Leukopenia in Kidney Transplant Patients with the Association of Valganciclovir and Mycophenolate Mofetil

Cytomegalovirus (CMV) is the most common viral infection after transplantation. Valganciclovir (VGC) is established for prophylaxis and treatment of CMV infections, but leukopenia which appears in 10% to 13% (severe in 4.9%) is the principal side effect. We have recently noted an increased incidence of leukopenia and severe neutropenia among our renal transplant patients and thought to identify the associated factors. We conducted a retrospective analysis of all kidney transplantations performed between January 2005 and December 2006. All patients received mycophenolate mofetil (MMF), tacrolimus, and steroids. VGC was used for targeted prophylaxis and preemptive therapy of CMV infection, with doses adjusted to renal function. Of the 64 patients undergoing renal transplantation 13 (20.3%) developed leukopenia within 3 +/- 2 months after transplantation with severe neutropenia in 5 (7.8%). All patients were on MMF and VGC (VGC 605 +/- 296 mg/d). Leukopenia was significantly associated with simultaneous liver-kidney transplantation and with second kidney transplantations (P < .01). The incidence of leukopenia was higher among patients under VGC since day 1 of transplantation (P = .008) with maximal incidence observed among patients prescribed 900 mg/d as opposed to those on lower doses (P < .01). There was no increase in CMV infection among patients with a low dose of VGC. No patient developed clinical CMV disease. In conclusion, VGC prophylaxis was associated with an increased frequency of leukopenia on MMF-tacrolimus treated patients or regimens. Low-dose VGC for CMV prophylaxis appeared to be as effective as high-dose treatment, and associated less frequently with leukopenia and neutropenia.

[Hematological malignancy: management of anemia and leukopenia by primary care physicians]

In hematological malignancies, the occurrence of anemia is very common and can have significant consequences on daily life. Treatment includes essentially red blood cell transfusions. The prescription of erythropoietic agents and/or iron is exceptionnal and often not registered in Switzerland. The onset of neutropenia is also frequently encountered and in some situations may require the prescription of myeloid growth factors. The purpose of this article is to focus on the current recommendations of these two issues for practitioners.

Systemic leukopenia, evaluation of laminar leukocyte infiltration and laminar lesions in horses with naturally occurring colic syndrome

The present study was aimed at identifying laminar lesions and leukocyte infiltration in hoof laminar tissue of horses with colic syndrome and its correlation with the total leukocyte count before death. Six healthy horses were used as control group (CG), and eighteen horses with lethal gastrointestinal disease were divided into two groups: leukopenic group (LG) with seven leukopenic horses, and non-leukopenic group (NLG) with 11 horses with total leukocyte count within reference range for the species. Leukocyte infiltration was examined by immunohistochemistry. Laminar lesions were observed in both LG and NLG, with no differences in severity between them. LG showed increase of the leukocyte infiltration in the hoof laminar tissue, when compared to CG and NLG. Horses with severe colic syndrome (LG and NLG) developed intense laminar lesions without clinical signs of laminitis, with increased leukocyte infiltration. However, the LG demonstrated an even higher increase of leukocyte infiltration compared to both CG and NLG.

Study of lymphocyte subpopulations in bone marrow in a model of protein-energy malnutrition

Objective: Protein-energy malnutrition (PEM) is an important public health problem affecting millions of people worldwide. Hematopoietic tissue requires a high nutrient supply, and a reduction in leukocytes, especially lymphocytes, suggests that some nutritional deficiencies might be altering bone marrow function and decreasing its ability to produce lymphocytes. In this study, we evaluated the effect that PEM has on lymphocyte subtypes and the cell cycle of CD5(+) cells. Methods: Swiss mice were subjected to PEM using a low-protein diet containing 4% protein. When the experimental group had lost about 20% of their original body weight, we collected blood and bone marrow cells and evaluated the hemogram, the myelogram, bone marrow lymphoid markers using flow cytometry, and the cell cycle in CD5(+) bone marrow. Results: Malnourished animals presented anemia, reticulocytopenia, and leukopenia with lymphopenia. The bone marrow was hypocellular, and flow cytometric analyses of bone marrow cells showed cells that were CD45(+) (91.2%), CD2(+) (84.9%), CD5(+) (37.3%), CD3(+) (23.5%), CD19(+) (43.3%), CD22(+) (34.7%), CD19(+)/CD2(+) (51.2%), CD19(+)/CD3(+)(24.0%), CD19(+)/CD5(+) (13.2%), CD22(+)/CD2(+) (40.1%), CD22(+)/CD3(+) (30.3%), and CD22(+)/CD5(+) (1.1%) in malnourished animals and CD45(+) (97.5%), CD2(+) (42.9%), CD5(+) (91.5%), CD3(+) (92.0%), CD19(+) (52.0%), CD22(+) (75.6%), CD19(+)/CD2(+) (62.0%), CD19(+)/CD3(+) (55.4%), CD19(+)/CO5(+) (6.7%), CD22(+)/CD2(+) (70.3%), CD22(+)/CD3(+) (55.9%), and CD22(+)/ CD5(+) (8.4%) in control animals. Malnourished animals also presented more CD5(+) cells in the G0 phase of cell cycle development. Conclusion: Malnourished animals presented bone marrow hypoplasia, maturation interruption, prominent lymphopenia with depletion in the lymphoid lineage, and changes in cellular development. We suggest that these changes are some of the primary causes of lymphopenia in cases of PEM and partly explain the increase in susceptibility to infections found in malnourished individuals. Published by Elsevier Inc.

Malnourished mice display an impaired hematologic response to granulocyte colony-stimulating factor administration

The aim of this Study was to determine if protein-energy malnutrition Could affect the hematologic response to granulocyte colony-stimulating factor (G-CSF). Swiss mice were fled a low-protein diet containing 4% protein, whereas control mice were fed a 20% protein-containing diet. After the malnourished group lost 20% of their original body weight, the mice were subdivided in 2 treatment groups, and hematopoietic parameters were studied. Mice were injected with either 8 mu g/kg per day of G-CSF or saline twice daily for 4 days. Malnourished mice developed anemia with reticulopenia and leukopenia with depletion of granulocytes and lymphocytes. Both malnourished and control mice treated with G-CSF showed a significant increase in neutrophils; however, in the control group, this increase was more pronounced compared to the malnourished group (4.5-fold and 3.4-fold, respectively). Granulocyte colony-stimulating factor administration increased bone marrow blastic (P < .001) and granulocytic (P < .01) compartments in the controls bill had no significant effect oil these hematopoietic compartments in the Malnourished animals (P = .08 and P = .62, respectively). We report that malnourished mice display an impaired response to G-CSF, which contributes to the decreased production of leukocytes in protein-energy malnutrition. (C) 2008 Elsevier Inc. All rights reserved.

Autoimmune hemolytic anemia in systemic lupus erythematosus: association with thrombocytopenia

Hematological disturbances are common in systemic lupus erythematous (SLE). Specifically, autoimmune hemolytic anemia (AHA) may manifest in SLE patients at the time of diagnosis or within the first year of the disease. AHA is often associated with thrombocytopenia, lupus nephritis, and central nervous system activity. In this study we investigated these associations in Brazilian patients with SLE. Forty-four consecutive SLE patients who had a history of AHA were age, gender, and disease duration matched with 318 SLE patients without AHA who formed the control group. All patients fulfilled the revised American College of Rheumatology criteria for SLE and were followed-up within our Service. Clinical and laboratorial manifestations were similar in both groups, except for the predominance of leukopenia, thrombocytopenia, and anti-dsDNA on univariate analysis in the AHA group. The multivariate logistic regression model revealed risk only for thrombocytopenia in the AHA group compared to the control group (odds ratio, 2.70; 95% confidence interval, 1.32-5.50). Our results corroborate previous data that AHA in SLE increases the risk of thrombocytopenia in individuals with SLE. This association suggests a common mechanism in AHA and SLE pathophysiologies.

Detection of Bartonella spp. in neotropical felids and evaluation of risk factors and hematological abnormalities associated with infection

Although antibodies to Bartonella henselae have been described in all neotropical felid species, DNA has been detected in only one species, Leopard us wiedii. The aim of this study was to determine whether DNA of Bartonella spp. could be detected in blood of other captive neotropical felids and evaluate risk factors and hematological findings associated with infection. Blood samples were collected from 57 small felids, including 1 Leopard us geoffroyi, 17 L wiedii, 22 Leopardus tigrinus, 14 Leopardus pardalis, and 3 Puma yagouaroundi; 10 blood samples from Panthera onca were retrieved from blood banks. Complete blood counts were performed on blood samples from small felids, while all samples were evaluated by PCR. DNA extraction was confirmed by amplification of the cat GAPDH gene. Bartonella spp. were assessed by amplifying a fragment of their 16S-23S rRNA intergenic spacer region; PCR products were purified and sequenced. For the small neotropical felids, risk factors [origin (wild-caught or zoo-born), gender, felid species, and flea exposure) were evaluated using exact multiple logistic regression. Hematological findings (anemia, polycythemia/hyperproteinemia, leukocytosis and leukopenia) were tested for association with infection using Fisher`s exact test. The 635 bp product amplified from 10 samples (10/67 = 14.92%) was identified as B. henselae by sequencing. Small neotropical felid males were more likely to be positive than females (95% CI = 0.00-0.451, p = 0.0028), however other analyzed variables were not considered risk factors (p > 0.05). Hematological abnormalities were not associated with infection (p > 0.05). This is the first report documenting B. henselae detection by PCR in several species of neotropical felids. (C) 2009 Elsevier B.V. All rights reserved.

Lymphocyte subpopulations and neutrophil function in chronic human Chagas' disease

The absolute numbers of total leukocytes, lymphocytes, T cells, helper/inducer, suppressor/cytotoxic and B cells were decreased in the peripheral blood of patients with chronic Chagas' disease. Since antilymphocyte antibodies were present only in a minority of patients they probably cannot account for the abnormalities in lymphocyte subsets. Patient neutrophils stimulated with endotoxin-treated autologous plasma showed depressed chemotactic activity and this seems to be an intrinsic cellular defect rather than plasma inhibition. Random migration of neutrophils was normal. Reduction of nitroblue tetrazolium by endotoxin- stimulated neutrophils was also decreased. These findings further document the presence of immunosuppression in human Chagas' disease. They may be relevant to autoimmunity, defense against microorganisms and against tumor cells at least in a subset of patients with more severe abnormalities.

Aerosolised pentamidine for Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

The goal of this study was to evaluate inhaled pentamidine for the treatment of patients with mild and moderate Pneumocystis carinii pneumonitis. Eight adults with AIDS and pneumocystis pneumonia (4 with a first episode and 4 with a repeat pneumocystosis) received daily inhalations of aerosol pentamidine isethionate for 21 days. Six patients were treated with doses of 300 mg of pentamidine and the remaining 2 received 600 mg every day. In the 300 mg treatment group, 2 individuals showed discrete and transient neutropenia. However, both subjects that received 600 mg of aerosol pentamidine daily developed leukopenia. One of them had major toxicity (overall severe intolerance of 12.5%) that required drug discontinuation and did not allow any analysis of the treatment efficacy. Of the 7 evaluable patients, 6 (88%) completed the treatment successfuly. One subject of the 300 mg regimen experienced an early recurrence. In conclusion, inhaled pentamidine is an effective treatment for mild and moderate cases of P. carinii pneumonia. It is less toxic than standard anti-pneumocystis therapy and is suitable for outpatient use.

Seroprevalência da Brucelose nos últimos cinco anos na Unidade Local de Saúde do Alto-Minho

A brucelose é uma zoonose com elevada importância, causada por bactérias gram-negativas que são altamente patogénicas para uma grande variedade de animais e humanos. Existem zonas endémicas onde esta se prolifera com mais facilidade. Neste estudo os dados são relativos ao distrito de Viana do Castelo, os dados são recolhidas da base de dados da Unidade Local de Saúde do Alto-Minho, uma zona não considerada endémica. Os animais infetados são a principal fonte de contaminação e dispersão da brucelose, é necessário uma reduzida carga bacteriana para ocorrer a infeção. Trata-se de uma doença que está longe de ser erradicada, impondo-se tomar medidas preventivas em relação à contaminação. Os testes usados na sua deteção podem ser alterados e melhorados de acordo com o estádio da doença. Na ULSAM são usados o teste de Wright e eventualmente a pesquisa microbiológica da bactéria Brucella. É pertinente saber o número de testes positivos que ocorrem por ano, se existe alguma sazonalidade relacionada com a doença, assim como, relacionar os parâmetros bioquímicos com um teste de Wright positivo. Os dados foram recolhidos entre o ano 2009-2013 com um número total de testes de 1035, dos quais o número total de positivos para o teste são 102, mas apenas trinta são positivos com significância. Os dados foram recolhidos através do programa Clinidata utilizado como base de armazenamento de dados da ULSAM e foram tratados estatisticamente com o programa SPSS juntamente com o Excel. Este estudo permitiu concluir que o número de casos em 2009 e 2010 era superior aos restantes anos, o que descreve uma tendência para diminuição do número de casos de brucelose atualmente no distrito de Viana do Castelo. Em relação a sazonalidade, os meses que apresentam uma percentagem superior a 50% em relação seroprevalência são os meses de Junho, Novembro e Dezembro. Os resultados revelam como declarado pela Organização Mundial de Saúde que o Distrito de Viana do Castelo não é uma zona endémica. Através da análise estatística foi possível concluir que um dos parâmetros bioquímicos, neste caso o número de leucócitos, poderá estar diretamente relacionado com um teste de Wright positivo, uma vez que, 37% da amostra de testes positivos revelam leucopenia.

Involvement of the central nervous system in dengue fever: three serologically confirmed cases from Fortaleza, Ceará, Brazil

Three cases of dengue fever involving the central nervous system (CNS) are reported. All occurred in 1994 during a dengue (DEN) epidemic caused by serotypes DEN-1 and DEN-2. The first case examined was a 17-year-old girl who complained of fever, nuchal rigidity and genital bleeding. Three blood samples were positive by anti-dengue IgM ELISA and showed hemagglutination-inhibition (HI) test titers ³ 1,280. The second case concerned a 86-year-old woman with fever, muscle and joint pains, altered consciousness, syncope, nuchal rigidity and meningismus. Her blood sample showed an HI titer of 1:320 for flaviviruses, and an IgM ELISA positive for dengue. The third case was a 67-year-old woman with fever, abnormal behaviour, seizures, tremor of extremities, thrombocytopenia, increased hematocrit and leukopenia. The patient suffered a typical case of dengue hemorrhagic fever with ensuing shock and a fatal outcome. A single blood sample showed HI antibodies of ³ 1,280 and an IgM ELISA positive for dengue. No virus could be isolated from any patient by inoculation of blood into C6/36 cells and suckling mice. No other agent of disease was encountered in the patient.

Scedosporium apiospermum SINUSITIS AFTER BONE MARROW TRANSPLANTATION: REPORT OF A CASE

A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. ltraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.

Five Cases of Atypical Rickettsial Infections

Background: Rickettsia conorii is the most frequent species of RickettsiaI causing disease in Portugal. In general the disease manifests itself by fever, exanthema, headaches and the presence of an eschar. However atypical forms can be present and physicians should be aware. Aims: Analyse the atypical presentation of rickettsiosis. Material and Methods: Children admitted at the CHLC Hospital from 2000 to 2010 with atypical presentation of rickettsiosis. Clinical diagnosis was confirmed by serology and molecular techniques (PCR). Results: Five cases of children with a median age of 2 years, 1 of which female, were admitted between June and August. The diagnoses were: myositis (1), synovitis (1), cholecystitis (1), orchiepididymitis (1) and meningitis (1). Myositis developped with functional disability, CPK 9600 U/L, lower limbs’ edema, hypoalbuminemia (1,6 g/dL) and arterial hypertension. Synovitis developped with functional disability, synovial fluid increase and CRP 16,2 mg/dL. The child with cholecystitis had abdominal pain, intraabdominal fluid increase, leukopenia (1900/μL), thrombocytopenia (75000/μL) and CRP 15,3 mg/dL. Orchiepididymitis developped with testicle’s inflammatory signs, leukopenia (2900/μL), thrombocytopenia (90000/μL) and CRP 14,45 mg/dL. The patient with meningitis, who had pleocytosis (320 cells/μL), hyperproteinorrachia (284 mg/dL), hypoglicorrachia (36 mg/dL), presented only with fever and headaches. The tache noire and the classical triad were present in 3/5 cases. The clinical course was favourable in all cases. Antibodies against Rickettsia of spotted fever group were detected in 3/5 cases. In one patient Rickettsia conorii Malish strain was identified by PCR and sequencing. Conclusions: Rickettsial infection may present itself unusually. In a country of high prevalence, especially during summer months and in the presence of an inoculation eschar, it is of the uttermost importance to study the atypical presentations for a possible rickettsial infection.

Hematological changes in mice experimentally infected with Trypanosoma Cruzi

Mice inoculated with trypanosoma cruzi display an intense thrombocytopenia which is more severe in animals infected with the Y than CL strain. In animals inoculated with a T. cruzi strain which induces chronic infection (Colombiana), the number of platelets decreases as parasitemia ascends, and then reverts to normal values as soon as the acute infection merges into the chronic phase. The mechanisms involved in the thrombocytopenia are still obscure and are likely to be related to more general phenomena affecting the host rather than to direct damage of platelets or precursor cells by parasitism. Anemia and leukopenia are also present in T. cruzi infected mice.

Short-course thymoglobulin induction and steroid-free immunosuppressive regimen in renal transplantation

Purpose: Optimal induction and maintenance immunosuppressive therapies in renal transplantation are still a matter of debate.Chronic corticosteroid usage is a major cause of morbidity but steroid-free immunosuppression (SF) can result in unacceptably high rates of acute rejection and even graft loss. Methods and materials: We have conducted a prospective openlabelled clinical trial in the Geneva-Lausanne Transplant Network from March 2005 to May 2008. 20 low immunological risk (<20% PRA, no DSA) adult recipients of a primary kidney allograft received a 4-day course of thymoglobulin (1.5 mg/kg/d) with methylprednisolone and maintenance based immunosuppression of tacrolimus and entericcoated mycophenolic acid (MPA). The control arm consisted of 16 matched recipients treated with basiliximab induction, tacrolimus, mycophenolate mofetil and corticosteroids. Primary endpoints were the percentage of recipients not taking steroids and the percentage of rejection-free recipients at 12 months.Secondary end points were allograft survival at 12 months and significant thymoglobulin and/or other drugs side effects. Results: In the SF group, 85% of the kidney recipients remained steroid-free at 12 months. The 3 cases of steroids introduction were due to one acute tubulo-interstitial rejection occurring at day 11, one tacrolimus withdrawal due to thrombotic microangiopathy and one MPA withdrawal because of multiple sinusitis and CMV reactivations. No BK viremia was detected nor CMV disease. The 6 CMV negative patients who received a positive CMV allograft had a symptomatic primoinfection after their 6-month course valgancyclovir prophylaxis. In the steroid-based group, 3 acute rejection episodes (acute humoral rejection, acute tubulointerstitial Banff IA and vascular Banff IIA) occurred in 2 recipients, 3 BK virus nephropathies were diagnosed between 45 and 135 days post transplant No side effects were associated with thymoglobulin infusion.In the SF group, 4 recipients presented severe leukopenia or agranulocytosis and one recipient had febrile hepatitis leading to transient MPA withdrawal. Discontinuation of MPA was needed in 2 patients for recurrent sinusitis and CMV reactivations. Patient and graft survival was 100% in both groups at 12 month follow-up. Conclusion: Steroid-free with short-course thymoglobulin induction therapy was a safe protocol in low-risk renal transplant recipients. Lower rates of acute rejection and BK virus infections episodes were seen compared to the steroid-based control group. A longer follow-up will be needed to determine whether this SF immunosuppressive regimen will result in higher graft and patient survival.