Serum bilirubin is negatively associated with white blood cell count

OBJECTIVE: Bilirubin is considered an important antioxidant, anti-inflammatory factor and immunomodulator. The current investigation aimed to explore the association between bilirubin and white blood cell (WBC) count in a large Chinese cohort. METHODS: A total of 61091 participants (29259 males, 31832 females) were recruited from a Chinese tertiary hospital. Data were sorted by sex, and the association between bilirubin and WBC count was analyzed after dividing bilirubin levels into quartiles. RESULTS: Most parameters (including age, body mass index, systolic blood pressure, diastolic blood pressure, alanine aminotransferase, total bilirubin, blood urea nitrogen, creatinine, uric acid, triglycerides and WBC count) were significantly higher in men than in women. Bilirubin displayed significant negative relationships with most other measured variables. Linear logistic regression analysis further indicated their negative relationships. Females showed a significantly higher frequency of leucopenia than males. Significant associations of leucopenia with high bilirubin quartiles were shown in binary logistic regression models for both sexes, with a much closer association in men than in women. For instance, for men with bilirubin levels in quartile 4, the adjusted likelihood of leucopenia was 1.600-times higher than that of men with values in quartile 1. For women with bilirubin levels in quartile 4, the adjusted likelihood of leucopenia was 1.135-times higher than that of women with values in quartile 1. CONCLUSION: Bilirubin is negatively related to WBC count. Significant associations exist between leucopenia and high bilirubin quartiles, and these associations are more obvious in men than in women.

Safety of reduced dose of mycophenolate mofetil combined with tacrolimus in living-donor liver transplantation

BACKGROUND/AIMS: The dose of mycophenolate mofetil (MMF) has been reduced in Asia due to side effects associated with the conventional fixed dose of 2-3 g/day. We aimed to determine the pharmacokinetics of a reduced dose of MMF and to validate its feasibility in combination with tacrolimus in living-donor liver transplantation (LDLT). METHODS: Two sequential studies were performed in adult LDLT between October 2009 and 2011. First, we performed a prospective pharmacokinetic study in 15 recipients. We measured the area under the curve from 0 to 12 hours (AUC0-12) for mycophenolic acid at postoperative days 7 and 14, and we performed a protocol biopsy before discharge. Second, among 215 recipients, we reviewed 74 patients who were initially administered a reduced dose of MMF (1.0 g/day) with tacrolimus (trough, 8-12 ng/mL during the first month, and 5-8 ng/mL thereafter), with a 1-year follow-up. We performed protocol biopsies at 2 weeks and 1 year post-LDLT. RESULTS: In the first part of study, AUC0-12 was less than 30 mgh/L in 93.3% of cases. In the second, validating study, 41.9% of the recipients needed dose reduction or cessation due to side effects within the first year after LDLT. At 12 months post-LDLT, 17.6% of the recipients were administered a lower dose of MMF (0.5 g/day), and 16.2% needed permanent cessation due to side effects. The 1- and 12-month rejection-free survival rates were 98.6% and 97.3%, respectively. CONCLUSIONS: A reduced dose of MMF was associated with low blood levels compared to the existing recommended therapeutic range. However, reducing the dose of MMF combined with a low level of tacrolimus was feasible clinically, with an excellent short-term outcome in LDLT.

Caso probable de fiebre manchada ( Rickettsia felis) transmitida por pulgas / Probable case of flea-borne spotted fever ( Rickettsia felis )

Rickettsia felis es el agente etiológico de la fiebre manchada transmitida por pulgas, cuyo principal vector y reservorio es Ctenocephalides felis . Típicamente, la enfermedad se presenta como fiebre aguda asociada a cefalea, astenia, exantema máculo-papular generalizado y, en algunos casos, con escara de inoculación. En los últimos años, R. felis ha venido adquiriendo un papel importante en la etiología del síndrome febril agudo, calificándola como una enfermedad emergente y subdiagnosticada. La inmunofluorescencia indirecta es actualmente el método diagnóstico de referencia. Sin embargo, esta técnica presenta limitaciones relacionadas con la reacción cruzada que existe entre las diferentes especies del género Rickettsia . En el presente reporte se describe el caso de un paciente de 16 años con síndrome febril agudo secundario a infección probable por R. felis .

Rickettsia felis is the etiologic agent of flea-borne spotted fever, with Ctenocephalides felis as its main vector and reservoir. Typically, the disease presents as acute fever associated with headache, asthenia, generalized maculo-papular rash, and in some cases, an inoculation eschar. In recent years, R. felis has acquired an important role in the etiology of the acute febrile syndrome; it is indeed an emerging infectious disease, albeit underdiagnosed. Indirect immunofluorescence assay (IFA) is currently the reference diagnostic method. However, this technique has limitations related to the cross reactivity among different species of rickettsiae. Herein, we describe a case of a 16 year-old patient with an acute febrile syndrome secondary to probable infection with R. felis.

Paradoxical effects of brain death and associated trauma on rat mesenteric microcirculation: an intravital microscopic study

OBJECTIVE: Experimental findings support clinical evidence that brain death impairs the viability of organs for transplantation, triggering hemodynamic, hormonal, and inflammatory responses. However, several of these events could be consequences of brain death-associated trauma. This study investigated microcirculatory alterations and systemic inflammatory markers in brain-dead rats and the influence of the associated trauma. METHOD: Brain death was induced using intracranial balloon inflation; sham-operated rats were trepanned only. After 30 or 180 min, the mesenteric microcirculation was observed using intravital microscopy. The expression of Pselectin and ICAM-1 on the endothelium was evaluated using immunohistochemistry. The serum cytokine, chemokine, and corticosterone levels were quantified using enzyme-linked immunosorbent assays. White blood cell counts were also determined. RESULTS: Brain death resulted in a decrease in the mesenteric perfusion to 30 percent, a 2.6-fold increase in the expression of ICAM-1 and leukocyte migration at the mesentery, a 70 percent reduction in the serum corticosterone level and pronounced leukopenia. Similar increases in the cytokine and chemokine levels were seen in the both the experimental and control animals. CONCLUSION: The data presented in this study suggest that brain death itself induces hypoperfusion in the mesenteric microcirculation that is associated with a pronounced reduction in the endogenous corticosterone level, thereby leading to increased local inflammation and organ dysfunction. These events are paradoxically associated with induced leukopenia after brain damage.

Pediatric patients with bicytopenia/pancytopenia: Review of etiologies and clinico-hematological profile at a tertiary center.

Background: The etiology of bicytopenia/pancytopenia varies widely in children, ranging from transient marrow viral suppression to marrow infiltration by fatal malignancy. Depending on the etiology, the clinical presentation can be with fever, pallor or infection. Knowing the exact etiology is important for specific treatment and prognostication. Aims: To evaluate the etiological and clinico-hematological profile in children with bicytopenia and pancytopenia. Materials and Methods: A review of bicytopenic and pancytopenic children referred for bone marrow examination from January 2007 to December 2008 was done. Detailed history, clinical examination and hematological parameters at presentation were recorded. Results and Conclusion: During the study period, a total of 990 children were referred for bone marrow examination for different indications. Of these, 571 (57.7%) had either pancytopenia (17.7%) or bicytopenia (40%). Commonest form of bicytopenia was anemia and thrombocytopenia seen in 77.5% cases, followed by anemia and leukopenia in 17.3% and leukopenia and thrombocytopenia in 5.5% cases. Most common etiology was acute leukemia (66.9%) in bicytopenic children and aplastic anemia (33.8%) in pancytopenic children. Children with bicytopenia had a higher incidence of underlying malignancy (69.5% vs. 26.6%), splenomegaly (60.5% vs. 37.4%), lymphadenopathy (41.8% vs. 15.1%) and circulating blasts (64.6% vs. 20.1%) and a lower incidence of bleeding manifestations (12.1% vs. 26.6%) as compared to children with pancytopenia.

Comparison of the Toxicities and Efficacies of the Combination Chemotherapy Regimens in Advanced Gastric Cancer Patients Who Achieved Complete Response after Chemotherapy / 대한소화기학회지

BACKGROUND/AIMS: We retrospectively analyzed comparative toxicities and efficacies of chemotherapy regimens in advanced gastric cancer (AGC) patients who achieved complete response (CR) after chemotherapy. METHODS: We reviewed the medical records of 1,203 patients, who were pathologically diagnosed as AGC in a single center between January 2001 and October 2007. On the basis of the Response Evaluation Criteria in Solid Tumors, CR was evaluated with abdominal computed tomography. Toxicities were evaluated using the National Cancer Institute's common toxicity criteria before each chemotherapy cycle. RESULTS: Among the 1,203 AGC patients enrolled in this study, 568 received chemotherapy and 635 received best supportive care. The major chemotherapy regimens were 5-fluorouracil, leucovorin and oxaliplatin (FOLFOX), docetaxel, cisplatin and 5-fluorouracil (DCF) and 5-fluorouracil, leucovorin and irinotecan (FOLFIRI). Among the 568 patients, 51 (9.0%) achieved CR (49 [8.6%] with FOLFOX [n=12], DCF [n=26], or FOLFIRI [n=11] and 2 [0.3%] with etoposide, leucovorin and 5-fluorouracil). For patients administered FOLFOX, DCF, and FOLFIRI, the median time to disease progression was 4 months (range, 1.8-59.5), 15 months (range, 2.9-31.2) and 10 months (range, 2.0-39.5), and the median survival times were 48 months (range, 5.9-74.0), 37 months (range, 14.0-86.0), and 30 months (range, 6.0-50.0), respectively. Grades 3-4 mucositis occurred mostly in patients administered DCF (n=8, 30.8%). Grades 3-4 leucopenia were observed in 1 (8.3%), 11 (42.3%), and 4 (36.4%) patients administered FOLFOX, DCF and FOLFIRI, respectively. No statistically significant differences were observed in the 3 regimens. CONCLUSIONS: All 3 regimens (FOLFOX, DCF and FOLFIRI) were active and tolerable. Their efficacies and toxicities were not significantly different.

Prevalence of megaloblastic anaemia in a paediatric unit

Megaloblastic anaemia is common in paediatric population of developing countries. The objective of this study was to find out the prevalence of megaloblastic anaemia in Paediatric Unit of District Headquarter Teaching Hospital, Dera Ismail Khan. A retrospective analysis of forty bone marrow aspirates was performed to find out the prevalence of megaloblastic anaemia in Paediatric unit of District Headquarter Teaching Hospital Dera Ismail Khan, from January 2007 to December 2008. Both male and female indoor patients up to 12 years of age were included in the study. Blood count and peripheral smear findings revealed anaemia in 40[100%], leukopenia in 17 [42.5%] and thrombocytopenia in 36 [90%] patients. Bicytopenia was present in 18 [45%] and pancytopenia in 17 [42.5%] patients. Analysis of the bone marrow findings showed megaloblastic anaemia in 23 [57.5%], bone marrow hypoplasia /aplasia in 8[20%] and Leukaemia in 6 [15%] patients. So megaloblastic anaemia was the most prevalent finding in this study. Next was bone marrow hypoplasia /aplasia, followed by leukaemia. Megaloblastic anaemia is the most prevalent diagnosis and the major cause of bicytopenia and pancytopenia in the bone marrow aspirates performed in the Paediatric unit of District Headquarter Teaching Hospital District Dera Ismail Khan

Step by step clinical diagnosis

A 49 years old man admitted in the emergency room with gingival hemorrhage. He was thrombocytopenic, had a huge splenomegaly, and a history of epistaxis. Huge splenomegaly has a large list of differential diagnosis [DDx] with infectious disease, Liver disease and cancers that we rolled out these DDx with step by step diagnosis. And finally we found hereditary Gucher's disease, in spite of his age [49yrs]. By the recurrent hemorrhage and severity of thrombocytopenia and leucopenia, spleenectomy was done and the patient discharged with good general appearance. Gaucher's disease should be considered in the differential diagnosis of patients with unexplained organomegaly, easy bruisability and/or bone pain. Bone marrow examination usually reveals the presence of Gaucher cells; however all suspected diagnoses should be confirmed by demonstrating deficient acid b-glucosidase activity in isolated leucocytes or cultured fibroblasts

Granulocyte-colony stimulating factors for secondary prevention of leucopenia in patients receiving chemotherapy.

OBJECTIVE: To evaluate the effectiveness of GCSF as a secondary preventive adjunct to chemotherapy in the gynaecologic cancer patients who previously had grade 3-4 neutropenia or leucopenia from chemotherapy. MATERIAL AND METHOD: We retrospectively reviewed the medical records of 94 chemotherapeutic cycles with GCSF as secondary prophylaxis in 29 patients with gynaecologic malignancy between January 1996 and April 2005. RESULTS: The median age of the patients was 51 years (21-75). Most of the patients had ovarian cancers (19 cases, 65.6%). From secondary GCSF, grade 4 neutropenia was developed in 12 of 94 cycles (12.8%), and grade 4 leucopenia was developed in 5 of 94 cycles (5.3%). There were no patients developing febrile neutropenia after GCSF support. CONCLUSION: Secondary GCSF prophylaxis was effective in preventing grade 4 leucopenia, grade 4 neutropenia, and febrile neutropenia.

Dengue fever outbreak in Karachi, 2005-A clinical experience

Dengue Fever is the most common arboviral disease in the world, and presents cyclically in tropical and subtropical regions of the world. In Pakistan there has been at least one confirmed outbreak in 1994. This is a series of 72 cases seen between September and December 2005 that were diagnosed as dengue fever, the case definition being acute fever with thrombocytopenia, leukopenia and high ALT, and with or without overt bleeding. There was no other explanation for the clinical and lab. investigations. Young adults were affected, males more often than females. Clinical presentation was fever, vomiting, abdominal pain, myalgia and minor to severe bleeding from the nose, gums, gastro intestinal tract or into the skin. Low platelets and TLC, and raised ALT were the salient laboratory features. Management consisted of judicious fluid replacement and fever reduction. Most patients recovered completely, except one young patient who presented with hypovolemic shock, and died of hemorrhage. Dengue viral infection must be regarded as a public health problem, and serious efforts undertaken for public awareness, surveillance and vector control

Seroprevalence of dengu infections amongst the children.

Serosurvillance of 650 children of clinically suspected dengue infection based on simple laboratory tests were evaluated to find out the early indicator for diagnosis of dengue infection. The study was conducted among the patients attending the Sir Salimullah Medical College (SSMC) and Mitford Hospital and Popular Diagnostic Center, Dhaka, during July 2002 to September 2002. Of these 650 suspected dengue cases, 294 were in the age group 1-5 years, 206 were in age group 6-10 years and 150 cases in age group 11-15 years, of which Seropositivity was found in 78 (26.53%), 60 (24.12%) and 65 (43.33%) cases respectively. Primary dengue IgM was positive in 123 (60.59%) cases and secondary dengue (IgG & IgM combined or IgG alone) was positive in 80 (39.41%) cases. Leucopenia was found in 90 (75%) cases and Thrombocytopenia was found in 95 (79.16%) cases in primary dengue cases. Similarly in secondary dengue cases TWBC and PLT was decreased in 60 (72.29%) and 65 (78.15%) cases respectively. Haemoconcentration was found in 40 (36.67%) cases of primary dengue and 13 (18%) cases in secondary dengue. Month wise distribution of dengue seropositivity shows that 10 (8.53%) cases was found in July, 175 (50.10%) cases in August and 78 (10.00%) cases in September. This study reveals that seropositivity is highest (43.33%), in the age group 11-15 years and incidence of dengue increased in the month of August. Leucopenia (WBC <or= 5000) and Thrombocytopenia (Patelet count <or= 100000) were two findings that help in the early diagnosis of dengue infection.

Kikuchi histiocytic necrotizing lymphadenitis: clinicopathological and immunohistochemical study

Clinical, morphological and immunohistochemical features of 10 cases having the lymphnodal histological pattern of Kikuchi disease were examined. Two of these were diagnosed as systemic lupus erythematosus [SLE]. Morphologically, Kikuchi disease and SLE were nearly indistinguishable. Plasma cells, neutrophilic infiltration, haematoxyphilic bodies and vasculitis were not useful in differentiating the conditions. Kikuchi lymphadenitis and malignant lymphoma however could be differentiated histologically. Morphological features that exclude malignancy included: polymorphous nature of cellular infiltrate, absence of abnormal mitosis, preservation of sinusoidal pattern on intervening areas and presence of extracellular and intracellular karyorrhectic debris

Manifestaciones hematológicas en la infección por VIH / Hematologic manifestations of HIV infection

Las manifestaciones hematológicas en la infección por el virus de la inmunodeficiencia humana son floridas, ya que esta patología ha adquirido particular relevancia en los últimos años por el aumento en la frecuencia de su presentación. Se analizan las distintas formas de compromiso hematológico, así como las indicaciones para la realización de estudios invasivos : biopsia de médula ósea y biopsia ganglionar

Cinco años de experiencia con sepsis neonatal en un centro pediátrico / Five years experience of neonatal sepsis in a pediatric center

Objetivo. Describir la etiología, manifestaciones clínicas y cambios hematológicos asociados a sepsis en la unidad de cuidados intensivos neonatales del Hospital Infantil de México Federico Gómez y determinar la frecuencia de citología hemática (CH) normal al diagnóstico de sepsis. Métodos. Análisis de expedientes clínicos de los pacientes sépticos hospitalizados entre enero de 1992 a diciembre de 1996. Resultados. Ingresaron 945 recién nacidos (RN). Se detectaron 147 bacteriemias en 103 pacientes. Los cocos grampositivos fueron los gérmenes más comunes (55 por ciento). El cuadro clínico de sepsis fue inespecífico y en los RN pretérmino (RNPT) la apnea y la ictericia fueron más frecuentes que en los RN de término (RNT) (p< 0.05). Al diagnóstico de sepsis, la CH fue normal en 19 por ciento y 8 por ciento de los RNPT y RNT respectivamente; la leucopenia fue un dato del mal pronóstico pues 7 de 35 fallecimientos tuvieron leucopenia vs uno de 68 sobrevivientes (p< 0.05) La mortalidad global fue de 34 por ciento pero la atribuible a sepsis fue de 13 por ciento. Conclusiones. La incidencia de sepsis en esta población fue alta predominando los cocos grampositivos. Las manifestaciones clínicas de sepsis fueron inespecíficas. La CH fue normal al diagnóstico en una proporción considerable de los RNPT séptico y la leucopenia fue un dato de mal pronóstico. La mortalidad asociada a sepsis fue alta

Basopenia as an indicator of ovulation (a short term clinical study).

In the present study 60 cases age ranging from 18-40 years were studied for variation in the absolute basophil count on the different days of menstrual cycle. At the time of ovulation a statistically significant decrease in the number of basophil count was noted. The decrease in the number of basophil at mid cycle coincided with the irregular follicle seen by sonography, which indicated ovulation. The basophil count then increased during the luteal phase. Basopenia at the time of ovulation was probably due to migration of these cells from the peripheral blood towards the rupturing follicle for the release of histamine required for ovulation.

Dengue fever with thrombocytopenia: studies towards defining vulnerability of bleeding

PURPOSE: To define the period of greater vulnerability of bleeding in patients with Dengue fever in reference to the onset of their constitutional symptoms and the laboratory abnormalities. PATIENTS AND METHODS: In a retrospective study we reviewed the records of all patients admitted to San Pablo Medical Center in 1991 with a diagnosis of Dengue Fever or Hemorrhagic Dengue. All patients with a platelet count of less than 125,000 were included for analysis. The exclusion criteria included the presence of systemic disorders which may influence the platelet count, and patients without documentation regarding the presence of constitutional symptoms suggestive of viral illness. RESULTS: A total of 101 patients were analyzed of which only 74 were included in the study. All patients had fever and chills; skin rash, asthenia and general malaise was seen in over 50 of patients. Over 70 of patients had recovery of their platelet count, and most had their maximal thrombocytopenia within the 5th day and 8th day from the onset of constitutional symptoms. Leukopenia was seen in over 70 of patients with its lowest level within the 5th and 8th day from the onset of the constitutional symptoms. Significantly prolonged partial thromboplastin time was seen in 11 of the patients. Proteinuria was seen in 22 of the patients, 38 of which had it within the first 4 days of the onset of constitutional symptoms and also noted on the 5th and 6th day. Alteration in liver enzymes were noted in 47 of patients, with a maximal severity distributed in all time frames. Hypoalbuminemia was present in 28 of the patients, of these 67 presented within the first 4 days from the onset of constitutional symptoms. The pulse rate was usually normal in spite of the patient's dehydration and fever. CONCLUSIONS: We identified three phases that define the sequence of events seen in the majority of patients with Dengue Fever and Thrombocytopenia. These are: 1. proteinuria and hypoalbuminemia; 2. maximal cytopenia; 3. bradycardia and liver enzyme elevation. We believe this information is useful in the management of patients with Dengue Fever and thrombocytopenia

Infección de tejidos blandos: revisión de 200 casos / Infections of soft tissue: review of 200 cases

Las infecciones quirúrgicas de tejidos blandos implican un amplio espectro de presentaciones clínicas, agentes bacteriológicos y resultados. La fascitis necrosante (FN) es una infección de tejidos blandos potencialmente fatal, de inicio súbito y rápidamente progresiva caracterizada por necrosis extensa de la fascia superficial y profunda. Se investigaron los factores de riesgo para las infecciones de tejidos blandos (ITB) en el medio. Se presentan 200 casos (129 hombres y 71 mujeres) con edad promedio de 47.5 años. El factor asociado con más frecuencia fue el traumatismo. La mortalidad global fue de 39 por ciento