Bleeding per rectum during induction chemotherapy: Looking beyond the leukaemia – 2 case reports and review of literature

Synchronous malignancies involving acute leukemia and a solid organ are rare. Bleeding per rectum is a common manifestation of acute leukemia during induction chemotherapy and might mask the presence of synchronous colorectal adenocarcinoma (CRC). Here we present two rare cases of acute leukemia with synchronous CRC. We also review previously reported synchronous malignancies to investigate demographics, diagnosis, and treatment modalities. Management of these cases requires a multispecialty approach

Study of bone marrow changes in antiretroviral naive human immunodeficiency virus-infected anemic patients.

Background: Bone marrow changes are common throughout the course of HIV infection. There is scanty data addressing this issue in Indian subcontinent. The present study was aimed at characterizing the bone marrow changes in the antiretroviral naive HIV-infected Indian patients with anemia. Materials and Methods: This was a nonrandomized cross-sectional observational study undertaken over a period of 2 years. Forty-six randomly selected patients with documented anemia served as the study population. None of them was on any antiretroviral therapy or suffering from any known causes of anemia. All the patients underwent thorough evaluation, including bone marrow examination. Results: Majority of the patients had normocytic-normochromic anemia (63%), in tune with the available data. In most of the cases bone marrow was hypercellular (63.04%), although in a significant proportion it was found to be hypocellular (19.57%). Erythropoiesis was suppressed in 36.96% of patients. Dysplastic changes involving isolated cell lines ranged from 13.04% to 45.65%, dysmegakaryopoiesis being the most common, followed by dyserythropoiesis. Marrow plasmacytosis was detected in 23.91% of patients. No statistically significant correlation was detected in between immunological status (CD4 count) and marrow cellularity, myelodysplastic changes or marrow plasmacytosis. In a fair number of cases bone marrow examination aided in the diagnosis of opportunistic infections. Conclusions: Bone marrow changes are common in Indian HIV-infected anemic population, particularly in the advanced stages of the disease. HIV infection should be considered in the differential diagnosis of patients with secondary myelodysplasia or unexplained bone marrow changes.

Hemophagoctic lymphohistiocytosis--recent concept.

Hemophagocytic lymphohistiocytosis is a rare condition characterized by highly stimulated but inactive immune response. The disease may be inherited or acquired due to infections, collagen vascular diseases and malignancies. The pathological hallmark of the syndrome is aggressive proliferation of macrophages and histiocytes. Decreased NK cell activity results in increased T cell activation resulting production of large quantities of interferon gamma (IFN gamma), tumor necrosis factor alpha (TNF alpha) and granulocyte macrophage colony stimulating factor (GM-CSF). This causes sustained macrophage activation and tissue infiltration as well as production of interleukin 1 (IL1) and interleukin 6 (IL6).The resulting inflammatory reaction causes extensive damage and associated symptoms. Patients with HLH commonly present with high fever, anemia and splenomegaly. Minimal diagnostic parameters are a complete hemogram, liver function test, serum triglycerides and ferritin, coagulation profile including fibrinogen and bone marrow aspiration. Two highly sensitive diagnostic marker are an increased plasma concentration of the alpha chain of soluble IL2 receptor (CD25) and impaired NK cell activity. Hyperinflammation can be treated with steroid, Cyclosporine prevents T lymphocytes and immunoglobulin infusion helps to control the infection. Etoposide may be life saving specially in case of HLH with Ebstein Barr Viruses infection. The Histiocyte Society in 1994 developed a common treatment protocol (HLH-94). In January 2004 a revised HLH treatment protocol was opened entitled HLH-2004, which is based on HLH-94 with minor modifications. There is a high remission rate on the HLH-94 and HLH-2004 treatment protocols.

Therapy-related acute promyelocytic leukemia after treatment of carcinoma breast--a case report.

We report a 43-year-old female, with acute promyelocytic leukemia occurring after 9 months of treatment for carcinoma breast. The diagnosis of APL was made on morphology, cytogenetics and molecular studies. In contrast to other published report of therapy related APL (tAPL) the present case presented early after the primary malignancy and underwent a rapid, downhill course.

Venous thrombosis: prevalence of prothrombotic defects in north Indian population.

431 patients with thrombosis of different venous system were evaluated for underlying acquired and inherited prothrombotic states. Associated acquired risk factors were observed to be present in 28.7% patients and possible inherited in 32.3%, in the rest, no cause could be identified. Major acquired risk factors included coexistence of liver disease (12.2%), oral contraceptives (4.1%), puerperium (2.5%), malignancy (2.3%) and lupus anticoagulant (2%). Low levels of protein C were detected in 21.1% and of which 11.3% were attributed to acquired factors. Protein S deficiency was found in 19.0% and of these 10.4% cases were associated with acquired risk factors. Antithrombin III (AT III) deficiency was detected in 6.4% of patients, of which 4.8% were secondary to acquired factors. In the rest, deficiency of protein C, protein S and AT III were attributed to inherited factors as no associated acquired risk factor was present. Activated protein C resistance (APC-R) was present in 12.5% cases.