[National guidelines of diagnosis and treatment of the non-Hodgkin lymphoma]

Non-Hodgkin lymphoma comprises a heterogeneous group of haematological malignancies, classified according to their clinic, anatomic-pathological features and, lately, to their molecular biomarkers. Despite the therapeutic advances, nearly half of the patients will die because of this disease. The new diagnostic tools have been the cornerstone to design recent therapy targets, which must be included in the current treatment guidelines of this sort of neoplasms by means of clinical trials and evidence-based medicine. In the face of poor diagnoses devices in most of the Mexican hospitals, we recommend the present diagnose stratification, and treatment guidelines for non-Hodgkin lymphoma, based on evidence. They include the latest and most innovative therapeutic approaches, as well as specific recommendations for hospitals with limited framework and therapy resources.

Significance of one human leukocyte antigen mismatch on outcome of nonmyeloablative allogeneic stem cell transplantation from related donors using the Mexican schedule

Using the Mexican approach to conduct nonablative stem cell transplantation (NST), we have prospectively performed 58 allografts in individuals with various malignant and nonmalignant hematological diseases using sibling donors, either HLA identical (6/6) or compatible, with one mismatch (5/6). When comparing allografts obtained from HLA identical (n=40) or compatible (n=18) siblings, respectively, the overall median survival was found to be 33 vs 8 months (P<0.01), the 52-month survival was 47 vs 38% (P>0.2), the prevalence of acute graft-versus-host disease (GVHD) 57 vs 38%, that of chronic GVHD 25 vs 11% and the relapse rate 45 vs 55%. The two patients who failed to engraft were both 5/6 matches. Probably stemming from the low number of patients, and despite a trend toward worse results in patients allografted from HLA compatible (5/6) siblings, most differences in outcome were not significant. It seems that NST can be offered to individuals with either an HLA identical or a compatible sibling donor.

A critical review of the prognostic value of the nutritional status at diagnosis in the outcome of therapy of children with acute lymphoblastic leukemia

The impact of undernutrition in the outcome of treatment of children with ALL has been analyzed by several authors who have highlighted undernutrition as another relevant prognostic factor in children with acute lymphoblastic leukemia (ALL). There are, however, some papers which have not confirmed the prognostic value of malnutrition at diagnosis in children with ALL. Overall, data from 1,123 children with ALL worldwide support the concept of malnutrition at diagnosis being useful as a prognostic factor, whereas data from 1,271 children fail to support this concept. We here critically analyze the information of these publications referring to a total of 2,394 children with ALL. Detailed information was available only from 500 of the 2,394 patients, stemming from six publications; of these individuals, at diagnosis, 376 were well nourished and 124 were malnourished. In this subset of patients, the analysis of the data shows that the 5-year (or longer) overall survival of undernourished children (UNC) was 26%, whereas that of well-nourished children (WNC) was 59% (p < 0.001); along the same line the relative risk of dying during this period was 1.8 times higher for UNC than WNC (p < 0.01; Interval of Confidence [IC] 95%: 1.72-1.88). On the other hand, the censoring time of these 500 children is different: 293 were censored at 5 years after diagnosis, whereas 207 where censored at 8-10 years: The overall survival for each of these periods was also different: 36% versus 2% for UNC (p < 0.001), and 56% versus 63% (p > 0.10) for WNC, data which support the concept that the differences in survival are more apparent in UNC if the period of observation is extended. These data suggest that undernutrition at diagnosis by itself and without interacting with other variables, may be a significant prognostic factor in the long-term outcome of treatment of pediatric patients with ALL. After identifying these variables as important, imaginative approaches to the treatment of cancer in childhood in the years ahead may lead into the improvement of the results of these treatments.

Role of bone marrow examination in staging Hodgkin's disease: experience in México

We assessed the value of bone marrow biopsy prospectively in a group of 91 individuals with Hodgkin's disease. The median age of our population was 29 years (range 4-87 years); 59 were males. Most patients (45%) had nodular sclerosing disease and most patients (44%) were in pathological stage II at diagnosis. The bone marrow biopsy showed infiltration by Hodgkin's disease in only three individuals (3.3%); two of these patients displayed constitutional symptoms and had been assigned to stage III before the biopsy. In one case, bone marrow biopsy was the diagnostic procedure, which was performed as part of the investigation of fever of unknown origin. Follow-up periods ranged between 1 and 117 months (median 16 months). All patients achieved complete remission, seven patients relapsed and four were given autologous stem cell transplants. The median survival of the whole group was 117 months, while the 3500-day survival was 76%. As bone marrow biopsy was the diagnostic procedure in one case, bone marrow biopsy was a useful staging procedure in only 2.2% of patients (two out of 90 patients). We suggest that bone marrow biopsy should be only be performed as a staging procedure in a selected subset of patients with Hodgkin's disease (clinical stage III, B symptoms, etc.).

An addition to geographic hematology: chronic myeloproliferative diseases are infrequent in Mexican Mestizos

BACKGROUND

The chronic myeloproliferative diseases (CMPDs) include chronic myelogenous leukemia (CML), primary (essential) thrombocythemia (PT), agnogenic myeloid metaplasia (AMM), and polycythemia vera (PV). Certain hematological malignancies have a different prevalence in our country than in countries with Caucasian populations. Data indicate that the prevalence of CML in our country is similar to that found in Caucasians; however, the prevalence of the other CMPDs has not been studied.

METHODS

In a total of 8069 individuals studied between June 1983 and March 2001 in the Centro de Hematologia y Medicina Interna de Puebla, we assessed the prevalence of CML, PT, AMM, and PV. Some of the clinical features of these individuals were also assessed.

RESULTS AND CONCLUSIONS

Forty-nine patients with CML, 14 with PT, 7 with AMM, and 3 with PV were identified. The clinical presentations of these CMPDs were not different from those described in Caucasians.

CONCLUSIONS

We found that CML was more than 3 times more frequent than PT, that both PV and AMM were exceptional, and that PT, AMM, and PV were significantly less frequent in Mexican than in Caucasian populations (P < .01).

[Thrombophilia, thromboembolism and the use of the unfractionated and low-molecular-weight heparins]

An overview of the key concepts about detection of thrombophilic states, establishment of risk factors for thrombosis, the current strategies on diagnosis of thrombophilia, as well as an analysis of the current experience with the use of fractionated and unfractionated heparins, is presented. It is well known that thrombotic disease is multifactorial and that its treatment must be interdisciplinary and multidisciplinary in order to perform an opportune diagnosis and to establish an adequate prophylaxis and anti-thrombotic therapy. Even though several advantages are observed when low molecular weight heparins are used, unfractionated heparins still have some specific indications. Furthermore, under specific conditions, they can work synergistically to achieve a maximal effect on the thromboembolic states. We propose that every medical unit should establish its own criteria and diagnostic and therapeutic algorithms that allow to detect, to diagnose, and to treat the thrombotic events in the best way thus diminishing the morbidity and mortality associated with these thrombotic events.

All trans-retinoic acid decreases early mortality in patients with promyelocytic leukemia and can be given entirely on an outpatient basis

The results of the treatment of 43 patients with acute promyelocytic leukemia (PML) are reported: 27 were treated initially with all-trans-retinoic acid (ATRA), whereas 16 were treated with conventional chemotherapy. All patients received myelosuppressive chemotherapy after the initial treatment. Respectively, the complete remission rate was 92% and 37% (P < 0.01), the 5-day mortality rate was 0% and 44% (P < 0.001), and the 28-day mortality rate was 4% and 44% (P < 0.001). The median disease-free survival was 12 and 1 months (P < 0.01), whereas the 12-month disease-free survival was 50% and 13% (P < 0.01) and the 36-month disease-free survival was 41% and 9% (P < 0.01). Thirteen of the patients treated with ATRA were given the treatment fully as outpatients. ATRA given as initial therapy decreased significantly early mortality in promyelocytic leukemia patients; because some promyelocytic leukemia patients given ATRA as initial therapy can be treated as outpatients, the costs of this treatment modality may be diminished.

Non-cryopreserved unmanipulated hematopoietic peripheral blood stem cell autotransplant program: long-term results

BACKGROUND

Methods to simplify bone marrow transplantation procedures are needed mainly in developing countries.

METHODS

Between May 1993 and February 1999 in a private-practice setting, we performed 29 autotransplants in 28 patients using non-cryopreserved and unmanipulated peripheral blood stem cells mobilized from the bone marrow to the peripheral blood by means of hematopoietic growth factors. The autografting procedure was performed entirely on an outpatient basis in 19 cases (65%). The median age of the patients was 30 years, with a range of 9-67. There were 15 patients with acute leukemia (9 with acute myelogenous leukemia), 3 with chronic myelogenous leukemia, 2 with multiple myeloma, 3 with Hodgkin's disease, 2 with non-Hodgkin's lymphoma, and 4 with metastatic breast carcinoma.

RESULTS

The median time to achieve > 0.5 x 10(9)/L granulocytes was 14 days (range 7-42), whereas the median time to achieve > 20 x 10(9)/L platelets was 20 days (range 5-49). The 64-month post-transplant survival was 38%, whereas the median post-transplant survival was 18 months. The transplant-related mortality was 3.4%. The approximate cost of this simplified procedure was 10.8% for in-hospital procedures and for outpatient autografts, substantially lower than figures reported from the U.S. for autotransplants.

CONCLUSIONS

This simplified method for autografting patients, avoiding in-hospital stays, purging procedures and cryopreservation of the cells is feasible and results in a substantial decrease of the cost of autologous hematopoietic stem cell transplantation methods.

A modified spectrophotometric assay for porphobilinogen deaminase: its application in the detection of both carriers and patients with acute intermittent porphyria

A spectrophotometric method for porphobilinogen deaminase assay in erythrocytes is described. This test is determinant for the definite diagnosis of acute intermittent porphyria. In the method described, delta-aminolevulinic acid is used as substrate. Mercaptoethanol and zinc ions are introduced to maintain delta-aminolevulinic acid dehydratase in optimal conditions and to guarantee the in vitro production of porphobilinogen. An incubation temperature of 45 degrees C leads to the production of uroporphyrins, which are measured spectrophotometrically at 405 nm, giving reproducible results. The assay can be performed easily in any clinical laboratory and is valuable for detecting both patients and carriers of acute intermittent porphyria.

Long-term treatment results for acute megakaryoblastic leukaemia patients: a multicentre study

The prognosis and long-term results of a group of 57 acute megakaryoblastic leukaemia (M7-AML) patients was analysed from a multicentre perspective. Ages ranged from 4 to 83 years, median 49 years; 30 were males and 27 were females. The median follow-up time was 7 months, range 1-24 months. Early exits occurred in 12 cases, their median age being 71 years. Forty-five patients were treated with combined aggressive chemotherapy (CT) (n = 26) or low-dose cytarabine (LD-AraC) (n = 19). The following results were obtained with combined CT or AraC, respectively. Complete remission (CR) rates were 73% and 84%, 12-month survival (SV) were 37% and 26%, 24-month SV were 12% and 11%, median SV 10 and 4 months, and relapse rates (RR) were 68% and 94%. These differences were not statistically significant. Irrespective of the treatment modality, the results were better for children (n = 10) than for adults (n = 35): RR rates were 90% and 74%, median SV: 7 and 5 months, 12-month SV: 40% and 22%, 24-month SV; 30% and 9%, and RR: 78% and 81%, respectively; these differences also were not statistically significant. In addition, a literature review of 42 patients from 18 previous reports is presented, including seven cases treated with allogeneic bone marrow transplantation (BMT). The best results were obtained with BMT: 12 and 24 month SV was 86% and the RR was 0%. On the above-mentioned basis, we feel that children and young adults with M7-AML should be offered BMT. In patients over 60 years old or not eligible for aggressive chemotherapy or BMT, an interesting possibility would be the use of LD-AraC which allows a high CR rate, followed by a classical consolidation regimen in order to prevent early relapses.

[Low doses of azidothymidine in the treatment of HIV-1 virus infection]

A group of 26 patients (18 males and 8 females) infected with HIV (42% through sexual route and 58% through blood/blood products transfusion) was prospectively studied to assess the efficacy of low doses (300 mg/day) of AZT combined (n = 15) or not (n = 11) with ACV (600 mg/day). According to CDC stages, 12% were in stage II, 73% in stage III and 15% in stage IV. Patients were followed for a maximum of 156 weeks. An objective response was observed in all patients who improved significantly in: performance status (Karnofsky 74.5 versus 97.6%, p less than 0.01), weight 58.9 versus 68.6 kg, p less than 0.01), and absolute CD4 T cell count (329/microL versus 480/microL, p less than 0.01). The levels of hemoglobin dropped after treatment (12.8 versus 11.5, p less than 0.01). Median survival was 114 weeks for all the group. With the exception of granulocytopenia in 42% of patients treated with AZT + ACV versus only in 22% of those treated solely with AZT (p = 0.02), similar effects were recorded in both treatments: 114-week survival was 60% for those treated solely with AZT, whereas 156-week survival was 93% for those treated with AZT + ACV (p NS), but the response was better for the combination of antivirals in the group of patients with more than 200 CD4 cells/microL at diagnosis as compared with those with less than 200 cells (110-week survival of 100% versus 50% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of 2 chemotherapy protocols in adult acute myeloblastic leukemia. Results of the Instituto Nacional de la Nutrición Salvador Zubirán cooperative group]

Up to now, the best treatment for patients with acute myelogenous leukemia (AML) is the induction of bone marrow hypoplasia by ablative combined chemotherapy; the prototype of these schedules is the so-called 7 + 3 (seven days of continuous infusion of cytarabine and three days of one-hour infusion of any anthracycline); these schedules require the support of both platelet transfusions and antibiotics. Other non-ablative schedules have also been tried in the treatment of such patients. Here we analyze the results of the treatment of 76 adult patients with AML; 43 were treated with the classical 7 + 3 schedule, whereas 33 were treated with a combination of chemotherapy used in non-ablative doses (TADOP: thioguanine, arabinosyl-citosine, doxorrubicin, vincristine and prednisone). The results were as follows, respectively, for 7 + 3 and TADOP: complete remission (CR) was achieved in 60 and 48% of patients (p NS); the number of cycles to achieve CR had a median of 1 and 5 months (p less than 0.001); the median duration of the CR was 21 and 10 months (p less than 0.05); fatal myelotoxicity was 30 and 42% (p NS), one-year disease free survival (DFS) was 45 and 46% (p NS) and three-year survival was 22% and 15% (p NS). Additionally, patients treated with 7 + 3 were divided into two groups according to the type of platelet transfusion support; those supported with apheresis equipment and those with centrifugation-derived platelets.(ABSTRACT TRUNCATED AT 250 WORDS)

Infusion of anti-CD10 monoclonal antibody (J5) following ablative chemotherapy in a patient with refractory pre-B acute lymphoblastic leukemia

The case of a 9-year old girl with end-stage refractory pre-B CD10/CALLA positive acute lymphoblastic leukaemia is described. The patient was treated with high doses of cytarabine followed by intravenous anti-CD10 monoclonal antibody (J5) in an effort to prevent the recovery of the leukemic CD10 positive clone following the bone marrow hypoplasia resulting from the chemotherapy. The number of CD10 positive cells dissapeared both in the peripheral blood as well as in the bone marrow, but when granulocytic recovery ensued, the patient died from respiratory infection. No evidence of antigenic modulation of the CD10 antigen was observed in the blast cells.

Disturbances in the tissue plasminogen activator/plasminogen activator inhibitor (TPA/PAI) system in systemic lupus erythematosus

Increased thrombogenesis observed in systemic lupus erythematosus (SLE) is derived from multiple mechanisms, including: Enhanced coagulation factor VIII:VWf activity, lupus anticoagulants, anti-phospholipid antibodies, acquired deficiencies of natural anti-thrombotic mechanisms (protein C, protein S, anti-thrombin III), and impaired fibrinolytic mechanisms. We studied the fibrinolytic mechanisms of 18 patients with systemic lupus erythematosus, selected carefully to avoid other possible causes of abnormalities in the fibrinolytic activity. Despite the fact that the euglobulin lysis time in steady state was normal in all instances, disturbances in the tissue plasminogen activator/plasminogen activator inhibitor (TPA/PAI) system were found in all SLE patients: TPA activity was undetectable in all cases, whereas it was above 0.4 IU/ml in a control group. In 72 percent of patients, the undetectable TPA activity was correlated with abnormally high PAI activity; PAI levels were normal in all members of the control group, their mean value being 0.74 versus 8.63 IU/ml for SLE patients (P less than .01). Coagulation protein C deficiency was found in 3 patients (17%). Even though within normal range, fibrinogen levels were significantly higher in SLE than in normal controls (219 versus 192 mg/dl, P less than .01) and plasminogen levels were significantly higher in SLE than in controls (117 versus 78.2%, P less than .01). Cross-linked fibrin derivatives (D-D dimers) were negative in all patients with SLE. Sixty-eight percent of SLE patients had high levels of antiphospholipid antibodies, but no correlation with the disturbances of the TPA/PAI system was found. It is concluded that most patients with SLE display severe abnormalities in the TPA/PAI anti-thrombotic system and that these abnormalities may be related to the lupus thrombophilia, apparently multifactorial in its origin.

[Prevalence and features of pre-B-cell acute lymphoblastic leukemia in Mexico: description of 9 patients]

A group of 9 patients with pre-B cell acute lymphoblastic leukaemia (pre-B ALL) was identified prospectively within 209 patients with ALL. This variant of leukaemia was defined by the presence of heavy mu-chains in the cytoplasm of the malignant cells, and no surface immunoglobulins. Four patients displayed the CD10 (CALLA) antigen, in addition to cytoplasmic mu chains. A G-0 acute leukaemia (no blast cells in S-phase) was identified in two cases. Response to treatment of the patients was poor: Only four achieved complete remission; median survival was 24 weeks and the 40-week disease free survival was 20%. These figures are significantly worse than those obtained in patients with early-pre-B (CD10+) ALL. We conclude that the prevalence of pre-B ALL is low in our experience (4.6% of all patients with ALL) and that a poor outcome of treatment was related to it.

[Primary gastric lymphoma: incidence, prognostic factors and effect of treatment with chemotherapy]

This paper deals with the prevalence, clinical features and therapeutic response of 19 patients with primary gastric lymphoma studied and treated at Centro de Hematologia y Medicina Interna de Puebla, Mexico and Instituto Nacional de la Nutricion Salvador Zubiran, Mexico City, Mexico, in a 10 year period (1979-1989). The main findings were as follows: 1) The prevalence of gastric lymphoma has increased in Mexico: Between 1950 and 1980 the prevalence was found at 4.5% of all gastric tumors, whereas between 1980 and 1990 it was found at the 7.6% level (chi square = .0001). 2) The significant prognostic factors for survival were in this series the clinico-pathologic stage and the degree of infiltration of the gastric wall: 80-month disease free survival was 80% and 44% respectively for stages I and III (p less than 0.02); 10-year disease free survival was 100% and 23% respectively for mucosal/submucosal infiltration VS mucosal/serosal infiltration (p less than 0.01). 3) The 10-year disease free survival was 68% for patients treated with chemotherapy and surgery; this figure is similar to those obtained using radiotherapy and surgery, but with a lower relapse rate. Two patients with lymphomatous lesion less than 3 cm. and invading only mucosae/submucosae were treated solely with chemotherapy and both of them remain disease free after 20 months of follow-up.

[Hypercalcemia and osteolytic lesions associated with pre-B-cell primary lymphoma of the bone marrow. A case report]

Primary bone marrow lymphomata are infrequent; most of them are of B-cell origin, and those of a T-cell lineage produce mainly both hypercalcemia and osteolytic lesions apparently due to abnormal production of osteoclast-activating factor. We report a 15-year old patient with a primary bone marrow lymphoma: 85% of his infiltrating malignant lymphocytes displayed cytoplasmic mu-chains compatible with a pre-B phenotype. The cells failed to display the CALLA/CD 10 antigen. Serum calcium was 7.5 mEq/L (range 4-5 mEq/L); the bone biopsy of an osteolytic lesion disclosed a large-cell, diffuse non-Hodgkin's lymphoma. No malignant cells were found in the peripheral blood and there were no enlarged lymph nodes. The patient was treated with 6 courses of chemotherapy: hydroxyldaunorubicin, vincristine and prednisone (HOP). Complete remission was achieved and the patient was placed on continuation chemotherapy with daily six-mercaptopurine and weekly methotrexate, together with HOP pulses every three months. The hypercalcemia disappeared together with the fever and the bone pain: the patient has been followed 6 months. Data on this case are discussed together with those previously published in regard to the low prevalence of bone lesions in primary B-cell lymphomas of the bone marrow, and to the similarity of this B-cell malignancy to others that produce both hypercalcemia and bone lesions, i.e. multiple myeloma.

[Leukemia and malnutrition. II. The magnitude of maintenance chemotherapy as a prognostic factor in the survival of patients with standard-risk acute lymphoblastic leukemia]

In previous papers we have shown that malnutrition is an adverse prognostic factor in the outcome of treatment in patients with standard-risk acute lymphoblastic leukemia. The reason why undernourished children do poorly as compared with well nourished children is that malnourishment leads to a diminished bone marrow reserve thus making necessary to delivery of suboptimal doses of maintenance chemotherapy (less than that calculated according to body surface). Undernourished children receive less 6-MP and MTX and relapse more frequently in the bone marrow, finally reflecting a 5 yr disease-free survival of 26% as compared with 83% in well-nourished children (p less than 0.001). In this paper we have analyzed the impact of the variable delivery of sub-optimal doses of maintenance chemotherapy in a group of 43 pediatric patient with standard-risk acute lymphoblastic leukemia. The 5 year disease free survival of children receiving suboptimal maintenance chemotherapy was 7% as compared with 65% for those receiving full doses of both 6-MP and MTX (p less than 0.001), and more frequent relapse involving the bone marrow in children receiving low doses (71% versus 3%, p = 0.000005). The impact of the variable suboptimal doses of chemotherapy was present in children with both normal and deficient nourishment status. It is concluded that the delivery of suboptimal doses of maintenance chemotherapy, due to bone marrow toxicity related to an abnormal myelopoietic reserve, is an adverse prognostic factor in the outcome to treatment of patients with lymphoblastic leukemia.

[Protein C, protein S and thrombomodulin: one of the natural antithrombotic mechanisms]

In this review paper, the salient features of the anticoagulant/fibrinolytic mechanism depending on coagulation protein C, protein S and thrombomodulin are reviewed. Coagulation protein C, activated at the endothelial cell surface in the presence of the complex thrombin/thrombomodulin exerts two anti-thrombotic effects: one anticoagulant dependent on the free protein S and the other pro-fibrinolytic, independent of protein S. Both inherited and acquired deficiencies of protein C and/or protein S lead to a thrombosis-prone state that has to be identified promptly to avoid vaso-occlusive episodes. The experience in Mexico with both the identification and treatment of these deficiencies is reviewed; it is interesting that we have found that patients with autoimmune disorders, mainly systemic lupus erythematosus and primary anti-phospholipid syndrome, have acquired deficiencies of this anticoagulant mechanism that may be related to the thrombogenesis observed in these patients.

The pretreatment DNA labelling index of the blast cells of patients with acute lymphoblastic leukaemia as a prognostic factor in the outcome of treatment: the concept of 'G-0 acute leukaemia'

A group of 15 patients with acute lymphoblastic leukaemia was studied prospectively to analyse the impact of the pretreatment DNA labelling indices of the blast cells. Patients with labelling indices less than 5% did significantly worse than those with labelling indices greater than 5%: the 60-week disease-free survival of patients with acute lymphoblastic leukaemia and labelling indices greater than 5% was 80%, whereas that for patients with labelling indices less than 5% was 24%, P less than 0.05. In addition, three patients with acute leukaemia and DNA labelling indices of 0%, so-called G-0 acute leukaemias, are described: all of them had refractory forms of acute lymphoblastic leukaemia with a very poor outcome to treatment.

[Paid blood donors: a new risk group for the development of AIDS in Mexico]

We analyzed the clinical and epidemiological characteristics of seven patients with AIDS who were infected through contaminated needles or blood letting equipment; no other risk factor was identified in these patients. In the Dirección de Epidemiología de los Servicios Coordinados de la Salud in the state of Puebla, 37 cases of AIDS were registered up to June 15, 1988. Nineteen percent of these were paid donors between the ages of 26 and 45. There were five males and two females. All of them had weight loss, fever, chronic diarrhea and adenomegaly. Six had respiratory complaints, four candidiasis and two pulmonary tuberculosis. In the state of Puebla, there are 517 paid donors registered as carriers of Human Immune Deficiency Virus (HIV). We do not know the number of blood donations and therefore the number of receptors. In this state, 52 percent of AIDS cases are post-transfusional and we fear an increase. We propose that all paid blood donors should be considered as a high risk group.

[Effect of danazol on heterozygous c protein coagulation deficiency exacerbated by Salmonella typhi sepsis]

The case of an 8-month-old male with heterozygous coagulation protein C deficiency is presented. Sepsis due to Salmonella typhi aggravated the protein C deficiency and resulted in arterial thrombosis of the distal third of the lower right limb. The patient was treated with both heparin and danazol, the levels of functional protein C increasing and the necrotic phenomenon resolving, thus making unnecessary amputation of the limb. The observation is discussed with the evidences of danazol being useful in the treatment of patients with protein C deficiency.

["Occupational" infection caused by the human immunodeficiency virus in 6 members of a single family]

The risk groups for AIDS have been defined and include homosexuals, bisexuals, polytransfused patients, drug addicts, sexual partners of any of the above groups and sons of infected fathers. We have previously proposed that paid donors should be considered also as high risk individuals. We report here a family in which six of its eight members had HIV infection without other risk factor than being paid blood donors.

[High doses of cytosine arabinoside in the treatment of patients with acute relapsing or refractory leukemia]

Ten patients either in relapse (n = 7) or refractory (n = 3) acute leukemia were treated with high-dose Ara-C (3000 mg/m2) every 12 hours to a total of eight 2 doses (24,000 mg/m2). Myeloblastic (n = 5), lymphoblastic (n = 4) and hybrid (n = 1) acute leukemias were included. In the total group, complete remission was achieved in 6 of 10 cases (60%); the remission rate was higher in the relapsed than in the refractory acute leukemia group (71 versus 33%;) the duration of the complete remission ranged between 1 and 13 months, with a median of 2 months; the remission duration was also higher in the relapsed than in the refractory acute leukemia group (4 versus 1 month). Refractoriness to the high-doses of Ara-C was observed in two cases, and fatal iatrogenic myelosuppression was produced in two patients. The rate of complete remission was 80% in myelogenous leukemia and 50% in lymphoblastic leukemia. It is concluded that high-dose Ara-C is another therapeutic choice in the treatment of relapsed and perhaps refractory acute leukemia.

[High prevalence of acquired immunodeficiency syndrome (AIDS) associated with transfusion in Puebla, Mexico]

The salient clinical and epidemiological features of the first cases of AIDS diagnosed in the city of Puebla, Mexico, are reviewed. Puebla has 2 million inhabitants and 37 cases of AIDS have been diagnosed since 1984. Thirty-two percent of patients acquired AIDS by blood transfusion, 20% were paid blood donors and 48% acquired the HIV infection by the sexual route, thus making a 52% prevalence of transfusion-related HIV infection. These data are substantially different from those reported in other countries and in other cities within Mexico, where the prevalence of transfusion-associated HIV infection is about 11.5%. The high prevalence of transfusion-related AIDS seems to be due to existence of "blood centers" where paid donors are bled using non-disposable material, and they are poorly selected. HIV infection is thus transmitted to paid-blood donors which in turn become transmitters of the disease. The new regulations on blood donation adopted in Mexico abolish paid blood-donation and the selection of blood donors is more stringent. This should result in reducing the serious problem of transfusion-associated HIV infection in the city of Puebla, Mexico.

[Dyshemopoietic anemias (AD) (myelodysplastic syndromes). Retrospective analysis of 40 cases from the Instituto Nacional de la Nutrición Salvador Zubirán (INNSZ)]

40 patients with DMPS were studied and diagnosed at the INNSZ during 1980-1985. Eighteen were males and twenty two females; age average of 55.7 years (17-82), with 72.5% over 50 years old. Their distribution according to the FAB classification was: 55% type I, 10% type II, 27.5% type III, 2.5% type IV and 5% type V. All of them had an anemic syndrome and 47.5% had bled, 52.5% had pancytopenia; there was anemia and thrombocytopenia in 32.5%, anemia and leukopenia in 7.5%, and anemia only in 7.5%. The bone marrow was normocellular in 42.5%, hypercellular in 40% and hypocellular in 17.5%, 45% of the patients survived; 22% achieved a complete remission (CR) and 9 patients (22.5%) died of causes related to DMPS. The rest was lost to follow up.

Leukaemia and nutrition. I: Malnutrition is an adverse prognostic factor in the outcome of treatment of patients with standard-risk acute lymphoblastic leukaemia

A group of 43 pediatric patients with standard-risk ALL were studied. Thirty-seven per cent of them presented with malnutrition at diagnosis. Malnourished children had a significantly worse outcome than well-nourished children. Five-year DFS was 83% for well-nourished children (WNC) and 26% for under-nourished children (UNC) (p less than 0.001). Relapses presented more frequently in the bone marrow in UNC than in WNC (56% vs 7%, p less than 0.0001). The doses of maintenance chemotherapy had to be reduced in 68% of UNC and 11% of WNC (p less than 0.005); the doses of maintenance myelosuppressive chemotherapy (6-MP, oral MTX and hydroxyldaunorubicin) received by UNC were approximately 50% of those received by WNC (p less than 0.01). The correlation between malnutrition and compromised treatment was 0.92. Malnutrition might be included as an adverse prognostic factor in acute lymphoblastic leukaemia (ALL).

The incidence of hybrid acute leukaemias

During a 4-yr period, 292 patients with acute leukaemia were studied using morphology, cytochemistry and immunologic reagents to determine the cell lineage of the leukaemia. One hundred and sixty-three cases were shown to be acute lymphoblastic leukaemia (ALL), 127 acute myeloblastic leukaemia (AML) and two cases (0.6%) were classified as hybrid acute leukaemias. One was biphenotypic in which the blast cells displayed both T-lymphoid (60% E-rosettes) and megakaryocytic markers (47% CDw41/glycoprotein IIb/IIIa antigen, 50% myeloperoxidase). The second was a bilineal acute leukaemia in which some blast cells displayed B-lymphoid (47% CD10/CALLA, 40% acid phosphatase) features and other megakaryocytic (33% coagulation factor VIII:WVf antigen)/myeloid (30% Sudan Black) features. This study suggests that hybrid acute leukaemia are rare.

Acute megakaryoblastic leukaemia: a prospective study of its identification and treatment

Acute megakaryoblastic leukaemia remains an uncommonly recognized disorder, usually identified by electron microscopy or with monoclonal antibodies. Using two monoclonal antibodies (HP1-1D identifying glycoprotein IIB/IIIA and W1-23 identifying von Willebrand factor) we have studied during a 12 month period all cases of acute leukaemia with FABL2,M1 or undifferentiated morphology presenting in our cooperative group 'Grupo de Hematólogos de Puebla' in México. Six of 21 FAB L2, M1 or undifferentiated leukaemias were classified immunologically as megakaryoblastic. Five of these patients had myelofibrosis and two had normal platelet counts but abnormal platelet aggregation function. All six patients were treated with low-dose cytosine arabinoside (10 mg/m2) administered subcutaneously, twice daily in 21 d courses). Haematologic response was achieved in five cases while the sixth died before completing one course. Three patients relapsed within the first month after completing the chemotherapy and died. Two patients remain in remission 11 and 15 months after initial treatment. It is our impression that the prevalence of acute megakaryoblastic leukaemia has been under-estimated, and that low-dose cytosine arabinoside treatment may be of value in its management.