[Successful treatment of post-allogeneic hematopoietic transplant immune thrombocytopenia with eltrombopag].

A 44-year-old woman in the first remission phase of mixed-phenotype acute leukemia (T-lymphoid and myeloid lineages) suddenly exhibited thrombocytopenia (1.1×104/µl) with generalized petechiae approximately 150 days after bone marrow transplantation (BMT) from a one-locus (HLA-B) mismatched unrelated donor. Until then, the donor bone marrow had smoothly engrafted, and the platelet count had promptly normalized. Despite extensively searching for the triggering agent such as GVHD, graft failure, relapsed leukemia, or adverse drug effects, it could not be determined. Suspecting immune thrombocytopenia secondary to BMT, prednisolone (1 mg/kg/2 days) therapy was initiated, but its effects were unsatisfactory. Next, eltrombopag, a thrombopoietin receptor agonist (TPO-RA), was administered, which exhibited a marked effect on thrombocytopenia, resulting in the withdrawal of prednisolone. Even though the efficacy of eltrombopag against immune thrombocytopenia is well established, limited studies have reported the efficacy and safety of eltrombopag against immune thrombocytopenia after allogeneic stem cell transplantation. Herein we report a case in which thrombocytopenia occurred late after transplantation but was successfully treated with a TPO-RA. In addition, we discuss suspected causative mechanisms and review the literature.

Concurrent Autoimmune Neutropenia and Idiopathic Thrombocytopenic Purpura Associated with IgG4-related Diease.

IgG4-related disease (IgG4RD) is a multi-organ disorder characterized by an elevated serum IgG4 level and IgG4-positive plasma cell infiltration of the affected organs, accompanied by tissue fibrosis and sclerosis. Although it can affect any organ, to our knowledge, no cases involving concurrent autoimmune neutropenia and thrombocytopenia have been reported. A 62-year-old man visited our hospital and was diagnosed with IgG4RD accompanied by interstitial pneumonitis, lymphadenopathy, and interstitial nephritis. During his clinical course, he developed autoimmune neutropenia and idiopathic thrombocytopenic purpura. Our case, invoving multiple hematological abnormalities, might help deepen our understanding of the pathophysiology of IgG4RD.

Sequential Use of Second-Generation Tyrosine Kinase Inhibitor Treatment and Intensive Chemotherapy Induced Long-Term Complete Molecular Response in Imatinib-Resistant CML Patient Presenting as a Myeloid Blast Crisis.

Myeloid blast crisis of chronic myeloid leukemia (CML-MBC) is rarely seen at presentation and has a poor prognosis. There is no standard therapy for CML-MBC. It is often difficult to distinguish CML-MBC from acute myeloid leukemia expressing the Philadelphia chromosome (Ph+ AML). We present a case in which CML-MBC was seen at the initial presentation in a 75-year-old male. He was treated with conventional AML-directed chemotherapy followed by imatinib mesylate monotherapy, which failed to induce response. However, he achieved long-term complete molecular response after combination therapy involving dasatinib, a second-generation tyrosine kinase inhibitor, and conventional chemotherapy.

A case of enteropathy-associated T-cell lymphoma: diagnosis by flow cytometric immunophenotyping and genome analysis using ascitic fluid.

Enteropathy-associated T-cell lymphoma (ETCL) is a primary extranodal T-cell lymphoma arising in the gastrointestinal tract, and is known as a rare and highly aggressive disease with a poor prognosis. The diagnosis of ETCL is usually established by histological examination using resected tumors or biopsy specimens during endoscopic studies. If tumor specimens for histopathological investigation are not available, then such a case might be difficult to accurately diagnose. We report here a case of ETCL which was diagnosed by cytopathology and flow cytometric immunophenotyping using paracentesis fluid without tumor specimens. Immunophenotyping by flow cytometry (FCM) of the ascitic fluid (AF) was invaluable in the final diagnosis of ETCL. Moreover, genetic alterations in the current case were also demonstrated. We emphasize the usefulness of effusion cytology for the expeditious diagnosis of ETCL. In particular, even in cases without tumor specimens, immunophenotyping by FCM using AF can play an important role in the diagnosis of ETCL, and simultaneous genome analysis may be useful to elucidate the biological characteristics of ETCL.

[Successful attainment of the third chronic phase by autologous peripheral blood stem cell transplantation and imatinib in a patient with chronic myeloid leukemia].

Chronic myeloid leukemia in a 61-year-old man progressed into the accelerated phase 8 months after the initial evaluation (Ph chromosome [20/20], FISH 93.5%), although the major cytogenetic response (Ph chromosome [0/20], FISH 9.7%) had been achieved 6 months after the initiation of the treatment with interferon and hydroxyurea. The Peripheral blood stem cells (Ph chromosome [0/20], FISH 5.8%, PCR 2.7 x 10(2) copies/microgram RNA) were harvested simultaneously with the attempt to induce the second chronic phase using the mini-ICE (idarubicin, cytosine arabinoside and etoposide) therapy. However, 2 months later, the disease progressed into blast crisis with the additional chromosomal abnormalities, and did not respond to the re-induction therapy with idarubicin and cytosine arabinoside. Autologous stem cell transplantation was then performed using the preparatory regimen with busulfan and cyclophosphamide. The third chronic phase was successfully achieved, and has been well maintained with imatinib for more than 13 months (Ph chromosome [0/20], FISH 0.0%, PCR < 10(2) copies/microgram RNA). This may be a rare case in which normal hematopoietic stem cells could be enriched in the peripheral blood in the accelerated phase, and that cytogenetic remission was achieved using these cells in the blast crisis. Flexible use of peripheral blood stem cells and imatinib could be an additional strategy for the better treatment of chronic myeloid leukemia.