A multicenter retrospective study defining the clinical and hematological manifestations of brucellosis and pancytopenia in a large series: Hematological malignancies, the unusual cause of pancytopenia in patients with brucellosis

The aim of the study is to review the clinical manifestations and the hematological findings of brucellosis and pancytopenia, with or without hematological malignancies. The records of 202 patients with brucellosis were evaluated retrospectively. Among these cases of brucellosis seen in a 6 year period between April 1999 and June 2005, 30 patients with pancytopenia were identified. The most common manifestation was fever, followed by weight loss, anorexia, malaise, arthralgia, and hepatosplenomegaly. Bone marrow biopsies revealed hypercellularity or normocellularity. The most common findings in the bone marrow evaluation were histiocytic hemophagocytosis and granulomas. Among all cases, we diagnosed 5 hematological malignancies (1 acute myelogenous leukemia, 2 acute lymphoblastic leukemia, and 2 multiple myeloma) concurrently with brucellosis. The clinical symptoms and findings were similar in patients with and without malignancies. In cases with malignancies, the bone marrow biopsy revealed predominant primary disease involvement. Significant increases in ESR and CRP, severe anemia and thrombocytopenia were observed in patients with malignancies. Peripheral blood counts in patients without malignancies returned to normal after antibiotic treatment for brucellosis. However, pancytopenia in two patients with malignancies did not recover because of primary resistant disease. We conclude that while histiocytic hemophagocytosis may be considered as a major cause of pancytopenia, leukemic infiltration can also be an extreme and unusual cause of pancytopenia in patients in whom brucellosis was concurrently diagnosed with hematological malignancies.     

Hepatic involvement of disseminated actinomycosis

A 35-year-old woman was admitted for weight loss, fatigue, and epigastric and back pain. She had undergone uterine myomectomy 6 weeks previously, and light microscopic examination revealed actinomycosis. Radiologic examination showed 5×4×4 cm and 2×2×2 cm solid lesions in the left liver lobe. Ultrasound-guided fine-needle aspiration biopsy could not exclude the possibility of malignancy. We decided to perform an explorative laparotomy. Frozen sections indicatedEchinococcus alveolaris infection or granulomatous inflammatory disease, and left hepatic lobectomy was performed. Histologic examination revealed hepatic actinomycosis. After 6 months' penicillin treatment, there was no sign of recurrence. This case of hepatic actinomycosis following uterine infection without gross involvement of any other abdominal organ raises questions on the dissemination pathway. The other interesting feature of this case is the short interval from the presumed initiatory event to the presence of the hepatic deposits.     

Primary lymphoma of the heart: three-dimensional reconstruction

Primary cardiac lymphoma is defined as a lymphoma of the heart and pericardium with little or no extracardiac or local involvement such as mediastinal lymph nodes or pleural effusion. Most cases are diagnosed only post mortem (1). If this disease could be diagnosed earlier, therapy with chlorpropamide, doxorubicin, vincristine and prednisone (CHOP) could bring about a remission (2,3,4). Transoesophageal echocardiography with three-dimensional acquisition is a new technique which can allow earlier diagnosis, and facilitate guided transvenous biopsy (5,6). We here report an example of the pre-mortem diagnosis of cardiac lymphoma by these techniques.     

Vaginal Delivery After Ileal Pouch-Anal Anastomosis: A Word of Caution

PURPOSE This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis.METHODS The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique.RESULTS Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001).CONCLUSIONS The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

The utility of cervical elastosonography in prediction of cervical insufficiency: cervical elastosonography and cervical insufficiency

Objective: To evaluate the utility of cervical elastosonography (ES) in prediction of cervical insufficiency (CI).

Methods: A total of 40 women, of which 20 who had previously received the diagnosis of CI and 20 healty women were included in the study. None of the women were pregnant. All subjects underwent sonographic evaluation including cervical length measurement and ES of uterine cervix. Adjacent muscular tissue was the reference point for elastosonography evaluation. Tissue strain ratio values were obtained from all the patients.

Results: The area around the internal cervical os of the group with CI was found to be significantly softer as compared to the control group (higher SR rate, p?<?0.05). Furthermore, the outer parts of the cervix (sites A and D) were also found harder in the group that had CI (lower SR rate, p?<?0.05).

Conclusions: According to our knowledge, this is preliminary study to evaluate the predictive value of cervical ES in CI and we concluded that ES can be used as reliable method to determine CI but it is necessary to be studied in different cohort groups.     

Effect of dopamine infusion on thyroid hormone tests and prolactin levels in very low birth weight infants

Objective: To evaluate the effect of dopamine on thyroid hormone tests and prolactin (PRL) and to assess requirement for L-thyroxin (LT4).

Methods: The infants (n?=?102) were divided into three groups (Group 1; received no dopamine, Group 2 received ≤25?mg/kg cumulative dose and Group 3; received >25?mg/kg cumulative dose). Blood samples were taken at 6–8 days (timepoint 1), 13–15 days (timepoint 2), and 4–6 weeks of life (timepoint 3).

Results: Respiratory distress syndrome was higher in group 2 and 3. Patnet ductus arteriosus was higher in group 3 than in groups 1 and 2. Duration and cumulative dose in group 3 were higher than group 2. There was no difference between thyroid hormones that were taken after stopping infusion at timepoint 3 among all groups. No therapy with LT4 was needed. PRL levels were higher at timepoint 1 in group 1 than compared to group 2 and 3 (p?p?>?0.05). This difference was disappeared at following timepoints.

Conclusions: The release of TSH, FT3, FT4 and PRL were not inhibited and prophylactic thyroid hormone treatment was not required in VLBW infants receiving dopamine infusions.     

Outcomes for haematological cancer patients admitted to an intensive care unit in a university hospital

Background

Haematological cancer (HC) patients are increasingly requiring intensive care (ICUs). The aim of this study was to investigate the outcome of HC patients in our ICU and evaluate 5 days-full support as a breakpoint for patients’ re-assessment for support.

A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study

Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment.We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1­75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.     

Compliance With Dyslipidemia Guidelines in Daily Practice: How Effective Is Cardiovascular Risk Prevention?

Purpose

Cardiovascular disease (CVD) due to atherosclerosis is the leading cause of early mortality and morbidity. The current European guidelines on CVD prevention in clinical practice recommend the use of the Systematic Coronary Risk Estimation (SCORE) system. The current American Heart Association guidelines recommend the use of the new pooled cohort risk assessment equations to estimate the 10-year atherosclerotic CVD risk. The purpose of this article was to investigate the compliance of dyslipidemia guidelines in daily practice in patients with dyslipidemia or who have risk factors for CVD.