Demyelinating brain lesions developing in a patient with chronic lymphocytic leukemia shortly after treatment with a fludarabine containing regimen.

Autoimmune manifestations are known to occur in patients with chronic lymphocytic leukemia (CLL) and of these hemolytic anemia and immune thrombocytopenia are the most well recognized. Autoimmunity may also be triggered by some of the therapeutic agents used like purine analoges and these events may sometimes be severe and even fatal. Non-hematological autoimmune stigmata occur far less frequently and are rarely encountered. Here we report a 59 year-old-woman, with CLL, who complained of recurrent headache starting 1 month after completing 6 cycles of fludarabine, cyclophosphamide, and rituximab combination therapy. Computed tomography scan of the brain showed a contrast enhancing lesion of 1 cm in diameter, with surrounding edema in the right frontal lobe. Brain MRI revealed ring enhancing lesions in the right frontal lobe and some additional small lesions in the left parietal lobe. Brain biopsy showed an inflammatory demyelinating lesion, not associated with JC virus. The patient subsequently improved after steroid therapy. Currently, after 2 years of follow-up, she remains in complete hematologic remission, has no neurological deficits, and is carefully followed by a team of neurologists and hematologists. Treating physicians should be aware of this rare autoimmune inflammatory demyelinating lesion which can occur in patients with CLL during the course of treatment and that may be linked to treatment with purine analogues like fludarabine.

[Impairment status and related predictors for adults hospitalized as children in a psychiatric ward in Israel].

BACKGROUND: The few studies that exist on long term outcome of psychiatric hospitalization of children show poor prognosis. OBJECTIVES: To study the level of functioning of adults who were hospitalized as children in a psychiatric ward in Israel and to identify prognosis predictors. METHODS: The study population consisted of all 1654 people who had been hospitalized in a psychiatric hospital in Israel and whose age at the time of the study was 21 years and above. For each subject, demographic and clinical data were extracted from a national case registry and data on disability benefits were retrieved from another file in the Ministry of Health. RESULTS: Only 8% of the study subjects were married, 8.3% died (3.5 times more in men compared to the general population), and 21% received disability benefits. More than half of the people who were hospitalized as children were rehospitalized during the follow-up (43% as adults). Younger age at first hospitalization was associated with a longer cumulative duration of hospitalization, while an older age was associated with a greater number of hospitalizations and a higher rate of eligibility for disability benefits. Diagnosis at first hospitalization was associated with all measures of functioning in adulthood. Diagnosis of an "organic" or severe psychiatric disorder was associated with poor prognosis. Longer duration of first hospitalization was associated with a higher rate of death and eligibility for disability benefits. CONCLUSIONS: This study shows poor prognosis for adults who were hospitalized in child psychiatry wards and calls for long-term prospective and controlled studies.