasma extractor) used in DFC method, donor pretreatment with anticoagulants and steroids, hydroxyethyl starch, and duration of leukapheresis scarcely influenced granulocyte morphology.

Evaluation of a protective environment in the management of granulocytopenic patients: a comparative study

Fever, clinical infection, bacteriologically documented infection, and death from infection were evaluated in 95 consecutive uninfected patients with severe granulocytopenia (less than 0.5 x 10(6)/liter). Patients were randomly allocated to reverse isolation and prophylactic oral nonabsorbable antibiotics or to open ward care. The microbiologic surveillance of air samples and stool cultures showed reduction of pathogenic organisms in patients treated in protective environment units. There was a statistically significant reduction in the incidence of fever (80% vs. 39.6%; P less than 0.001), clinical infections (55.3% vs. 25%; P less than 0.01), bacteriologically documented infections (53.2% vs. 20.8%; P less than 0.01), and deaths from infections (25.5% vs. 8.3%; P = 0.02) in patients treated in a protective environment as compared with patients treated on the open ward.

Prognostic significance of bone-marrow patterns in chronic lymphocytic leukaemia

Bone-marrow biopsy has been performed in 63 cases of chronic lymphocytic leukaemia (CLL). Four different histological patterns were observed: (a) interstitial (lymphoid infiltration without displacement of fat cells) in 12 cases; (b) nodular (abnormal lymphoid nodules without interstitial infiltration) in 10 cases; (c) mixed (combination of the first two patterns) in 21 cases; and (d) diffuse (replacement of both haemopoietic and fat cells by lymphoid infiltration) in 20 cases. Statistical analysis of actuarial curves showed a significant difference of survival probability according to the bone marrow infiltration patterns. Thus, in patients with interstitial or nodular patterns the life expectancy is significantly longer than in those with mixed or diffuse patterns. furthermore, a significant degree of correlation between bone marrow infiltration patterns and different methods of clinical staging in CLL was apparent. The different bone marrow infiltration patterns in CLL probably reflects variations in the amount of lymphoid accumulation during the natural course of this disease. Because of its prognostic significance, bone marrow biopsy should have a place in CLL evaluation and staging.

Prognosis in acquired aplastic anaemia. A multivariate statistical analysis of 80 cases

Prognostic factors were studied in a series of 80 patients with aplastic anaemia. The most important and easily obtainable individual variables, isolated in a previous univariate statistical analysis, were placed in a linear logistic regression model. A prognostic formula was derived containing the following 4 variables, in decreasing order of significance: (1) reticulocytes, (2) interval from onset of symptoms to first visit, (3) mean red cell volume, and (4) platelets. The prognostic formula permits an estimate of the probability of death within 3 months from the first visit. Its usefulness in several clinical situations, especially those related to bone marrow transplantation, is illustrated.

[Legionnaires' disease. First observations in Catalonia (author's transl)]

The authors report the first two cases of legionnaires' disease from Catalonia. Both patients were chronic bronchitic males, and the cases were sporadic. The onset of the disease was characterized by a febrile illness with muscle and joint pains, respiratory symptoms (cough and mucous sputum production), and mental changes. There were no digestive complaints. Pulmonary consolidation occurred in both patients in the left upper lobe. Blood chemistries disclosed the existence of an absolute lymphopenia, altered liver function tests, and elevated CPK levels. Bacterial cultures of blood and sputum, respiratory virus screening (influenza A and B, parainfluenza 1, 2 and 3, and adenoviruses), and tests for Mycoplasma pneumoniae, Coxiella burnetti and Chlamydia psittaci were all negative. Antibody titers against Legionella pneumophila by indirect immunofluorescence were 1/1024 (positive) for serotype 1 and 1/1024 (positive) for serotype II in one patient, and 1/1024 (positive) for serotype I and 1/128 (negative) for serotype II in the other patient. The authors review the epidemiological, clinical, biochemical and diagnostic aspects of legionnaires' disease, which knowledge will undoubtedly allow to detect an increasing number of cases.

[Hodgkin's disease presenting as an hepatic disease. Report of two cases (author's transl)]

During the course of Hodgkin's disease there is a low incidence of clinical manifestations of liver involvement: less than 15% of the patients present jaundice at some time during the evolution of their disease. The initial manifestation of Hodgkin's disease as an hepatic illness is a rare event. Two such cases are herein reported. The first patient was a 68 year-old male with a febrile illness of one month duration who 15 days before admission presented painless jaundice, dark urine, and discolored stools. The clinical work-up pointed to the possible existence of an extrahepatic cholestasis. At laparotomy a normal biliary tree was found, and surgical liver biopsy disclosed severe tissue cholestasis and a granulomatous portal reaction constituted by white blood cells, eosinophiles and histiocytes, most of them atypical and some showing features of Reed-Sternberg cells. The second patient was a 21 year-old male with a febrile illness of four months duration who developed jaundice and progressive mental obtundation one week before admission. The biochemical studies demonstrated severe pancytopenia and signs of advanced liver failure. Percutaneous liver biopsy disclosed a normal hepatic architecture and the presence of numerous atypical histiocytes in the portal areas. Lymphography showed sizeable pelvic and paraaortic lymph nodes. Subsequent laparotomy for lymph node biopsy confirmed the diagnosis of Hodgkin's disease, nodular sclerosis type. The authors suggest that hepatic Hodgkin's disease must be considered in the differential diagnosis of any febrile illness with jaundice.

[Reflections on internal medicine in university-affiliated hospitals (author's transl)]

The author analyzes the origins of the crisis of Internal Medicine and deals with its present situation as it is currently lived in the academic institutions. The identity and qualities of the internist are discussed, and the requirements to be fulfilled for a physician to be defined as an internist are outlined. The main conditions for the proper operation of an Internal Medicine Department are defined as it regards its structure and the different facets of the assistant, teaching and research functions. Finally, the author discusses the roles of the internists and the specialists in the fulfillment of the above functions.

Mesenteric hyaline plasma cell lymph node hyperplasia with amyloid deposits

Lymph node hyperplasia (mixed hyaline vascular and plasma cell type) of mesenteric localization in a young woman was accompanied by noticeable systemic manifestations--fever, highly increased sedimentation rate, anemia, and hypergammaglobulinemia--that disappeared after the tumor was removed. Perivascular deposits of amyloid material were found within the tumor and in the spleen. To our knowledge, this finding has not been previously reported. On the basis of earlier studies in the literature and other considerations, an immunologic disorder is proposed as the cause of both the general symptoms and the amyloid deposits.

Multiple myeloma in primary biliary cirrhosis

A patient who had primary biliary cirrhosis and, simultaneously, multiple myeloma (IgG, lambda) is reported. In chronic liver diseases, polyclonal hypergammaglobulinaemia is common, monoclonal gammopathies have also been found in rare instances, being attributed to chronic antigenic stimulation of the reticuloendothelial system by antigens from the intestinal flora. The mechanisms (as chronic antigenic stimulation, immunologic disturbances and granulomata formation) which apply to explain the development of monoclonal gammopathies in other conditions are also found in primary biliary cirrhosis. It is postulated that, in this disease, the development of multiple myeloma could be not merely coincidental but also the result of chronic stimulation of the reticuloendothelial system.

Ultrastructural findings in acute and chronic graft-vs-hos reaction of the skin

Two cases of graft-vs-host reaction (GVHR) after allogeneic bone marrow transplantation were studied by transmission electron microscopy. One was observed only in the acute phase and the other, after a mild acute reaction, showed a chronic lichen planus-like pattern. All types of skin damage described in experimental GVHR have been confirmed in both cases. Our findings indicate an involvement of aggressor lymphocytes against keratinocytes as the chief pathogenetic mechanism of the disease, even in its chronic form, although the participation of humoral factors in some phases of the disorder cannot be excluded. The participation of Langerhans cells and macrophages in the reaction could not be demonstrated in these cases.

[Syndrome of aplastic anemia-paroxysmal nocturnal hemoglobinuria. Comparative study of the clinical and biological features with the disease paroxysmal nocturnal hemoglobinuria]

Aplastic anemia was followed by the development of paroxysmal nocturnal hemoglobinuria. Comparative study of the clinical and biological features with the disease paroxysmal nocturnal hemoglobinuria.

Low-dose vincristine in the treatment of corticosteroid-refractory idiopathic thrombocytopenic purpura (ITP) in non-splenectomized patients

Eight non-splenectomized patients with corticosteroid-refractory idiopathic thrombocytopenic purpura (ITP) were treated with low-dose vincristine (1 mg/week up to a total dose of 4 mg). Complete remission was achieved in 2 cases and partial remission in 3. Bleeding stopped in one patient who failed to remit. No statistical relationship was found between the response to vincristine and the duration of the disease or the corticosteroid-therapy. Side effects were only observed in one patient. By comparing these results with those reported in the literature, it can be inferred that low-dose vincristine may be useful in the management of corticosteroid-refractory ITP.

[Massive pulmonary embolism due to hydatid vesicles. Report of a case (author's transl)]

A patient with hepatic and peritoneal hydatidosis suffered acute episodes of restrictive bronchial disease for the last 2 years. The patient was admitted during the course of one of this acute episodes with clinical symptoms of pulmonary embolism. Supportive therapeutic measures were prescribed, but the patient died 12 hours latter. Autopsy revealed hepatic, peritoneal and pulmonary hidatidosis as well as multiple pulmonary thromboembolisms due to hydatid vesicles. Literature on this subject is reviewed, and different clinical forms and therapeutic possibilities are discussed. The importance of small therapeutic possibilities are discussed. The importance of small recurrent hydatid embolisms in the pathogenesis of acute or subacute cor pulmonale in patients with liver hydatidosis is stressed.

Lymphocyte size and survival of patients with chronic lymphocytic leukaemia (B-type)

In 57 cases of B-type chronic lymphocytic leukaemia (B-CLL), the size of peripheral blood lymphocytes was estimated by means of transmission electron microscopy. The mean lymphocyte diameter (MLD) of 50 cells was correlated with the clinical staging as well as the survival. 30 out of 38 patients found in stages 0, I, and II displayed a normal or increased MLD. Conversely, this value was decreased in 12 out of 17 cases in stages III and IV. MLD of patients in clinical stages III and IV was significantly lower as compared with MLD of patients in stages 0, I, and II (P < 0.001). The actuarial curve of 57 patients showed a roughly estimated median survival probability of 43 months. This was of more than 54 months in patients with normal or increased MLD, but only of 22 months in those with a decreased MLD. The difference between these 2 survival curves was statistically significant (P < 0.01). A reduced peripheral blood lymphocyte size, as estimated in suspension by means of transmission electron microscopy, appears to have a bad prognostic significance.

Acute and chronic graft-vs-host reaction in skin: report of two cases

The cutaneous changes of the acute form of graft-vs-host reaction are described in two patients who underwent bone marrow transplantation for treatment of severe aplastic anaemia. One patient went on to develop a chronic reaction of the lichenoid type. Histopathology confirmed the presence of 'satellite cell necrosis' from the acute stage of the disease onwards. Direct immunofluorescence showed deposits of immunoglobulin (IgG, IgM), fibrinogen and complement on the necrotic keratinocytes, whilst the basement membrane was positive for C3. These findings suggest that humoral immunity as well as cellular immunity may play a part in the production of the rash.

Thrombocytosis in quiescent chronic granulocytic leukaemia after vincristine and 6-mercaptopurine therapy

In an attempt to retard the appearance of blastic transformation 11 patients recently diagnosed with chronic granulocytic leukaemia were given courses of vincristine and 6-mercaptopurine after stabilization of the disease by busulfan. In 4 of the patients a marked thrombocytosis developed shortly after the administration of such courses. When we compared the clinical and biological features at the moment of diagnosis, the patients in whom thrombocytosis developed after vincristine and 6-mercaptopurine courses showed higher platelet counts and a smaller spleen size than the other ones, although no statistical significance was reached. A possible thrombocytopoietic effect of vincristine is discussed.

[Value of hemophagocytosis in the morphological examination of the bone marrow (author's transl)]

The hemophagocytosis or the process of ingestion of blood cells by phagocytes and macrophages of the mononuclear phagocytic system (MFS), is a phenomenon that rarely could be observed in the morphological examination of the bone marrow aspirate. Occasionally it is present in certain pathologic conditions such as, malignant histiocitosis, autimmune hemolytic anemia, or some chronic inflammatory diseases. The capacity of ingestion is not an exlusive property of the phagocytes and macrophages of the MFS, so that different neoplastic cells can show it too. This study analyzes the presence of hemophagocytosis by neoplastic cells in a total of 552 bone marrow aspirates corresponding to a series of 130 patients with acute leukemia and 422 patients with diverse solid tumors. In the group of patients with acute leukemia, hemophagocytosis by blastic cells was observed in five cases with acute monocytic leukemia. In the other group with solid tumors, hemophagocytosis was present in three patients with oat-cell lung carcinomas and diffuse bone marrow metastases. The interest of the evaluation of hemophagocytosis by neoplastic cells in the morphological examination of the bone marrow is stressed, as well as it possible value in the cytological diagnosis of acute monocytic leukemia. However, in these circumstances a sdiffuse metastases by solid tumors should be always discarded, since their cytomorphological characteristics are in most cases superimposed to those of the leukemic bone marrow infiltrate.

[Endocarditis by Coxiella burnetti. A chronic form of Q fever. Report of one case (author's transl)]

The authors describe a case of chronic endocarditis by Q fever, in a patient who had been operated for coarctation of the aorta twelve years previously and at the same time was carrier of a congenital bivalve aorta. The clinical picture was suggestive of subacute endocarditis, but the blood culture was negative repeatedly. There was also a prolonged and relapsing febrile syndrome over a period of one-year-and-a-half. The following data are also worthy of note: the coexistence of a liver disorder and a focal and segmentary glomerulonephritis. Based on some recent publications (one by the same group) the authors feel that Coxiellosis burnetti must be more frequent in their environment than is suspected.

[Chronic lymphoid leukemia. Survival in relation to clinical stages. Statistical analysis of 95 cases (author's transl)]

The prognosis of patients with chronic lymphocytic leukemia is very difficult to evaluate. The classification system by stages, which at the present time is the most simple and useful method for the prognosis of this disease, recognizes five degrees of involvement: stage 0 (medullary and peripheral lymphocytosis); stage I (lymphocytosis + enlarged lymph nodes); stage II (lymphocyosis + hepato-and/or splenomegaly); stage III (lymphocytosis + anemia), and stage IV (lymphocytosis + thrombocytopenia). In the present report 95 controlled patients at the Farreras Valentí School of Hematology are analyzed using the classification by stages; there were 19 cases in stage 0; 16 in stage I; 30 in stage II; 21 in stage III, and 9 in stage IV. The mean survival rate in the global series was 63 months and the average 90.9 months. As in other series, it was observed that patients in stages 0 and I have a much better prognosis than those in stages III and IV. Stage II occupies an intermediate position in relation to prognosis, since the actuarial survival figure for this stage can practically be superimposed on that of the global series. The classification of chronic lymphocytic leukemia by stages permits the specification of the therapeutic indications for this condition; it also encourages the search for new modalities of treatment for stages with poor prognosis, since in these cases chronic lymphocytic leukemia behaves in the manner of an acute or subacute hemopathy.

Chronic myelomonocytic leukemia associated with hereditary pyruvate kinase deficiency and multiple acquired erythrocyte abnormalities

A congenital erythrocyte pyruvate kinase (PK) deficiency was found in a 72-year old female patient with chronic myelomonocytic leukemia (CMML). Erythrocyte PK deficiency was associated with an increase in the activity of hexokinase, 6-phosphogluconate dehydrogenase and glutathione peroxidase in erythrocytes as well as a decrease in acetylcholinesterase, glutathione reductase and glucosephosphate isomerase activities. The enzymatic abnormalities were accompanied by alterations in hemoglobin and in i antigen content of erythrocyte membrane. In addition, bone marrow ultrastructural studies showed dyshemopoietic changes in all blood cell lines and especially in erythroblasts. The present findings confirm the close relationship between CMML and acquired dyserythropoietic syndromes and constitute a new observation of the infrequent association of hereditary erythrocyte enzymopathies and leukemia. A survey of the literature is presented.

Prolymphocytic leukaemia of T-cell type: immunological, enzymatic and ultrastructural morphometric characteristics

A case of prolymphocytic leukaemia with immunological characteristics of T-cell type is reported. Three noteworthy findings can be emphasized: the presence of C3 receptors on the T-prolymphocytes, the study of the acid-phosphatase isoenzymatic pattern, which showed an increased band 3 with absence of band 3b, and the morphometric ultrastructural investigation. Cytochemistry and ultrastructural morphometry may be useful for a more precise characterization of prolymphocytic leukaemia and help to distinguish it from other lymphoproliferative disorders.

Benign liver-cell adenoma associated with long-term administration of an androgenic-anabolic steroid (methandienone)

A 19-year-old man with paroxysmal nocturnal hemoglobinuria treated for 3 years with Methandienone was admitted to the hospital with hemoperitoneum due to the rupture of an hepatic tumor. Histology revealed that it was a benign liver cell adenoma, with a pathologic appearance and mode of clinical presentation closely resembling those of cases observed to develop in association to contraceptive steroids.

Systemic mastocytosis: a case report. Cytological, cytochemical and ultrastructural considerations

A case of systemic mastocytosis with unusual clinical manifestations, appearing as an isolated splenohepatomegaly, is described. The proliferative character is evident from the cytological characteristics of immaturity and the presence of a moderate percentage of mast cells in the peripheral blood. These cells make up 40% of the total cells in the bone marrow. Special attention is given to the optical, morphological, cytochemical, and ultrastructural studies of the disease. Some anomalies were found at the subcellular level which apparetnly have not been recorded until present. Various dyshematopoietic features of this case are reported, which may be considered as manifestations of a paraneoplastic syndrome.

Hereditary hemolytic anemia with erythrocyte pyrimidine 5'-nucleotidase deficiency in Spain. Clinical, biological and familial studies

We report a hereditary hemolytic anemia associated with a severe erythrocyte pyrimidine 5'-nucleotidase deficiency in a Spanish family of five members in which the parents are first cousins. Both parents exhibited decreased nucleotidase activity without clinical or hematologic abnormalities. Two children (a male and a female) showed severe pyrimidine 5'-nucleotidase deficiency with hemolytic anemia. The remaining child (a male) showed no signs of the disease. The findings strongly suggest an autosomal recessive mode of inheritance in this enzymopathy. This seems to be the first report of pyrimidine 5'-nucleotidase deficiency in Spain.

Ribosome-lamellae complex in chronic lymphatic leukaemia

The Ribosome Lamellae Complex (RLC) was found in two out of 35 patients with Chronic Lymphatic Leukaemia (CLL). The proportion of lymphocytes bearing RLC was very small (4% in the first case and less than 0.5% in the second case). The significance of this type of inclusion is discussed and the possible relationship to the circular profiles of endoplasmic reticulum is emphasized.

Oxymetholone effect of acute myeloblastic leukemia cells in vitro

The possibility that oxymetholone might induce or enhance leukemia after androgen therapy for aplastic anemia prompted us to study the direct action of oxymetholone on the DNA synthesis of AML cells in vitro. The peripheral blasts of 10 patients, 8 with AML and 2 with CML in blast crisis have been studied. The DNA synthesis of the leukemic cells with and without oxymetholone was measured by the 3H-methyl-thymidine incorporation determined by liquid scintillation. The results have been shown a wide variation of DNA synthesis from patient to patient with a range from 2,000 to 40,000 cpm but no significant difference between test and control cultures. We may conclude that oxymetholone does not increase directly the proliferation capacity of the peripheral AML cells cultured in vitro.

Glucose phosphate isomerase deficiency with hereditary hemolytic anemia in a Spanish family: clinical and familial studies

A new case of glucose phosphate isomerase deficiency associated with cogenital nonspherocytic hemolytic anemia is described in a 12-year-old girl of Spanish origin. The parents exhibited erythrocyte glucose phosphate isomerase activity between 50 and 60% of normal. The enzyme of the propositus had normal Michaelis-Menten constants both for F-6-P and G-6-P, but abnormal pH optimum and decreased heat stability at 48 degrees C. On starch-gel electrophoresis the father's enzyme was normal but the mother's showed a cathodic migrating band in addition to the normal one. The enzyme from the propositus exhibited only one band with cathodal mobility of 116% of the main band found in normal subjects. It is postulated that the propositus is double heterozygous for two abnormal alleles, and the mother contributes a mutant allele with abnormal electrophoretic mobility and thermolability at 48 degrees C whereas the father contributes an allele without enzymatic activity.