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Three cases are reported of disseminated infection due to Fusarium species in severely neutropenic patients. The clinical findings in all patients included fever, painful disseminated nodular skin lesions and severe myalgia. The outcome was fatal despite early administration of amphotericin B. The portal of entry of the organism was probably the nasal sinus in two cases. [ABSTRACT FROM AUTHOR] more...

Contrast-induced thrombocytopenia is a rare complication distinguished by acute and severe platelet consumption, with spontaneous recovery within days. We describe a case of acute thrombocytopenia 6 hours after coronary angioplasty in a patient with a negative antiplatelet factor 4 test. The count reached 1 × 10 3 /µL, but improved spontaneously to 210 × 10 3 /µL after 8 days. In conclusion, physicians should be aware of this complication, particularly when dual antiplatelet therapy is being considered. more...

Background: Early assessment of response to chemotherapy in acute myeloid leukemia may be performed by examining bone marrow aspirate (BMA) or biopsy (BMB); a hypocellular bone marrow sample indicates adequate anti-leukemic activity. We sought to evaluate the quantitative and qualitative assessment of BMA performed on day 14 (D14) of chemotherapy, to verify the inter-observer agreement, to compare the results of BMA and BMB, and to evaluate the impact of D14 blast clearance on the overall survival (OS)., Methods: A total of 107 patients who received standard induction chemotherapy and had bone marrow samples were included. BMA evaluation was performed by two observers using two methods: quantitative assessment and a qualitative (Likert) scale. ROC curves were obtained correlating the BMA quantification of blasts and the qualitative scale, by both observers, with BMB result as gold-standard., Results: There was a significant agreement between the two observers in both the qualitative and quantitative assessments (Kw = 0.737, p < 0.001, and rs = 0.798, p < 0.001; ICC = 0.836, p < 0.001, respectively). The areas under the curve (AUC) were 0.924 and 0.946 for observer 1 and 0.867 and 0.870 for observer 2 for assessments of the percentage of blasts and qualitative scale, respectively. The best cutoff for blast percentage in BMA was 6% and 7% for observers 1 and 2, respectively. A similar analysis for the qualitative scale showed the best cutoff as "probably infiltrated". Patients who attained higher grades of cytoreduction on D14 had better OS., Conclusions: Evaluation of D14 BMA using both methods had a significant agreement with BMB and between observers, identifying a population of patients with poor outcome. more...

Background: Current chemotherapy regimens for adults with acute lymphoblastic leukemia (ALL) result in high rates of complete remission (CR), but relapses are still frequent., Patients and Methods: In this retrospective single-center study, we evaluated the results of the Hyper-CVAD (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) regimen in 49 ALL patients treated between 2001 and 2013. No exclusion criteria were applied. The primary outcome measure was the CR rate., Results: Forty-six of the 49 patients (93.8%) obtained CR, and 3 (6%) patients died during induction. Philadelphia chromosome was present in 6 patients (12.2%); in all a CR was obtained. Among the 46 patients in CR, 30 (65.2%) received the full planned intensive-phase treatment (8 cycles). Allogeneic hematopoietic cell transplantation was performed in 2 (4%) patients in first CR and in 3 (6%) patients after a second CR. Nonrelapse mortality was observed in 8 patients (16.3%). The median overall survival (OS) and 5-year OS were 24.4 months and 35%, respectively. Initial leukocyte count (> 30 × 10(9)/L) was an important prognostic factor., Conclusion: Hyper-CVAD as an induction regimen for adults and adolescents with ALL was feasible and yielded a high rate of CR. Relapse rates and OS were comparable to other series but still unsatisfactory., (Copyright © 2015 Elsevier Inc. All rights reserved.) more...

The human germinal center-associated lymphoma (HGAL) gene has prognostic value in diffuse large B-cell lymphoma, and expression of its cognate protein is germinal center-specific. A previous study had suggested that HGAL protein expression might also be related to the outcome in patients with Hodgkin lymphoma (HL). The aim of this study was to confirm the prognostic impact of HGAL protein expression in an independent, well-characterized cohort of 232 patients with classic HL treated uniformly with doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). Tissue microarray analysis showed HGAL staining in 188 specimens (81%). Failure-free survival (FFS) was superior in patients with early-stage disease, low-risk IPS, and HGAL-positive patients. The estimated 5-year FFS for HGAL-positive and HGAL-negative patients was 82% and 67%, respectively (p = 0.03). In the multivariate analysis, advanced stage and absence of HGAL staining were independent predictors of a worse FFS. This study confirms and validates recent findings of a correlation between HGAL expression and outcome in classical HL. more...

Eosinophilic granuloma is classified as a Langerhans cell histiocytosis. Although considered a rare pathology, up to 20% of all cases occur in the jaw bones, and radiographically may mimic odontogenic cysts or benign and malignant tumours. Different protocols have been suggested in the literature for treating eosinophilic granuloma. We report a case of polyostotic eosinophilic granuloma in a 34-year-old man showing ill defined mandibular and palatal radiolucencies. Due to the presence of multiple jaw lesions the treatment choice was chemotherapy. The clinical and radiographic feature are described, as well as treatment, complications and patient's follow-up. more...

This study was undertaken to evaluate the clinical significance of the expression of Bcl-2, p53 and LMP-1 in Hodgkin and Reed - Sternberg cells of patients with Hodgkin's lymphoma. The expression of these proteins in pre-treatment tissue biopsy specimens was correlated with presenting clinical features, failure-free survival (FFS) and overall survival (OS) in 83 patients with a confirmed Hodgkin's lymphoma treated in a single institution. HIV-positive patients were excluded. Patients were classified according to the International Prognostic Score (IPS) in low-risk (0 - 2 factors) and high-risk groups. The median age was 41 years (15 - 84), 41% were women, and 93% had advanced-stage disease (IIB - IVB). The expression of Bcl-2, p53 and LMP-1 was not associated with the complete remission rate, FFS or OS. The IPS risk group was the only factor significantly associated with OS. Patients with a high IPS had a lower 5 year OS (43% vs. 79%, P = 0.003). The expression of Bcl-2, p53 and LMP-1 did not add prognostic information to the IPS. more...

This report describes the results of a multicenter study designed to determine the efficacy and toxicity of a novel combination (ABVP) in patients with newly diagnosed Hodgkin's disease. The ABVP protocol is a modification of ABVD in which prednisone is substituted for DTIC. In order to attempt an increase in drug intensity, doxorubicin, bleomycin and vinblastine were administered on days 1 and 8 of each cycle, and a new cycle began on day 22. Patients who developed phlebitis were allowed to receive the drugs every two weeks. Patients with bulky mediastinal disease received involved field radiation therapy after chemotherapy. Fifty-one patients were treated. Complete remission was achieved in 40 patients (78%). Actuarial failure-free survival in 55 months was 59%, and overall survival was 81%. The overall survival for the 32 patients treated with the intensified regimen was higher than that for those who switched to the bi-weekly schedule (89% vs. 68%, p=0.03). ABVP appears to be equivalent to ABVD. The higher overall survival rate in patients treated every 21 days suggests that this intensified schedule might be more effective. The placement of a Port catheter is recommended, due to the high incidence of phlebitis. more...

We evaluated the impact of applying the Infectious Diseases Society of America guidelines for febrile neutropenic patients in reducing the use of glycopeptides. Forty-five prior episodes of febrile neutropenia were compared to 97 episodes seen after application of the guidelines. Glycopeptide use was reduced from 73% to 43% of episodes (P=.0008), without changes in outcome. more...

We investigated the presence of free mRNA in the plasma of patients with chronic myeloid leukemia (CML), through RT-PCR analysis of G3PDH, a metabolism gene. We also analysed the presence of mRNA for HLM, a human oxysterol-binding protein homologue recently described as a potential marker for blood dissemination of solid tumors. Our results showed the presence of metabolism G3PDH mRNA in the plasma of 5/11 (45%) CML patients studied but HLM mRNA was not detected in any of the plasma studied. HLM mRNA was detected in the leukocytes of 4/5 (80%) CML patients. This work reports for the first time free mRNA in the plasma of CML patients. Our results also suggest that the detection of HLM could be a potential molecular marker for the follow-up in hematological malignancies. more...

Institutions that treat patients with lymphoma must know their local therapy results and adapt their treatment strategies accordingly. To allow the application of the international prognostic factor index (IPI) in institutions where some of the data necessary are not available, we devised an approach by which the missing data would not impair the applicability of the index. We also collapsed the four categories of the IPI into two categories, and applied this adapted IPI to patients with aggressive non-Hodgkin's lymphoma treated in a public university hospital. Among the 72 patients treated with combination chemotherapy regimens containing doxorubicin, the following outcomes were observed for low and high risk groups, respectively: complete remission rates were 62% and 45% (p=0.2), overall survival rates were 48% and 14% (p=0.0098) and failure-free survival rates were 44% and 17% (p=0.03). This adapted IPI was very effective in predicting the outcome in the patients studied. The survival rates observed in our population were substantially lower than the rates reported in the IPI study. Patient selection might have played an important role in this difference, although other factors related to the social and general health status of the patients treated need to be prospectively studied. more...

A total of 21 patients with hematologic malignancies were given thiabendazole for treatment of strongyloidiasis. Fifteen patients were cured. Since there were no relapses, it is unlikely that maintenance therapy has a role in the management of strongyloidiasis in this population of patients. more...

A multicentric randomized trial was undertaken to compare the toxicity of amphotericin B in 5% dextrose with that of amphotericin B in a fat emulsion (Intralipid) in cancer patients. Group 1 (n = 33) received amphotericin B diluted in 5% dextrose with premedication consisting of promethazine plus an antipyretic. Group 2 (n = 28) received amphotericin B diluted in 20% Intralipid without premedication. Amphotericin B was infused daily at a dose of 1 mg/kg of body weight over a 1-h period to members of both groups for empirical antifungal therapy (in neutropenic patients) or for the treatment of documented fungal infections. The majority of patients (80%) received empirical amphotericin B treatment. The two groups were comparable with regard to age, gender, underlying disease, and the following baseline characteristics: use of other nephrotoxic drugs and serum levels of potassium and creatinine. The median cumulative doses of amphotericin B were 240 mg in group 1 and 245 mg in group 2 (P = 0.73). Acute adverse events occurred in 88% of patients in group 1 and in 71% of those in group 2 (P = 0.11). Forty percent of the infusions in group 1 were associated with fever, compared to 23% in group 2 (P < 0.0001). In addition, patients in group 2 required less meperidine for the control of acute adverse events (P = 0.008), and fewer members of this group presented with hypokalemia (P = 0.004) or rigors (P < 0.0001). There was no difference in the proportions of patients with nephrotoxicity (P = 0.44). The success rates of empirical antifungal treatment were similar in the two groups (P = 0.9). Amphotericin B diluted in a lipid emulsion seems to be associated with a smaller number of acute adverse events and fewer cases of hypokalemia than amphotericin B diluted in 5% dextrose. more...

In order to identify prognostic factors for death among cancer patients with fungemia, an 18-month survey of fungemia in patients with cancer was undertaken in three hospitals in Rio de Janeiro. For the assessment of risk factors for death, the following variables were analyzed: age; gender; underlying cancer; last treatment for the underlying disease; previous surgery; use of antibiotics, antifungal agents, steroids, or total parenteral nutrition; use of a central venous catheter; chemotherapy; radiotherapy; presence and duration of neutropenia; etiologic agent of the fungemia; treatment of the fungemia; clinical manifestations; and performance status (Karnofsky score) on the day of the positive blood culture. In multivariate analysis, the variables associated with an increased risk for death were older age, persistent neutropenia, and low performance status. Identifying risk factors for death may help to define a group-risk patients for whom new therapeutic options should be tried. more...

The objective of this study was to characterize the epidemiology of candidemia in cancer patients in the city of Rio de Janeiro, Brazil. An 18-month survey of fungemia in patients with cancer was undertaken in three Hospitals in Rio de Janeiro. Forty-three episodes of candidemia were identified in 43 patients, 43 of which were episodes of candidemia; in ten case the strains were not available for further identification of species and were excluded from this analysis. The overall distribution of fungi causing fungemia was: Candida albicans (5), Candida tropicalis (16), Candida parapsilosis (6), Candida guilliermondii (4), Candida lusitaniae (1) and Candida stellatoidea (1). Antifungal prophylaxis had been administered before the episode of fungemia in only six patients (18.2%): oral itraconazole in three patients and oral nistatin, low dose intravenous amphotericin B and oral fluconazole in one patient each. There was no difference in the presence of risk factors, clinical characteristics or in the outcome between albicans and non-albicans species, nor between Candida tropicalis and other non-albicans species. There was a clear predominance of non-albicans species, regardless of the underlying disease, antifungal prophylaxis or the presence of neutropenia. more...

The role of bone marrow biopsy in the staging of Hodgkin's disease is undergoing reevaluation. We have studied the relationship of clinical factors to the presence of bone marrow involvement in 130 previously untreated patients with Hodgkin's disease. The presence of fever, spleen enlargement, anemia, leukopenia, poor performance status and poor histologic subgroups were positively correlated with the presence of bone marrow involvement in the univariate analysis. In the multivariate analysis, only fever, spleen involvement, leukopenia and poor histologic subgroups were significant. The predictive value of the absence of fever in regard to the absence of bone marrow involvement was 98%. The likelihood of bone marrow involvement in the absence of all four significant factors was only 0.05%. Patients without these clinical factors should probably not be submitted to a bone marrow biopsy as part of the staging procedures performed in Hodgkin's disease. more...

Extramedullary hematopoiesis is a common accompaniment of a variety of hematologic diseases such as hereditary spherocytosis, thalassemia and myelofibrosis. The association of extramedullary hematopoiesis with polycythemia vera in the proliferative phase is much less usual. We report a patient who presented with paraplegia due to spinal cord compression; clinical investigation revealed a paravertebral hematopoietic tumor, and the diagnosis of polycythemia vera was then established. more...

In this paper we report a eight-year prospective study designed to further characterize incidence, epidemiology, specific syndromes, treatment and prognosis associated with fungal infections in neutropenic patients. During the study period 30 fungal infections were diagnosed in 30 patients among 313 episodes of fever and neutropenia (10%). There were 15 cases of candidiasis, 5 pulmonary aspergillosis, 3 sinusitis by Aspergillus fumigatus, 5 infections by Fusarium sp., one infection by Trichosporon sp., and one infection due to Rhodotorula rubra. Blood cultures were positive in 18 cases (60%). The predisposing factors for fungal infection in multivariate analysis were the presence of central venous catheter (p < 0.001), longer duration of profound (< 100/mm3) neutropenia (p < 0.001), the use of corticosteroids (p < 0.001), gram-positive bacteremia (p = 0.002) and younger age (p = 0.03). In multivariate analysis only recovery of the neutropenia (p < 0.001) was associated with good prognosis whereas the diagnosis of infection by Fusarium sp. (p = 0.006) was strongly associated with a poor outcome. The death rate was 43%. There was no statistically significant difference in the death rate between patients who did receive (52%) or did not receive (50%) antifungal treatment. Identifying patients at risk, specific syndromes and prognostic factors may help to reduce the high mortality associated with disseminated fungal infections in neutropenic patients. more...

In a cohort of 79 febrile episodes in 50 consecutive neutropenic patients seen at the University Hospital, Federal University of Rio de Janeiro, Brazil, between 1987 and 1991, it was observed that the cumulative incidence of disseminated fungal infections rose from 3% to 19% after the introduction of a new empirical antibiotic regimen. In order to identify risk factors, as well as to assess the impact of the new antibiotic regimen on the emergence of fungal infections, a nested case-control study was undertaken, in which 10 cases of disseminated fungal infections were compared with 30 randomly chosen controls, drawn from the same cohort. In a multiple logistic regression analysis, the predictive factors for disseminated fungal infection were younger age (odds ratio 0.85, 95% confidence interval 0.75-0.97) and use of the new antibiotic regimen (odds ratio 14.18, 95% confidence interval 1.05-191.80) The probable explanation for the emergence of fungal infections is that the new antibiotic regimen, by lowering the incidence of bacteraemia-related deaths, allowed patients to be at risk for the development of disseminated fungal infections. more...

Progression of a low-grade non-Hodgkin's lymphoma into a more aggressive histologic pattern is a well-described phenomenon. The converse phenomenon, often called downgrading, is much less frequent. We report 2 patients in whom relapse with an indolent lymphoma was noted after chemotherapy for higher-grade disease. Other previously reported cases are reviewed. The implications for appropriate management and pathogenesis are discussed. more...

Skin nodules can be the first evidence of a disseminated fungal infection in febrile neutropenic patients. We present our experience in the diagnosis of this clinical problem in five patients treated for serious hematologic conditions in our Service. There were two cases of Candida sp., two of Fusarium sp., and one of Trichosporon sp.. The immediate assessment of any suspicious lesion, including a biopsy of the lesion for microbiological and histopathologic examinations, will usually lead to the correct diagnosis. more...