Neutropenic enterocolitis as a presenting complication of acute lymphoblastic leukemia: an unusual case marked by delayed perforation of the descending colon

Neutropenic enterocolitis (NE) is a life-threatening complication most commonly seen in patients receiving intensive chemotherapy for acute leukemia. The condition usually affects the terminal ileum, cecum, or ascending colon. In rare instances, NE may occur before the initiation of chemotherapy or involve more distal bowel. The authors report the case of a 2-year-old girl who had NE affecting the descending colon as a presenting complication of acute lymphoblastic leukemia. Despite aggressive medical interventions, including granulocyte infusions, she had a delayed bowel perforation that was managed successfully with surgery. This case highlights the challenges of treating patients who have NE as an initial manifestation of acute leukemia.     

Charcot-Marie-Tooth disease type I diagnosed in a 5-year-old boy after vincristine neurotoxicity, resulting in maternal diagnosis

Charcot-Marie-Tooth disease type 1, also known as hereditary motor sensory neuropathy type 1, is an uncommon autosomal dominant disease that causes destruction of peripheral nerves with a varied clinical course, but often leads to muscle weakness. If the peroneal muscle is involved, the patient may develop a characteristic slapping gait. The dose-limiting side effect of the chemotherapeutic agent vincristine is usually its neurotoxicity. We report the case of a 5-year-old patient with leukemia who developed an acute polyneuropathy after treatment with vincristine. Charcot-Marie-Tooth disease type 1 was diagnosed in the patient and, subsequently, in his mother only after vincristine toxicity was observed.     

Effects of vasoactive agents in healthy and diseased human saphenous veins

Purpose: Smooth muscle reactivity is one of the factors involved in the pathogenesis of varicose veins. We investigated the myotropic effects of the 3 main vasoconstrictor agents—norepinephrine (NE), angiotensin II (Ang II), and endothelin-1 (ET-1)—in isolated human saphenous veins. Methods: Human saphenous veins were collected from 23 patients with primary chronic venous insufficiency who underwent elective varicose vein resections and who were stratified into the following 3 groups: group 1, 7 patients in clinical class 2; group 2, 9 patients in clinical classes 3 and 4; and group 3, 7 patients in clinical classes 5 and 6. Moreover, 6 patients who underwent arterial bypass grafting procedures represented the control group. The tissues were suspended in organ baths that contained Krebs solution, and their mechanical responses were measured isometrically. The cumulative concentration–response curves to Ang II, NE, and ET-1 were performed at 90-minute intervals in each tissue. Results: In the control tissues, NE, Ang II, and ET-1 induced concentration-dependent contractions with apparent affinities (pEC₅₀, the negative logarithm to base 10 of the molar concentration of the agonist, which produces the 50% of the maximal effect) and maximal effects (maximum effect, g of contraction) that were equal to 7.06 ± 0.23, 8.53 ± 0.34, 7.63 ± 0.10, and 2.21 ± 0.33, 1.65 ± 0.31, 2.60 ± 0.77, respectively. Two main findings were evident in comparison of varicose veins with control tissues. First, the maximum effect that was evoked by all of the stimulants was reduced progressively with the increasing severity of the disease, which raised the third group to statistical significance for both NE and Ang II (P < .05). Second, a marked reduction of Ang II apparent affinity was already evident in tissues that were taken from patients in an early stage of the disease (P < .05). Conclusion: The demonstration of a significant reduction in Ang II and NE contractile activities and the important reduction of that of ET-1 in the diseased veins as compared with the control tissues extends the previous observations regarding the impairment of smooth muscle contractility in primary chronic venous insufficiency. Moreover, the dramatic reduction of Ang II affinity, which appears in an early stage of the disease, supports the hypothesis that such abnormality within the venous wall could play a role in the pathogenesis of primary varicose vein disease. (J Vasc Surg 1998;28:855-61.)     

Sympathetic Nervous System Tonicity and Post-Coronary Artery Bypass Hypertension

To elucidate the pathogenesis of hypertension following coronary bypass surgery, blood pressure and plasma catecholamine concentration were measured in 28 patients with coronary artery disease who were undergoing myocardial revascularizat ion procedures. Measurements were obtained on arrival in the operating room and 1 and 4 h after surgery.
One hour after surgery, plasma norepinephrine (NE) increased significantly by 495k 108 pg/ml (P<0.001) in the coronary artery disease group which developed hypertension, but the increase was not significant in the coronary artery patients who remained normotensive after surgery. However, 4 h after surgery, plasma NE increased significantly and to the same extent in both coronary artery disease groups, regardless of the change in blood pressure.
Plasma epinephrine (E) also increased significantly 1 and 4 h after surgery in both groups. The observed change in plasma catecholamine concentration is direct evidence that the stress of surgery is a potent adrenergic stimulus, but the hemodynamic significance of the plasma catecholamine change remains unclear.     

Neuroendocrine differentiation in adenocarcinoma of prostate during combined androgen blockade therapy: a case report

Prostatic neuroendocrine (NE) carcinoma is a rare disease with a poor prognosis because of its rapid progression and the androgen-independent characteristic, for which no successful therapy is available presently. We report a case of NE differentiated prostate cancer, which was diagnosed as adenocarcinoma initially and progressed with NE differentiation during the combined androgen blockade therapy.     

Clinical significance of elevation in neuroendocrine factors and interleukin-6 in metastatic prostate cancer

Serum biomarkers that reflect the complex pathways of cancer progression have contributed to the clinical understanding of many malignancies. Recent studies have suggested that certain neuroendocrine (NE) elements participate in prostate cancer (PCa) progression. Interleukin-6 (IL-6) may serve as a useful marker of and contribute to PCa morbidity. The purpose of this study was to assess the frequency of elevation of two NE factors, chromogranin A (CGA) and bombesin-like immunoreactivity (BLI), in patients with advanced PCa and to determine their relationship to serum prostate-specific antigen PSA) and IL-6 levels, as well as known prognostic indicators (hormonal state, stage). Serum CGA determined by radioimmunoassay was elevated in I (7%) of 15 androgen-dependent (AD) patients and II (52%) of 21 androgen-independent (AI) patients; and urine BLI determined by radioimmunoassay was elevated in 2 (13%) of 16 AD patients and 10 (39%) of 21 AI patients. Frequency of elevation was higher in patients with distant metastasis (bone, visceral) compared with those with local/regional extensions of the disease. Levels of the NE factors correlated well with serum and bone marrow aspirate IL-6 concentrations but not with serum PSA levels. Elevation in either NE factor predicted for shortened survival. Measurement of NE factors in PCa identifies a subset of patients with advanced disease likely to express high levels of IL-6 and have a shorter survival. If confirmed, these findings will support the existence of a clinically relevant subset of patients in whom NE factors are involved in AI PCA progression.     

Norepinephrine transporter gene (NET) polymorphism in patients with type 2 diabetes

BACKGROUND: Norepinephrine transporter (NET) is involved in the regulation of norepinephrine (NE) turnover and metabolism. Neuronal NE reuptake may be impaired in individuals with renal disease and/or hypertension due to dysfunction of the NE transporter. A silent G1287A nucleotide substitution in exon 9 of the NET gene was studied in human conditions involving hypertension. We investigated its effect in patients with type 2 diabetes. METHODS: The study involved 215 type 2 diabetes patients with nephropathy, 95 patients with diabetes duration > or =10 years, free of nephropathy, and 360 healthy subjects. All individuals were genotyped for the NET-8 gene polymorphism with the PCR-RFLP method. Genotype and allele frequencies were compared between the groups. NE was measured by high-performance liquid chromatography and electrochemical detection. RESULTS: We genotyped 310 patients and 360 controls for the NET gene polymorphism. Genotype distribution in both groups was in accordance with the Hardy-Weinberg equilibrium. There were no significant differences in the frequency of genotypes and alleles between patients and controls (p = 0.43). The frequencies were also similar for patients with nephropathy and those without. After dividing the patient group into hypertensive (n = 208) and normotensive (n = 102) subjects, there was a significant increase in the frequency of the AA genotype in patients with hypertension compared to normotensives (19 vs. 10%, p < 0.05). CONCLUSION: No association was found between G1287A polymorphism in the NET gene and diabetes. Our results suggest that this polymorphism has a possible role in increased susceptibility to hypertension in patients with type 2 diabetes.     

Factors Predicting Postoperative Infectious Complications and Early Induction of Inflammatory Mediators in Ulcerative Colitis Patients

Background Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC). Methods To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients. Results Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups. Conclusions Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.     

Neuroendocrine cells in human prostate over-express the anti-apoptosis protein survivin

BACKGROUND: Neuroendocrine (NE) differentiation may be related to the growth and progression of prostate cancer, especially androgen-insensitive tumors. Recently the over-expression of a new anti-apoptosis protein, survivin, has attracted attention for its potential implication in many human cancers. The fact that NE cells in prostate are bcl-2 negative prompted us to investigate if the prostatic NE cells over-express survivin. METHODS: Double immunohistochemical staining and immunofluorescence of chromogranin A (CgA) and survivin were performed in 57 patients with localized prostate cancer who underwent radical prostatectomy. The terminal deoxynucleotidyl transferase (TDT)-mediated dUTP-digoxigenin nick end-labeling (TUNEL) method was used for apoptosis detection in three prostate cancer specimens with NE differentiation. The relationship between NE differentiation and clinicopathological characteristics, disease progression as well as patient survival, were analyzed retrospectively. RESULTS: It was found that NE cells in both benign and malignant prostate tissues over-expressed the anti-apoptosis protein survivin. While apoptosis was detected in non-NE epithelial cells, all NE cells were negative for apoptosis detection. During the period of follow-up, 17 (63%) of 27 patients with NE differentiation had prostate cancer progression, while 12 (40%) of 30 patients without NE differentiation had systemic prostate cancer progression. 10 (37%) of 27 patients with NE differentiation died from prostate cancer during the period of follow up, while 6 (20%) of 30 patients without NE differentiation died from prostate cancer. However, none of these characteristics reached statistical significance, probably because of the small number of cases enrolled. CONCLUSIONS: This study discovers that all the prostatic NE cells express the new anti-apoptosis protein survivin. This provides a strong molecular basis for the hypothesis that NE cells may endure stressful conditions and escape from apoptosis. While our results suggest a trend of NE differentiation with poorer prognosis, the prognosis implication cannot be concluded due to our small sample size.     

Early renal involvement in acute lymphoblastic leukemia and nonHodgkin's lymphoma in children

Clinical manifestations of kidney disease, particularly renal failure, caused by malignant infiltration in patients with acute lymphoblastic leukemia or nonHodgkin's lymphoma have been described rarely. We report 1 case of acute lymphoblastic leukemia and 3 cases of nonHodgkin's lymphoma in which renal disease was the only or one of the presenting manifestations of malignancy. Of these patients 2 had rapidly progressive renal failure with nephromegaly, 1 presented with bilateral abdominal masses caused by severe nephromegaly and with microscopic hematuria, and 1 had microscopic hematuria without nephromegaly. In all 4 patients kidney biopsy revealed malignant infiltration. In the 2 patients who presented with renal failure kidney function promptly returned to normal after chemotherapy and irradiation of the kidneys. Prompt and correct diagnosis of nephropathy, when it is the only or one of the presenting signs of acute lymphoblastic leukemia or nonHodgkin's lymphoma, is necessary to expedite initiation of specific antitumor therapy.     

Utility of 111Indium-pentetreotide Scintigraphy in Patients with Neuroendocrine Tumors

Background

Neuroendocrine (NE) tumors pose a diagnostic challenge with the need to utilize a combination of biochemical analysis, standard cross-sectional imaging, and more recently, nuclear medicine scans such as ¹¹¹indium–pentetreotide scintigraphy (somatostatin receptor scintigraphy, SRS; OctreoScan, Covidien Imaging Solutions, Hazelwood, MO). In this study we sought to evaluate the clinical utility of scintigraphy in the diagnosis and management of patients with NE tumors at a major university hospital.

Methods

A retrospective chart review was performed on all patients who underwent both ¹¹¹indium–pentetreotide scintigraphy and computed tomography/magnetic resonance imaging (CT/MRI) at a single institution between February 2001 and July 2008. Charts were reviewed for patient demographics, symptoms of NE disease, and results of biochemical testing, imaging studies, histopathologic diagnosis, and medical and/or surgical management.

Results

One hundred forty-five patients received ¹¹¹indium–pentetreotide scintigraphy (SRS) and concurrent cross-sectional imaging (CT/MRI) over the 7-year period studied. In the evaluation of primary disease, 60 % of tumors were localized by anatomic imaging, significantly greater than the 15 % detection rate achieved by SRS. In the evaluation of recurrent disease, 61 % of NE tumors were localized by cross-sectional imaging, significantly greater than the 31 % detection rate of SRS. Scintigraphy identified disease foci not seen on CT/MRI in just 8 of 74 of the cohort with evidence of disease and only altered the surgical management in 3 of 74 cases.

Conclusions

Cross-sectional CT/MRI imaging is sufficient for the localization of NE tumors. ¹¹¹Indium–pentetreotide scintigraphy does not significantly alter the surgical management of patients with NE tumors, and we suggest that it be selectively reserved for patients with disease that is occult to cross-sectional imaging.     

Changes in airway inflammation with pseudomonas eradication in early cystic fibrosis

Background: Neutrophil elastase is a significant risk factor for structural lung disease in cystic fibrosis, and Pseudomonas aeruginosa airway infection is linked with neutrophilic inflammation and substantial respiratory morbidity. We aimed to evaluate how neutrophil elastase (NE) activity changes after P. aeruginosa eradication and influences early disease outcomes.Methods: We assessed participants in the AREST CF cohort between 2000 and 2018 who had P. aeruginosa cultured from their routine annual bronchoalveolar lavage (BAL) fluid and who underwent eradication treatment and a post eradication BAL. Factors associated with persistent P. aeruginosa infection, persistent neutrophilic inflammation following eradication and worse structural lung disease one year post-eradication were evaluated.Results: Eighty-eight episodes (3 months to 6 years old) of P. aeruginosa infection were studied. Eradication was successful in 84.1% of episodes. Median activity of NE was significantly reduced post-eradication from 9.15 to 3.4 nM (p = 0.008) but persisted in 33 subjects. High post-eradication NE levels were associated with an increased risk for P. aeruginosa infection in the next annual visit (odds ratio=1.7, 95% confidence interval 1.1–2.7, p = 0.014). Post-eradication NE levels (difference, 0.8; 95% confidence interval, 0.1–1.5) and baseline bronchiectasis computed tomography (CT) score (difference, 0.4; 95% confidence interval, 0.1–0.8) were the best predictors of bronchiectasis progression within 1 year (backward stepwise linear regression model, R²= 0.608, P<0.001), independent of eradication.Conclusion: In children with CF, NE activity may persist following successful P. aeruginosa eradication and is significantly associated with bronchiectasis progression. Evaluating strategies to diminish neutrophilic inflammation is essential for improving long-term outcomes.     

Impaired autofeedback regulation of hypothalamic norepinephrine release in experimental uremia

Chronic renal failure (CRF) is associated with multiple hypothalamic dysfunctions, including reduced secretion of gonadotropin-releasing hormone (GnRH). Because GnRH release is tightly controlled by sympathetic neuronal input, a possible alteration of local noradrenergic neurotransmission in experimental CRF was evaluated. Basal, stimulated, and autoinhibited norepinephrine (NE) release was assessed in hypothalamic and hippocampal tissue slices obtained from 5/6-nephrectomized and control rats. Autoinhibition-free NE release from brain slices, prelabeled with [3H]NE and superfused with physiologic buffer, was stimulated by six electrical pulses, 100 Hz (pseudo-one-pulse stimulation). Autoinhibited NE release was induced by 90 pulses at 3 Hz. The release of tritiated NE was measured upon addition of increasing concentrations of unlabeled NE to exogenously activate the inhibitory alpha2-autoreceptor. Although neither basal nor stimulated NE release differed between the groups, significantly lower pIC50 and Imax estimates of the concentration-response curves of exogenous NE on [3H]NE release were observed in CRF rats, suggesting a diminished autoinhibition of hypothalamic noradrenergic terminals in CRF. Western blotting of tissue homogenates disclosed a significantly reduced abundance of alpha2-autoreceptor protein in hypothalamic tissue from CRF rats. These abnormalities were selectively observed in the hypothalamus, whereas noradrenergic autoinhibition seemed unaltered in the hippocampus. The results suggest a diminished autoinhibition of hypothalamic NE release in CRF. Although impaired hypothalamic NE autoinhibition does not explain reduced GnRH secretion in CRF, it may be involved in the pathogenesis of sympathetic hyperactivity associated with this condition.     

New perspectives on basic mechanisms in lung disease. 6. Proteinase imbalance: its role in lung disease.

The hypothesis, some 30 years ago, that NE was the sole proteolytic agent responsible for the development of emphysema seems naive in retrospect. The availability of technology to measure NE facilitated the early research into the relationship between NE and lung disease. Despite an abundance of information on the activity of NE in the lung, it will probably require prospective studies in man with specific NE inhibitors or control at the gene level to establish a causal relationship between NE and lung disease. Parallel research has resulted in the isolation and characterisation of NE inhibitors other than PI and, indeed, alternative proteolytic enzymes that might contribute to lung disease. It is perhaps impossible now to think that a single proteinase, however omnipotent it may be, causes lung diseases as diverse as emphysema and fibrosis. An important aspect that is emerging is the interrelationship between proteolytic enzymes produced by different, or sometimes the same, cells that could potentiate tissue proteolysis. The evidence suggests that there is likely to be coordinated action between neutrophils, macrophages, and possibly mesenchymal proteinases which can activate or inactivate each other. In addition, one class of proteinases often appears able to proteolytically inactivate inhibitors of the opposite class, which presumably could amplify proteolysis if it occurred in vivo. Although the work on this aspect of proteinase activity is in its infancy, one suspects that part of the normal regulation of proteinase activity might include compartmentalisation. For example, the neutrophil stores proteinases before appropriate release and can inactivate PI to enable proteolytic action pericellularly, whereas degradation of extracellular matrix by macrophages requires interaction between the cell and matrix which is facilitated by cell receptor bound uPA. Disintegration of these "compartments" due to oedema, proteolysis, or for mechanical reasons could, firstly, expose further extracellular matrix substrates to inflammatory and damaged cell proteinases but, secondly, might enhance proteinase potential by the cooperative action of these enzymes. It seems increasingly likely that, where proteinases play a part, there is a cocktail of proteinases that is characteristic of the injury that develops (fig). What remains unclear is why only a proportion of those susceptible, such as smokers or those with acute lung injury, develop irreversible lung disease. This suggests that there are other factors acquired or inherited that need to be considered.     

Biphenotypic acute leukemia following intensive adjuvant chemotherapy for breast cancer: case report and review of the literature

The risk of secondary leukemia in breast cancer patients who receive adjuvant chemotherapy is an open question. We describe the case a 38-year-old woman who developed acute leukemia 18 months after completion of intense adjuvant chemotherapy with prophylactic granulocyte colony-stimulating factor (G-CSF) support and chest wall irradiation. The diagnosis of biphenotypic T-cell acute myeloid leukemia (AML) was based on morphologic and immunophenotypic criteria. Chromosomal analysis of blasts revealed multiple trisomies and tetrasomies. The patient failed to respond to induction and salvage chemotherapy and died 4 months later. This case of acute leukemia occurred in a cohort of 65 high-risk breast cancer patients who were given intense adjuvant chemotherapy during the last 5 years in our hospital. This is the first case reported in the literature of acute leukemia following intense adjuvant chemotherapy with continuous prophylactic G-CSF, which is an actively investigated therapeutic strategy. Vigilance and investigation are needed to determine the leukemogenic potential of intense adjuvant chemotherapy plus radiotherapy in breast cancer patients. A brief review of the literature that deals with acute leukemia that develops after adjuvant chemotherapy for breast cancer and with secondary biphenotypic acute leukemia is presented.     

Congenital leukemia cutis presenting as multiple violaceous lesions in a newborn

We present a case of congenital leukemia cutis that was the presenting sign of systemic acute myeloid leukemia. The initial diagnosis was benign hemangiomatosis because ultrasound of the liver was negative for visceral involvement. However, biopsy showed monocytic cells and led to a further workup which involved a bone marrow biopsy, giving the final diagnosis of acute myeloid leukemia with leukemia cutis. Even with a thorough knowledge of the differential diagnosis of such presenting lesions, a diagnostic biopsy is often needed for a final histologic diagnosis, to proceed with the proper course of treatment. We review congenital leukemia cutis and the differential diagnosis for violaceous lesions in the newborn that may be encountered by the pediatric plastic surgeon.     

Neuroendocrine differentiation and metastasized to brain stem, intraorbit and base of tongue in prostate cancer during hormonal treatment: a case report

Prostatic neuroendocrine (NE) carcinoma is a rare disease and the NE differentiation in prostate cancer is characterized by poor prognosis, rapidly progressing tumor and an androgen-independent state, for which there is currently no successful therapy. Herein, we report a case of NE differentiatiated prostatic cancer, which metastasized to the base of tongue, intraorbit and brain stem. This is the first Japanese report of prostate cancer metastasis to the brain stem and base of the tongue.     

Androgen-induced norepinephrine release mediating guinea pig seminal vesicle smooth muscle proliferation: potential role of pre-synaptic alpha2-adrenoceptors

BACKGROUND: Recent studies from our laboratory have demonstrated that androgen-induced basal norepinephrine (NE) release is responsible for the onset of proliferation in seminal vesicle smooth muscle (SVM) cells during early puberty. With subsequent sexual maturation, SVM was irreversibly differentiated to an androgen-resistant-amitotic state in which basal NE release remained elevated and resistant to androgen withdrawal or repletion. Based on these findings, we hypothesized that this irreversible elevation of basal NE release during pubertal development is caused, at least in part, by the down-regulation of pre-synaptic NE feedback inhibition, secondary to irreversible reduction in the expression of neuronal (pre-synaptic) alpha(2)-adrenoceptors. Functional alpha(2)-adrenoceptors are selectively localized to pre-synaptic sites in SVM. METHODS: To test this hypothesis, we employed ligand binding techniques with [(3)H]RX821002, an antagonist which labeled all alpha(2)-adrenoceptor sub-types. Initial experiments focused on analysis of competitor specificity to identify the predominant alpha(2)-adrenoceptor sub-type in SVM. Subsequently, we quantified the changes in the receptor concentration (B(max)) for [(3)H]RX821002 at the point of maximal dihydrotestosterone (DHT)-induced change in basal NE release. RESULTS: Based on competitor specificity for [(3)H]RX821002, the alpha(2D)-adrenoceptor sub-type predominated in SVM. We treated pre-pubertal castrate animals with DHT for 7 days, which was previously demonstrated to maximally induce basal NE release. This treatment reduced the pre-synaptic alpha(2)-adrenoceptor B(max) 4-fold. In animals which had been castrated as adults, the B(max) for [(3)H]RX821002 remained irreversibly suppressed. CONCLUSIONS: The DHT-dependent reduction in the alpha(2)-adrenoceptor concentration is consistent with the developmental pattern of increased basal NE release. These findings support the hypothesis that the down-regulation of pre-synaptic NE feedback is mechanistically involved in the irreversible elevation of basal NE release. NE mediates proliferation in SVM in early pubertal development. Thus, the androgen-dependent pubertal growth of smooth muscle cells may be indirectly controlled at the level of neurotransmission.