Acute lymphoblastic leukemia with a late- appearing Philadelphia chromosome: Case report and review of the literature

We describe a rare presentation of acute lymphoblastic leukemia in a young adult male who at the beginning of the disease lacked the Philadelphia chromosome in bone marrow and blood cells and fluorescence in situ hybridization was negative for the presence of a clone with the BCR-ABL1 rearrangement. The patient initially had pancytopenia with a blast cell count of 5% in the peripheral blood that evolved to a phase with progressive leukocytosis and a sudden rise in blast cells 7 months later. At this time, his bone marrow aspirate showed the presence of a neartriploid karyotype containing two Philadelphia chromosomes. The multiple karyotypic changes observed in our patient support the notion that leukemic progression involves several cytogenetic evolutionary processes, the first step of which may not necessarily involve acquisition of the Philadelphia chromosome

Empiric antibiotic therapy in febrile neutropenic cancer patients

Neutropenia predispose cancer patients to severe and rapidly progressive infections by bacterial and fungal pathogens. Although the incidence of gram-positive infections is increasing, gram-negative organisms like Pseudomonas aerogenosa cause fulminant sepsis in theses patients. Empiric antibiotic therapy before definitive microbiological data is an accepted standard practice. Combination of antipseudomonas penicillin or cephalosporins with aminoglycoside are the most frequently used empiric regiments. Monotherapy with agents such as third generation cephalosporins may be used in patients with briefer moderate neutropenia. The issue of initial and empiric use of glycopeptide, for treatment of infections caused by gram-positive organisms, remained unsettled. Vancomycin / teicoplanin should however, be used in the initial empiric regimen in centers and patients with high incidence of grampositive infections especially due to streptococci. Antifungal agents such as amphotercin B are indicated in patients who remain febrile despite broad spectrum antibiotic coverage. Granulocyte colony simulating factors may benefit subset of patients with protracted neutropenia or tissue infection

Accessory spleen in splenectomized patients of idiopathic thrombocytopenic purpura in relopse

We describe two patients with idiopathic thrombocytopenia who relapsed after splenectomy due to the presence of accessory spleens. This report highlights the usefulness of 99m Technetium scans especially with heat denatured red blood cells, in the detection of accessory spleens

All-trans-retinoic acid as a frontline therapy for acute promgelocytic leukemia

Four newly diagnosed patients of acute promyelocytic leukemia [APL] were treated with 45 mg/m2 all-trans-retinoic acid [ATRA] daily. Two patients achieved complete remission [CR] after 32 and 75 days of ATRA therapy, respectively, and were subsequently consolidated with three courses of combination chemotherapy. Both patients continue to be in first CR for 7 and 12 months, respectively. The third patient achieved partial response while the fourth died of multi-organ failure secondary to retinoic acid syndrome. Major side effects of the treatment included retinoic acid syndrome in two patients, and bone pains, hypertriglyceridemia and cheilitis in one patient. ATRA is an effective initial agent for the treatment of APL, resulting in early resolution of coagulopathy and induction of remission without aplasia