Fatal invasive cerebral Absidia corymbifera infection following bone marrow transplantation

A 56-year-old dairy farmer received a fully HLA matched unrelated donor marrow transplant for high risk CML in chronic phase. His early post-transplant course was complicated by a series of massive intracerebral bleeds and by sepsis related to a malignant otitis externa. The microbial pathogen isolated from ear swabs was found to be Absidia corymbifera, but CT scan at the time showed no intracerebral extension. Despite neutrophil engraftment and aggressive antifungal management he succumbed. Autopsy revealed invasion of Absidia into the brain from the ear. We speculate that colonisation by Absidia resulted from occupational exposure.

The cutaneous side-effects of hydroxyurea

The cutaneous side-effects of long-term hydroxyurea therapy are not widely known and only rarely reported. We report on a patient who developed widespread skin changes, including the recently recognized hydroxyurea dermopathy, during long-term treatment with hydroxyurea for polycythaemia rubra vera. The time course of the clinical changes suggests that they result from direct toxicity of hydroxyurea on the basal layer of the epidermis and mucosal surfaces. We aim to increase clinical awareness of this problem.

Severe iron deficiency anaemia and stroke

Neurological complications of severe anaemia in childhood are rare. We report a case of severe iron deficiency in a child of 23 months, presenting as an acute hemiparesis.

Anaemia, vitamin E deficiency and failure to thrive in an infant

An 8-week-old boy presented with failure to thrive from birth. He had been fed with breast and formula milk. He had an anaemia of 6.6 g/dl with polychromasia, nucleated red blood cells and immature myeloid cells in the peripheral blood. He showed evidence of haemolysis with a reticulocyte count of 120 x 10(9)/l, a raised unconjugated bilirubin and had low plasma protein levels. Investigation revealed a low vitamin E level and a diagnosis of cystic fibrosis.

Long-term follow-up of aplastic anaemia

Of 61 patients with aplastic anaemia (AA) diagnosed in our hospitals, 37 survived more than 2 years; actuarial survival of this latter group was 58%, with a median follow-up of living patients of 10.2 years. Laboratory and clinical data pertaining to these long-term survivors was scrutinized to determine the incidence of clonal disorders, which was identified in 43%. Morphological evidence of the myelodysplastic syndrome (MDS) was found in 13 (35%), including four cases of RAEB; four (11%) developed PNH. Of 23 patients studied, four showed karyotypic abnormalities, but these did not always coincide with morphological features of MDS. Although four patients now have completely normal blood and marrow morphology, and another had normal blood and marrow morphology at the time of death due to unrelated disease, the study confirms the high incidence of cytopenia and morphological abnormality, sufficient to justify a diagnosis of MDS, in patients with a history of AA. No definite survival plateau was identified. However, the natural history of MDS secondary to AA seems to be different to that of MDS arising de novo; the clinical course is relatively indolent, possibly implying a different biology.

First use of G-CSF in chlorpromazine-induced agranulocytosis: a report of two cases

Chlorpromazine-induced agranulocytosis is an uncommon disorder associated with a high frequency of fatality. We describe two patients with chlorpromazine-induced granulocytosis in whom granulocyte colony stimulating factor (G-CSF) administration enhanced the speed of neutrophil recovery. No toxicity was noted with G-CSF and both patients made a successful recovery. We propose there is a role for such cytokine therapy in patients with life-threatening agranulocytosis in order to speed the recovery of neutrophils.

Bone marrow necrosis at transformation of chronic granulocytic leukaemia treated with interferon

A patient with chronic myeloid leukaemia was treated with interferon without using conventional cytotoxic agents. Bone marrow necrosis developed at the onset of blast transformation. It is suggested that cytotoxic drugs should be given before treatment with interferon for chronic myeloid leukaemia. Cytotoxic drugs may also be needed to prevent rapid bone marrow growth once interferon has been withdrawn.

Large granular T lymphocytes, neutropenia and polyarthropathy: an underdiagnosed syndrome?

Thirteen patients with expansion of an unusual subset of T lymphocytes, defined by large size, cytoplasmic granularity and CD3+ CD8+ Leu 7+ surface phenotype, are reported. Although morphologically and/or phenotypically abnormal lymphocytes were found in all patients, only five had an absolute peripheral blood lymphocytosis. Ten patients had a bone marrow lymphocytosis. As in previous series, there was a strong association with neutropenia (12 patients) and polyarthropathy (seven patients). The latter group displayed a wide range of articular disease: classical or definite rheumatoid arthritis in four patients and milder non-erosive disease in the remainder. All 13 patients showed evidence of abnormal B cell function: IgM rheumatoid factor was present in nine patients, neutrophil-specific antibodies in six and all showed an increased level of at least one immunoglobulin isotype. These patients may be difficult to distinguish from those with idiopathic neutropenia and Felty's syndrome. Such a distinction may not be made on clinical grounds alone: critical assessment of lymphocyte morphology, bone marrow examination and analysis of lymphocyte phenotype should be considered in all patients with unexplained neutropenia, particularly in the context of arthritis. It is suggested that the true prevalence of this syndrome may have been greatly underestimated.

Prediction and prevention of relapse of acute lymphoblastic leukaemia after bone marrow transplantation

Results of bone marrow transplantation (BMT) in 63 adults and children with ALL transplanted in the 5-year period 1979-83 were analysed. Twenty-one patients (33%) relapsed, 25% of the group died in relapse and 19% died from complications of BMT. The actuarial disease-free survival at 6 years was 38%. Relapse after BMT could be predicted by standard prognostic diagnostic features such as age, sex, cell type and presenting blast cell count. Patients transplanted in first remission selected for their poor prognosis had a lower relapse risk than a similar group of poor prognosis patients transplanted in second or subsequent remission (P less than 0.05). Relapse following second and subsequent remission BMT was predicted by a score based on standard prognostic features or by the pace of the disease: patients with an interval of less than 2 years between diagnosis and first relapse having a 15% actuarial disease-free survival, compared with 81% for patients with an interval greater than 2 years (P less than 0.001). These results emphasize that ALL is a heterogeneous disease and establishes the importance of determining relapse risk when selecting BMT and other treatment schedules for ALL patients.

Dermatological aspects of the use of Cyclosporin A for prophylaxis of graft-versus-host disease

Oral Cyclosporin A (CyA) was given for the prophylaxis of graft-versus-host disease (GVHD) to sixty-seven patients receiving a bone marrow transplant, and was found to be extremely effective in reducing the severity of acute GVHD. Side-effects of CyA included hypertrichosis, gum hypertrophy, and a rare but serious 'capillary leak' syndrome.

Platelet- and granulocyte-specific antibodies after allogeneic and autologous bone marrow grafts

After bone marrow grafting, severe unexplained thrombocytopenia and granulocytopenia may complicate the post-graft recovery of the patient. The present study has shown the presence of antibodies to platelets and granulocytes of donor origin in recipients of both allogeneic and autologous bone marrow grafts. In the case of autografts, such antibodies are by definition autoantibodies, and similar antibodies after allografting may also have an autoimmune origin. It is likely that this is the result of transient immune system imbalance, common to both allo- and autografts, in the early post-graft period. The extent to which these antibodies affect the peripheral counts probably depends on the ability of the engrafted marrow to compensate for the rate of antibody-mediated cell destruction.

Bone marrow transplantation for severe aplastic anaemia. A review of the Westminster experience of 24 cases

Twenty-four patients have received bone marrow transplantation for severe aplastic anaemia at the Westminster Hospitals since 1974. Twelve patients are long term survivors. Infectious complications in association with graft rejection, graft versus host disease or prolonged neutropenia were the major cause of death. In the last 18 months the introduction of more effective conditioning regimes and Cyclosporin A as graft versus host disease prophylaxis has improved the survival rate to 85%. One patient has required regrafting for late graft failure without evidence of graft rejection.

Tetanus after allogeneic bone-marrow transplantation

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Bone marrow transplantation for acute lymphoblastic leukaemia

Twenty patients have undergone bone marrow transplantation for acute lymphoblastic leukaemia (ALL). Eighteen patients were in complete remission and two had less than 10% leukaemic blasts in the marrow aspirate in the week prior to transplantation. Eighteen patients were grafted from HLA/MLC compatible siblings. One identical twin and one fully compatible parent were also used as donors. Two patients died of graft-versus-host disease and one of radiation-induced pneumonitis. Four have subsequently relapsed. Thirteen patients remain well and in remission from 202 to 1126 d post transplantation. These results show that morbidity and mortality from the bone marrow transplantation procedure is low. However, the major obstacle to permanent success in marrow transplantation of patients with ALL is recurrence of the disease (35% actuarial disease free survival at 1126 d).

Cyclosporin A as prophylaxis against graft-versus-host disease in 36 patients

Oral cyclosporin A was used as prophylaxis against graft-versus-host disease in (a) 31 patients with acute leukaemia or aplastic anaemia given transplants of HLA-matched bone marrow and (b) five patients with inborn errors of metabolism given transplants of haplotype-identical (parental) bone marrow. Twenty-six patients survived longer than two months after the operation. Despite the cyclosporin A, 31 patients (86%) suffered an acute form of graft-versus-host disease and 22 (61%) a chronic form. Nevertheless, the disease was usually treatable with immunosuppressive agents and caused the death of only one patient. Cyclosporin A caused renal toxicity in all cases; occasionally this was associated with a "capillary leak" syndrome, fatal in two patients. In children hypertension, fits, and fluid retention were common side effects. Blood concentrations of cyclosporin A correlated with blood urea values and blood pressure but did not predict the occurrence of graft-versus-host disease. Four different dose schedules were used to find the optimum way to administer this drug. Oral cyclosporin A is extremely effective at reducing the severity of graft-versus-host disease, but prevention of the disease is limited by toxicity of the drug and variable absorption. Better results might be achieved with parenteral administration or by using the drug in combination with other methods.