[Atypical presentation of acute myeloblastic leukemia in two pediatric patients]

Acute myeloblastic leukemia (MLA) is an uncommon disease in childhood and its prognosis is worse than that of lymphoblastic leukemia. Severe hemorrhage, infections and perfusion disorders secondary to leukostasis are the main complications leading to its high mortality rate. Two pediatric patients with MLA (M5a and M2) are presented. Both patients were admitted to the pediatric intensive care unit with acute respiratory distress syndrome and intracranial hemorrhage respectively, secondary to leukostasis. The first patient showed favorable clinical course and underwent bone marrow transplantation four months later; in contrast, the second patient died a few hours after admission. The physiopathology of each case, the therapeutic approach and the use of leukopheresis as a therapeutic alternative in patients with hyperleukocytosis and leukostasis are discussed. A high degree of suspicion is required to make a diagnosis as early as possible in order to avoid the death of a large percentage of patients before cytostatic treatment begins.

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma

BACKGROUND

Extended cervical mediastinoscopy (ECM) is a technique in the staging of bronchogenic carcinoma described first by Ginsberg in 1984. To update our experience we have prospectively evaluated our results on 106 patients who underwent the technique from 1985 to 1998.

METHODS

The ECM technique is performed once the operability of the patient has been evaluated, according to the computed tomography findings. The intervention is carried out at the same time as a standard cervical mediastinoscopy through the same incision following the same technique as previously published. The ECM is considered positive when metastatic nodes or tumor involvement directly in the paraaortic or subaortic regions is detected and confirmed histologically. Negative cases of ECM and positive cases of standard cervical mediastinoscopy are excluded from this study. A false-negative ECM is defined as the presence of infiltrated adenopathies at the paraortic level detected on postoperative histologic study.

RESULTS

We had performed ECM in 106 patients, and a total of 13 were subsequently excluded for the reasons stated above. Of the remaining cases, 26 were positive, 61 negative and 6 had false-negative results with no false-positive results. Sensitivity was 81.2%, specificity 100%, accuracy 93.3%, positive predictive value 100%, and negative predictive value 91%. There were no complications with the technique.

CONCLUSIONS

We conclude that ECM is a useful technique for staging bronchogenic carcinoma that allows samples to be taken from paraortic and subaortic regions with minimally invasive techniques.

[Effect of cyclosporine on plasma levels of uric acid in patients treated with bone marrow transplantation]

In patients treated with cyclosporine, an increase in the incidence of goiter has been demonstrated. This agent produces changes in the lipidic metabolisms, among which the increase in VLDL stands put. Given that the hyperlipemia more frequently associated to hyperuricemia is the increase of such lipoprotein, we decided to study the behaviour of plasmatic uric acid in patients receiving treatment with cyclosporine. The study was conducted in patients with bone marrow transplant undergoing immunosuppressive therapy, considering the effect of cyclosporine as the only drug or following a scheme of mixed immunosuppression associated to prednisone. We observed a reversible increase in the plasmatic levels of uric acid in patients treated with cyclosporine, which was positively correlated to an increase in VLDL triglycerides. Hence, the cyclosporine produced an increase of uric acid which was neither observed when associated to prednisone nor in the group of self-transplanted patients.

[Bone marrow necrosis as a manifestation of leukemic relapse in a patient with bone marrow transplant]

A case of bone marrow necrosis (BMN) in transplanted acute lymphoblastic leukaemia (ALL) is presented. The propositus is a 16 year-old boy with L-2 type ALL on whom allogeneic bone marrow transplantation (BMT) had been performed after the second relapse. He was admitted to hospital at 415 after BMT with fever, malaise and hip pain. One week later he had aplasia without blast cells. Scanty cellularity with necrobiosis was found in bone marrow aspirates; bone marrow biopsy confirmed the suspicion of BMN. Osseus scintigraphy with 99-Tc-diphosphonate showed poor, irregular distribution. Steroid therapy was followed by a favourable response. Peripheral blast cells appeared two weeks later, and the relapse was confirmed by bone marrow aspiration. Chemotherapy was started, but the patient died on day 467 after BMT. BMN has been reported in ALL at onset, in relapses, after chemotherapy and as necropsy finding; however, it had not been found in patients subjected to BMT. The experience of these Service was revised, this being the only case of 140 patients subjected to BMT who presented such severe complication.