Background: Haematological malignancy is an important cause of pleural effusion. Pleural effusions secondary to haematological malignancy are usually lymphocyte predominant. However, several other conditions such as carcinoma, tuberculosis, and chronic heart failure also cause lymphocytic effusions. Lymphocyte subset (LS) analysis may be a useful test to identify haematological malignancy in patients with lymphocytic effusions. However, research into their utility in pleural effusion diagnostic algorithms has not yet been published. Objectives: We aimed to determine the clinical utility of pleural fluid LS analysis and whether it can be applied to a diagnostic algorithm to identify effusions secondary to haematological malignancy. The secondary aim was to evaluate the diagnostic value of pleural fluid differential cell count. Methods: Consecutive consenting patients presenting to our pleural service between 2008 and 2013 underwent thoracentesis and differential cell count analysis. We proposed an algorithm which selected patients with lymphocytic effusions (>50%) to have further fluid sent for LS analysis. Two independent consultants agreed on the cause of the original effusion after a 12-month follow-up period. Results: A total of 60 patients had samples sent for LS analysis. LS analysis had an 80% sensitivity (8/10) and a 100% specificity for the diagnosis of haematological malignancy. The positive and negative predictive values were 100 and 96.1%, respectively. Overall 344 differential cell counts were analysed; 16% of pleural effusions with a malignant aetiology were neutrophilic or eosinophilic at presentation. A higher neutrophil and eosinophil count was associated with benign diagnoses, whereas a higher lymphocyte count was associated with malignant diagnoses. Conclusions: LS analysis may identify haematological malignancy in a specific cohort of patients with undiagnosed pleural effusions. A pleural fluid differential cell count provides useful additional information to streamline patient pathway decisions.

No abstract

The results of unrelated donor bone marrow transplantation are continually improving. These improved results are due to a better understanding of the complications of the procedure and the devising of strategies to avoid them. Nonetheless, many problems remain. This review will address some of the major controversies of the field including the indications for UD-BMT, infection, GVHD prophylaxis and treatment and whether UD-BMT should only be performed in specialist centres. Conclusions will be supported by evidence from the limited published literature and the authors' experience in 3 major transplant centres.

No abstract

A 66-year-old man presented with fevers, myalgia, weight loss and an urticarial rash. A full blood count showed haemoglobin concentration 70 g/l and white cell count 1Á7 9 10 9 /l with rouleaux and lymphoplasmacytoid lymphocytes seen in the blood film. He was positive for anti-neutrophil cytoplasmic antibodies (cANCA) and anti-proteinase 3 (weakly). Parvovirus immunoglobulin (Ig) M and IgG antibodies were detected, but polymerase chain reaction (PCR) for parvovirus DNA was negative. A computed tomography (CT) scan demonstrated widespread lymphadenopathy and hepatosplenomegaly (top left). A lymph node biopsy showed proliferation of capillaries with an infiltrate of small to medium sized atypical lymphocytes admixed with eosinophils, plasma cells and large blasts (bottom left). These lymphocytes were CD2 + CD3 + CD5 + with the blasts being CD10 + on immunohistochemistry, confirming a diagnosis of angioimmunoblastic T-cell lymphoma (AITL). Prior to starting treatment, the symptoms improved spontaneously with normalisation of his full blood count. Repeat CT imaging 5 months after the initial presentation confirmed complete remission (top centre).He remained well for 52 months before re-presenting with a similar symptom complex, including rash, sweats and weight loss, with widespread lymphadenopathy and splenomegaly on CT imaging (top right). Serological tests for human immunodeficiency virus (HIV) and human T-cell lymphotropic virus 1 (HTLV1) were positive, but an HIV line immunoassay and HTLV1 PCR confirmed neither infection was present. A lymph node biopsy showed increased blood vessels with a polymorphous lymphoid infiltrate, including some blasts, and numerous eosinophils (bottom right). The blasts co-expressed CD10 and PD-1 (also termed PDCD1) on immunohistochemistry, consistent with relapsed AITL. The patient was subsequently commenced on combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) achieving a very good partial response after four cycles.AITL is frequently associated with abnormal immune phenomena, such as inflammatory rashes and false positive serology results. Spontaneous remissions are rare and usually short-lived, with a median of 9 months (Pangalis et al, 1983) but, as shown in our patient, can be more sustained.