Hematological Syndrome Research Articles

P77 – 2515: Case of generalized osteopetrosis (marble disease) associated with neurological impairment

Objective Marble bone disease is an inherited condition, characterized by diffuse hardening of bones, their brittleness due to malfunction of osteoclasts. Secondary to bone expansion bone marrow narrows, extramedullar hemopoesis develops, nerves injury might happen. Mutations in 9 genes had been described. CLCN7 mutation leads to 75% cases of autosomal dominant osteopetrosis with benign course, 10 to 15% cases are autosomal recessive with malignant course. Methods A child was born uneventfully from healthy, non-consanguineous parents. First signs of illness appeared at 10 weeks when parents noted tense fontanelle, child became very irritated, horizontal nystagmus appeared, development had stopped. At 6 months the child neither fixed nor followed, but reacted positively to the mother's voice, smiled, had horizontal nystagmus, tetraparesis, diffuse hypotonia, high tendon reflexes, head circumference – 40 cm. Brain MRI showed signs of Chiari I malformation, hypogenesis of corpus callosum, ventriculodilation of lateral ventriculi (12 mm on the level of frontal horn) dilation of fronto – temporal subarhnoid spaces of 7–8 mm, decreased volume of white matter, cerebellum tonsillar herniation of 6 mm. Laboratory finding showed: LDH – 1093, AST – 103, Hgb – 81 g/l, Plt – 72×10 9 /l, WBC under 3×10 9 /l, Chitotriosidase 80 (78–120) nmol/g/mg/protein. USD demonstrated tenfold increasing of spleen size. EMG showed secondary myopathic syndrome. X-ray revealed typical sign of osteopetrosis – “bone in bone” syndrome, clavate thickening of metaphyses, ostesclerosis of pelvis and femurs. Horizontal nystagmus, partial atrophy of optic nerves. Results We made the diagnosis of generalized osteopetrosis, autosomal recessive form, hematology syndrome (anemia, thrombocytopenia, hepatosplenomegaly), bones deformities, development retardation. Genetic risk for sibs is 25%. The disease had malignant course. Despite symptomatic treatment the child had died aged 17 months. Conclusion Presented case of generalized osteopetrosis illustrates progressive course of the disease, with hematologic syndrome and involvement of neurological system, that lead to first presentation of the patient to neurology clinic

Childhood diagnosis of genetic thrombocytopenia with mutation in the ankyrine repeat domain 26 gene.

The most common diagnosis for pediatric thrombocytopenia is immune thrombocytopenia. Nevertheless, in atypical cases, the hypothesis of an inherited thrombocytopenia has to be investigated. We report a series of cases of a newly described entity, genetic thrombocytopenia with mutation in the ankyrine 26 gene, diagnosed from the exploration of five pediatric cases of thrombocytopenia. This entity is characterized by a moderate thrombocytopenia with normal mean platelet volume, and poorly bleeding. Its transmission is autosomal dominant. Final diagnosis is made by sequencing of a short DNA region of ANKRD26 gene. This pathology can be considered as an hematological malignancy predisposition syndrome. We report the first cohort of pediatric patients diagnosed with thrombocytopenia with mutation in the ankyrine 26. The aim is to underline the specificities of this entity in children and bring it to the knowledge of pediatricians who may be in first place to manage these patients. • Genetic thrombocytopenia with mutation in the ankyrine 26 gene is a recently described entity, which seems to be considered as a predisposition for hematologic malignancies. • The first cohort has been reported in 2011, by Noris et al., in 78 Italian adult patients. What is New: • We describe clinical and biological features of the first pediatric cohort diagnosed with genetic thrombocytopenia with mutation in the ankyrine 26 gene. • It seemed important to consider the pediatric specificities of this entity to enable pediatricians to investigate, diagnose, and manage pediatric patients and their families.

Reduced administration of rasburicase for tumor lysis syndrome: A single-institution experience.

In the present study, the dosage and duration of rasburicase administration were retrospectively evaluated for the ability to control the serum uric acid (S-UA) level in 13 patients diagnosed with hematological malignancies and tumor lysis syndrome (TLS), or those at risk of developing TLS, at the University of Fukui Hospital. At the time of diagnosis, seven patients already exhibited laboratory TLS, and three demonstrated clinical TLS. All patients received rasburicase in addition to chemotherapy agents. The median dose was 0.19 mg/kg (range, 0.13-0.25 mg/kg), and the median duration was four days (range, 1-7 days). Six patients sequentially received a xanthine oxidase inhibitor, allopurinol or febuxostat. The primary estimate was the normalization of the S-UA level at the end of rasburicase treatment and on treatment day seven. The average S-UA level prior to treatment was 10.4±4.5 mg/dl (mean ±standard deviation), and 11 out of 13 patients demonstrated a S-UA level >7 mg/dl. The S-UA level at the end of rasburicase administration was 0.5±1.5 mg/dl and the S-UA level at day seven was 1.4±1.5 mg/dl. All the patients achieved normalization of the S-UA level. On day seven subsequent to the initiation of treatment, the patients receiving rasburicase for a maximum of three days exhibited an S-UA level of 1.9±1.8 mg/dl, while the patients receiving rasburicase for longer than three days demonstrated an S-UA level of 1.0±1.3 mg/dl (P=0.20; Mann-Whitney test). The administration of 0.13 mg/kg and 0.22 mg/kg resulted in comparable UA level reductions. The administration of allopurinol or febuxostat following rasburicase administration suppressed the re-increase in S-UA level. Therefore, it was concluded that reduced administration of rasburicase successfully controlled the S-UA level in TLS.

Abstract B19: Lysine specific demethylase-1 inhibition as a therapeutic strategy that leverages the requirement for growth factor independence-1 in Notch-driven T-ALL

Abstract The zinc-finger (ZnF) transcriptional repressor Growth Factor Independence (GFI) 1 is a master regulator of lineage allocation in hematopoietic, aerodigestive tract and central nervous system development. Transcriptional repression by GFI1 requires a SNAG domain at its N-terminus and a concatemer of six ZnFs at its C-terminus. The SNAG domain recruits Lysine Specific Demethylase (LSD) 1, a dominant effector of transcriptional repression by GFI1, while ZnFs 3-5 bind a consensus response element in the promoters of GFI1 target genes. A linker region separates the SNAG and ZnF domains in GFI1, and likely provides sites for protein—protein interactions and post-translational modifications that modulate GFI1 functions in cell fate determination. In hematopoiesis, GFI1 regulates self-renewal and maintenance within the hematopoietic stem cell (HSC) compartment, supports early events in lymphopoiesis and is required for maturation of granulocytic precursors. Mutations in GFI1 cause severe congenital neutropenia (SCN) type II, a pre-leukemic condition, and recent evidence shows that GFI1 maintains the malignant phenotype in lymphoid leukemias and lymphomas. These findings intimate that regulators and effectors of GFI1 may be attractive candidates for therapeutic development in hematologic malignancy and maturational failure syndromes. How GFI1 is regulated to control cell fates during hematopoiesis is unknown. We show that GFI1 contains a consensus SUMOylation motif, centered on lysine (K) 239 within its linker region that is required for GFI1 conjugation by SUMO/Ubiquitin-like (UBL) proteins. K239 is found within the binding site for PIAS3, an E3 SUMO ligase and known GFI1 binding protein. PIAS3 antagonizes GFI1-mediated transcriptional repression. Arginine substitution at K239 (GFI1-K239R) preserves transcriptional repression by GFI1 yet resists the inhibitory effects of PIAS3. Moreover, the GFI1-K239R derivative displays a prolonged half-life and preferentially segregates with chromatin in fractionated cells. These findings suggest that GFI1-mediated transcriptional repression is limited by SUMO/UBL protein conjugation and that its roles in cell fate determination may be altered by factors governing these modifications. Among these factors is the Notch1 intracellular domain (N1-ICD), which we show interacts with the same region in GFI1 that binds PIAS3 and competes with PIAS3 for GFI1 binding. Furthermore, N1-ICD abolishes GFI1 conjugation by SUMO/UBL proteins, prolongs GFI1 half-life and reverses the inhibitory effect of PIAS3 toward GFI1-mediated transcriptional repression. In so doing, N1-ICD supports the function of GFI1 as a transcriptional repressor. We also show that Gfi1 depletion causes profound apoptosis in T-ALL cells driven by N1-ICD, suggesting GFI1 inhibitors and/or small molecule inhibitors of its effectors may prove efficacious in T-ALL treatment. To address this hypothesis, we have developed reversible small molecule inhibitors of LSD1. These inhibitors display sub-micromolar IC50 toward T-ALL cell lines and primary patient isolates in the ex vivo setting, including those resistant to γ-secretase inhibitors. These findings suggest that the GFI1—LSD1 axis has significant influence over T-ALL viability and that LSD1 may be a novel therapeutic target in cancers driven by Notch activating mutations. Citation Format: Jason Singer, Daniel Andrade, Diana Bareyan, David McClellan, Helena Lucente, Matthew Velinder, Luke Maese, Mahesh Chandrasekharan, Emily Theisen, Fang Liu, Sunil Sharma, Michael Engel. Lysine specific demethylase-1 inhibition as a therapeutic strategy that leverages the requirement for growth factor independence-1 in Notch-driven T-ALL. [abstract]. In: Proceedings of the AACR Special Conference on Pediatric Cancer at the Crossroads: Translating Discovery into Improved Outcomes; Nov 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;74(20 Suppl):Abstract nr B19.

Significance of bioindicators to predict survival in irradiated minipigs.

The minipig is emerging as a potential alternative non-rodent animal model. Several biological markers (e.g., blood counts, laboratory parameters, and clinical signs) have been proposed for rapid triage of radiation victims. Here, the authors focus on the significance of bio-indicators for prediction of survivors after irradiation and compare it with human data; the relationship between these biomarkers and radiation dose is not part of this study. Male Göttingen minipigs (age 4-5 mo, weight 9-10 kg) were irradiated (or sham-irradiated) bilaterally with gamma-photons (⁶⁰Co, 0.5-0.6 Gy min⁻¹) in the dose range of 1.6-12 Gy. Peripheral blood cell counts, laboratory parameters, and clinical symptoms were collected up to 10 d after irradiation and analyzed using logistic regression analysis and calculating ROC curves. In moribund pigs, parameters such as decreased lymphocyte/granulocyte counts, increased C-reactive protein, alkaline phosphatase values, as well as increased citrulline values and body temperature, significantly (p < 0.002 up to p < 0.0001) discriminated non-survivors from survivors with high precision (ROC > 0.8). However, most predictive within the first 3 d after exposure was a combination of decreased lymphocyte counts and increased body temperature observed as early as 3 h after radiation exposure (ROC: 0.93-0.96, p < 0.0001). Sham-irradiated animals (corresponding to "worried wells") could be easily discriminated from dying pigs, thus pointing to the diagnostic significance of this analysis. These data corroborate with earlier findings performed on human radiation victims suffering from severe hematological syndrome and provide further evidence for the suitability of the minipig model as a potential alternative non-rodent animal model.

Reactive Hemophagocytic Syndrome in Adults: A Retrospective Analysis of 162 Patients

ObjectivesCurrent knowledge in reactive hemophagocytic syndrome mainly relies on single-center case series including a relatively small number of patients. We aimed to identify a multicenter large cohort of adult patients with reactive hemophagocytic syndrome and to describe relevant clinical and laboratory features, underlying conditions, and outcome. MethodsWe conducted a multicenter study in 3 tertiary care centers in France over a 6-year period. The medical files of 312 patients with suspected hemophagocytic syndrome were retrospectively reviewed. Patients were classified with a positive, negative, or undetermined diagnosis of hemophagocytic syndrome by experts' consensus. ResultsAmong the 312 patients fulfilling our inclusion criteria, 162 were classified with positive hemophagocytic syndrome (male, 67%; median age, 48 [35-62] years). Compared with patients without hemophagocytic syndrome, patients with hemophagocytic syndrome more frequently had an underlying immunodepression (45% vs 33%, P = .03) and exhibited higher temperature, ferritin, triglycerides, aspartate transaminase, bilirubin, lactate dehydrogenase, and C-reactive protein, and lower hemoglobin, leukocytes, platelets, and sodium levels. Only 70% of them had hemophagocytosis features on bone marrow aspiration. Hematologic malignancies, especially non-Hodgkin lymphomas, were the main trigger of hemophagocytic syndrome, accounting for 56% of cases. The early mortality rate (ie, within 1 month after diagnosis) was 20%. Patients with hematologic malignancies-associated hemophagocytic syndrome had a poorer early outcome than those with underlying infection. ConclusionsIn this large, multicenter study, hematologic malignancies are the main disease associated with hemophagocytic syndrome in adults. Early mortality is high, and outcome is influenced by the underlying disease.

Histiocytoid Sweet syndrome may indicate leukemia cutis: A novel application of fluorescence in situ hybridization

In patients with malignancy-associated Sweet syndrome, a thorough evaluation for leukemia cutis should be considered. We sought to describe the clinicopathologic characteristics of histiocytoid Sweet syndrome. We retrospectively identified patients with histiocytoid Sweet syndrome at our institution from January 1992 through December 2010. We evaluated the underlying cutaneous infiltrate using immunohistochemistry and fluorescence in situ hybridization. We re-evaluated all 22 patients with hematologic malignancy-associated Sweet syndrome. Six patients had a monocytoid infiltrate that was consistent with histiocytoid Sweet syndrome; subsequent evaluation of these patients demonstrated cytogenetic abnormalities on prior bone-marrow biopsy specimens. Fluorescence in situ hybridization analysis was feasible in cutaneous specimens from 5 of the 6 patients and demonstrated the same cytogenetic abnormalities that were identified on prior bone-marrow biopsy specimens in 4 patients. Therefore, these 4 patients may have had a form of leukemia cutis. This was a retrospective study. For patients with histiocytoid Sweet syndrome, an underlying hematologic malignancy, and a monocytoid infiltrate on biopsy specimen, fluorescence in situ hybridization of the cutaneous infiltrate may be beneficial to identify cytogenetic abnormalities that may indicate leukemia cutis.

An enabling act.

Infection with human T-lymphotropic virus type 1 (HTLV-1) can be associated with hematologic malignancy, inflammatory syndromes, or infectious complications. Herein, we bring attention to HTLV-1 infection complications as we discuss a case of disseminated cryptococcosis in a patient with HTLV-1-associated T cell lymphoma.

The network between hematological centers for the standardization of myelodysplastic syndromes diagnosis

A network of hematological centers specialized in the study of myelodysplastic syndromes (MDS) may be a useful tool for the standardization of the diagnosis of this heterogeneous group of hematologic syndromes and possibly provide not only biological but also epidemiological information. In each center included in the network the diagnosis of MDS will be performed according to criteria of WHO 2008 classification and the last recommendations published by European LeukemiaNet in 2013. In detail the following analyses will be carried out: morphological examination, bone marrow biopsy, conventional cytogenetic and possibly molecular cytogenetic studies. In each region will be identified a reference center that will collect data on all patients with suspected MDS creating a database with clinical, morphological and molecular-cytogenetic information. In particular, the morphological evaluation will be carried out in collaboration between the peripheral centers and the regional reference center through the sharing of images from slides. The collaboration between experts hematologists will allow the formulation of more precise diagnosis. Moreover, the national network for the standardization of MDS diagnosis could facilitate the ideation of new research projects and the identification of new prognostic markers.

Accelerated hematopoietic syndrome after radiation doses bridging hematopoietic (H-ARS) and gastrointestinal (GI-ARS) acute radiation syndrome: Early hematological changes and systemic inflammatory response syndrome in minipig

Purpose: To characterize acute radiation syndrome (ARS) sequelae at doses intermediate between the bone marrow (H-ARS) and full gastrointestinal (GI-ARS) syndrome.Methods: Male minipigs, approximately 5 months old, 9–12 kg in weight, were irradiated with Cobalt-60 (total body, bilateral gamma irradiation, 0.6 Gy/min). Endpoints were 10-day survival, gastrointestinal histology, plasma citrulline, bacterial translocation, vomiting, diarrhea, vital signs, systemic inflammatory response syndrome (SIRS), febrile neutropenia (FN).Results: We exposed animals to doses (2.2–5.0 Gy) above those causing H-ARS (1.6–2.0 Gy), and evaluated development of ARS. Compared to what was observed during H-ARS (historical data: ), doses above 2 Gy produced signs of increasingly severe pulmonary damage, faster deterioration of clinical conditions, and faster increases in levels of C-reactive protein (CRP). In the range of 4.6–5.0 Gy, animals died by day 9–10; signs of the classic GI syndrome, as measured by diarrhea, vomiting and bacterial translocation, did not occur. At doses above 2 Gy we observed transient reduction in circulating citrulline levels, and animals exhibited earlier depletion of blood elements and faster onset of SIRS and FN.Conclusions: An accelerated hematopoietic subsyndrome (AH-ARS) is observed at radiation doses between those producing H-ARS and GI-ARS. It is characterized by early onset of SIRS and FN, and greater lung damage, compared to H-ARS.

Paraneoplastic syndromes associated with lung cancer.

Paraneoplastic syndromes are signs or symptoms that occur as a result of organ or tissue damage at locations remote from the site of the primary tumor or metastases. Paraneoplastic syndromes associated with lung cancer can impair various organ functions and include neurologic, endocrine, dermatologic, rheumatologic, hematologic, and ophthalmological syndromes, as well as glomerulopathy and coagulopathy (Trousseau's syndrome). The histological type of lung cancer is generally dependent on the associated syndrome, the two most common of which are humoral hypercalcemia of malignancy in squamous cell carcinoma and the syndrome of inappropriate antidiuretic hormone secretion in small cell lung cancer. The symptoms often precede the diagnosis of the associated lung cancer, especially when the symptoms are neurologic or dermatologic. The proposed mechanisms of paraneoplastic processes include the aberrant release of humoral mediators, such as hormones and hormone-like peptides, cytokines, and antibodies. Treating the underlying cancer is generally the most effective therapy for paraneoplastic syndromes, and treatment soon after symptom onset appears to offer the best potential for symptom improvement. In this article, we review the diagnosis, potential mechanisms, and treatments of a wide variety of paraneoplastic syndromes associated with lung cancer.

Risk Factors for Early Fatal Outcomes Among Children with Hemophagocytic Lymphohistiocytosis (HLH): A Single-Institution Case-Series in Vietnam

Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal hematological syndrome that causes a disturbance of the immune system. Overall mortality of HLH is greater than 50% and the majority of patients who die do so within the first 8 weeks of chemotherapy treatment. To find clinical parameters relating to high-risk HLH patients, this study examined associations between an early fatal outcome and potential prognostic clinical factors and laboratory findings on admission. Eighty-nine pediatric HLH patients were prospectively recruited in Children's Hospital No. 1, Ho-Chi-Minh City, Vietnam, during the period from January 2010 to August 2012. Associations between early fatal outcome and clinical and laboratory findings, including a cerebrospinal fluid examination and virological test on admission, were examined. During the 8-week therapy, 25 (28%) HLH patients died. Persistent fever (>2 weeks), severe thrombocytopenia (<75 × 109/L), hyperbilirubinemia, and prolonged activated partial thromboplastin time (APTT) (>33 sec) were significant risk factors of early fatal outcome. Multivariate logistic regression analysis revealed that thrombocytopenia and prolonged APTT (P for trend was 0.054 and 0.013, respectively) were independently associated with the early fatal outcome. Persistent fever, severe thrombocytopenia, hyperbilirubinemia, and prolonged APTT on admission will be useful and practical predictors to determine high-risk HLH patients.

Diverse Genetic Lesions In Myelodysplastic Syndromes Originate Exclusively In Rare MDS Stem Cells

BackgroundThe popular concept that human cancers might be driven by rare self-renewing cancer stem cells (CSCs) has extensive implications for cancer biology and modelling, as well for development of more efficient and targeted therapies. However, experimental support for the existence of distinct and rare CSCs in human malignancies remain contentious, particularly in light of compelling evidence that cancer-propagating cells frequently fail to read out in existing human stem cell assays. Therefore, to unequivocally establish the existence and identity of human CSCs, the challenge is first to identify candidate CSCs, and to establish their unique ability to self-renew and replenish molecularly and functionally distinct non-tumorigenic progeny followed by functional in situ validation within the patients themselves. MethodsWe have in the hematological malignancy myelodysplastic syndromes (MDS) characterize candidate hematopoietic stem and progenitor stages in the bone marrow of low-intermediate risk MDS patients by flow cytometry. Distinct cell populations were functionally characterised for lineage commitment in standard colony forming cell (CFC) assays, and for self-renewal potential in long-term culture initiating cell (LTC-IC) assays and in immune-deficient (NSG) mice. Moreover, we tracked the cellular origin of all identified somatic genetic lesions identified in each patient by targeted next-generation sequencing of genomic DNA isolated from each purified MDS stem and progenitor cell population. ResultsIn low-intermediate risk MDS patients, regardless whether they were del(5q) (n=19) or non-del(5q) (n=11), we could identify rare but distinct Lin-CD34+CD38-CD90+CD45RA- candidate stem cells, granuclocyte-monocyte progenitors (GMPs) and megakaryocyte-erythroid progenitors (MEPs) with frequencies within total BM similar to that of normal age-matched controls. Global gene expression analysis by RNA sequencing of MDS stem cells, GMPs and MEPs suggested that these are molecularly distinct populations. Myeloid and erythroid gene expression signatures were restricted to the GMPs and MEPs, respectively, whereas a transcriptional stem cell signature was restricted to the MDS stem cells. GMPs and MEPs isolated from del(5q) (n=12) and non-del(5q) (n=8) MDS patients displayed lineage-restricted myeloid and erythroid differentiation potentials, respectively. Self-renewal in LTC-IC assay was restricted exclusively to MDS Lin-CD34+CD38-CD90+CD45RA- stem cells in del(5q) (n=11) and non-del(5q) (n=8) MDS patients. Xenotransplantation into NSG mice also confirmed that only Lin-CD34+CD38-CD90+CD45RA- MDS stem cells have in vivo self-renewal potential, and these experiments also demonstrated their ability to replenish downstream CMPs, GMPs and MEPs, establishing the hierarchical relationship of MDS stem and progenitor cells. Targeted DNA sequencing of 88 genes recurrently mutated in MDS and other myeloid malignancies was pursued to identify somatic genetic lesions within the bulk bone marrow of MDS patients (n=13). In total we identified 30 presumed genetic driver lesions, including del(5q) and mutations in key transcription factors (RUNX1), signalling pathways (JAK2, CSF3R), epigenetic regulators (TET2, ASXL1), apoptosis regulators (TP53), and spliceosome components (SF3B1, SRSF2, U2AF2, SRSF6). Importantly, in support of their unique ability to self-renew and replenish lineage-restricted MDS progenitors, all stable somatic genetic lesions identified could in each MDS patient be backtracked to the rare stem cell population as defined phenotypically by flow cytometry and functionally by LTC-IC or xenograft potential, unequivocally establishing their unique stem cell identity within the malignant clone. ConclusionsThese findings provide definitive evidence for the existence of rare and distinct stem cells in MDS, a finding with extensive implications for therapeutic strategies in MDS and other cancers whose existence might also strictly depend on the persistence of rare CSCs. MDS stem cells typically acquire multiple driver mutations, together conferring a competitive advantage over normal stem cells, while even in combination failing to inflict self-renewal ability on MDS myelo-erythroid progenitor cells. Disclosures:No relevant conflicts of interest to declare.

Unusual Cluster In Time and Space Of Dengue-Associated Hemophagocytic Lymphohistiocytosis In Puerto Rico

Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal hematologic syndrome characterized by hyperinflammation due to uncontrolled proliferation of activated lymphocytes, resulting in prolonged fever, pancytopenia, jaundice, and hepatosplenomegaly. While infection with Epstein Barr virus (EBV) is the most common recognized cause of infection-triggered HLH, there have been cases associated with other viral infections including dengue. Dengue is an acute febrile illness that is caused by any of four related but serologically distinct, mosquito-borne dengue viruses (DENV-1–4) that are endemic throughout the tropics and subtropics including Puerto Rico, a territory of the United States. Dengue can lead to a wide range of clinical outcomes, ranging from no symptoms or mild fever to potentially fatal severe dengue. In Puerto Rico, dengue most commonly affects adolescents 10–19 years old. Dengue-associated HLH (dengue-HLH) has been described in 26 case reports since 1966, but has not been previously recognized in Puerto Rico.During the start of a dengue epidemic in December 2012, the Centers for Disease Control and Prevention Dengue Branch were notified of several dengue-HLH cases at four hospitals in Puerto Rico. An investigation was conducted to: 1) determine the incidence of HLH in children since 2008; and 2) determine the infecting agent(s) associated with HLH cases. Medical records were queried to identify patients with findings compatible with HLH. To date, 681 records have been reviewed and 38 patients identified that met accepted criteria for HLH. The majority (25 patients) of the HLH cases had diagnostic evidence of DENV infection by anti-dengue IgM Enzyme Linked Immunosorbent Assay (36%) and/or DENV Polymerase Chain Reaction (68%): DENV types -1 and -4 were detected. Other causes of HLH identified were EBV and Cytomegalovirus co-infections (2), Herpes Simplex Virus (2), EBV (1), and systemic onset juvenile arthritis (2). There was one fatal dengue-HLH case (case-fatality rate [CFR]: 4.0%). Dengue-HLH cases ranged in age from 0.1–16 years, 48% were infants, and all resided in northern Puerto Rico. Among children aged 0–16 years, the average annual incidence of dengue-HLH cases in Puerto Rico from 2008 through 2011 was 0.1 cases per 100, 000 versus 2.2 cases per 100,000 in the last 12 months from June 1, 2012 to May 31, 2013, which demonstrates the dramatic increase in recent cases. The number of HLH cases may have been higher since in 14 additional cases with suspected HLH who only fullfilled 4 of the required 5/8 diagnostic criteria, laboratory investigations were incomplete.This is an unusual cluster of dengue-HLH cases in time and space afflicting mostly infants and cannot be explained by heredity. Currently there is no explanation for this outbreak of dengue-HLH. Some cases of dengue-HLH may have been overlooked in the past if severe dengue cases were not investigated for the presence of HLH criteria. We are presently conducting a case-control study to identify risk factors for developing dengue-HLH and determine why in contrast to previous experience infants were predominantly affected. Physicians in dengue endemic areas should be made aware that infection with dengue virus may lead to the hyperinflammatory syndrome HLH. Disclosures:No relevant conflicts of interest to declare.

Reactive Myeloproliferative Syndrome Secondary to Tumor-Related Inflammation in Giant-Cell Tumor of the Scapula: A Case Report.

Giant-cell tumor of bone (GCTB) is a benign lesion with variable aggressiveness that occurs primarily in the metaepiphyseal regions of long bones. The most frequent locations, in order of decreasing prevalence, are the distal aspect of the femur, the proximal aspect of the tibia, the distal aspect of the radius, and the sacrum1. Although flat-bone involvement is rare, GCTB has been reported in the scapula2. This case report describes the unusual occurrence of a hematological paraneoplastic syndrome in association with GCTB. Systemic manifestations, such as oncogenic osteomalacia secondary to GCTB with resolution of clinical symptoms following tumor resection, have been described3-5. However, to the best of our knowledge, there are no reports of GCTB associated with a paraneoplastic syndrome consisting of hematological abnormalities and evidence of systemic inflammation. We describe a case of a reactive myeloproliferative syndrome secondary to tumor-related inflammation in GCTB. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A thirty-year-old man presented with a one-year history of a mass in the posterior aspect of the right shoulder, progressive fatigue, and occasional chills, fevers, and night sweats. The patient reported that the mass had grown substantially over the last few months. Radiographs, computed tomography (CT) (Figs. 1-A, 1-B, and 1-C), and magnetic resonance imaging (MRI) (Figs. 2-A, 2-B, and 2-C) revealed a 15.0 cm × 15.5-cm hemorrhagic lytic osseous lesion of the right inferior scapular body with soft-tissue extension. In addition, the patient had anemia (hematocrit, 26.6%; hemoglobin level, 8.6 g/dL); iron deficiency (iron, 20 μg/dL; percent saturation, 11%; transferrin, 138 mg/dL); evidence of highly proliferative marrow (red blood-cell [RBC] distribution width, 17.2%); thrombocytosis (platelet count, 873 × 103/mm3); mild coagulopathy (international normalized …

Mycosis Fungoides and Head and Neck Malignancies

Mycosis fungoides is a cutaneous T-cell lymphoma characterized by cutaneous patches and plaques that may progress to hematologic involvement and Sezary syndrome. Second primary tumors have been described in the literature without emphasis on head and neck neoplasms. We report two cases of head and neck malignancies in patients with a history of mycosis fungoides. A PubMed literature search was performed and results were reviewed. Second primary tumors in the head and neck have been reported in the nose and nasal cavity, sinuses, oral cavity, pharynx, hypopharynx, larynx, tracheobronchial tree, thymus, and skin. We present cases of submandibular mucoepidermoid carcinoma and papillary thyroid carcinoma in patients with a history of mycosis fungoides. Mycosis fungoides may confer increased risk of developing a second primary neoplasm of the head and neck. Possible mechanisms may include immunosuppression inherent in treatment modalities, the disease course of mycosis fungoides, or related genetic mutations.

Mutations in the TNFRSF1A, CEBPE and ELANE genes in a Congenital Cyclic Neutropenia Patient: A New Syndrome?

Abstract 11Cyclic neutropenia (CyN) is a hematologic disorder in which blood cell counts particularly granulocytic neutrophil numbers show cycles at 21 day intervals. The majority of CyN patients (ca 90 %) harbor inherited mutations in the ELANE gene. Intriguingly, same ELANE mutations are present in two different hematologic syndromes: congenital as well as in cyclic neutropenias. It is unclear how mutation in the same gene cause congenital or cyclic neutropenia. We aimed to identify genes which are exclusively mutated in cyclic or in congenital neutropenia additionaly to the ELANE gene mutations. Recently, we found in congenital neutropenia patients additional to ELANE mutations inherited mutations in for example the G6PC3 gene or the HAX1 gene (Germeshausen, M., et al, Haematologica 2010). This suggests cooperating effects of different defective intracellular signaling pathways and excludes that mutated ELANE alone is responsible for the pathogenesis of congenital or cyclic neutropenia.To identify gene mutations causing cyclic neutropenia in association with ELANE mutation, we performed whole genome sequencing using Complete Genomics technology (Complete Genomics. Inc, Mountain View, CA.) of a family with an affected CyN patient. The CyN patient harbors sporadic heterozygous ELANE mutation (c.761C>G p.W241L) and her family consists of a healthy brother and healthy parents. We identified a novel heterozygous point mutation in the tumor necrosis factor receptor superfamily, member 1A (TNFRSF1A) gene (c.664C>T; p.R121Q) in the affected patient and her mother. This mutation was confirmed by Sanger sequencing. The TNFRSF1A gene encodes p55 subunit of the TNFa receptor (TNFR1) and intriguingly this gene is known to be frequently mutated in patients with Tumour necrosis factor receptor-associated periodic fever syndrome (TRAPS), a disease clinically similar to cyclic neutropenia. TRAPS is an autosomal dominant disorder characterized by episodes of fever, inflammation and periodical changes in the neutrophil counts. Functional studies in patients with TRAPS described heterogenous effects of different TNFRSF1A mutations on the surface expression and PMA-induced clevage of TNFR1 on the neutrophilic granulocytes and monocytes. In our CyN patient we measured elevated mRNA levels of TNFR1 on neutrophils, in comparison to her healthy family members and unrelated healthy individuals. However, we detected diminished surface expression of the TNFR1 protein, but elevated PMA-induced receptor shedding in the affected CyN patient, in comparison to healthy individuals, as assessed by estimation of soluble TNFR1 in supernatants of PMA-stimulated neutrophils.We also identified in the same patient and her father a second novel heterozygous point mutation in the CEBPE gene (c.636C>A; p.L155M), which was also confirmed by Sanger sequencing. This C>A substitution changes CTG to ATG creating a new start site for translation of a novel isoform of C/EBPε protein. C/EBPε is a myeloid-specific transcription factor playing an important role in granulopoiesis. Mutations in the CEBPE gene have been described in patients with neutrophil-specific granule deficiency (SGD).In summary, we identified additional to the ELANE mutation two novel mutations in a CyN patient, one in the TNFRSF1A gene inherited from the mother, another in the CEBPE gene inherited from the father. Mutations in both genes are already described in patients with TRAPS (periodic fever syndrome) and granulocyte abnormalities, respectively. These mutations in association with the ELANE gene mutation may contribute to the pathogenesis of cyclic neutropenia in this patient. Whether the combination of these three mutations might be responsible for a subgroup of CyN patients remains to be investigated. Disclosures:No relevant conflicts of interest to declare.

A Perspective on the Comparative Antileukemic Activity of 5-Aza-2′-deoxycytidine (Decitabine) and 5-Azacytidine (Vidaza)

5-Aza-2′-deoxycytidine (5-AZA-CdR, decitabine, Dacogen®) and 5-azacytidine (5-AC, Vidaza®) are epigenetic agents that have been approved for the clinical treatment of the hematological malignancy myelodysplastic syndrome (MDS) and are currently under clinical evaluation for the treatment of acute myeloid leukemia (AML). Most investigators currently classify 5-AZA-CdR and 5-AC as inhibitors of DNA methylation, which can reactivate tumor suppressor genes silenced by this epigenetic event. Examination of the pharmacology of these analogues reveals important differences with respect to their molecular mechanism of action. The action of 5-AZA-CdR is due to its incorporation into DNA. 5-AC is a riboside analogue that is incorporated primarily into RNA. A small fraction of 5-AC is converted to its deoxyribose form by ribonucleotide reductase and subsequently incorporated into DNA. The incorporation of 5-AC into RNA can interfere with the biological function of RNA and result in an inhibition protein synthesis. Microarray analysis revealed that both these analogues target the expression of different cohorts of genes. Preclinical studies show that 5-AZA-CdR is a more effective antileukemic agent than 5-AC. One explanation for this observation is that 5-AC blocks the progression of some leukemic cells from G1 into S phase, and this protects these cells from the chemotherapeutic action of this riboside analogue related to its incorporation into DNA. However, differences in chemotherapeutic efficacy of these related analogues have not been clearly demonstrated in clinical trials in patients with hematological malignancies. These observations should be taken into consideration in the design of new clinical trials using 5-AZA-CdR or 5-AC in patients with MDS and AML.

Paraneoplastic neurological and hematological syndromes associated with prostate cancer

Paraneoplastic neurological syndromes are defined as the remote effects of cancer on the nervous system. Here we report a 68-year-old man who initially presented with worsening paresthesia in the lower extremities. Although the culprit lesion remained to be identified, he coincidentally had diagnosis of prostate cancer by an annual prostate-specific antigen examination. Leukocytosis and elevated granulocyte colony-stimulating factor in serum were also detected. Neurological symptoms and leukocytosis improved after initiation of androgen-deprivation therapy followed by external beam radiotherapy. A total of 9 months after treatment, the patient showed no evidence of cancer recurrence or neurological signs. Paraneoplastic neurological syndromes are rare in prostate cancer and therefore have received little attention. We should be aware that when paraneoplastic neurological syndromes occur, they usually occur as the first sign of or during progression of prostate cancer. Furthermore, we should take into account the existence of malignancy when the cause of neurological symptoms cannot be specified.

H- AND L-FERRITINS IN ACUTE LEUKEMIA

We have studied H- and L-subunits of ferritin in acute leukemia. Our data makes it possible to suggest that the appearance of considerable numbers of ferritin in the serum of patients with clonal blood diseases is connected with its secretion with lymphocytes. As it is impossible to establish the reliable correlation between the dimension of the tumor in leukemia and the level of ferritin, then the ferritin secretion is hypothetically relating to its regulatory functions. We have shown that the separate testing of H- and L-forms of ferritin makes it possible to determine the content of serum ferritin. It has been established that the content of serum ferritin differs in acute leukemia at attacks and remission but it is necessary to accumulate the data for the comprehension of true diagnostic H-ferritin value. It is possible that in the nearest future hematologic syndromes in malignant tumors, i.e. clonal processes from the inflammation-associated syndromes, can be differentiated according to the content of serum ferritin.