Sacral epidural abscess complicating closed sacral fracture: a case report.

OBJECTIVE: To describe the clinical course of the development of an epidural abscess with a rare localization. SUMMARY OF BACKGROUND DATA: Epidural abscess usually presents with severe back pain and neurologic deterioration. Spinal fracture may lead to the development of epidural abscess. To the author's knowledge, this is the first reported case of epidural abscess following sacral fracture. MATERIALS AND METHODS: The patient was observed closely in the hospital after a sacral fracture with bilateral S2, S3 dermotome numbness. Fever, bacteremia, and urinary tract infection developed. Fever responded partially with antibiotics. RESULTS: Sacral laminectomy for decompression was performed. Unexpectedly, sacral epidural abscess was found during the operation. Sacral roots were decompressed. Epidural abscess was drained. CONCLUSION: A rare case of sacral epidural abscess following sacral fracture was reported.

Clinical profiles of human immunodeficiency virus-associated lymphoma in Hong Kong.

OBJECTIVE: To identify the clinical and prognostic features of human immunodeficiency virus-associated lymphoma in the local population with a view to designing more effective treatment strategies. DESIGN: Retrospective review. SETTING: Referral hospital, Hong Kong. SUBJECTS AND METHODS: All patients (n=10) with human immunodeficiency virus-associated lymphoma managed at Queen Elizabeth Hospital from January 1995 to December 2001. RESULTS: All patients were men with a median age of 39 years. The median CD4 cell count at the time of diagnosis of lymphoma was 0.056 x 10(9)/L. All tumours were diffuse large B-cell lymphomas, with the exception of one systemic Burkittlike lymphoma. Systemic lymphoma was diagnosed in seven patients and three had primary central nervous system lymphoma. Combined antiretroviral therapy was continued or given to five of the six patients who received some form of chemotherapy or radiotherapy treatment. Of the two patients with primary central nervous system lymphoma who received whole brain irradiation therapy, one patient survived 41 months in clinical remission after diagnosis and the other patient died of sepsis while in partial remission 19 months after diagnosis. The four patients with systemic lymphoma who received standard- or reduced-dose chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone had a median survival of 3 months. CONCLUSION: The clinical profiles of these patients were similar to those of patients with human immunodeficiency virus-associated lymphoma in western countries. The overall survival of patients was poor with conventional chemoradiotherapy. Other innovative treatment approaches should be investigated to prolong the survival of this patient group.

Arsenic trioxide in comparison with chemotherapy and bone marrow transplantation for the treatment of relapsed acute promyelocytic leukaemia.

BACKGROUND: The best overall treatment strategy for patients with acute promyelocytic leukaemia (APL) in relapse with chemotherapy, bone marrow transplantation (BMT) or arsenic trioxide (As(2)O(3)) based therapy remains undefined. PATIENTS AND METHODS: We reviewed the clinical course and treatment outcome of 143 APL cases seen in four major hospitals in Hong Kong over a 10-year period. RESULTS: Complete remission (CR) was attained in 113 cases (79%) with all-trans retinoic acid (ATRA) and chemotherapy. Relapse occurred at a median of 16 months in 54 cases, with a 3-year disease free survival of 56%. Post-relapse treatment was successful in 41 cases (76%), giving an actuarial 3-year overall survival (OS) of 81% from CR1. Three different protocols were used: chemotherapy alone (n = 19), allogeneic BMT (n = 14) and an As(2)O(3)-based regimen (n = 21). Chemotherapy was associated with the highest treatment-related mortality (TRM) at 53%, giving a CR2 rate of 47%. TRM was 36% for BMT. The CR2 rate for the As(2)O(3)-based regimen was 100%, with no TRM. However, 38% of As(2)O(3) treated patients had subsequent relapses, which were further salvaged in 75% by combined As(2)O(3) plus ATRA. The actuarial OS for the three protocols leveled off by 2 years at 82% for As(2)O(3), 43% for BMT and 23% for chemotherapy (P = 0.0004). CONCLUSIONS: Our results suggest that As(2)O(3) may be superior to chemotherapy and BMT for the treatment of APL in relapse.

Consolidation therapy with autologous blood stem cell transplantation in a patient with primary plasma cell leukaemia.

Primary plasma cell leukaemia (PPCL) is a rare form of plasma cell dyscrasia. Conventional melphalan-based treatment is often ineffective, with a reported median survival of 2-7 months only. We report a 53-year-old man with PPCL who was treated with four cycles of combination chemotherapy including vincristine, adriamycin and dexamethasone that resulted in a good partial remission. High-dose melphalan 200 mg/m2 and autologous peripheral blood stem cell (PBSC) rescue was then given 6 months after diagnosis. Maintenance interferon-alpha was started 8 weeks after transplantation with good drug compliance. Complete remission was achieved and molecular remission was documented 11 months after autologous PBSC transplantation. In conclusion, high-dose therapy followed by autologous stem cell rescue is a feasible option for PPCL that can result in a reasonably sustained remission.

Idiopathic myelofibrosis with extramedullary haemopoiesis involving the urinary bladder in a Chinese lady.

Extramedullary haemopoiesis (EMH) associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen and liver, although ectopic haemopoietic tissue has also been described rarely in the lymph nodes, skin, gastrointestinal tract, pleura, peritoneum, central nervous system, and genital and urinary tracts. We report on a 54-year-old Chinese lady with a long history of idiopathic myelofibrosis who presented with gross haematuria and left hydronephrosis due to EMH in the bladder trigone. Cystoscopic examination revealed a sessile necrotic papillary growth at the trigone, obstructing the left ureteric orifice. Transurethral resection of the bladder tumour was performed, and microscopic examination of the tumour chips demonstrated atypical megakaryocytes, immature granulocytes and normoblasts, confirming the presence of EMH. The residual bladder tumour responded well to low dose radiotherapy, with subsequent disappearance of haematuria and normalization of ultrasonogram findings.

Radiologic analysis of the tibial intramedullary canal in Chinese varus knees: implications in total knee arthroplasty.

Seventy-two lower limb long radiographs were reviewed with respect to mechanical and anatomic axes. A template of an intramedullary tibial guide rod was employed to determine the accuracy of the intramedullary guide in producing ideal tibial cuts (ie, 90 degrees ) and acceptable tibial cuts (ie, 90 degrees +/- 2 degrees ). The mean difference of the angle formed by the 2 axes was 1.84 degrees +/- 1.42 degrees. In our findings, 22.2% of patients would have unacceptable cuts if an intramedullary device were employed for the tibial cut during a total knee arthroplasty. A radiograph showing the whole tibia is required preoperatively to identify varus tibiae that are not suitable for the intramedullary method.

Autologous bone marrow transplantation for patients with acute myeloid leukaemia: prospective follow-up study.

OBJECTIVE: To study the use of autologous bone marrow transplantation to treat acute myeloid leukaemia when complete remission had been achieved and when no human leukocyte antigen matched related donor was available. DESIGN: Prospective follow-up study. SETTING: Government hospital, Hong Kong. PATIENTS: Eight patients (median age, 34 years [range, 16-45 years]) with acute myeloid leukaemia in whom complete remission had been achieved. INTERVENTION: Conditioning regimen of carmustine, amsacrine, etoposide VP-16, cytarabine, and infusion of unpurged marrow. MAIN OUTCOME MEASURES: Median time taken to reach neutrophil and platelet counts of > or =0.5 x 10(9) /L and > or = x 10(9) /L, respectively; mortality and relapse rates; and follow-up regimens used. RESULTS: Engraftment was successfully achieved in all patients and there were no early procedure-related mortalities. The median times required to reach a neutrophil count of > or =0.5 x 10(9) /L and a platelet count of > or =20 x 10(9) /L were 30 days (range, 18-36 days) and 38 days (range, 15-53 days), respectively. The median duration of hospital stay was 37 days (range, 25-43 days). Two patients died of a relapse of leukaemia at 6 and 9 months post-transplantation. Two patients experienced relapses: one at 8 months post-transplantation, for which conventional chemotherapy was restarted, and one at 18 months; treatment with all-trans-retinoic acid and conventional chemotherapy achieved a third complete remission in the latter patient, who had acute promyelocytic leukaemia. Continuous remission has been achieved in four of the eight patients after a median follow-up duration of 26 months (range, 6-43 months). CONCLUSION: Autologous bone marrow transplantation is an acceptable treatment for patients with acute myeloid leukaemia who lack a human leukocyte antigen-matched related donor.

Hairy cell leukemia in Hong Kong Chinese: a 12-year retrospective survey.

BACKGROUND: Hairy cell leukemia (HCL) is a unique chronic B cell lymphoproliferative disease (B-LPD), with distinct clinical and pathological features, and excellent treatment response to 2-chlorodeoxyadenosine (2-CDA) and pentostatin. There have been few reports of HCL from oriental countries. PATIENTS AND METHODS: A retrospective survey of HCL in six major hematology units in Hong Kong over a 12-year period. RESULTS: There were 18 cases of HCL identified. Most patients presented with fever, splenomegaly and monocytopenia. Lymphadenopathy was present in three patients, and open biopsy revealed tuberculosis infection in two cases. Seven cases received interferon and 12 cases received 2-CDA. Four patients died from bronchogenic carcinoma, cerebral vascular accident, fulminant hepatitis B virus reactivation and malignant melanoma. The remaining 14 patients are in clinical remission at a median of 6 years' follow-up; two are also surviving from second malignancies (thyroid papillary carcinoma and renal cell carcinoma). CONCLUSIONS: Parallel to the low incidence of B-LPD in Chinese, the incidence of HCL (0.035/100000 population per year) is much lower than in Western series. Other clinical features such as male dominance, clinical presentation, response to 2-CDA treatment, and association with second malignancy are similar to Western reports. However, two common complications in the Chinese population are the fulminant reactivation of hepatitis B infection and disseminated tuberculosis infection.

The management of isolated thrombocytopenia in Chinese adults: does bone marrow examination have a role at presentation?

We performed a retrospective analysis of bone marrow examination (BME) in the management of Chinese adult patients less than 60 years of age with isolated thrombocytopenia at presentation. Eighty-three patients with a median age of 39 years presenting with isolated thrombocytopenia (median platelet count: 38 x 10(9)/l) had routinely undergone BME as part of the laboratory investigations during the period from January 1996 to December 1999. All 83 patients had bone marrow findings of active marrow suggesting causes due to peripheral destruction. All of these patients responded to steroid or intravenous immunoglobulin (IVIg) therapy at presentation if their platelet counts were significantly low or if they had mucosal bleeding. Eighty-one of the 83 patients, after a median of 20 months follow-up, were finally diagnosed as having idiopathic thrombocytopenic purpura (ITP). The remaining two patients were finally confirmed as cases of systemic lupus erythematosus (SLE). Our results suggest that BME is not helpful in the diagnosis of isolated thrombocytopenia or suspected ITP in adult patients at presentation, provided that a thorough clinical history and physical examination are undertaken and that the blood count and peripheral blood smear show no abnormalities apart from the thrombocytopenia.

Expression of the recA gene in recombination-deficient (rec-) strains of Escherichia coli.

Basal and induced levels of recA expression in wild-type and isogenic derivatives of Escherichia coli carrying various rec mutations were measured using a low-copy number recApo-lacZ fusion, pKLC3.2. Basal recA expression in wild-type and isogenic derivatives containing single rec- mutations, as well as in the recBCsbcA strain and isogenic recA, recF and recJ derivatives, ranged from 1000 to 3900 units. In the recBCsbcBC strain and isogenic recL and recN derivatives basal recA expressions were 3- to 5-fold higher than that of wild-type cells and were inducible by mitomycin C. Except for the recA and lexA3(lnd-) mutants, recA expression was induced by mitomycin C in wild-type cells and its isogenic recB, recD, recF, recG, recJ, recL, recN, recO and ruv derivatives. RecF was required for induction of recA expression by mitomycin C, but not by naladixic acid in the recBCsbcA and recBCsbcBC genetic backgrounds. In wild-type cells, induction of recA expression by naladixic acid required the recBC, but not the recD function of the RecBCD enzyme. This requirement is suppressed by either an additional sbcA or sbcC mutation, but not by an sbcB mutation.

The impact of thrombolytic therapy on hospital mortality from acute myocardial infarction in the Chinese in Hong Kong.

Thrombolytic therapy using recombinant-tissue plasminogen activator, urokinase and streptokinase for acute myocardial infarction was instituted in the coronary care unit of the Prince of Wales Hospital in Hong Kong in 1988. To evaluate its impact on hospital mortality of acute myocardial infarction, the database of 465 patients (mean age 65.2 +/- 12.6 yr) admitted into the coronary care unit in the period between 1985-1990 was collected prospectively and their clinical course reviewed. Three hundred and thirty-five patients were males and 130 were females. Patients in the prethrombolytic era (1985-87) and the thrombolytic era (1988-90) were matched for age, proportion of females and clinical severity. One hundred and two patients (39.5%) received thrombolytic therapy. The overall hospital mortality (18.6%) in the thrombolytic era and that for each sex (18.2% in the males; 19.5% in the females) were significantly lower than those of prethrombolytic era (27.1%, 23.4% and 37.7%, respectively). No death was due to bleeding complication. The benefit of thrombolytic therapies in the Chinese was confirmed. More effort is needed to popularize this concept in the Chinese communities, to shorten the prehospital delay of patients and to extend its utilisation to the elderly patients.

Recombinant tissue plasminogen activator in acute myocardial infarction in the Chinese in Hong Kong.

Eighty-nine consecutive Chinese patients (69 males, 20 females) with acute myocardial infarction treated by 100 mg recombinant tissue plasminogen activator (7 intracoronarily, 82 intravenously) at 3.7 +/- 1.0 h after onset, and intravenous heparin or dipyridamole therapy started at 3 h, were studied prospectively. Their mean age was 59.6 +/- 10.6 yr. Forty-six patients (51.7%) had anterior and 39 patients (43.8%) had inferior infarcts. Clinical evidence of reperfusion were seen in 63 patients (70.8%), while new complications included hypotension (5.6%), heart failure (6.7%), cardiac arrhythmias (76.4%) majority of which are related to reperfusion and self-remitting, haematoma around vascular access sites (23.6%), melaena (3.3%) and cerebral infarction (2.2%). Maximal changes in coagulation profiles were seen at 3 h, including a decrease in fibrinogen by 64.2% and an increase in fibrin degradation products by 47 times. The changes in haemostatic variables were not related to body weight or bleeding complications. Nine patients (10.1%) had recurrence of angina and 6 patients (6.9%) died due to pump failure and reinfarction. Angiogram at 14 days confirmed TIMI 2 or 3 patency of infarct-related arteries in 63 out of 73 (86.3%) patients, with a mean global ejection fraction of 52.5 +/- 12.4%. Nearly all survivors could maintain class I-II functional status after discharge. The safety and promise of recombinant tissue plasminogen activator for acute myocardial infarction in the Chinese were confirmed.

Recombinant tissue-plasminogen activator (rt-PA) in acute myocardial infarction in the Chinese in Hong Kong.

Eighty-nine consecutive Chinese patients (69 males, 20 females) with acute myocardial infarction treated by 100 mg recombinant tissue-plasminogen activator (rt-PA) (7 intracoronarily, 82 intravenously) at 3.7 +/- 1.0 hours after onset, and intravenous heparin or dipyridamole therapy started at 3 hours, were studied prospectively. Their mean age was 59.6 +/- 10.6 years. Forty-six patients (51.7%) had anterior and 39 patients (43.8%) had inferior infarcts. Clinical evidence of reperfusion was seen in 63 patients (72.8%), while new complications included hypotension (5.6%), heart failure (6.7%), cardiac arrhythmias (76.4%), hematoma around vascular access sites (23.6%), melena (2.2%) and cerebral infarction (2.2%). Maximal changes in coagulation profiles were seen at 3 hours, including a decrease in fibrinogen (by 64.2%), an increase in FDP by 11.7 times and D-dimers by 4.4 times. Nine patients (10.1%) had recurrence of angina and 6 patients (6.9%) died due to pump failure (5) and reinfarction (1). Angiogram at 14 days confirmed TIMI (2 or 3) patency of infarct related arteries in 62/81 (76.5%) patients, with a mean global ejection fraction of 52.5 +/- 12.4%. Nearly all survivors could maintain class I-II functional status after discharge. The safety and promises of rt-PA for acute myocardial infarction in the Chinese were confirmed.