Hemophagocytic syndrome in Dengue hemorrhagic fever with severe multiorgan complications.

A 46 year old woman who presented with severe multiorgans involvement including liver brain, cardio-pulmonary failure, gastrointestinal bleeding, progressive cytopenia, DIC and hemophagocytic syndrome during the convalescent phase of Dengue type II has been successfully treated primarily with pulse methyl prednisolone and high dose intravenous immunoglobulin G. The authors believe that HPCS are not infrequently seen with high mortality and recommended early diagnosis and treatment with the regimen. This is the first complete report of hemophagocytic syndrome in adult dengue hemorrhagic fever in Thailand. The literature of HPCS in DHF was reviewed and discussed.

Successful treatment of retinoic acid syndrome with dexamethasone: a case report.

Retinoic acid syndrome (RAS) is the clinical syndrome that occurs after treatment of acute promyelocytic leukemia with all-trans-retinoic acid (ATRA). The patients experience fever, dyspnea, hypotension, respiratory distress, edema and weight gain. Chest x-ray will show pulmonary infiltrates and pleuropericardial effusion. The onset of this syndrome is usually 5-21 days after ATRA treatment when white blood cell counts are rising more than 10,000/cu.mm. The authors have reported a case of RAS. The patient was a 29-year-old man who had been working in a battery manufacturing factory for 7 years. He presented with easily bruising for one month. The initial blood test showed hematocrit of 36.2%, white blood cells count of 3,200/cu.mm with 28% neutrophils, 20% lymphocytes, 2% eosinophils and 50% promyelocytes and platelet of 20,000/cu.mm. Peripheral blood smear revealed numerous fragmented red blood cells. Bone marrow examination showed hypercellularity with abnormal promyelocytes of 95% and bone marrow cytogenetics was translocation of chromosome 15 and 17 [t (15;17)(q22;q12)]. The diagnosis was acute promyelocytic leukemia and the patient was treated with ATRA 45 mg/m2/day per oral starting on day 1 and intravenous idarubicin 10 mg/n2 on day 4, 5 and 6. On day 13, he had a body temperature of 39 degrees C and a dry cough. The white blood cells were rising to 7,400/cu.mm with 16% neutrophils. On day 18, he had oliguria, high grade fever, hypotension, cough with chest pain and white blood cells rose to 21,300/cu.mm with 65% neutrophils and rising of blood urea nitrogen and creatinine. Chest x-ray showed enlarged cardiac shadow with pleural effusion. Echocardiogram revealed moderate amount of pericardial effusion. The diagnosis of RAS was made and ATRA was withdrawn. Intravenous dexamethasone 4 mg every 6 hours and hemodialysis was started. The patient's symptoms improved dramatically and bone marrow examination was in complete remission. He was subsequently given cytarabine and idarubicin as consolidation. This patient had clinical manifestation consistent with RAS, which improved after prompt treatment.

Comparative study of low-dose oral granisetron plus dexamethasone and high-dose metoclopramide plus dexamethasone in prevention of nausea and vomiting induced by CHOP-therapy in young patients with non-Hodgkin's lymphoma.

Standard-dose (2 mg/day) oral granisetron seems to have more antiemetic efficacy than that of high-dose (0.5-1 mg/kg/dose) metoclopramide in moderately emetogenic chemotherapy. However, the cost of oral granisetron is much higher than that of metoclopramide so the authors tried to overcome this disadvantage by dose reduction and adding dexamethasone to enhance the antiemetic effect of oral granisetron. Twenty four young patients (aged < 50 years), with non-Hodgkin's lymphoma receiving CHOP-therapy were enrolled and evaluated in a randomized, double-blind, crossover study comparing the antiemetic efficacy, toxicity and patients' preference of a combination of low-dose oral granisetron plus intravenous dexamethasone (gran/dex) with a combination of high-dose metoclopramide plus intravenous dexamethasone (met/dex) on days 1-5 after chemotherapy. The acute, delayed (day 2-5) and 5-day total control of nausea and vomiting in the gran/dex group were significantly higher than those of the met/dex group (75.0% vs 25.0%; p-value = 0.004, 79.2% vs 33.3%; p-value = 0.007 and 75.0% vs 25.0%; p-value = 0.004, respectively). Except for extrapyramidal reactions in the met/dex group, the side effects in both groups were comparable. The mean total score of antiemetic preference in the gran/dex group was also significantly higher than that of the met/dex group (9.0 vs 7.5; p-value = 0.004). In conclusion, low-dose oral granisetron combined with intravenous dexamethasone had significantly higher protective effects against both acute and delayed nausea and vomiting induced by CHOP-therapy. Thus, this regimen may be considered as an alternative outpatient antiemetic treatment for young patients with non-Hodgkin's lymphoma.

Polycythaemia vera and secondary polycythaemia: Differential diagnosis by serum vitamin B12 and Its binding proteins.

That the suggested criteria for diagnosis of polycythaemia vera (PV) are rather complicated, therefore accurate diagnosis of PV from other types of polycythaemia is needed. Serum Vitamin B12 and Vitamin B12 binding proteins were determined in a patients with PV and other 5 patients with secondary polycythaemia. Both serum Vitamin B12 and unsaturated Vitamin B12 binding capacity (UBBC) increased considerably. TCIII and TCI increased also markedly, i.e., 16 and 8 folds, respectively, resulting in a decreased ratio of TCI/TCIII from the normal value of 1.34 to 0.71. Patients with secondary polycythaemia had slightly increased serum Vitamin B12 while serum UBBC, TCI and TCIII levels showed no significant alteration from those of normal subjects. These findings indicated that not only increased serum Vitamin B12 and UBBC but also an increase of TCIII and the ratio of TCIII/TCI are the positive findings in patients with PV. Therefore determinations of serum Vitamin B12 and its binding proteins can be used as a criteria for the differential diagnosis of PV from secondary polythaemia.

Transition from polycythaemia vera to myelofibrosis with myeloid metaplasia: A case report.

An 80-year-old woman was admitted to the hospital with of pain in the right upper abdominal region. She had splenomegaly and CT scan showed gall stones and splenic infarction. Blood examination revealed erythrocytosis, raised LAP, elevated serum vitamin B12, vitamin B12 binding proteins and reversed TCI/TCIII ratio. All these findings confirmed the diagnosis of polycythaemia vera. After splenectomy and cholecystectomy, a leucoerythroblastic blood picture with teardrop poikilocytosis was detected in the peripheral blood smear. The haemoglobin concentration decreased but leucocytosis and thrombocytosis still persisted. Bone marrow aspirate showed erythroid hypoplasia, decreased megakaryocytes and some degree of fibrosis. This was compatible with the criterial diagnosis of myelofibrosis with myeloid metaplasia. Blood transfusions and myleran were given. Peritoneal dialysis was performed and the patient had severe bleeding and died from cardiac failure due to septic shock. This patient is an example of the transition from polycythaemia vera to myelofibrosis with myeloid metaplasia.

Pure red cell aplasia associated with chronic neutrophilic leukemia: A case report.

A 79-yesr-old woman was admitted to the hospital with evidence of pure red cell aplasia and chronic neutrophilic leukemia. Bone marrow aspiration showed almost absence of erythropoiesis, marked hyperplastic granulopoiesis with normal maturation and normal megakaryocytes. Serum vitamin B12, unsaturated vitamin B12 binding capacity, transcobalamin I and transcobamin III increased considerably. Chronic myelocytic leukaemia could be ruled out by the blood and bone marrow examination and a high leucocyte alkaline phosphatase score. This case of pure red cell aplasia accompanied by proliferative feature in other cell lines is an example of a link between erythrodysplastic and myeloproliferative disorders.

A case with multiple myeloma, polycythemia vera and acute myelomonocytic leukemia.

An 83-year-old man with evidence of multiple myelome was admitted to the hospital with a history of weakness. His serum protein immunoelectrophoresis demonstrated monoclonal IgA lambda and bone marrow aspiration revealed plasma cells 20%. Two months alter, hematological examinations showed erythrocytosis, luecocytosis and thrombocytosis. The bone marrow showed hypercellular with increased plasma cells and monoblasts. Serum vitamin B12 and vitamin B12 binding proteins confirmed the diagnosis of polycythemia vera. After treatment with Busulfan, Prednisolone and Endoxan for 6 months, his blood examination revealed increased monocytes, metamyelocytes and myelocytes. Bone marrow examination confirmed the diagnosis of acute myelomonocytic leukemia with plasma cells. This patient is an example of the simultaneous occurrence of lympoproliferative and myeoproliferative disorder.