Neonatal alloimmune thrombocytopenia may be less severe in a subsequent pregnancy.

Neonatal alloimmune thrombocytopenia (NAIT) is more common than previously appreciated. Clinical presentation is varied, but it is generally a severe disorder and it is said to be more severe in subsequent pregnancies. The authors present a case of fatal disseminated intravascular coagulation that was diagnosed as NAIT only after presentation of a subsequent surviving sibling with intracranial hemorrhage and thrombocytopenia. Despite the perinatal complications, this second sibling had good neurodevelopmental outcome. This is the first reported case of less severe disease occurring in a subsequent pregnancy.

Autoimmune thrombocytopenia associated with the first cycle of fludarabine therapy in the treatment of relapsed non-Hodgkin's lymphoma.

Fludarabine phosphate is a purine analogue now commonly used in the treatment of low-grade lymphoid malignancies. An increased incidence of autoimmune haemolytic anaemia is reported with the use of fludarabine for the treatment of chronic lymphocytic leukaemia (CLL). CLL already confers a high risk of autoimmune disorders and, although these are recognized in non-Hodgkiin's lymphoma (NHL), they are less common. Immune thrombocytopenia occurring in patients with CLL treated with fludarabine has been reported and we describe a further case in a patient with relapsed NHL. Possible mechanisms of the effect of fludarabine on autoimmune disorders are discussed.

Unexpected presentation of type 2N von Willebrand disease in pregnancy.

The finding of low factor VIII levels in pregnancy immediately raises concern of haemophilia A carriage, especially with a history of bleeding in the maternal grandfather. However, the diagnosis of type 2N von Willebrand disease (2N vWD) should also be considered as illustrated here. This is also the first reported case of the management of 2N vWD in pregnancy.

Early onset of bilateral brachial plexopathy during mantle radiotherapy for Hodgkin's disease.

We report a case of brachial plexus neuropathy occurring in a 50-year-old man treated with standard mantle radiotherapy for early-stage Hodgkin's disease. A dose of 35 Gy in 20 fractions was given to the mantle field, following by a boost to the right side of the neck (8 Gy in four fractions). The onset of symptoms was early in the course of treatment and a gradual and almost full recovery was observed over 3 years after completion ofradiotherapy. The diagnosis was supported by electromyography. The temporal relationship of the radiotherapy and the onset of the brachial plexus neuropathy suggests a cause and effect, but this association is rarely reported after mantle radiotherapy. We review the aetiology of this condition and postulate possible mechanisms in this patient.

Personal exposure to pesticide among workers engaged in pesticide container recycling operations.

Pesticide container handling operations in western Canada were examined to determine the exposure of workers to residual pesticide in sorting, metal-container crushing, metal-container shredding, plastic-container shredding, metal washing, and metal melting. Environmental exposure monitoring and biological monitoring were applied, including measurement of pesticide deposition density on outer clothing (test coveralls and other protective wear), deposition on fabric and gauze patches under the outer clothing, inhalation of airborne pesticide residues, dislodgement of pesticide residues by hand washing, and pre- and postexposure urinary excretion of pesticide (2,4-D). Exposure levels were highly variable; some variability was accounted for by work practices or lapses in protection. The highest levels of exposure were observed for metal washing, metal crushing, and metal shredding; sorting and plastic shredding were intermediate, and metal melting was associated with very little exposure. Urinary 2,4-D excretion, as an indicator of internal dose, correlated most closely with exposure by the inhalation route, and both were highest for metal washing and shredding. Deposition of pesticide on garments was highest for metal crushing. Melting of washed metal does not appear to present a significant hazard of exposure. Recommendations are proposed for the protection of workers emphasizing health and safety guidelines, worker education, personal hygiene, exposure and health monitoring, and record-keeping, and specific recommendations for each process. These recommendations apply to all pesticide container recycling operations except melting of washed metal containers.

Myelofibrosis in chronic granulocytic leukaemia.

Serial trephine biopsies were performed in 45 cases of chronic granulocytic leukaemia (CGL) in order to determine the frequency and significance of secondary myelofibrosis in the evolution of the disease. Histological changes were graded 1-5b, ranging from no increase in reticulin to dense osteomyelosclerosis. Many cases showed a progressive increase from Grade 1 to Grade 3, and accelerated disease, or blast crisis, often supervened when Grade 3 changes were present. However, a significant number of cases showed Grade 4 and 5 changes, which were indistinguishable histologically from those found in agnogenic myeloid metaplasia (AMM) (idiopathic myelofibrosis), at the time of diagnosis. These patients did not always show a rapidly fatal course and may be considered as an example of 'transitional myeloproliferative disorder', with features intermediate between CGL and AMM.

Acquired von Willebrand's syndrome and Ehlers-Danlos syndrome presenting with gastro-intestinal bleeding.

The clinical and laboratory findings in a patient with severe gastro-intestinal bleeding and the Ehlers-Danlos syndrome are described. Coagulation studies and a lack of history of previous haemorrhage were consistent with a diagnosis of acquired von Willebrand's syndrome. His response to treatment with blood transfusion, Factor VIII, cimetidine, tranexamic acid and cyclophosphamide is described. Family studies revealed other members with Ehlers-Danlos syndrome but normal coagulation.