Summary. Bartonella henselae is a hitherto unidentified cause of autoimmune haemolytic anaemia. Here we report a case of Coombs-negative autoimmune haemolytic anaemia. The episode was preceded by exposure to a cat and a non-specific infectious syndrome. Concomitant serum titres of B. henselae antibodies were indicative of a recent infection. The case report suggests that B. henselae infection can trigger secondary autoimmune haemolytic anaemia.Keywords: autoimmune haemolytic anaemia, Bartonella henselae.A 60-year-old-man with a history of smoking, recurring gastric ulcers and arteriosclerotic disease, was referred from another hospital because of severe Coombs-negative haemolytic anaemia. He experienced pleuritic right-sided chest pain for 2 weeks, and night sweats for several weeks. A computerized tomography (CT) scan performed at the referring hospital had revealed a limited pleural effusion at the base of the right lung. In the referring hospital he had been administered amoxicillin/clavulanic acid and doxycyclin for 5 d, but otherwise no new drugs had been added to his prescriptions in the preceding weeks.On arrival the patient was pale and tachypneic, with an otherwise unremarkable physical examination. A blood smear revealed spherocytosis and polychromatophilia, but no schistocytes. Absolute and relative reticulocyte count were strongly elevated, with undetectable serum haptoglobin, unconjugated hyperbilirubinaemia, increased serum lactate dehydrogenase (LDH) ( Table I) and free plasma haemoglobin [390 mg/l on d 3 (normal value 0±100 mg/ l)]. Direct and indirect antiglobulin tests were negative, as were cold agglutinins and Donath±Landsteiner antibodies. Examination of a bone marrow aspirate showed a hyperplastic erythropoiesis, without erythrocyte inclusions or haemophagocytosis.Based on a negative medical and negative family history and on exclusion of other known mechanisms that can produce infection-related anaemia or haemolysis, a diagnosis of Coombs-negative autoimmune haemolytic anaemia was made. Antibiotics were discontinued upon admission (d 1), and methylprednisolone was given at 1 g/d for 3d, followed by oral methylprednisolone in tapering doses. Two units of erythrocyte concentrates were given on d 5. In the following weeks control of haemolytic anaemia was rapidly achieved (Table I).Because of recent exposure to a cat at his daughter's home, serology for B. henselae was requested. On d 8 an IgM titre of 1/64 and an Ig G titre of . 1/512 were found. Follow-up on d 68 gave a negative IgM titre and an IgG titre of . 1/512. Serological tests were otherwise negative for Chlamydia, Mycoplasma pneumoniae, cytomegalovirus, Epstein-Barr virus, parvo virus B19, human immunodeficiency virus (HIV), and hepatitis B and C virus. A CT scan during hospital admission failed to show enlarged lymph nodes or hepatosplenomegaly. DISCUSSIONGiven the patient's recent exposure to a cat, the high antibody titres (both IgG and IgM) specific for B. henselae at the time of the haemolytic episode with negative IgM titres ...
Extranodal natural killer/T-cell lymphoma, nasal type, should be suspected in a painless periorbital cellulitis with chronic sinusitis, not responding to conventional therapy. A high index of suspicion is necessary in biopsies showing angiodestruction and necrosis. Epstein-Barr virus encoded RNA in situ hybridization and expert hematopathologist consultation is necessary to decrease the delay in diagnosis.
Fludarabine is an antineoplastic agent used in the treatment of hematological malignancies, particularly chronic lymphocytic leukemia (CLL) and indolent B-cell lymphoma. Because of its immunosuppressive effects, fludarabine has been added to reduced intensity conditioning regimens. The oral formulation of fludarabine has become widely available. Pharmacokinetic studies have shown that an oral dose of 40 mg/m2/d would provide systemic drug exposure similar to the standard intravenous (IV) dose of 25 mg/m2/d. The oral dose can be taken once daily without any dietary restrictions. Dose adjustments are mandatory in patients with renal impairment to avoid increased toxicity. Several noncomparative trials in previously untreated and treated patients with CLL have shown that treatment with the oral formulation demonstrates similar efficacy compared to historical control groups treated with the IV formulation. The tolerability profile of oral fludarabine seems similar to that of the IV formulation. Myelosuppression and infectious complications are the most frequently reported adverse events. Gastrointestinal toxicity is more frequent with the oral formulation, but is usually of mild or moderate severity. Although oral fludarabine makes treatment more convenient, health care workers must be aware of the compliance behavior of each patient.
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