Frequency of bone marrow involvement in Hodgkin's lymphoma on first presentation

To determine the frequency of bone marrow involvement in patients of Hodgkin's lymphoma on first presentation at oncology department. Case series. The Oncology Department, Combined Military Hospital, Rawalpindi, from April 2006 to February 2007. Thirty five patients of Hodgkin's lymphoma diagnosed on lymph node biopsy presenting for the first time at Oncology Department, Combined Military Hospital, Rawalpindi were included. They were admitted in the ward and evaluated with history, physical examination and staging investigations. Bone marrow trephine biopsy was performed in all patients. Descriptive statistics were used to analyze data. On clinical and radiological evaluation, 8 patients [22.9%] had clinical stage [CS], 12 [34.3%] had CS II, 9 [25.7%] had CS III and 6 [17.1%] had CS IV. The microscopic appearance in bone marrow trephine examination showed lymphoma infiltrates in 6 [17.14%] patients and chronic disorder in 29 [82.85%] patients. Among patients with bone marrow infiltration, one had CS II disease, three had CS III disease and two had CS IV disease. One patient had bone marrow infiltration as the only manifestation of disease. Bone marrow involvement was seen in patients with Hodgkin's lymphoma clinical stage II or higher

Presenting phases of chronic myeloid leukaemia

To determine the frequency of three phases of chronic myeloid leukaemia at first presentation. Department of Oncology, Combined Military Hospital [CMH], Rawalpindi, from June 2006 to December 2007. Forty-five patients of either gender with Chronic Myeloid Leukaemia [CML] at their first presentation in outpatient department were included in the study by consecutive sampling technique. All patients were diagnosed on blood complete picture and bone marrow examination including aspiration, trephine and cytogenetics at Armed Forces Institute of Pathology [AFIP]. Each phase was defined on the basis of World Health Organization [WHO] criteria. Out of 45, there were 31 [68.9%] male and 14 [31.1%] female patients. The mean age of presentation was 37.9 years. The pattern of presentation revealed 35 [77.8%] in Chronic Phase [CP], 7 [15.5%] in Accelerated Phase [AP] and 3 [6.7%] in Blast Crisis [BC]. Philadelphia chromosome was detected in 39 [86.7%] cases on culture method. Splenomegaly was observed in 37 [82.2%] patients. The mean total leukocyte count, platelet count, haemoglobin and marrow blast were 214.3x10[9]/L, 551.4x10[9]/L, 9.94 g/dl and 9.3% respectively. CML presented at a younger age in the chronic phase

Post-transplant outcome in chronic myeloid leukaemia

To determine post-transplant survival in chronic myeloid leukaemia patients undergoing allogeneic stem cell transplant. Longitudinal, descriptive study. Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan, between April 2002 and August 2007. All patients of chronic myeloid leukaemia in chronic phase having HLA identical donor and age under 55 years, normal hepatic, renal and cardiac functions with good performance status were selected. Patients in accelerated phase or blast crisis, poor performance status, impaired hepatic, renal, cardiac functions or pregnancy were excluded. Survival was calculated from the date of transplant to death or last follow-up according to Kaplan-Meier and Cox [proportional hazard] regression analysis methods. Thirty seven patients with chronic myeloid leukaemia underwent allogeneic stem cell transplant from HLA identical sibling donors. Thirty two patients were male and five were females. Median age of patients was 28 years. All patients and donors were CMV positive. Post-transplant complications encountered were acute GvHD [Grade II-IV] [n=13, 35.1%], chronic GvHD in 18.9% [n=7], Veno Occlusive Disease [VOD] in 5.4% [n=2], acute renal failure in 2.7% [n=1], haemorrhagic cystitis in 2.7% [n=1], bacterial infections in 40.5% [n=15], fungal infections in 16.2% [n=6], CMV infection in 5.4% [n=2], tuberculosis in 5.4% [n=2], Herpes zoster infection 2.7% [n=1] and relapse in 2.7% [n=1]. Mortality was observed in 27% [n=10]. Major causes of mortality were GvHD, VOD, septicemia, CMV infection and disseminated Aspergillosis. Overall Disease Free Survival [DPS] was 73% with a median duration of follow-up of 47.4 +/- 12 months. DPS was 81% in standard risk and 54.5% in high-risk group. Results of allogeneic stem cell transplant in standard risk group CML patients were good and comparable with other international centres, however, results in high-risk CML patients need further improvement, although, number of patients in this group is small

Comparison of anthracycline-based combination chemotherapy with or without all-trans retinoic acid in acute promyelocytic leukemia

To compare survival in Acute Promyelocytic Leukemia [APL] patients treated with or without All-Trans Retinoic Acid [ATRA]. Longitudinal, comparative study. The Armed Forces Bone Marrow Transplant Centre [AFBMTC], Rawalpindi, Pakistan from May 2001 to April 2007. All consecutive newly diagnosed patients of acute promyelocytic leukemia, treated at Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan, between May 2001 and April 2007, were included and given chemotherapy according to availability of ATRA. Diagnosis was confirmed on morphology/ karyotyping/ molecular analysis. Eligibility criteria included confirmed morphologic diagnosis and/or by demonstration of t[15;17] and/or PML/RAR alpha re-arrangement, no prior chemotherapy, normal hepatic and renal function, Eastern Cooperative Oncology Group [ECOG] performance status of 0 - 2 and no contraindications to ATRA [history of sensitivity to Vit. A or other retinoids]. All patients having history of cardiac failure [LVEF < 50] and arrhythmias, ECOG performance status 3 and 4, relapse / refractory disease, ALT twice normal values, serum creatinine > 150 micro mol/L and pregnancy were excluded from this study. Survival was calculated from the date of chemotherapy to death or last follow-up according to Kaplan-Meier and Cox [Proportional hazard] regression analysis methods. During the 6 years study period, 31 newly diagnosed patients with acute promyelocytic leukemia received treatment at AFBMTC. Seventeen patients received anthracycline-based remission induction and consolidation chemotherapy, while 14 received ATRA-based remission induction, consolidation and by two years maintenance therapy. Overall Survival [OS], Disease Free Survival [DFS] and mortality were 29.4%, 29.4% and 70.6% respectively in 17 patients who received anthracycline based chemotherapy, whereas in patients who received ATRA-based chemotherapy OS, DFS and mortality was 71.4%, 64.2% and 28.6% respectively. Major causes of mortality were septicemia and chemotherapy related toxicity. Response to ATRA-based chemotherapy in patient cohort was better as compared with anthracycline based chemotherapy [71.4% vs. 29.4%] in terms of survival and mortality

Pneumocystis carinii and Trichosporon beigelii pneumonia following allogeneic haemopoeitic stem cell transplantation

Pneumocystis Carinii and Trichosporon beigelii are opportunistic infections in immunocompromised patients. We report a case of a young lady who underwent haemopoeitic stem cell transplantation for relapsed acute lymphoblastic leukemia. This 25 years old female developed fever, dry cough and rapidly progressive dyspnoea during post transplant neutropenia and was found to be suffering from Pneumocystis carinii pneumonia. She was successfully treated with Co-trimoxazole. The patient again presented with similar symptoms on day 55 post transplant. This time Trichosporon beigelii was isolated from bronchoalveolar lavage and she responded to prompt antifungal therapy. Other complications encountered during the subsequent course were extensive subcutaneous emphysema and spontaneous pneumothorax that required chest intubation and brief hospitalization. The patient is presently nine months post transplant and is asymptomatic

Graft versus host disease in allogeneic stem cell transplantation - 3 l/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22] ALL [n=3], AML [n=l] Fanconi's anaemia [n=2], and Gaucher's disease [n=l], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in B-Thalassaemia, 50% [n=ll/22] in CML, 50% [n=2/4] in Acute Leukaemias and 25% [n=8/32] in Aplastic Anaemia. Chronic GvHD was 25% [n=l/4] in Acute Leukaemias, 18.8% [n=6/32] in Aplastic Anaemia, 18.2% [n=4/22] in CML and 4% [n=l/25] in B-Thalassaemia. The overall survival in acute GvHD was 84.2% [n=32] where as the overall survival in chronic GvHD was 50% [n=6]. The overall mortality in acute GvHD was 15.8% [n=6] and 50% in chronic GvHD [n=6]. The morbidity and mortality due to severe acute and chronic GvHD remains high despite standard prophylaxis against GvHD. New strategies are needed to prevent and treat GvHD

Multiple myeloma in a young male of 25 years

We report a case of multiple myeloma with unusual presentation. Patient was only 25 years of age and presented with vague local symptoms. MRI examination revealed a lesion along inferior pubic ramus that turned out to be plasmacytoma on biopsy. Although the bone marrow had 30% plasma cells and some plasma cells were also present in peripheral blood yet there were no constitutional and other symptoms

Frequency of tuberculosis in haematological malignancies and stem cell transplant recipients

To assess magnitude of tuberculosis [TB] in patients suffering from various haematological malignancies and stem cell transplant [SCT] recipients. Descriptive study. Oncology Department, Combined Military Hospital, Rawalpindi, and Armed Forces Bone Marrow Transplant Centre, Rawalpindi, from July 2001 to December 2002. Patients suffering from various haematological malignancies treated between July 2001 and December 2002 were included in the study. The hospital records and out-patient follow-up charts were reviewed for demographic information, diagnosis, clinical presentation, laboratory investigations, radiological and pathological examinations, sites involved in TB, methods of diagnosis, number and type of anti-tuberculosis drugs given and response to treatment. During the study period a total of 213 [including 25 allogeneic stem cell transplant [SCT] recipients] patients with different haematological disorders were treated. Out of these, 34, including 4 SCT recipients developed tuberculosis. Overall frequency of TB was 16%. Median age of TB patients was 33.5 years [range 8-80 years]. Median time between diagnosis of haematological disorders and tuberculosis was 21 weeks. Sites of involvement by TB were lung [18], disseminated [6], lymph node [5], pleura [2], spine [2] and pericardium [1]. Three of the patients died of TB; one undiagnosed, second with multi-drug resistant TB and the third soon after the start of anti-tuberculosis treatment while remaining 31 cases responded to anti-tuberculosis treatment. Tuberculosis is a major problem in immunocompromised patients and there is need to establish guidelines for TB chemoprophylaxis in our setup

Posttransplant Guillain Barre Syndrome

This case report describes a patient with severe aplastic anaemia, who developed Guillain Barre Syndrome [GBS] 10 weeks after allogeneic haematopoietic stem cell transplantation [HSCT] from HLA-matched siblingíyounger sister. GBS was preceded by pneumonia, herpes labialis and oral candidiasis a week earlier. Treatment with ventilatory management, intravenous human immunoglobulin [IVIg] and antimicrobials resulted in smooth recovery in thirty-one days

Toxicity profile and objective response of paclitaxel in metastatic breast cancer

To evaluate the efficacy and toxicity of 1-hour weekly Paclitaxel in metastatic breast cancer along with evaluation of overall survival. A phase II interventional trial. Oncology Department, Combined Military Hospital, Rawalpindi, between August 2001 to July 2003. Thirtysix patients were enrolled in the study. All patients with histologically confirmed and bidimensionally measurable metastatic breast cancer who had received previously either chemotherapy or hormone therapy were included in the study. Paclitaxel was administered in 1-hour weekly infusion in a dose of 100 mg/m2 for 12 doses. All patients had received previous chemotherapy with either CAF or CMF. Twenty five patients had also received hormone therapy, 61% had two or more metastatic sites involved, and lung was the common site of involvement. Complete response was observed in 4 [11.1%] patients, partial response in 14 [38.8%] patients, with an overall response rate of 50.0%. Clinical benefit was 94.4% and median overall survival was 11 months. Treatment was well-tolerated with no grade 3 or 4 toxicity. Common side effects were arthralgias, myalgias and neutropenia. Treatment with 1-hour weekly infusion of Paclitaxel is a well-tolerated chemotherapy with a substantial degree of efficacy in patients with metastatic breast cancer

Graft versus host disease in allogeneic stem cell transplantation - 3 1/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22], ALL [n=3], AML [n=1] Fanconi's anaemia [n=2], and Gaucher's disease [n=1], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in

Allogeneic stem cell transplantation in chronic myeloid leukaemia 2 1/2 year experience

To evaluate out come of allogeneic Stem Cell Transplantation [SCT] in chronic myeloid leukaemia [CMC] at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from April 2002 to October 2004. Twenty-two patients with CML underwent allogeneic SCT from HLA matched siblings. Patients were divided into standard [n=14] and high-risk [n=8] groups. Patients were subjected to conditioning regimens consisting of Busulphan and Cyclophosphamide. Cyclosporin, Prednisolone and Methotrexate were given for GvHD prophylaxis. All donors were subjected to PBSC harvest after G-CSF therapy for five days. All received G-CSF from Day+5 until ANC >0.5 x 109/l. The median age of the patients was 29 years [range 7-53 years] with a male to female ratio of 6.3:1. Engraftment was achieved in all patients. Median time to achieve neutrophil [ANC 0.5x109/l] and platelet [20x109/l] recovery was 13 days and 12 days respectively. Median stay in hospital was 18 days. Acute GvHD [Grade-II-IV] was observed in eleven patients [50%] while chronic GvHD was seen in four patients [18%]. One patient relapsed 8 months post transplant. Two patients [9%] developed Veno-occlusive disease [VOD] liver. One patient had haemorrhagic cystitis. Four patients [18%] had post transplant infectious complications, which included pseudomonas septicemia, aspergillosis, tuberculous pleural effusion and herpes zoster. Overall mortality was 22.7% [n=5]. The major causes of mortality were VOD liver, GvHD grade IV, Pseudomonas septicaemia and aspergillosis. Overall survival was 77.2% [n=17] and disease free survival was [n=16] 72.7%. Follow up ranges were from 23 to 828 days [median 212 days]. The preliminary results of SCT in this small series of patients with CML are very encouraging. To improve the long-term survival it is imperative that patients are transplanted early after diagnosis and conditioning regimens are selected carefully

FLAG-IDA in the treatment of refractory/ relapsed acute leukaemias: Single center study

To evaluate the efficacy and toxicity profile of the combination of fludarabine, high dose cytarabine, idarubicin, and granulocyte colony stimulating factor in refractory relapsed cases of acute leukaemia, a study is being conducted at Armed Forces Bone Marrow Transplant Centre [AFBMTC] Rawalpindi since January 2003. Data up to June 2004 [early report] is being presented. Twelve Patients with refractory/relapsed [Ref/Rel] acute leukaemia [AL] were treated with fludarabine 30mg/m2 and cytosine arabinoside [AraC] Arac 2 g/m2 for 5 days, idarubicin 10mg/m2 for 3 days, and granulocyte colony stimulating factor G-CSF 5 micro g/kg from day 0 till neutrophil recovery [ANC >1.0 x 109/l]. Response was evaluated by bone marrow examination on day 20-post chemotherapy. Patients included were refractory acute lymphoblastic leukaemia [ALL] [n=2], relapsed ALL [n=3], refractory acute myeloid leukaemia [AML] [n=3], secondary AML [n=2] relapsed AML [n=1] and acute undifferentiated leukaemia [AUL] [n=1]. Complete remission [CR] was achieved in 8 [66.6%] patients. Three [25%] patients died of post chemotherapy complications and one patient failed to achieve remission. Out of 8 patients who achieved CR, 4 underwent allogeneic bone marrow transfusion [BMT], 1 is being evaluated for the same, 1 received idorubicin, AraC and etopuside [ICE] and high dose AraC, 1 did not receive further chemotherapy and 1 relapsed two months after remission. Seven patients are still in CR after a median follow up of 8 months [range 3-18]. Major complications encountered were diarrhoea, mucositis, toxic ileus, transient hepatic toxicity, fungal and bacterial infections. In our experience, FLAG-IDA is well tolerated and effective regimen in relapsed / refractory acute leukaemias. The toxicity is acceptable, enabling most patients to receive further treatment, including transplantation procedures

Role of isoniazid prophylaxis for prevention of tuberculosis in haemopoietic stem cell transplant recipients

To evaluate the role of isoniazid prophylaxis in prevention of tuberculosis among allogeneic stem cell transplant recipients. This study was conducted at Armed Forces Bone Marrow Transplant Center Rawalpindi, Pakistan from July 2001 to October 2003. Patients suffering from various haematological disorders undergoing allogeneic stem cell transplantation were included in the study. The demographic information, primary diagnoses and relevant investigations were recorded. Patients had negative tuberculin skin tests and chest X-Ray at pre-transplant assessment. First 25 patients [group I] did not receive isoniazid prophylaxis while the next 25 [group II] were given isoniazid in a dose of 5-10 mg/kg [maximum 300 mg/day]. Isoniazid prophylaxis was started on day-1 and continued for 6 months post transplant. The patients developing tuberculosis were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide during first 3 months followed by 2 drugs for a total duration of 12 months. Minimum follow up in group I and II was 783 and 403 days respectively. There was significant difference [p<0.001] in frequency of tuberculosis between two groups. In group I, four patients developed Tuberculosis [frequency 16%] whereas none of the patients in group II had the disease. Out of these four cases 3 had extrapulmonary disease. One patient died two weeks after the start of anti tuberculosis treatment while others successfully completed the treatment. Tuberculosis in stem cell transplant recipients is an important opportunistic infection especially in areas of high disease prevalence like Pakistan. Isoniazid prophylaxis for 6 months is effective in preventing tuberculosis among this class of patients

Management of cancer related anaemia [CRA]

Cancer Related Anaemia [CRA], manifesting as fatigue, dizziness, shortness of breath and anorexia is common among patients with cancer. Correcting CRA will not only improve quality of life but also reduce morbidity and mortality by enhancing the efficiency of cancer treatment. Transfusion of red blood cells is the common approach to treat anaemia in cancer patients. Transfusion is comparatively cheap and leads to rapid correction of anaemia in virtually all patients. However, it carries certain risks like transfusion reactions and transmission of disease. Recombinant Human Erythropoietin [rHu EPO] is effective in correcting anaemia in at least two-third of the cases, without exposing them to the hazards of blood transfusion. Clinical trials have proved rHu EPO to be safe and effective in cancer patients. However it is costlier than blood transfusion and cost-benefit ratio would favour red cell transfusions in our setup. rHu EPO should be considered an option in selected cases in which red blood cell transfusions cannot be given due to various factors

Depression in medical in-patients

This study was conducted to detect the prevalence of depression in medical inpatients staying for more than one week in the hospital and to assess the possible role of depression in prolonging the stay of the patients in the hospital. Two hundred and ninety eight patients with over a week stay in the hospital were screened for probable depression during three months with Hospital Anxiety and Depression Scale [Depression Subscale] and consequently they were assessed by two psychiatrists twice at 1 week interval with clinical interview and Hamilton Depression Rating Scale. Final diagnosis was made by using the ICD-30 diagnostic criteria. Depression in some form was detected in 39.26% of the total patients including major depression in 9.73% of the total patients. The hospital stay of the patients showed significant relation with depression. The substantial prevalence of depression with its significant association with longer hospital stay in medical inpatients requires greater cognizance and attention by simple screening instruments like HADS and subsequent liaison with the psychiatrist in selected cases for its appropriate management. This may help in improving the patient's physical and psychological health and reducing the hospital stay and costs. Future sound methodological studies are needed to explore the possible therapeutic and economic benefits of screening the patients in the medical wards for depression

Guidelines for management of snake bite cases

Poisonous snakes occur in many parts of the world and are especially prevalent in Indian subcontinent. Keeping in view the nature of work, the Army personnel are at an increased risk of snake bite. The management of snake bite has been divided into Field and Hospital management. A review of current opinions on the first aid and hospital management has been discussed and guidelines for management of snake bite cases is formulated

Salmonella paratyphi a induced pancytopenia-a new association

A case of salmonella paratyphi A fever with reversible pancytopenia in a 15 year old boy who presented with history of high grade continuous fever, epistaxis and haemoptysis, relative bradycardia and splenomegaly is described here. A brief review of the literature on possible causes of reversible pancytopenia in this case is also discussed