318
Letters and Correspondence
TABLE 1. The Average PFL Which is Within Normal Limits in Negative Test Results Is Seen to Increase Together With the Degree of Positivity in Positive Test Results'
2. Balci K: "A Slide Teat To Reveal Sonic Diaeaac Sldtc\ Procccdings o l Third Al-Arliar lntsrnationnl Medical Coiitiercncc. Cairo. Egypt. 198Y. p I "
Plaviia fibrinogen IcvcIs, inp/dL
GranulocyteColony Stimulating Factor Corrects Granulocytopenia in Felty's Syndrome
side to side and observed by sloping gently at 30 second intervals. I n a positive result numerous small red particles appear in the mixture within 2 minulea. In a negative result no such particles could be seen by the naked eye. However even in negative results small precipitates could be observed in the inixture o n the slide both singly and in clusters under light microscope (10 X 40). But these clusters are not big enough to be observed by the naked eye. Test reactions have been evaluated as follows: ( - ) no particles could be seen by the naked eye. ( + ) particles forming late and appearing only in the upper portion of the mixture, ( + + ) striking and difrused particles. or (t t )very striking and diffused particles forming within the first 30 seconds. Fisher's F test was used to determine the significance of the difference between PFL values in various test groups. The results o t the test carried out using EDTA-anticoagulated blood are given in Table I . As seen in the table in the ( - ) test result PFL was 3 1 7 k 14.2 nig/dL. and in the ( + ) , (+t),and ( + + + ) test results PFL were, respectively, 538.2 2 12.8. 784 i- 6.9, and 1 . 1 14.3 t 12 mg/dL. For each subject, including those in good health. the test with plasma was always positive. the reaction being inore pronounced in cases in which EDTA-anticoagulated blood test was also positive. On the other hand tests with serum samples remained negative in all subjects. Regardless of the results o f the test with blood the fact that the lest with plasma always yielded positive results and the test with serum always yielded negative results led us to conclude that these particles consist of fibrinogen precipitates. The statistical significance ( P < .01) of the relations between test results and PFL also supports this conclusion. We hope that a possibility for obtaining inforination about PFL. even approximately. under all condition5 may be helpful to the physician. For exaniple, only the positive or negative result of a practical test may constitute the preliminary investigation of whether a person has one of the diseases that increases plasma level of fibrinogen which is an acute phase reactant ['I. Can this test make any contribution, however small. to the criteria established for differentiating AIDS from seroconversion in HIV infections'! This point also deserves investigation. In conclusion it will be helpful to research further the various aspect\ of this test.
+
To rlw Ecfiror:We report a case of successful use ol' reconibinant granulocyte colony-stimulating factor (rC-CSF) to treat a patient with Felty's syndrome (FSI complicated with a severe infection. An 82-year-old woman had been suffering Iron1 rheumatoid arthritis siiice 1980 and was treated with anti-intlammatory drugs by a general practitioner. In 19x9 severe neutropenia with a high fever developed. and she was referred to the Nippon Medical School hospital on November 22, 1989. Physical examination showed deformed distal joints in both hands and a palpable spleen to 2 cm below the left costal margin. The complete blood count revealed hemoglobin 10.5 gidl, platelet count IS0 x I0"iL. white blood cell count 0.5 X I0"iL with 10% neutrophils. Bone marrow aspiration revealed a normocellar marrow with 0% segmented neutrophils. Serological examination showed rheumatoid factor (RF) of 39 IUirnl (normal: 103). platelet-as\ociated IgG (PA IgG) [ 1 J of 1,682 ngilO' cell\ (normal: 9-25). positive antinuclear antibody. and direct Coombs' test. Testing for anti-neutrophil antibody (neutrophil-associated IgC) by flow cytometry 121 yielded a positive result. The patient wab diagnosed as having FS and received rG-CSF (Chugai Phar. Co.: Tokyo. Japan) subcutaneously at a dose of 2 pgikg daily for IS days (Fig. I ). Because the neutrophil count did not increase after the initial dose of rG-CSF. the dose was increased to 5 pgikgiday thereafter. A dramatic increase of the neutrophil count in the peripheral blood was observed on day 7 after increasing the dose of rGCSF. Bone marrow aspiration at that time showed normocellularity with 1 .h% segmented neutrophils. The neutrophil count increased rapidly to a
( x lo*/ L)
!OO 80
A2
20 2
+
I00
;
80 60
ACKNOWLEDGMENTS The authors gratefully acknowledge the technical assistance of the staff ofrhe hematology laboratory at the Medical Faculty of Selsuk University.
KEMAL BALCI
MECIT SUERDEM Department of Chest Diseases, faculty of Medicine, Selcuk University, Konya- Turkey
REFERENCES I . C h a r A: "Gcrinnunpaphy\ioloFischc Schncllmcthode Iur Bc\timmung drs Fihrinogcns." Act3 Haeinaiol (Basel) 237. 1957
1989
Nov.
Dec.
IBo
Jan.
Feb.
Mar
Fig. 1 . The clinical course of the patient. Recombinant granulocytecolony stimulating factor (rG-CSF) was subcutaneously injected at 2 pglkg daily for 14 days, subsequently at 5 pgikg daily for 20 days. Methylprednisolon (mPSL) was given daily at 1 g for 3 days, followed by maintenance therapy with prednisolon at 5 rng daily.
Letters and Correspondence
319
“snioldering” CLL ia possible 13.4). It should be stressed. however, that the attempts to define “smoldering” CLL are mainly based o n clinical features such as lymphocyte count, hemoglobin level. lymphocyte doubling time. and bone marrow histology 131. In this context the study by Oscieret al. [Sl is noteworthy in which biological parameters such as cells’ karyotype and immunological phenotype were found to affect disease progression signilicantly. 111 this study we show that myelomunocytic antigens are frequently expressed on B-CLL cells and the presence or absence of these markers correlates with diseaae activity of patients i n early clinical ctage. Forty-seven stage A CLL patients formed the basis ofthis study aimed at investigating the relationship between the expression of myelomonocytic antigens and disease activity. There were 36 men and I I women. The average age was 66 years (SD 8.9). Our patients were further sub-classified as having “smoldering” or live” disease. respectively. The following features defined “smoldering” CLL: stage A . non-diffuse bone marrow hiatology. hemoglobin level 2 13 g/dl. lyiiiphocyte count < 30 x IO”/L. lymphocyte doubling time > I ? months 131. On this basis 28 patients fulfilled criteria of ”smoldering” and I8 of “active” CLL. linmunophenotype studies were performed on peripheral blood cells. In TOSHIHARU ITO all cases lymphocytes exceeded 5 X IO’iL and more than 7 5 4 cells were YASURO MIVAIRI CD5 and CD19 positive. Studies of myelomonocytic antigens were perTETSUO KUWABARA formed in 3 I patients at presentation and s u b q u e n t l y in the remaining I h KAZUO DAN patients (while still in stage A). The following myelomonocytic monoTAKEO NOMURAclonal antibodies were used in indirect fluorescence: CDI Ib (OK-MI). Third Depadment of Internal Medicine, Nippon Medical School, CD13 (OK-Ml3). CD14 (OK-M14). CD33 (MY9). CD36 (OK-MS). FluTokyo, Japan orescence reading was performed by using a CYTORON cytofluorograph (Ortho Diagnostic System) flow cytometry. Tu determine whether lymREFERENCES phoid and myeloid antigens wet-e expressed on the same cells double-label I. Tubahio T. Kurata Y . Yimezawa T, Kitani 1’:Quantification of platclot-arwciated immunofluorescence WBE performed in several patients by using phycoeriIgG with coinpctitivc wlid-phue cnrynie immunoassay. Acta Hdeinalol (Bascl) trin (PE)-conjugated (OK-B7) (CD21) and FTIC-conjugated MY9 (CD33). 66:251, I981 OK-MI3 (CD13). OK-M14(CD14). respectively. 2 . Furuaawa S: Autoinimunc neuiropenia Acta Hacnratol Jpn 4X. 1753. 19x5. The frequencies of marker expression analyzed as a function of disease 3. H u m b e r g BPC. Van Lccuwen M A , Van Rijswijk MH. Stern AC. Vellenga E. activity are depicted in Table 1. As shown, higher CD13 and CD33 expresCnrrcclion of granulocyiopcnia in Fclty’\ ayndmmc hy Eranulocyte-macrophage sion was associated with ”active” disease. colony-stimulating factor Sirnultaneotir induction o l interleukin-6 release and Such an association raises important questions about the natural history tlare-up ofthe arthritis. Blood 74.2769, 1Y89. of CLL. I n this context our results might therefore suggest that clinical disease progression to an active phase is manifested by the expression oC mqclomonocytic antigens. Furthermore, such a feature might imply a close relationship between B-lymphoid and myelomonocytic lineages of differentiation. In addition, “in citro” studies seem to support the view that the expression of niyelomonocytic antigens might be a feature of B-cell activation [ 61. Myelomonocytic Associated Antigens in Early B-Chronic Although the number of patients included in this study is small 10 draw Lymphocytic Leukemia Correlate With firm conclusions. the inmunophenotypic analysis, including myelomonoDisease Activity cytic markers. becomes a useful tool to disclose subgroups of CLL patients To the Editor: The expression u l myelomonocytic antigens is a phcnome- in early phase of disease with different prognoses. non occurring with a definite frequency in B-chronic lyniphocytic leukemia (B-CLL). As far as its clinical implication is concerned, such a finding ha5 STEFANO MOLICA been associated with features influencing the behaviour of disease such as a Divisione di €matologia, Ospedale Regionale, “A. Pugliese”, diffuse hone marrow histology and a short lymphocyte doubling time [ I .?I. Cafanzaro, M y However, studies dealing with myelomonocytic antigens in early B-CLL are virtually absent. REFERENCES For the large majority of patients with early B-CLL (Binet’s stage A or Rai’s stage 0 or I ) no staging system is able to predict those who will I . Pinto A . Vcl Vecchio L. Cai-hone A . el iil Exprrsaion of tnycluiiionr,cyiic milremain at the same clinical stage. Recent studies suggest that a definition 0 1 gens i?. aawclated with unfavorable clinicopr In B-cell chronic peak level 0 1 14.5 x 10y/L on the 20th day. when rG-CSF had to be discontinued because of the appearance of exanthema on both legs. which was regarded as an allergic reaction to rC-CSF. After discontinuation of the G C S F therapy the neutrophil count returned to the pretreatment level within a week. and the exanthema disappeared. No noteworthy side effects other than the skin eruption were noted. Subsequently. two courses of bolus methyl-prednisolone (mPSL) therapy were given resulting in a gradual increase in the neutrophil count to a level of 2 X IO’iL. During the maintenance therapy with prednisolone. pneumonia developed and the patient died of respiratory failure. It has been reported that rGM-CSF could correct the neutropenia in FS. but side effecta such a h fever and flare-up of the arthritis were observed 131. On the other hand. to our knowledge, there have been no reports ofrG-CSF in treating patients with FS. The mechanism ofthe effects of rC-CSF in this case is unclear. but there is a posaibility that excess production of neutrophils by rC-CSF might outweigh the destruction of IgG-bound neutrophik in the peripheral blood. Further clinicid study is required to evaluate the long-term effects of rG-CSF and to determine its optimum dosages for initial and maintenance therapies.
’
TABLE 1. Myelomonocytic Associated Antigens in Stage A Chronic Lymphocytic Leukemia’ Diseaw \talus
__~
~
Smoldering C L L (mean 5 SD) Active CLL (mean z SD) t’.\,illuc
*NS
=
not >igiiificanl
CD13 _ _ _ _ _
C D I Ib
5.59 6X.3
?
2
NS
3S.6 3S.X
38.6 -t 3 S . I 61.2 27.5
Letters and Correspondence
TABLE 1. The Average PFL Which is Within Normal Limits in Negative Test Results Is Seen to Increase Together With the Degree of Positivity in Positive Test Results'
2. Balci K: "A Slide Teat To Reveal Sonic Diaeaac Sldtc\ Procccdings o l Third Al-Arliar lntsrnationnl Medical Coiitiercncc. Cairo. Egypt. 198Y. p I "
Plaviia fibrinogen IcvcIs, inp/dL
GranulocyteColony Stimulating Factor Corrects Granulocytopenia in Felty's Syndrome
side to side and observed by sloping gently at 30 second intervals. I n a positive result numerous small red particles appear in the mixture within 2 minulea. In a negative result no such particles could be seen by the naked eye. However even in negative results small precipitates could be observed in the inixture o n the slide both singly and in clusters under light microscope (10 X 40). But these clusters are not big enough to be observed by the naked eye. Test reactions have been evaluated as follows: ( - ) no particles could be seen by the naked eye. ( + ) particles forming late and appearing only in the upper portion of the mixture, ( + + ) striking and difrused particles. or (t t )very striking and diffused particles forming within the first 30 seconds. Fisher's F test was used to determine the significance of the difference between PFL values in various test groups. The results o t the test carried out using EDTA-anticoagulated blood are given in Table I . As seen in the table in the ( - ) test result PFL was 3 1 7 k 14.2 nig/dL. and in the ( + ) , (+t),and ( + + + ) test results PFL were, respectively, 538.2 2 12.8. 784 i- 6.9, and 1 . 1 14.3 t 12 mg/dL. For each subject, including those in good health. the test with plasma was always positive. the reaction being inore pronounced in cases in which EDTA-anticoagulated blood test was also positive. On the other hand tests with serum samples remained negative in all subjects. Regardless of the results o f the test with blood the fact that the lest with plasma always yielded positive results and the test with serum always yielded negative results led us to conclude that these particles consist of fibrinogen precipitates. The statistical significance ( P < .01) of the relations between test results and PFL also supports this conclusion. We hope that a possibility for obtaining inforination about PFL. even approximately. under all condition5 may be helpful to the physician. For exaniple, only the positive or negative result of a practical test may constitute the preliminary investigation of whether a person has one of the diseases that increases plasma level of fibrinogen which is an acute phase reactant ['I. Can this test make any contribution, however small. to the criteria established for differentiating AIDS from seroconversion in HIV infections'! This point also deserves investigation. In conclusion it will be helpful to research further the various aspect\ of this test.
+
To rlw Ecfiror:We report a case of successful use ol' reconibinant granulocyte colony-stimulating factor (rC-CSF) to treat a patient with Felty's syndrome (FSI complicated with a severe infection. An 82-year-old woman had been suffering Iron1 rheumatoid arthritis siiice 1980 and was treated with anti-intlammatory drugs by a general practitioner. In 19x9 severe neutropenia with a high fever developed. and she was referred to the Nippon Medical School hospital on November 22, 1989. Physical examination showed deformed distal joints in both hands and a palpable spleen to 2 cm below the left costal margin. The complete blood count revealed hemoglobin 10.5 gidl, platelet count IS0 x I0"iL. white blood cell count 0.5 X I0"iL with 10% neutrophils. Bone marrow aspiration revealed a normocellar marrow with 0% segmented neutrophils. Serological examination showed rheumatoid factor (RF) of 39 IUirnl (normal: 103). platelet-as\ociated IgG (PA IgG) [ 1 J of 1,682 ngilO' cell\ (normal: 9-25). positive antinuclear antibody. and direct Coombs' test. Testing for anti-neutrophil antibody (neutrophil-associated IgC) by flow cytometry 121 yielded a positive result. The patient wab diagnosed as having FS and received rG-CSF (Chugai Phar. Co.: Tokyo. Japan) subcutaneously at a dose of 2 pgikg daily for IS days (Fig. I ). Because the neutrophil count did not increase after the initial dose of rG-CSF. the dose was increased to 5 pgikgiday thereafter. A dramatic increase of the neutrophil count in the peripheral blood was observed on day 7 after increasing the dose of rGCSF. Bone marrow aspiration at that time showed normocellularity with 1 .h% segmented neutrophils. The neutrophil count increased rapidly to a
( x lo*/ L)
!OO 80
A2
20 2
+
I00
;
80 60
ACKNOWLEDGMENTS The authors gratefully acknowledge the technical assistance of the staff ofrhe hematology laboratory at the Medical Faculty of Selsuk University.
KEMAL BALCI
MECIT SUERDEM Department of Chest Diseases, faculty of Medicine, Selcuk University, Konya- Turkey
REFERENCES I . C h a r A: "Gcrinnunpaphy\ioloFischc Schncllmcthode Iur Bc\timmung drs Fihrinogcns." Act3 Haeinaiol (Basel) 237. 1957
1989
Nov.
Dec.
IBo
Jan.
Feb.
Mar
Fig. 1 . The clinical course of the patient. Recombinant granulocytecolony stimulating factor (rG-CSF) was subcutaneously injected at 2 pglkg daily for 14 days, subsequently at 5 pgikg daily for 20 days. Methylprednisolon (mPSL) was given daily at 1 g for 3 days, followed by maintenance therapy with prednisolon at 5 rng daily.
Letters and Correspondence
319
“snioldering” CLL ia possible 13.4). It should be stressed. however, that the attempts to define “smoldering” CLL are mainly based o n clinical features such as lymphocyte count, hemoglobin level. lymphocyte doubling time. and bone marrow histology 131. In this context the study by Oscieret al. [Sl is noteworthy in which biological parameters such as cells’ karyotype and immunological phenotype were found to affect disease progression signilicantly. 111 this study we show that myelomunocytic antigens are frequently expressed on B-CLL cells and the presence or absence of these markers correlates with diseaae activity of patients i n early clinical ctage. Forty-seven stage A CLL patients formed the basis ofthis study aimed at investigating the relationship between the expression of myelomonocytic antigens and disease activity. There were 36 men and I I women. The average age was 66 years (SD 8.9). Our patients were further sub-classified as having “smoldering” or live” disease. respectively. The following features defined “smoldering” CLL: stage A . non-diffuse bone marrow hiatology. hemoglobin level 2 13 g/dl. lyiiiphocyte count < 30 x IO”/L. lymphocyte doubling time > I ? months 131. On this basis 28 patients fulfilled criteria of ”smoldering” and I8 of “active” CLL. linmunophenotype studies were performed on peripheral blood cells. In TOSHIHARU ITO all cases lymphocytes exceeded 5 X IO’iL and more than 7 5 4 cells were YASURO MIVAIRI CD5 and CD19 positive. Studies of myelomonocytic antigens were perTETSUO KUWABARA formed in 3 I patients at presentation and s u b q u e n t l y in the remaining I h KAZUO DAN patients (while still in stage A). The following myelomonocytic monoTAKEO NOMURAclonal antibodies were used in indirect fluorescence: CDI Ib (OK-MI). Third Depadment of Internal Medicine, Nippon Medical School, CD13 (OK-Ml3). CD14 (OK-M14). CD33 (MY9). CD36 (OK-MS). FluTokyo, Japan orescence reading was performed by using a CYTORON cytofluorograph (Ortho Diagnostic System) flow cytometry. Tu determine whether lymREFERENCES phoid and myeloid antigens wet-e expressed on the same cells double-label I. Tubahio T. Kurata Y . Yimezawa T, Kitani 1’:Quantification of platclot-arwciated immunofluorescence WBE performed in several patients by using phycoeriIgG with coinpctitivc wlid-phue cnrynie immunoassay. Acta Hdeinalol (Bascl) trin (PE)-conjugated (OK-B7) (CD21) and FTIC-conjugated MY9 (CD33). 66:251, I981 OK-MI3 (CD13). OK-M14(CD14). respectively. 2 . Furuaawa S: Autoinimunc neuiropenia Acta Hacnratol Jpn 4X. 1753. 19x5. The frequencies of marker expression analyzed as a function of disease 3. H u m b e r g BPC. Van Lccuwen M A , Van Rijswijk MH. Stern AC. Vellenga E. activity are depicted in Table 1. As shown, higher CD13 and CD33 expresCnrrcclion of granulocyiopcnia in Fclty’\ ayndmmc hy Eranulocyte-macrophage sion was associated with ”active” disease. colony-stimulating factor Sirnultaneotir induction o l interleukin-6 release and Such an association raises important questions about the natural history tlare-up ofthe arthritis. Blood 74.2769, 1Y89. of CLL. I n this context our results might therefore suggest that clinical disease progression to an active phase is manifested by the expression oC mqclomonocytic antigens. Furthermore, such a feature might imply a close relationship between B-lymphoid and myelomonocytic lineages of differentiation. In addition, “in citro” studies seem to support the view that the expression of niyelomonocytic antigens might be a feature of B-cell activation [ 61. Myelomonocytic Associated Antigens in Early B-Chronic Although the number of patients included in this study is small 10 draw Lymphocytic Leukemia Correlate With firm conclusions. the inmunophenotypic analysis, including myelomonoDisease Activity cytic markers. becomes a useful tool to disclose subgroups of CLL patients To the Editor: The expression u l myelomonocytic antigens is a phcnome- in early phase of disease with different prognoses. non occurring with a definite frequency in B-chronic lyniphocytic leukemia (B-CLL). As far as its clinical implication is concerned, such a finding ha5 STEFANO MOLICA been associated with features influencing the behaviour of disease such as a Divisione di €matologia, Ospedale Regionale, “A. Pugliese”, diffuse hone marrow histology and a short lymphocyte doubling time [ I .?I. Cafanzaro, M y However, studies dealing with myelomonocytic antigens in early B-CLL are virtually absent. REFERENCES For the large majority of patients with early B-CLL (Binet’s stage A or Rai’s stage 0 or I ) no staging system is able to predict those who will I . Pinto A . Vcl Vecchio L. Cai-hone A . el iil Exprrsaion of tnycluiiionr,cyiic milremain at the same clinical stage. Recent studies suggest that a definition 0 1 gens i?. aawclated with unfavorable clinicopr In B-cell chronic peak level 0 1 14.5 x 10y/L on the 20th day. when rG-CSF had to be discontinued because of the appearance of exanthema on both legs. which was regarded as an allergic reaction to rC-CSF. After discontinuation of the G C S F therapy the neutrophil count returned to the pretreatment level within a week. and the exanthema disappeared. No noteworthy side effects other than the skin eruption were noted. Subsequently. two courses of bolus methyl-prednisolone (mPSL) therapy were given resulting in a gradual increase in the neutrophil count to a level of 2 X IO’iL. During the maintenance therapy with prednisolone. pneumonia developed and the patient died of respiratory failure. It has been reported that rGM-CSF could correct the neutropenia in FS. but side effecta such a h fever and flare-up of the arthritis were observed 131. On the other hand. to our knowledge, there have been no reports ofrG-CSF in treating patients with FS. The mechanism ofthe effects of rC-CSF in this case is unclear. but there is a posaibility that excess production of neutrophils by rC-CSF might outweigh the destruction of IgG-bound neutrophik in the peripheral blood. Further clinicid study is required to evaluate the long-term effects of rG-CSF and to determine its optimum dosages for initial and maintenance therapies.
’
TABLE 1. Myelomonocytic Associated Antigens in Stage A Chronic Lymphocytic Leukemia’ Diseaw \talus
__~
~
Smoldering C L L (mean 5 SD) Active CLL (mean z SD) t’.\,illuc
*NS
=
not >igiiificanl
CD13 _ _ _ _ _
C D I Ib
5.59 6X.3
?
2
NS
3S.6 3S.X
38.6 -t 3 S . I 61.2 27.5
