Fig. 1. Axial MRI showing many lesions in both hemispheres. High-Disseminated Aspergillosis After Mobilization With intensity signal on T2, with a moderate surrounding edema and Intensive Chemotherapy Prior to Autologous Stem-Cell effect of mass.
Transplant in Chronic Myeloid Leukemia
To the Editor: Autologous transplantation with stem cells mobilized after intensive chemotherapy may achieve Ph-negative hemopoiesis in patients with chronic myeloid leukemia (CML), and this may prolong survival [1]. However, this procedure is not without risks. We report on a case of and seizures. Cerebrospinal fluid study was negative. MRI showed many lesions in both cerebral hemispheres (Fig. ). On day 50, a maculopapular disseminated Aspergillus flavus infection during the protracted period of neutropenia following mobilization. rash with a few subcutaneous nodules was noted. Skin biopsy revealed a septal panniculitis, and its culture grew Aspergillus flavus. In spite of adding A 34-year-old male was diagnosed in December 1991 with Ph-positive chronic-phase CML. The patient received hydroxiurea throughout his dis-flucitosine, the neurological condition of the patient deteriorated and he died on day 66. Postmortem examination was not allowed. ease, except for a 7-month trial with interferon without any response. After an unsuccessful search for an HLA-identical donor, the patient was proposed ASCT is an alternative therapy for patients with CML who lack an HLAidentical donor . PSC collected during early recovery from intensive for ASCT 40 months from his diagnosis.
With the aim of mobilizing Ph-negative peripheral stem cells (PSC), the chemotherapy may be Ph-and even PCR-negative. Using this material, Carella et al. [1, have shown that some patients might achieve a sustained patient received cytarabine, 300 mg/m 2 /days 1-5, mitoxantrone 12 mg/m 2 / days 1-3, and etoposide 150 mg/m 2 /days 1-3. G-CSF (8.8 g/kg/day) Ph-negative hemopoiesis after ASCT. However, this potential benefit must be carefully weighed against the risk of treatment-associated mortality. The was given from absolute neutrophil count (ANC) ฯฝ1.5 ฯซ 10 9 /l, and the leukaphereses were planned when the absolute white blood cell count Italian Group [1] observed an 8% mortality after transplant in patients who failed to engraft, but there are no clear data about mobilizations's related exceeded 1 ฯซ 10 9 /l. Ciprofloxacin and fluconazole were used as prophilaxis against infection. The time of ANC ฯฝ0.5 ฯซ 10 9 /l lasted 30 days (days mortality. With a similar approach, Kantarjian et al. [4] reported a 7% mortality for mobilization chemotherapy. 8-38), and the nadir was 0 during 16 days.
On day 21, the patient developed fever and dry cough. Physical examina-Our patient had a 30-day period of profound neutropenia, during which he developed a fatal disseminated aspergillosis by A. flavus. This filamentous tion showed erythema in the catheter exit site, and left lung sibilants. CXR was normal. Streptococcus mitis grew from blood cultures. He was started fungus is ubiquitous, and caution is necessary in the evaluation of its isolation. However, its identification in skin culture (based on morphological on imipenem and vancomycin, and subsequent blood cultures were negative but symptoms persisted. On day 26, bronchoalveolar lavage (BAL) dis-criteria: conidiophores of biseriate) along with clinical evolution is highly suggestive of this diagnosis. [5]. closed fungal elements in the gram-stain. Although cultures were negative, amphotericin B (1 mg/kg/day) was added. In the following days, despite
In conclusion, our case illustrates a risk of life-threatening fungal infection associated with these innovative therapies. This emphasizes the need granulocyte recovery, he developed an interstitial pneumonitis that precluded the leukoapheresis procedure. A new BAL and transbronchial biopsy for launching randomized trials in order to show survival advantages in comparison with more conventional therapeutic approaches. were uninformative. On day 47, the patient presented with right hemiparesis แฎ 1997 Wiley-Liss, Inc. F. FERRER levels of aldosterone and plasma renin activity in 2 patients with Castleman's disease. Patients' clinical characteristics and laboratory data are summarized J.M. MORALEDA M.C. TOLDOS in Table I. Both patients had high levels of C-reactive protein (CRP), hyper-โฅ-globulinemia, and extremely elevated serum IL-6. However, their serum I. HERAS V. VICENTE potassium remained in normal range over 2 years after diagnosis. Moreover, Microbiology Service and Bone Marrow Transplant Unit, patient 1 had a normal serum aldosterone concentration and normal plasma Department of Hematology, School of Medicine, Hospital renin activity. Patient 2 had a slightly reduced serum aldosterone concentra-General Universitatio, Murcia, Spain tion and elevated plasma renin activity. Their normal serum cortisol levels suggest that they are free from adrenal insufficiency. There was no elevation REFERENCES of plasma adrenocorticotropin (ACTH) in either patient. Thus it was thought that the mild hypoaldosteronism in patient 2 was not induced by the elevated 1. Carella AM, Chimirri F, Podesta `M, et al.: High-dose chemo-radiotherapy followed ACTH level [4]. Although it is still possible that she has true hyperreninemic by autologous Philadelphia chromosome-negative blood progenitor cell transhypoaldosteronism without hyperkalemia, these findings imply that high plantation in patients with chronic myelogenous leukemia. Bone Marrow Transplant levels of serum IL-6 alone do not cause hyperkalemia and hypoaldosteron-17:(2)201-205, 1996. 2. O'Brien SG, Goldman JM: Autografting in chronic myeloid leukemia. Blood Rev ism in patients with Castleman's disease. Serum IL-6 levels of these 2 8:63-69, 1994. patients are considerably higher than those of 3 patients described by Chung 3. Carella AM, Podesta M, Frassoni F, et al.: Collection of "normal" blood repopulatet al. [1]. Hence it seems that hypoaldosteronism in their patients was ing cells during early hemopoietic recovery after intensive conventional chemothercaused by other factors than elevated plasma IL-6, e.g., metastasis to the apy in chronic myelogenous leukemia. Bone Marrow Transplant 12:267-271, 1993.
adrenal glands [5]. Moreover, the IL-6 concentrations that they used in in 4. Kantarjian HM, Talpaz M, Hester J, et al.: Collection of peripheral-blood diploid vitro experiments were extremely higher than the plasma levels of their cells from chronic myelogenous leukemia patients early in the recovery phase patients; therefore, it is not clear that IL-6 truly inhibits the secretion of from myelosuppression induced by intensive-dose chemotherapy. J Clin Oncol aldosterone by adrenal tissue in vivo.