[Kala-azar originating in Ischia]. / Kala-Azar aus Ischia.

Four weeks after returning from a holiday on Ischia, a 53-year-old man fell ill with nocturnal sweating, fever, severe general malaise and hepatosplenomegaly. Sternal marrow and liver punctures revealed an infection with Leishmania donovani, i.e. Kala-Azar. Characteristic features were hyperplasia of the plasma cells in the bone marrow and liver, together with lymphoplasmocytoid cell wash-out and polyclonal IgG proteinaemia. Treatment with pentamidine (Lomidine) was unsatisfactory, while all manifestations of the disease regressed after two courses of sodium stibogluconate (Pentostam), although the hypergammaglobulinaemia and hyperproteinaemia disappeared only slowly. The plasma-cell hyperplasia in conjunction with the hypergammaglobulinaemia, which suggest multiple myeloma, is interpreted as a result of antibody formation by the chronic parasitic infection. Together with storage-cell hyperplasia it is also taken to be the cause of the peripheral leukopenia and thrombocytopenia.

[Hypercalcemias in chronic lymphatic leukemias and other non-Hodgkin's lymphomas]. / Hypercalcämien bei chronisch lymphatischen Leukämien und anderen Non-Hodgkin-Lymphomen.

Three years after diagnosis of chronic lymphocytic leukaemia in a 57 year old man developed a hypercalcaemia with multiple bone fractures, concomitant an increase of activity of the leukaemia. There was no hyperparathyroidism, nor in serum, nor inside the lymphocytes. The osteopenia was caused by leukaemic infiltrations. An additional activation of osteoclasts was caused by an osteoclasts activating factor (OAF), produced by the leukaemic cells. 2 (= 2.25%) of 89 Non-Hodgkin-Lymphomas except chronic lymphatic leukaemia had a moderate hypercalcaemia with concomitant activation of the underlying disease. 9 (= 7.7%) of 116 chronic lymphocytic leukaemias had hypercalcaemia, 2 thereof with increased activity of the leukaemia. Hypercalcaemia is thus very rarely found in other Non-Hodgkin-Lymphomas, in chronic lymphocytic leukaemia some what more often, and only here a concomitant increase in the activity of the underlying disease could be observed in some cases.

[Pneumonia in acute leukemias]. / Pneumonien bei akuten Leukämien.

Acute leukaemia was complicated by pneumonia in 38 (34.8%) of 109 patients treated between 1979 and 1983; in 39.5% of the patients pneumonia occurred more than once. In 23 patients (60.5%) pneumonia occurred during cytostatic therapy, and 25 patients (65.8%) had less than 1000 mm2 granulocytes. Antibiotic therapy had no or only little effect in 70%. A total of 21 patients (55.3%) died of pneumonia. In 15 patients a direct relationship could be seen between pneumonia and the bacterial spectrum in the sputum. A prevalence of gram-negative bacteria was found (24 of 40 bacteria isolated, especially Enterobacteriaceae (19). Fungi were cultivated in 10 cases. Each of the typical pneumonia bacteria was only seen once respectively. It is most important that therapy begin immediately, even before the bacteria have been identified. Only then is there hope that the survival time of patients with acute leukaemia can be influenced.

[Septicemia in leukemia and malignant lymphoma. Incidence pathogens--causes]. / Septikämien bei Leukämien und malignen Lymphomen. Häufigkeit--Erreger--Ursachen.

Septicemia occurred in 81 (= 23.9%) of 339 patients with leukemias an malignant lymphomas during 1979-1984/VI. In leukemias the acute forms and in malignant lymphomas the high malignant forms were mostly affected. The frequency of gramnegative bacterias (46 = 56.8%) was higher than that of gram-positive bacterias (32 = 39.5%) and of fungus (3 = 3.7%). The frequency of septicemia in leukemias (alone) between 1966-1977 was 13.9%, between 1979-1984/VI 30%. In this comparison septicemias caused by gram-negative bacterias and fungus decreased, whereas gram-positive septicemias increased. The focus of septicemia remained unknown in 30 cases, Pneumonias and the urinary tract were the most common source, followed by the skin. All patients were under cytostatics and therefore leukopenic, most of them received corticosteroids simultaneously and were thus immunosuppressed. A combination of granulocytopenia less than 1,000 mm3 with hypogammaglobulinemia less than 10 rel.% were mostly found in acute leukemias and in chronic lymphatic leukemia. 41.5% of febrile episodes from all groups of these diseases were of non-microbic origin (local or septic) an thus possibly symptom of activity of the underlying disease.

[Acute leukaemic course of centroblastic-centrocytic non-Hodgkin lymphomas]. / Akut leukämische Verlaufsformen von zentroblastisch-zentrozytischen Non-Hodgkin-Lymphomen.

Despite histologically limited malignancy blastic leukaemia developed in two patients with centroblastic-centrocytic malignant lymphoma. Blastic cells were peroxidase- and PAS-negative, whereas alpha-naphthylacetate-esterase was predominantly positive. In one case blastic acid phosphatase showed a positive reaction. Despite multiple therapeutic attempts remission of acute leukaemia could not be achieved. Centroblastic-centrocytic malignant lymphoma is thus not only endangered by the histologic transformation to higher malignancy but also by the development of blastic leukaemia. Among our 18 patients with centroblastic-centrocytic lymphomas these two patients were the only to develop terminal blastic leukaemia. There was no leukaemic course in ten primarily centroblastic malignant lymphomas. The association of haematologic acute blastic leukaemia and simultaneous diffuse lymphnode swelling and enlargement of the spleen must lead to consideration of blastic leukaemia originating from a centroblastic-centrocytic lymphoma.

[Severe forms of mycoplasma pneumonia (author's transl)]. / Schwere Verlaufsformen von Mykoplasma-Pneumonien.

Respiratory tract infections with mycoplasma can cause severe infiltrating pneumonia (with pleuritis), associated with marked inflammatory reactions (maximal E.S.R., high leucocytosis with shift to the left and marked alpha 2-proteinaemia). Serial measurements of cold-agglutinin titres as well as complement-fixation reaction to Mycoplasma pneumoniae will confirm the diagnosis. Atypical forms of pneumonia can also be documented in that they respond only to erythromycin and extrapulmonary complications accompany the disease, giving them a protean character. In two such patients there was the clinical picture of pneumonia with high fever and marked inflammatory reaction, associated with anicteric hepatitis. In one there was also thoracic lymphadenitis, myositis and rash, in the other a meta- and post-infectious polyarthritis.

[Hodgkin's disease. Results of diagnosis and therapy (author's transl)]. / Morbus Hodgkin. Ergebnisse der Diagnostik und Therapie.

The principles of modern diagnosis and therapy of lymphogranulomatosis are largely standardized today. Whereas the 50% probability survival rate in a group of patients diagnosed before 1970 was about 2 years, 23 out of 30 with standardized diagnosis and therapy have survived until now. Full remission was obtained in 21 of 30 patients. In spite of these encouraging results, the synopsis of the course of the disease shows that relapses and complications must be reckoned with in lymphogranulomatosis. Side effects of therapy may also acquire considerable clinical importance in the individual case.

[Extreme pseudoagglutination of the red blood corpuscles by cold-labile IgM paraprotein (author's transl)]. / Extreme Ballungsneigung (Pseudoagglutination) der roten Blutkörperchen durch ein kältelabiles IgM-Paraprotein.

Electronic cell count and blood smear was impossible because of extreme pseudoagglutination of erythrocytes in a 70-year-old woman with chronic lymphoid leukaemia and associated antibody deficiency. Cold precipitation of citrated plasma occurred at 4 degrees C, turbidity was noted at room temperature, and the plasma was clear at 37 degrees C. Serum immunoelectrophoresis demonstrated IgM paraprotein of kappa type which was also present in the eluate after breaking up the erythrocyte surface at 37 degrees C. This demonstrates that the pseudoagglutination was caused by loading of the red blood corpuscles by a serologically defined cryoglobulin.

[Early detection of bronchial cancer (author's transl)]. / Früherkennung des Bronchialkarzinoms. Vergleichende Untersuchungen.

Compared with the results of a retrospective study (1954) of early detecting bronchial cancer, our present investigations showed, that females are relatively more concerned than formerly, that the climax of frequency has removed for about ten years to the aged, that more non-smokers are concerned than formerly (16% to 3.5% respectively) and that the time between manifestation of the first symptoms and admittance to hospital has shortened remarkably (one month 26%, three months 33% = 59% compared with 28.3%). In four patients the disease has been discovered by x-ray mass-screening, two of them were nevertheless admitted to hospital too late. Whereas the value of tomography has been established, the results of bronchoscopy ameliorated. Only one patient could be operated: perhaps the shift of age for one decade and a certain negative selection may be responsible for these disappointing results. The x-ray-examination in 2 levels must be performed in every adult male patient, even if bronchopulmonal symptoms do not exist. Moreover, exposed persons (e.g. strong smokers) must be controlled by x-ray examination in regular intervals. It is in this sense, that we see the scope of x-ray mass-screening.

[Immune defects as a cause of septic complications in leukemias and malignant lymphomas (author's transl)]. / Immundefekte bei Leukämien und malignen Lymphomen als Ursache septischer Komplikationen.

Septicemias, especially those due to gram-negative pathogens, frequently occur in leukemias, malignant lymphomas and other malignant or metabolic diseases leading to inanition. The causes are disturbances of cellular defense and humoral immune defects. The immune reaction can be affected by disordered antibody function. In addition to a disturbance of leukocyte function due to reduction of granulocytes (granulocytopenia) disturbances of leukocyte function also occur with a normal cell count (granulocytopathy) especially under cytostatic therapy. Besides specific antibiotic therapy it is important to improve the defense position of the organism by treating the primary disease and to assess the disordered immune status correctly.

[Autoimmune haemolytic anaemia, thrombocytopenia and thyroiditis: an immunopathological triad (author's transl)]. / Autoimmune hämolytische Anämie, Thrombozytopenie und Thyreoiditis: eine immunpathologische Trias.

A 37-year-old woman developed acquired haemolytic anaemia and thrombocytopenic purpura. At the same time there were signs of hypothyroidism. Incomplete heat antibodies (direct Coombs test) were demonstrated as cause of the haemolytic changes, while high-titre thyroglobulin and microsomal thyroid antibodies as cause of the immunothyroiditis explained the hypothyroidism. Although serological demonstration of platelet antibodies did not succeed, the clinical and haematological findings suggested immunothrombocytopenia. Antibodies against smooth muscle produced no clinical symptoms. The activity of the incomplete heat autoantibodies was diminished as result of immunosuppressive treatment and haemolytic signs regressed. Platelet count rose and the haemorrhagic diathesis disappeared. Thyroid antibody titre rose at first but then markedly decreased. There was no demonstrable effect on the hypothyroidism so that it was necessary to administer thyroid hormones. This is the first published case of such immunopathological triad resulting from immunothyroiditis.

[Septicaemia in leukaemia (author's transl)]. / Septikämien bei Leukämien

From 244 patients with leukaemia 34 (13,9%) suffered from septicaemia. Although all forms of leukaemia had been concerned, lymphocytic leukaemias (acute and chronic) predominated. Besides other factors, the most important one is the cellular and humoral immuno-deficiency state in this disease. Gram-negative bacteria occur most frequently, followed by staphylococci, streptococci and fungi. The site of origin of infection is rarely known, presumably in most cases the skin, intestinal and genital mucous membranes and the lungs. The clinical picture of septicaemia in leukaemia is not a typical septicaemic one, as the symptoms of the underlying disease predominate. Diagnosis therefore is only based on blood cultures. As therapy is necessary previous to the knowledge of the bacteriological result, it may be initiated by the application of gentamycin (or, in case of resistance, amikacin) combined with ampicillin or chloramphenicol, corrected later in accordance with the antibiogram. High doses of corticosteroids are used specially in shock states. The prevention of septicaemic complications in leukaemia is most important with regard to better results in cytostatic therapy of leukaemias.