Treatment of dyskeratosis congenita with granulocyte colony-stimulating factor and erythropoietin.

Aplastic anaemia is both frequent and difficult to manage in patients with dyskeratosis congenita (DC). We recently treated a 23-year-old male for a year with granulocyte colony-stimulating factor (G-CSF) and erythropoietin (Ep), with an excellent neutrophil response, and a transient effect on haemoglobin levels. G-CSF alone or combined with other cytokines may provide at least a partial effect in pancytopenic patients with DC.

Peripheral blood picture in primary hypocellular refractory anemia and idiopathic acquired aplastic anemia: an additional tool for differential diagnosis.

BACKGROUND AND OBJECTIVE: Hypoplastic myelodysplastic syndromes (MDS) are being reported with increasing frequency. Aplastic anemia (AA) needs to be differentiated from hypoplastic MDS particularly primary hypoplastic refractory anemia (PHRA) because of the impact on management and prognosis. This distinction may be morphologically difficult even with careful marrow examination which may provide insufficient material due to extreme hypocellularity. The value of peripheral blood (PB) parameters in making the distinction between AA and PHRA is not well studied. In this work, we attempt to examine peripheral blood findings as an additional tool for differentiating PHRA from acquired idiopathic AA. METHODS: PB findings in ten cases of PHRA, which are selected based on the following: less than 30% cellularity, multilineage dysplasia and/or clonal cytogenetic abnormality, are compared to ten cases of classic AA. The PB is examined for automated parameters, differential white cell count, morphologic changes in red cells, white cells, platelets, and the presence of circulating blasts, megakaryocytic fragments and micromegakaryocytes. RESULTS: AA patients tend to have lower platelet and monocytic counts and higher lymphocytic percentages. The following morphologic findings are seen only in PHRA but not in AA: hypochromic red cells, left shift, circulating blasts, hypersegmentation with long filaments, hypogranular, ring, and pelgeroid neutrophils, Dohle bodies, circulating micromegakaryocytes and megakaryocytic fragments. INTERPRETATION AND CONCLUSIONS: We conclude that careful examination of peripheral blood may provide sufficient information to allow for the distinction between PHRA and AA early in the course of the disease. Similarly, patients with classic AA who subsequently develop unusual blood findings during routine follow up should be suspected of having a clonal evolution which needs to be confirmed by marrow examination and cytogenetic analysis.

Low-dose ARA-C consistently induces hematologic responses in the clinical 5q- syndrome.

Five patients with the classical clinical syndrome associated with a deletion of the long arm of chromosome 5, i.e., anemia, macrocytosis, and thrombocytosis, or a normal platelet count, were treated successfully with subcutaneous low-dose cytosine arabinoside (LDARA-C). Prior therapy with other drugs had failed in four of the five patients. A total of nine complete and one partial hematologic responses were induced in five patients. Duration of the first hematologic response ranged from 3 to 30+ months. Two patients (cases 3 and 4) continue in their first hematologic response at 29 and 30 months. Upon relapse, up to three responses could be reinduced in two patients. Duration of the subsequent hematologic responses in case 1 was 16, 8, and 10 months and case 2 achieved two responses of 15 and 18+ months duration. LDARA-C therapy was associated with mild to severe neutropenia and moderate to severe thrombocytopenia. Thus, subcutaneous LDARA-C is highly effective in the treatment of patients with myelodysplasia associated with deletion of the long-arm of chromosome 5 (5q-).

Successful treatment of severe refractory aplastic anemia with 3-beta etiocholanolone and nandrolone decanoate.

A patient with aplastic anemia, who had been unresponsive to androgens, antithymocyte globulin, high-dose methylprednisolone, and cyclosporine, responded to treatment with 3-beta-etiocholanolone, nandrolone decanoate, and prednisolone acetate. Six months following initiation of therapy, she became red cell and platelet transfusion independent with neutrophils persistently over 1,000/microliters. A sustained partial remission has persisted for over 2 years. This observation suggests that a combined hematostimulatory approach may be of benefit, even in patients with long-standing refractory aplasia.

Human long-term bone marrow cultures in aplastic anemia.

Long-term bone marrow cultures (LTMC) were initiated with marrow from five normal subjects and eight patients with aplastic anemia (AA). Near confluent to confluent adherent layers developed in all cultures from normal subjects and AA patients. When present, the 'cobblestone' areas in LTMC from AA subjects were smaller than those observed in the LTMC from normal subjects. The decline in total and viable cell numbers in the LTMC was similar for both normal subjects and AA patients. Granulocyte-macrophage colony-forming units (CFU-gm) were present in nonadherent cells (NAC) from normal LTMC for a mean of 5.2 weeks. CFU-gm were present in the NAC of only two of the eight AA cultures for one week. The absent or small 'cobblestone' areas and the absence of CFU-gm production in AA-LTMC suggest a decrease in the reproductive potential of adherent hematopoietic stem cells, which may be the result of either an abnormal hematopoietic stem cell or an abnormal stromal microenvironment or both.

Abnormality of platelet size and T-lymphocyte proliferation in an autosomal recessive form of dyskeratosis congenita.

Dyskeratosis congenita (DC) is a rare familial hematologic disorder that has various modes of inheritance. We have studied 2 siblings with DC. 1 sibling had thrombocytopenia, which responded to therapy with nandrolone decanoate and oxymetholone. Platelets were abnormally small, which indicates that a qualitatively abnormal megakaryocytopoiesis is a feature of DC. Myeloid and erythroid progenitors in specimens of the blood and bone marrow from both siblings were either absent or greatly reduced in numbers. The qualitatively abnormal megakaryocytopoiesis, and the quantitative abnormality of hematopoietic progenitor cells committed to myelopoiesis and erythropoiesis, indicates involvement of the pluripotent stem cell in DC. Cytogenetic studies of the bone marrow and peripheral blood lymphocytes from these patients showed normal karyotypes, a normal sister chromatid exchange frequency, and a rapid proliferation of peripheral T lymphocytes, a feature of the disorder that has not been reported previously.

Androstane therapy to treat aplastic anaemia in adults: an uncontrolled pilot study.

During the past 9 years, 43 adult patients with severe aplastic anaemia have been treated with a combination of 3 alpha etiocholanolone and nandrolone decanoate in an uncontrolled pilot study. Eleven patients were considered acute and the remainder as chronic severe aplasia. 50% (22 patients) had a haematopoietic recovery and 40% have had a sustained remission varying from 1.5 to 8 years. Three patients who did not respond to 3 alpha etiocholanolone had a haematologic response when treated with the isomer 3 beta etiocholanolone. The recovery did not appear to be associated with age or duration of marrow aplasia. In view of the reproducible chemical structure of these androstanes, we believe this group of steroids should be evaluated further in the treatment of severe aplastic anaemia.

Development and evaluation of a microtiter plate enzyme immunoassay for antibodies to 3,3'-dichlorobenzidine.

The authors obtained and evaluated antisera from rabbits injected with a derivative of a potent bladder carcinogen, dichlorobenzidine (DCB), conjugated to bovine serum albumin (BSA). A 14C-radioimmunoassay (RIA) was able to detect the presence of DCB antibodies, but its relative insensitivity led to the development of a more sensitive enzyme immunoassay (EIA). The EIA test was a "sandwich" method in which a second antibody, labeled with an enzyme (horseradish peroxidase), was used to measure antibody binding to transferrin (Tf)-conjugated DCB immobilized on a microtiter plate. Antibody titers measured by RIA were approximately 1:40; when measured by EIA, they were approximately 1:40,000. Antibody specificity was assessed by comparing the antibody binding activities of DCB, BSA, Tf, BSA-conjugated to DCB, and a number of N-substituted aromatic compounds that included benzidine (Bz). Among the compounds tested, the rabbit antiserum reacted only with DCB and the carrier protein, BSA. Moreover, antibody binding activity to Tf-conjugated DCB was significantly inhibited by unconjugated DCB concentrations between 30 and 500 ng/mL. The precision of antibody binding activities as a function of DCB concentration (expressed by the CV) ranged from 9% for low (30 ng/mL) DCB levels to 12% for higher (500 ng/mL) levels. This evaluation suggests that the antiserum obtained would be appropriate for detecting DCB levels at the ng/mL level.

Refractory anemia in the elderly.

Anatomical observations have indicated a decrease of marrow cellularity with age, but these changes are not associated with anemia in the healthy geriatric patient. Aged patients with refractory anemia should be studied by utilizing red cell volume (MCV) and red cell heterogeneity (RDW). A classification with these indices initially can separate the anemias for a more fruitful investigation. By old age the anemias of hereditary red cell membrane or hemoglobin disorders should be known to the patient. In the absence of tumor, elderly patients have an increasing frequency of refractory anemias that can be called preleukemia or myelodysplastic syndrome. Morphological observations have emphasized the importance of abnormal megakaryocytes and platelets in all phases of preleukemia, and these cytologic changes should be used to guide the physician in the early diagnosis of the syndrome complex. This group of refractory anemias have a limited survival, but nonspecific marrow stimulation can be effective and should be tried. With a more complete classification of the chromosomal abnormalities in the myelodysplastic syndrome, a more accurate prognosis can be anticipated. The anemias of marrow aplasia and ineffective iron utilization (anemia of chronic disease) are found frequently in the elderly, and the physician may offer more effective therapy by an early diagnosis.

Malignant atrophic papulosis: absence of circulating immune complexes or vasculitis.

A 26-year-old woman presented with the classic manifestations of malignant atrophic papulosis, a rare disease of unknown cause. We report the results of our immunologic studies, which may help to explain why treatment with systemic immunosuppressant therapy has not been effective.

Indium-111 chloride bone marrow imaging in chronic renal disease.

Eight patients with anemia and chronic renal disease being maintained by chronic hemodialysis were evaluated with In-111 chloride bone marrow imaging and bone marrow core biopsies. There was no correlation between the erythrocyte cellularity of the marrow and the indium bone marrow scan grade in any patient. Bone marrow imaging can not be used as an indicator of the presence of erythroid marrow in these patients.

Normal human marrow stromal cells induce clonal growth of human malignant T-lymphoblasts.

The effect of marrow stromal cells (MSC) on the clonal growth of a human malignant T-lymphoblast (MTL) cell line was investigated in a bilayer culture system. The MSC consistently stimulated clonal growth of MTL, and no stimulatory humoral factor was present in the medium conditioned by the MSC. These observations and other reports suggest that marrow stromal cells may provide a microenvironment in vivo that is not only conducive to the growth of malignant lymphoblasts, but may actually enhance proliferation of malignant T-lymphoblasts in the bone marrow.

Functionally abnormal marrow stromal cells in aplastic anemia.

We studied the myeloid colony-stimulating activity (CSA) of marrow stromal cells (MSC) derived from normal subjects and patients with aplastic anemia, acute leukemia, and other myeloproliferative disorders. CSA of the MSC was determined in a bilayer system. Feeder layers with varying numbers of MSC (10(4) to 2 X 10(5)) were used. Of 40 MSC tested, 39 stimulated myeloid colony formation by the normal target marrow mononuclear cells. The optimal concentration of MSC exhibiting the maximal stimulation of myeloid progenitors (CFU-GM) varied with different MSC. MSC from normal subjects and from patients with acute leukemia and myeloproliferative disorders were potent stimulators of CFU-GM differentiation. In contrast, MSC from patients with aplastic anemia had poor CSA, suggesting that the marrow microenvironment is functionally abnormal in aplastic anemia.