Platelet kinetics in autosomal dominant macrothrombocytopenia

A family with autosomal dominant macrothrombocytopenia is described. Despite severe thrombocytopenia, only a moderate hemorrhagic tendency was observed. Kinetic studies revealed a normal platelet survival, normal megakaryocytic numbers, and normal bone marrow responsiveness. The rate of platelet production was set low, despite moderately impaired hemostasis and thrombocytopenia; it apparently was set to maintain another platelet parameter at an optimal level. Measurements of total circulating platelet mass and platelet surface suggested that the platelet production was set to maintain the platelet surface rather than the platelet mass at a normal value.

Mortality-associated factors in infected lymphoma patients

Three hundred eighty-eight medical records of patients with lymphoma seen between 1971 and 1980 were analyzed for factors related to infection-associated mortality. Infection occurred in 100 patients (36 Hodgkin's lymphoma [HL], and 64 non-Hodgkin's lymphoma [NHL]). The overall mortality with infection was 17% (6 of 36) for HL and 52% (33 of 64) for NHL. In patients with NHL mortality correlated with infection in the respiratory tract (P less than or equal to 0.0001), blood (P less than or equal to 0.003), and multiple sites (P less than or equal to 0.0004) and with the following factors: granulocytopenia (P less than or equal to 0.05), thrombocytopenia (P less than or equal to 0.035), and cytotoxic therapy (P less than or equal to 0.034). Patients with HL showed a positive correlation only with staphylococcal infections (P less than or equal to 0.001) and monocytopenia (P less than or equal to 0.01). The above data may be used to generate a risk factor profile of patients at greater risk of mortality associated with such infections. Advance knowledge of such a profile may assist in the clinical management of these high-risk patients.

Histologically proven leukemia cutis carries a poor prognosis in acute nonlymphocytic leukemia

A retrospective study of fifty-eight patients with acute nonlymphocytic leukemia was undertaken to determine the incidence of leukemia cutis and whether skin involvement serves as a prognostic indicator. A clinical diagnosis of leukemia cutis was made in eleven patients (19 percent), and five patients (8.6 percent) had biopsy-confirmed skin involvement. Patients with biopsy-proven leukemia cutis had a median postdiagnosis survival of only 12.5 weeks compared with fifty weeks for the group without skin involvement. We conclude that leukemia cutis is a biopsy diagnosis that occurs in a minimum of 8.6 percent of patients with acute nonlymphocytic leukemia in whom survival appears to be shortened.

Transfusion pattern of fresh frozen plasma in a medical school hospital

364 units of fresh frozen plasma (FFP) used at the Medical College of Ohio Hospital between April and July 1982 were analyzed for their pattern of use. According to the criteria developed for the survey, 33% of the units were used for blood pressure support, 34% were used for clotting support, 14% were used for the combined reasons of blood pressure and clotting support, 11% of the units were used during therapeutic pheresis, and the remaining 7% were used for unidentified reasons. 39% of the FFP were given with red blood cells. Since FFP transfusions carry potentially more serious adverse effects than albumin/plasma protein fractions, their use as volume expanders, or to reconstitute whole blood, should be discouraged.

Pineal germinoma with widespread extracranial metastases

A case of primary pineal germinoma with widespread extracranial metastasis in a 36-year-old man is presented. A clinical work-up revealed bilateral pleural effusions, ascites, and metastatic lesions involving the lung. Cytology and electron microscopic study of the pleural and ascitic fluid and of the fine needle aspiration material revealed metastatic germinoma. Although the cytologic features were not distinct from those of anaplastic carcinoma, they were distinguishable from those of glial neoplasms, lymphoma, and sarcoma. The computed tomography findings, elevated human chorionic gonadotropin level, and electron microscopic features contributed significantly to the diagnosis of extracranial metastasis of the pineal germinoma. Metastatic spread most likely occurred via the ventriculoperitoneal shunt.

Changing patterns of infections in patients with multiple myeloma

A total of 59 infections were encountered in 29/46 patients with multiple myeloma (MM). Most infections arose in the urinary tract (31%), respiratory tract (29%), followed by blood (12%), oropharynx (12%), skin and soft tissue (7%). Gram-negative bacilli were identified in 51% of infections, most common being Enterobacteriaceae and Haemophilus influenzae. Gram-positive organisms were responsible for 7% of infections. 24% of patients with urinary tract infections had signs of cord compression Absolute lymphopenia was common, and was seen in 65% of patients with urinary infections, 75% of respiratory infections, and 86% of septicemic patients. In contrast, granulocytopenia was mainly observed in patients with septicemia (71%), followed by those with respiratory infections (31%). All patients were on cytotoxic chemotherapy, and most were hypoglobulinemic. About one third of septicemias, and one half of urinary and respiratory infections, respectively, were hospital-acquired. Results indicate that the current pattern of infections in MM seems to favor gram-negative organisms. The role of predisposing factors in the pathogenesis of infections in these patients is discussed.

Radionuclide imaging of experimental myocarditis

The ability of 67Ga citrate and 99mTc pyrophosphate cardiac imaging to detect myocarditis was assessed in an experimental rabbit model. Twenty-three rabbits were imaged approximately 72 hours after infusion of i.v. norepinephrine. Diffuse cardiac uptake was found in 13 of 15 rabbits scanned with 67Ga. Tissue distribution studies documented significant myocardial uptake of 67Ga in those with positive scans. Precordial imaging and tissue distribution studies revealed no cardiac uptake in the eight rabbits scanned with 99mTc. Histologic examination of all 23 hearts revealed qualitatively similar, typical lesions of myocarditis. This study suggests that cardiac imaging with 67Ga may be useful in the detection of myocarditis.

Platelet function, ultrastructure, and survival in the May-Hegglin anomaly

The May-Hegglin anomaly is one of the rare forms of heriditary thrombocytopenia. Since fewer than 100 cases of May-Hegglin anomaly have been described to date, major controversies regarding the adequacy of hemostasis in vivo and abnormalities of platelet function in vitro continue to prevail. This report describes the results of coagulation, platelet function, platelet ultrastructure, and survival studies performed for a family with six previously unreported cases occurring in three generations. One member of this family also had frequent epistaxis and a prolonged bleeding time associated with cyanotic heart disease that required open heart surgery for correction. The laboratory assessment of hemostasis in such patients before major surgery is also discussed.

Selective use of daunorubicin for remission-induction chemotherapy in acute non-lymphoblastic leukemia

Twenty-eight patients with acute non-lymphoblastic leukemia (ANLL) were started on induction chemotherapy consisting of Cytosine Arbinoside (Ara C) and 6 thioguanine (TG). Daunorubicin (DNR) was used selectively in 20 of 28 patients who failed to respond by day 14 to the Ara C and TG combination. Seven patients, or 25%, achieved complete remission (CR) without requiring DNR during remission induction. The overall response rate was 89% (64% CR and 25% PR). The median duration of survival for the CR group was 578 days. 189 days for the partial remission (PR) group (P = .02). Patients in the age groups of 18--40 years and with acute myelomonocytic leukemia subtype had the best response rate. There was no difference in the survival of the DNR treated group of complete responders as compared to DNR non-treated group. These results suggest that even though the majority of patients do require DNR for the remission induction, a significant number, perhaps as high as 25% of previously untreated patients, will achieve remission without the use of DNR. A significant minority of patients, therefore, be spared the toxicity of DNR early in the course of their disease.

Colonization of nasal ulcers as a source of Candida parapsilosis fungemia

Candida parapsilosis fungemia secondary to nasal colonization following application of nasal prongs for oxygen therapy developed in a 61-year-old man with known chronic lymphocytic leukemia and pulmonary infiltrates. Amphotericin B controlled the candidal infection, but the patient died of complications related to Aspergillus pneumonitis, intra-abdominal mucormycosis, and leukemia. The source of candidal infection was probably a combination of nasal ulceration resulting from oxygen administration by nasal prongs and alteration of the normal mucosal flora by multiple broad-spectrum antibiotics. Oxygen administration by mask to patients at risk of opportunistic infections may help obviate this potential complication, with its attendant danger of spread to the brain and cavernous sinuses. We discuss the rarity of triple infection with these three organisms.

The differential inhibition of prostaglandin synthesis in platelets and vascular tissue in response to aspirin

Since aspirin inhibits the platelet as well as vascular prostaglandin synthesis it may therefore, paradoxically induce a thrombotic tendency when used as an antithrombotic agent. The in vivo effect of therapeutic doses of aspirin on the prostaglandin synthetic capacity of the rat platelets and vascular tissue was therefore studied to determine the significance of this paradoxical aspirin effect. A single aspirin dose of 5 mg/kg or greater was found to significantly decrease the synthesis of prostaglandin E by rat platelets. Even the normal augmentation of PGE synthesis by N-ethyl maleimide was significantly reduced by this single aspirin dose. In contrast, doses as high as 20 mg/kg of aspirin failed to reduce the production of 6-keto PGF1 alpha by aortic slices from rats pretreated with aspirin. These results indicate that the cyclo-oxygenase enzyme (CO) system in the prostaglandin biosynthetic pathway within blood vessel walls has the capacity to recover from this inhibitory effect of aspirin or it is less susceptible to inhibition than the CO in platelets. This relative resistance of CO to the inhibitory effects of aspirin may serve to protect the organism from excessive thrombotic tendencies brought about by the effect of aspirin on the vascular prostaglandin generating system. These results indicate that an aspirin dose of 5-10 mg/kg would be optimal if aspirin were to be used as an antithrombotic agent.

Vertebral disc space infection and osteomyelitis due to Candida albicans in a patient with acute myelomonocytic leukemia

A 67-year old man with acute myelomonocytic leukemia had Candida albicans fungemia during induction chemotherapy. Bilateral pulmonary infiltrates and hepatic granulomata containing yeast forms and septate hyphae developed, but cultures of the hepatic tissue failed to grow a fungus. Although his pulmonary and liver disease improved following appropriate therapy, vertebral osteomyelitis due to Candida albicans developed approximately 12-15 weeks after the original fungemia. The fungal osteomyelitis was successfully treated with amphotericin B and 5-fluorocytosine. This case illustrates the need for early diagnosis and aggressive treatment of fungal infections in patients with leukemia.

Septicemia due to Streptococcus equisimilis in a child with acute lymphoblastic leukemia

A 4-year-old boy with acute lymphoblastic leukemia in relapse with documented septicemia due to group C Streptococci (Streptococcus equisimilis) is described. The patient responded well to therapy with appropriate cytotoxic and antimicrobial agents. There is a general lack of recognition of the pathogenicity of group C Streptococci in man. The potential opportunistic nature of these organisms in immunocompromised hosts and the need for early recognition and appropriate treatment of such infection is emphasized.

Thrombocytopenia in polycythemic mice

Significant and sustained thrombocytopenia in mice maintained in a polycythemic state with weekly injections of washed packed RBCs prompted the examination of the relationship between the observed thrombocytopenia and the polycythemic state. Platelet production was determined by measurement of 75SeM incorporation into platelets. Platelet survival was studied with 51Cr-labeled platelets. Platelet sequestration was assessed by measuring the trapped platelet 51Cr-bound radioactivity in the spleens of these animals. Blood volume was calculated by measuring the dilution of injected 59Fe-tagged RBCs. These studies failed to reveal decreased platelet production, a shortening of the platelet survival, or significant splenic pooling as factors contributing to the observed thrombocytopenia. The blood volumes in the polycythemic group of animals were 8.9% +/- 0.15 (1 S.D.) body weight vs. 6.4% +/- 0.69 in the normals (p less than 0.001). Contrary to what has been reported for hypoxia-induced polycythemia, our results indicate that transfusion-induced polycythemia does not cause thrombocytopenia by decreasing platelet production. We suggest instead that the observed thrombocytopenia is mainly due to dilution of the circulating platelet mass by the expanded blood volume.

Effect of aspirin on prostaglandin synthesis by human platelets

When platelet rich plasma is exposed to N-ethylmaleimide, a ten fold increase in measurable prostaglandin E synthesis occurs. This effect is almost completely abolished within 2 hours of ingestion of 600 mg of aspirin by human volunteers. Recovery of this platelet function is slow for the first two days, returning sharply to normal over the next six days and plateauing approximately 8 days following initial removal from aspirin. It is suggested from these studies that platelet prostaglandin E production following NEM may be a useful test of platelet function.