Hypoplastic Bone Marrow Research Articles

Side Effects Of Immunosuppressive Therapy(IST) Of Aplastic Anemia In Children

IntroductionAcquired aplastic anemia is very rare disease characterized by and pancytopenia and hypoplastic bone marrow. In 70% of cases the etiology is idiopathic but some cases can be caused by drugs, chemical substances and viruses. One of the main pathophysiological mechanism of aplastic anemia is immune-mediated destruction of hematopoietic cells. As a result of that the immunosuppressive therapy (IST) persists the treatment of choice in patients with severe acquired aplastic anemia (SAA), who don't have matched sibling donor. Since few last years there is a discussion if it is still the best way of treatment. We wanted to show the side effects of IST during the therapy of SAA using the rabbit antithymocyte globulin(r-ATG) MethodsThe group of 55 children ( 32 boys, 23 girls) with SAA and vSAA (very severe aplastic anemia) treated with r-ATG , steroids, CSA, and/or GSF-CS was retrospectively analyzed. The median age of the children was 10 years (range 6mth-17,5 years). Response rate was assessed on days 84, 112,180, 360. Kaplan–Meier estimator, univariate analysis and multivariate Cox regression models were used to estimate the influence of side effects for PFS (progression free survival) and EFS( event free survival). ResultsInfectious complications (fever of unknown origin-FUO-26,92%, stomatitis -19,23% and sepsis -17,03% ) were the most common side effects of IST. The most common etiology were : E. coli, P. aureginosa, S. aureus, Kl. pneumonie, E. fecium, E. cloace. There was a significant association between EFS and infectious side effects (p=0,00093- log rank). Among side effects of r-ATG fever (30,30%) and dyspnoe (24,24%) were the most common.After CSA mainly gingival hyperplasia, hirsutysm and hypertension were observed. The most common hemorrhagic side effects of IST were skin petechiae. The other were central nervous system bleeding, gastrointestinal tract bleeding. There was significant correlation between the hemorrhagic side effects and PFS(p= 0,0144 log rank).After the G-CSF therapy muscular pains, and capillary leak syndrome, was observed but it didn't influence survival. Among all patients 15 deaths was observed (27,27%)-5 early and 10 late deaths. Infections were the main causes of death. The relapse rate was 1,81%. The 2-year probability of not having relapse was 87,68%. Relapse free survival was 75,16% at 5 and 10 years. There was one transformation to paroxysmal nocturnal hemoglobinuria (PNH). There were no transformation to MDS or AML.Discussion. Infections are the most common side effects during the IST with r- ATG. Hemorrhagic side effects and infectious complications are very important factors which can affect the survival rate in children with SAA. Disclosures:Szczepanski:Octapharma AG: Investigator Other.

Ezh2 Loss Accelerates JAK2V617F-Driven Primary Myelofibrosis

Polycomb group proteins are transcriptional repressors that epigenetically regulate transcription via histone modifications. There are two major polycomb-complexes, the Polycomb Repressive Complexes (PRC1 and PRC2). PRC2 contains SUZ12, EED, and EZH2 that catalyze the trimethylation of histone H3 at lysine 27 (H3K27me3) and silence target-genes expression. EZH2 is generally thought to act as an oncogene in lymphoma by silencing tumor suppressor genes through H3K27me3 modifications. However, loss-of-function mutations of EZH2 have been found in myeloid malignancies such as MDS and MPN including primary myelofibrosis (PMF). In a recent study, EZH2 mutations were independently associated with shorter survival in PMF patients, suggesting that EZH2 functions as a tumor suppressor in PMF.Although JAK2V617F mutant is found in approximately 50% of PMF patients, it remains obscure whether the presence of JAK2V617F mutant predicts survival of PMF patients, and the functional contribution of JAK2V617F to the development of PMF has not been fully delineated. JAK2 has been shown to directly phosphorylate H3Y41 (H3Y41p) and reduce HP1a binding, thereby activating expression of target genes. However, it is unknown how JAK2V617F epigenetically alter expression of target genes in the development of PMF. Given that JAK2V617F mutation is significantly associated with EZH2 mutations in PMF patients, in order to understand how EZH2 mutations contribute to the pathogenesis of JAK2V617F-positive PMF, we generated a novel mouse model of PMF utilizing H2K-JAK2V617F transgenic mice and Ezh2 conditional knockout mice.We first harvested 5x106 bone marrow cells from tamoxifen-inducible Cre-ERT;Ezh2wild/wild (WT), Cre-ERT;Ezh2flox/flox (Ezh2 cKO), JAK2V617F TG/Cre-ERT;Ezh2wild/wild (JAK2 TG) and JAK2V617F TG/Cre-ERT;Ezh2flox/flox (JAK2 TG/Ezh2 cKO) mice, and then transplanted into lethally irradiated recipient mice. At 4 weeks post transplantation, we deleted Ezh2 via administration of tamoxifen, and observed disease progression until 9 months post transplantation. WT and Ezh2 cKO mice did not develop myeloid malignancies. While all 11 JAK2 TG mice died due to PMF-like disease after a long latency as previously reported, 10 out of 10 JAK2 TG/Ezh2 cKO mice immediately developed PMF and died by approximately 50 days post-deletion of Ezh2. JAK2 TG/Ezh2 cKO mice showed a significantly shorter median survival than did JAK2 TG mice (36.5 days versus 245 days, p<0.01). In the peripheral blood, moribund JAK2 TG/Ezh2 cKO mice showed increased mature neutrophils, severe anemia, and thrombocytopenia, compared to WT or JAK2 TG mice at 2 months post transplantation. At the time of sacrifice, JAK2 TG/Ezh2 cKO mice showed a significant hypoplastic bone marrow without an increased myeloblast cells, but also had a marked splenomegaly due to infiltration of myeloid cells compared to JAK2 TG mice. In addition, JAK2 TG/Ezh2 cKO mice showed a severe myelofibrosis in both bone marrow and spleen, indicating that Ezh2 loss obviously promotes JAK2 V617F-driven PMF in vivo.To understand a molecular mechanism how Ezh2 functions as a tumor suppressor for PMF, we performed gene expression analysis in Lin-Sca1+c-Kit+ (LSK) cells. While Ezh2 cKO LSKs and JAK2 TG LSKs showed up-regulation (>2-fold) of 1044 and 861 genes, respectively, JAK2 TG/Ezh2 cKO LSKs showed up-regulation (>2-fold) of more genes (1306), compared to WT LSKs. As expected, H3Y41p and H3K27me3 target genes were significantly upregulated in JAK2 TG/Ezh2 cKO LSKs, whereas H3K27me3 targets were significantly repressed in JAK2 TG LSKs, consistent with the tumor suppressor role of Ezh2 in PMF. We are now working to understand how dysregulated genes are involved in the progression of JAK2V617F-induced PMF after deletion of Ezh2. In conclusion, we have successfully established the progressive PMF in mice reconstituted with Ezh2 null cells expressing JAK2V617F mutant, and demonstrated that Ezh2 functions as a tumor suppressor in this context. This model can be utilized for innovating new therapies for PMF. Disclosures:No relevant conflicts of interest to declare.

Initial Results Of a Phase II Trial Of Sorafenib Plus Standard Induction In Older Adults With Mutant FLT3 Acute Myeloid Leukemia (AML) (Alliance trial C11001)

Sorafenib is an oral multikinase inhibitor that blocks the autophosphorylation and activation of a number of tyrosine kinases; it has potent activity against the FLT3 tyrosine kinase with an internal tandem duplication mutation (FLT3-ITD). Sorafenib has activity against AML with FLT3-ITD mutations as a single agent in the setting of post-transplant relapse (Metzelder et al., Blood 2009) and in combination with chemotherapy for newly diagnosed AML (Ravandi et al., JCO 2010). The prevalence of FLT3 mutations among older adults (>60 years) with AML is not yet well defined. Historical CALGB results using standard chemotherapy for older AML patients with FLT3-ITD have shown a complete remission (CR) rate of 67%, median survival of 0.8 yrs, and 1-yr survival of 30% (Whitman et al., Blood 2010). We hypothesized that the addition of sorafenib to induction and post-remission therapy would improve the overall survival of older patients with FLT3-mutated AML.We conducted a multicenter, single-arm phase 2 study in patients ≥ 60 years old with newly diagnosed AML (including therapy-related AML) and either a FLT3-ITD or a point mutation in the activation loop of the kinase domain (FLT3-TKD). Subjects with PML-RARA or CBF leukemias were excluded. Induction chemotherapy consisted of cytarabine 100 mg/m2 CIVI on days 1-7 and daunorubicin 60 mg/m2 IV on days 1-3 (7+3) with oral sorafenib 400 mg bid on days 1-7. Those not achieving a hypoplastic bone marrow on day 14 were to receive 5+2 plus sorafenib 400 mg bid on days 1-7. Patients achieving CR were encouraged to undergo allogeneic HSCT if possible. For all others, consolidation consisted of intermediate-dose cytarabine 2 g/m2 over 3 hours on days 1-5 with sorafenib 400 mg bid on days 1-28 for 2 cycles. Following consolidation, maintenance sorafenib 400 mg bid was administered daily for 12 28-day cycles. The primary endpoint for this study is the 1-year overall survival of the FLT3-ITD patients.A total of 459 older adults were screened for FLT3 mutations though a central laboratory. FLT3 mutations were identified in 81 subjects (17.6%). The median turn-around time for FLT3 testing was 46 hours, with 99.1% of cases returned within the cutoff time of 48 hours. Fifty-two patients to date have enrolled on the study, including 37 with FLT3-ITD (71%) and 15 with FLT3-TKD (29%). The median age is 67 years (range, 60-83) and 19 pts were > 70 years (37%). The median follow up is 4.5 months. Of the 52 evaluable patients, 36 have achieved a CR or CRi (69%) of which 4 were CRi (8%). The CR/CRi rate did not differ between subjects with an ITD (26 of 37, 70%) vs a TKD (10 of 15, 67%). The CR/CRi rate was 58% for those >70 years old. Eight pts are known to have received a second induction course. Four of 52 patients (8%) died within 30 days of starting their most recent induction course with no additional deaths occurring within 60 days. Treatment-related toxicities were those typical during AML induction, and no additional or unexpected toxicities were attributed to sorafenib. There were 2 grade 5 nonhematologic adverse events (lung infection; oral mucositis) and 7 grade 4 events among the first 40 evaluable patients, including infection, cardiac, respiratory, metabolic, and kidney injury.This study represents the first prospective clinical trial for older adults with AML targeting a specific mutational profile within the US cooperative group setting. It demonstrates the feasibility of rapid screening for FLT3 mutations prior to initial remission induction chemotherapy. The addition of sorafenib to chemotherapy for older adults with AML is associated with a high rate of CR, relatively low risk of mortality during induction, and an acceptable toxicity profile. Disclosures:Off Label Use: sorafenib for AML.

Prominent Reactive Plasmacytic Proliferation Presenting with Transient Pancytopenia: An Unusual Case

Reactive bone marrow plasmacytosis occurs in association with a variety of conditions. In such reactive cases, Plasma Cells (PCs) usually account for 10%-20% of cells in bone marrow trephine biopsy sections and rarely exceed 50%. Here in we report an unusual case of bone marrow aplasia associated with prominent atypical plasma cell proliferation and hypoplastic bone marrow.

High Incidence of tMDS in Elderly Lymphoma Patients Subjected to Radioimmunotherapy

AbstractAbstract 4882 Background:Conventional therapies with cytotoxic agents for disseminated NHL are associated with a high risk of therapy related myeloid neoplasm (tMN). The latency period between exposure to this agents and development of tMN ranges from one to 10 years.Radioimmunotherapy (RIT) uses monoclonal antibodies, specifically binding to antigens of tumor cells, as a carrier for the radioisotope. The radiation is delivered not only to the antibody –bound tumor cell, but also neighboring cells. Methods:In the years 2005–2011 radioimmunotherapy with ibritumomab tiuxetan was used in 102 patients with FL (during consolidation therapy), MCL (as consolidation of the first-line treatment and after achieving PR in the first- or second-line therapy), DLBCL and MCL (in the HDT supported by auto-SCT). 5 patients (4,9%) ( 4 with MCL/ 1 with FL) subjected to RIT developed tMDS. All patients with MCL in previous treatment were exposed to alkylating agents, antymetabolites and inhibitors of II topoisomerase. All patients had hypoplastic bone marrow year after RIT. Results:Median time to diagnosis of tMDS after treatment with RIT was 2,3 years. 4/5 during 6 month transformed into tAML. In peripheral blood of all patients anemia, thrombocytopenia or pancytopenia was observed. All patient in histophatology had dysplastic changes in 3 hematopoetic lines with 5% blast cells, without elevated percentage of ring sideroblasts. Each patient had typical for tMDS complex abnormalities with monosomy of chromosome 5 or 7, or abnormalities of this chromosome [table 1]. Three of this patients was treated with azacitidine, one of this patients was prepared to RIC allo BMT but developed tAML and died during induction therapy. All patients received supportive care.Tab 1Cytogenetic changesP 143-44,XY,del(3)(p21),-5,-7[4]/43,sl,-12,add(21)(q22)[10]P 247,XX,+11,add(17)(q25)P 342-45,XY,del(3)(p21),-5,r(7)(p22p12),del(12)(p11p13),-15, +mar1,+ mar2 [25cp]P 445,XX,-7,-16,-19,+mar1,+mar2[6]P 545,X,-X,del(5)(p12p35),add(12)(p13) Conclusion:The development of secondary hematological malignancies (tMDS and tAML) after RIT is very closely related to the drugs applied in the induction treatment especially purine analogues. Higher incidence of tMDS in patients with MCL confirm the relationship of occurrence of secondary MDS and AML after radioimmunotherapy with the earlier use of purine analogs (fludarabine) and cumulative damage to bone marrow cells rather than exclusively associated with administration of RIT. Disclosures:No relevant conflicts of interest to declare.

Activation of the NLRP1 Inflammasome Induces the Pyroptotic Death of Hematopoietic Progenitor Cells

AbstractAbstract 1213The inflammasome is an innate immune complex that recognizes a wide range of pathogen, cellular stress and damage signals. It triggers the Caspase-1-dependent production of inflammatory cytokines including IL-1β and IL-18. Sensors for the inflammasome include the nucleotide-binding oligomerisation domain, leucine-rich repeat (NLR) proteins. The best-characterised of these is NLRP3, which mediates antibacterial, viral, fungal and parasitic immune responses, and is mutated in a spectrum of autoinflammatory diseases. Activation of mammalian NLRs can also result in a Caspase-1-dependent form of cell death termed pyroptosis, the importance of which in disease states remains unclear. For example, it is known that NLRP3 activating mutations in humans can be effectively treated by neutralising IL-1β, suggesting that cell death induced by NLRP3 activation does not play a significant role in pathology. Similarly, the NLRP1b inflammasome is activated by anthrax lethal toxin to cause macrophage pyroptosis, but this does not play a role in anthrax sensitivity in vivo.Here we define a role for NLRP1 in autoinflammatory disease and the pyroptotic death of hematopoietic progenitor cells. We began by generating two mouse models, one carrying a point mutation in NLRP1a that results in constitutive activation of the protein, and another harbouring a deletion of the entire NLRP1 locus. Animals homozygous for the NRLP1a activating mutation developed a multi-organ neutrophilic inflammatory disease characterised by meningitis, hepatitis, pneumonitis, pancreatitis, pulmonary peri-arteritis, myocarditis and inflammatory bowel disease. Mean survival was approximately 3 months of age. Genetic crosses established that this inflammatory disease was driven by Caspase-1 and IL-1β, but was independent of ASC and Caspase-11, and ameliorated by IL-18. Surprisingly, in the absence of IL-1β-driven inflammation, constitutively active NLRP1a triggered the Caspase-1-dependent death of hematopoietic progenitor cells resulting in leukopenia at steady state.To evaluate the effect of activated NLRP1a during hematopoietic stress, IL-1 receptor-deficient mice homozygous for the NRLP1a activating mutation were challenged with 5-fluorouracil. Strikingly, these animals succumbed shortly after the nadir of leukopenia at 12 days post-injection. They exhibited hypoplastic bone marrow, lymphopenia, monocytopenia and a deficit of reticulocytes consistent with a functional deficiency in hematopoietic progenitor cells. Conversely, in mice lacking NLRP1, we observed improved recovery of the hematopoietic compartment following hemoablative chemotherapy, with increases in the numbers of platelets, lymphocytes and monocytes relative to littermate controls.Severe infections are commonly associated with a range of cytopenias including anemia, lymphopenia, neutropenia and thrombocytopenia, however, the etiological triggers for these conditions have not been elucidated. We therefore infected IL-1 receptor-deficient mice homozygous for the NRLP1a activating mutation with lymphocytic choriomeningitis virus (LCMV). Relative to controls, more severe cytopenia and bone marrow hypoplasia was observed. In contrast, NLRP1-deficient animals showed enhanced recovery from LCMV. Our results suggest that activation of the NLRP1 inflammasome in hematopoietic progenitors may contribute to cytopenias induced by hematopoietic stresses such as chemotherapy or infection. Disclosures:No relevant conflicts of interest to declare.

Recurrent 6pLOH Is the Most Common Somatic Lesion in Refractory Cytopenia of Childhood and Occurs Very Infrequently in Severe Aplastic Anemia

AbstractAbstract 644Refractory cytopenia of the childhood (RCC) and severe aplastic anemia (SAA) are the most common causes of acquired hypoplastic bone marrow failure (BMF) in children. Although predisposing genetic factors and inciting immunological events had been implicated, little is known about the molecular origins of these conditions. Whole-genome scanning using single nucleotide polymorphism arrays (SNP-A) can complement standard cytogenetics in terms of the detection of submicrocopic aberrations and regions with copy number neutral loss of heterozygosity (CN-LOH).Here we present the results of an analysis of 181 children with bone marrow failure: MDS, n=106; SAA, n=41; and for hematological control, 34 patients with Diamond Blackfan anemia (DBA). To enrich for the myeloid lineage, we used granulocytes from bone marrow as source for DNA. We employed Affymetrix 6.0 arrays and used CNAG v3.3 and Genotyping Console v4.0 platforms for data analysis.To identify somatic aberrations that might have been missed by standard metaphase cytogenetics (MC), we initially looked at cases with abnormal MC, presenting as RCC or advanced MDS (n=25, median age 12.4 years). While SNP-A generally confirmed the cytogenetic lesions identified by MC, no novel recurrent somatic aberrations with pathogenic character were discovered.In the next step we focused on the analysis of RCC patients with normal karyotype (N=81, median age 10.2 years). In one case a small monosomy 7 clone was identified using SNP-A, that has been missed by standard MC. Most strikingly, 11 patients (14%) carried clones with a terminal CN-LOH of the short arm of chromosome 6 (6pLOH), with a length of 30–42Mb and various clonal size. The somatic myeloid origin was confirmed by the analysis of CD4+/CD8+ sorted T-cells in several cases. The 6pLOH lesion encompasses the HLA gene cluster leading to the loss of one HLA haplotype, has previously been reported in adults with SAA diagnosed in USA and Japan (Afable/Wlodarski, and Katagiri 2011), and was generally associated with a good prognosis.Regarding treatment modalities in RCC patients, the 6pLOH clone was overrepresented in the watch and wait (W&W) cohort: 10/55 (18%) of W&W cases carried this clone, as compared to 1/26 (4%) patient who received therapy within 6 months from diagnosis. Out of the 10 W&W patients with 6pLOH clone, only two required later therapeutic interventions (stem cell transplantation) due to progressive cytopenia at 10 and 11 months after diagnosis. The remaining 8/10 patients are still under W&W strategy with a median FUP of 6.6 (1.6.-12.2) years. In summary, all 11 RCC 6pLOH patients are alive with a median FUP of 6.6 years without disease progression. Interestingly, the 6pLOH clone survives over a long period of time, as confirmed in 2 patients in different bone marrow samples obtained 7 years apart. To answer the question if the persistence of the 6pLOH clones has an effect on telomere maintenance in the hematopoietic cell compartment, we measured telomere length using a quantitative PCR-based approach. All 11 RCC cases with 6pLOH studied had normal telomere length as compared to age-matched controls.Since the immune-mediated attack is the main operating mechanism of BMF in SAA, we next asked whether the 6pLOH clone can also arise in the bone marrow of children with SAA. We SNP-A genotyped a cohort of 41 SAA patients (median age 10.4 years) including 5 hepatitis-associated SAA (HSAA) cases. While no genomic copy number alterations were found, the somatic 6pLOH clone was discovered in only one HSAA patient, in whom the SAA developed 6 months after onset of hepatitis. When compared to the SAA patients, the 6pLOH clone is significantly more frequent in the RCC W&W cohort (P <0.04). Finally, to compare the results to a “non-immune-mediated” BMF, we analyzed 34 children with Diamond Blackfan anemia in whom no 6pLOH clone or other somatic defects were identified.In summary, 6pLOH is the most common somatic lesion found in the myeloid compartment in RCC patients and correlates with a very good prognosis. The absence of 6pLOH in children with SAA with no other associated pathologies supports the concept that RCC and SAA are two distinct entities in children. Disclosures:No relevant conflicts of interest to declare.

Predictive value of clinical and laboratory findings for overt bone marrow metastasis in patients with solid tumor.

e19529 Background: Bone marrow (BM) involvement is not a rare finding in advanced stages of solid tumors, it may have a profound influence on prognosis and affect a treatment approach. Methods: 103 patients (pts) with an advanced metastatic solid tumor were included in retrospective study. BM metastasis were diagnosed in 72 cases according to Bone marrow biopsy (BMB) ; 31 other metastatic pts. didn't have a marrow spread. We analyzed a basic demographic characteristics, localization of primary tumors and metastasis, laboratory tests, blood smears, BM aspirates (BMA) and biopsies reports.Results: Pts in both groups had comparable median age, gender distribution, pattern of primary tumor and metastatic spread. Hematological parameters' strong correlated with marrow metastasis were: anemia 83% vs. 61% p=0.015 ,thrombocytopenia 55% vs.16% p&lt;0.001 with higher MPV p=0.01, hypocellular/ dry tap marrow aspirate 58% vs.14% p=0.001 and leukoerythroblastic blood smear 82% vs.0% p&lt;0.0001. Leukoerythroblastosis(LEB) in 92% reflected hypocellular aspirate was not included in final analysis because of low rate recorder blood smears. Analysis of biochemical finding showed higher increase by 2 upper limits (&gt;2ULN) of LDH and ALP in the metastatic BM cohort: 50% vs. 16% and 35% vs. 9%, p=0.002 and p=0.007 respectively. Factors predicted metastatic BM by multivariate analysis were: thrombocytopenia &lt;50x109/L OR 14.4 95%CI (1.6-128), hypocellular BMA OR 7.0 95%CI (1.82-21.2) and alkaline phosphatase &gt;2ULN levels OR 6.5 95%CI ( 1.2-35.3). Causes which influenced the survival of pts with BM metastasis: thrombocytopenia &lt; 50X109/ L median survival 0.8 month 95% CI (0.1-1.5) vs. 4.1m 95%CI( 2.0-6.1), LDH level &gt;2ULN 1.8m 95%CI(0.5-3.0) vs.4.7m 95%CI(3.0-6.3) and tumor presenting with BM metastasis vs. previously recognized carcinoma with BM involvement 1.8m 95% CI(0.3-3.0) vs.4.0 m.95%CI(1.3-6.7).Conclusions: Our study demonstrated that thrombocytopenia , alkaline phosphatase level&gt;2ULN and probably LEB reflect hypoplastic BM predict BM metastasis in cancer patients; furthermore, thrombocytopenia, LDH&gt;2ULN and BM metastasis in a clinical presentation affect their survival.

Rabbit-antithymocyte globulin combined with cyclosporin A as a first-line therapy: improved, effective, and safe for children with acquired severe aplastic anemia

Acquired aplastic anemia is an organ-specific auto-immune disease characterized by pancytopenia and hypoplastic bone marrow. Immunosuppression with anti-thymocyte globulin (ATG) and cyclosporine A (CsA) is an effective and safe therapy for patients without undergoing hematopoietic stem cell transplantation. The aim of the current study was to investigate the effect of rabbit-ATG (r-ATG) combined with CsA as an intensive immunosuppressive therapy (IST) for acquired severe aplastic anemia (SAA) in children. From January 2003 to November 2008, 46 children (30 boys and 16 girls), with a median age of 7 years (between 2 and 15 years) were diagnosed with acquired SAA. They received an IST of r-ATG combined with CsA. The average time was 3.4 months (ranging from 1 to 13 months). The effective rates 3, 6, 9, and 12 months after treatment were 30.4, 65.2, 78.8, and 84.8%, respectively. After 2 years of follow-up, the response rate was 84.8% (39/46). No response was found in five cases and relapse was found in two. Among the five cases without response, two received unrelated hematopoietic stem cell transplantation and are already disease-free and two died from infection caused by long-term dependence on infusion. No myelodysplastic syndrome or acute myeloid leukemia was found among the patients. We propose that r-ATG combined with CsA as an intensive IST is effective and safe in treating acquired SAA in children.

CD34+ gene expression profiling of individual children with very severe aplastic anemia indicates a pathogenic role of integrin receptors and the proapoptotic death ligand TRAIL

BACKGROUND Very severe aplastic anemia is characterized by a hypoplastic bone marrow due to destruction of CD34(+) stem cells by autoreactive T cells. Investigation of the pathomechanism by patient-specific gene expression analysis of the attacked stem cells has previously been impractical because of the scarcity of these cells at diagnosis. Employing unbiased RNA amplification, patient-specific gene expression profiling was carried out for CD34(+) cells from patients newly diagnosed with very severe aplastic anemia (n=13), refractory anemia (n=8) and healthy controls (n=10). These data were compared to profiles of myelodysplastic disease (n=55), including refractory anemia (n=18). To identify possible targets of autoimmune attack, presence of autoreactive antibodies was tested in pre-therapeutic sera of patients with very severe aplastic anemia (n=19). CD34(+) gene expression profiling distinguished between healthy controls, children with aplastic or refractory anemia and clonal disease. Interferon stimulated genes such as the apoptosis inducing death ligand TRAIL were strongly up-regulated in CD34(+) cells of patients with aplastic anemia, in particular in patients responding to immunosuppressive treatment. In contrast, mRNA expression of integrin GPVI and the integrin complexes GPIa/IIa, GPIIb/IIIa, GPIB/GPIX/GPV was significantly down-regulated and corresponding antibodies were detected in 7 of 11 profiled patients and in 11 of 19 aplastic anemia patients. CONCLUSIONS As a potential diagnostic tool, patient-specific gene expression profiling of CD34(+) stem cells made it possible to make the difficult differential diagnosis of most patients with aplastic and refractory anemia. Profiling indicated a prognostic correlation of TRAIL expression and patient benefit from immunosuppressive therapy. Downregulation of integrin expression and concurrent presence of autoreactive anti-integrin-antibodies suggested a previously unrecognized pathological role of integrins in aplastic anemia.

Acute lymphoblastic leukemia of childhood presenting as aplastic anemia: report of two cases

Acute lymphoblastic leukemia is the most common malignancy in pediatric patients; its diagnosis is usually easy to establish as malignant lymphoblasts invade the bone marrow and peripheral blood. Some acute lymphoblastic leukemia patients may initially present with pancytopenia and a hypoplastic bone marrow leading to the initial diagnosis of aplastic anemia. In most of these patients clinical improvement occurs, with normalization of the complete blood count within six months, although recovery can also develop a few weeks after initiating steroid therapy. The etiologic relationship between the aplastic anemia features and the subsequent overt development of acute lymphoblastic leukemia has not been established. We describe the cases of two children who presented with severe infection and signs and symptoms of aplastic anemia confirmed by bone marrow aspirate and bone marrow biopsy that developed acute lymphoblastic leukemia thereafter. No specific therapy for aplastic anemia was administered, nevertheless a full spontaneous recovery was observed in both cases. Acute lymphoblastic leukemia was successfully treated with standard chemotherapy, both children remaining in complete remission 16 and 17 months after their initial aplastic anemia diagnosis.

Comparison of Clinical Outcome Between Children with Aplastic Anemia and Refractory Cytopenia of Childhood Who Received Immunosuppressive Therapy with Antithymocyte Globulin and Cyclosporine

Abstract 53▪▪This icon denotes a clinically relevant abstractThe revised 2008 WHO classification contains the newly proposed term, “refractory cytopenia of childhood (RCC)”. This term applies to children with myelodysplastic syndrome (MDS), which is characterized by a low blast count. RCC is defined as persistent cytopenia with <5% blasts in the bone marrow and <2% blasts in the peripheral blood. In addition, bone marrow aspirate smears need to show dysplastic changes in >2 cell lineages or >10% within 1 cell lineage. The distinction between RCC and aplastic anemia (AA) is normally difficult to make, especially when the bone marrow is hypoplastic and no chromosomal abnormalities can be detected. The spectrum of patients defined as having RCC is quite wide. Cases range from patients with severe hypocellular marrow and mild dysplasia in hematopoietic cells to patients with normocellular marrow and severe dysplasia that meets the criteria of refractory cytopenia with multilineage dysplasia (RCMD) in adult MDS. However, there are few studies that have focused on the difference between these two diseases.Therefore, in order to determine the specific clinical differences between AA and RCC, we retrospectively reviewed bone marrow samples of 117 bone marrow failure syndrome children (males: 69, females: 48) who were administered the same immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporine. These patients were classified into AA, RCC and RCMD groups. AA patients exhibited no morphologically dysplastic changes in any of their hematopoietic cell lineages, while RCC patients had <10% dysplastic changes in >2 cell lineages, or >10% in 1 cell lineage. Patients classified as RCMD exhibited >10% of the dysplastic changes in >2 cell lineages. In accordance with the internationally defined criteria for AA, patients were further subdivided on the basis of severity, with 26 classified as non-severe, 35 as severe and 56 as very severe. At the time of initial presentation, 16 patients had a history of acute hepatitis, while one patient had the chromosomal abnormality 49,XY,+8,+16,+18.Out of the 117 patients enrolled, 58 (50%) were classified as AA, 47 (40%) as RCC and 12 (10%) as RCMD. AA and RCC patients tended to exhibit severe hypoplastic bone marrow cellularity, while the RCMD patients were normal or only exhibited mild hypoplastic marrow. The median ages in the AA, RCC, and RCMD groups were 9, 8 and 10 years, respectively. While most of the patients in the AA group (73%) had very severe disease, more than half of the RCMD patients (58%) only had non-severe disease (p<0.001). New chromosome abnormalities were detected in six patients in the AA group (monosomy 7: 4 cases, trisomy 8: 1 case, and 45,X,-X: 1 case), in one patient in the RCC group (46,XX,add(1)(q32),del(13)(q?),del(15)(q?)), and in four patients in the RCMD group (trisomy 8: 3 cases, monosomy 7: 1 case). Cumulative incidence (CI) of clonal evolution at 8 years was 10.9±4.2% in AA, 2.2±2.2% in RCC and 35.7±14.6% in RCMD (p=0.003) (Figure 1). At 6 months after IST, the response rates were 65% in AA, 70% in RCC and 58% in the RCMD group. Failure free survival (FFS) and overall survival (OS) rates at 5 years were 64.1±6.5/94.8±2.9% in AA, 60.4±7.3/97.9±2.1% in RCC and 56.3±14.8/100% in the RCMD group, respectively. A second therapeutic intervention was required in some children, with a second IST performed in eight children (3 in AA and 5 in the RCC group) and hematopoietic stem cell transplantations performed in 25 children (14 in AA, 9 in RCC and 2 in the RCMD group).Since the RCMD group exhibited a significantly high CI for clonal evolution, this suggests that the RCMD criteria should be applied to childhood MDS. However, the FFS and OS rates did not differ among these three groups. Thus, in order to definitively determine whether these three diseases are different entities, it will be necessary to use newly developed methods, such as whole exome analysis, to prospectively compare the clinical outcomes and biological findings in a larger number of the AA, RCC and RCMD patients. Disclosures:No relevant conflicts of interest to declare.

Pesticide induced marrow toxicity and effects on marrow cell population and on hematopoietic stroma

Long term inhalation of toxic pesticides used for the domestic and industrial purposes have been shown to cause moderate to severe hematotoxicity and increased incidence of several marrow degenerative diseases, specifically hypoplastic bone marrow failure condition in humans. The progression of pesticide induced hematotoxicity and the exact underlying mechanisms of toxicity that play major role in limiting normal hematopoiesis are not quite well explained. In this present study, we have developed an animal model of hypoplastic bone marrow failure following pesticide exposure to show the deleterious effects of toxic pesticides on mouse hematopoietic system. Here we have presented the results of studying long-term marrow explant culture, IL-2, IL-3 and IL-5 receptors expression profile, fibroblast colony forming unit (CFU-F), hematopoietic progenitor cell colony formation and caspase-3 expression by the bone marrow cells. We have also identified the expression levels of several extracellular apoptosis markers (CD95/Fas) and intracellular apoptosis inducer proteins (pASK1, pJNK, caspase-3 and cleaved caspase-3) in the bone marrow cells of pesticide exposed mice. The long-term marrow explant culture demonstrated the impairment in proliferation of the stromal cells/stromal fibroblasts in culture. Decreased IL-2, IL-3 and IL-5 receptors expression profile essentially hinted at the suppressed cytokine activity in the pesticide exposed marrow. CFU-F analysis showed the defect in functional maturation of the stromal fibroblasts. The decreased hematopoietic progenitor cell colony formation indicated the toxicity induced inhibition of cellular proliferation and functional maturation of hematopoietic stem/progenitor cells in pesticide exposed marrow. We have detected a sharp increase in the expression levels of both the extracellular Fas-antigen and intracellular apoptosis inducer proteins in the bone marrow cells of pesticide exposed mice that explained well, the apoptosis pathway involved following marrow toxicity. The decreased proliferation and functional maturation of marrow stromal cells and hematopoietic progenitors with subsequent increase in marrow cellular apoptosis following pesticide toxicity provided the base necessary for explaining the increased incidence of hypoplastic bone marrow failure in humans exposed to moderate to high concentrations of pesticides.

Acute Parvovirus B19 Infection Leading to Severe Aplastic Anemia in a Previously Healthy Adult Female

Human Parvovirus B19 has been linked to a variety of diseases. One of the most common complications is transient aplastic crisis in patients with chronic hemolytic anemia. Very few case reports have implicated this virus as a putative etiology behind hepatitis and severe aplastic anemia in immuno competent individuals. We report a case of severe aplastic anemia in a previously healthy adult female due to acute parvovirus B19 infection. Laboratory examination showed pancytopenia in peripheral blood and severe hypoplastic bone marrow on biopsy. Serological analysis (ELISA) revealed acute Parvovirus B19 infection. In the face of unavailable HLA matched bone marrow donor, immuno-supressive therapy was contemplated, but could not be given because of financial constraints. Pancytopenia persists till date, 4months after the diagnosis, with the patient requiring repeated packed red cell and irradiated platelet transfusions. Thus, acute infection with this virus must be considered a cause of acquired aplastic anemia even in individuals without underlying disease.

A Recurrent Pattern of Acquired Genomic Abnormalities In Myelodysplasia and Leukemia of Fanconi Anemia Includes Cryptic RUNX1/AML1 abnormalities

AbstractAbstract 975Fanconi anemia (FA) is a rare genetic condition characterized by congenital abnormalities, chromosome fragility, progressive bone marrow failure during childhood, and cancer susceptibility. FA patients experience a high risk to develop myelodysplasia (MDS) and secondary-type acute myeloid leukemia (AML) during their teens or in young adulthood. Severity of the cytopenia, excess of blast cells and presence of a cytogenetic clone in the bone marrow are usual criteria to undertake hematopoietic stem cell transplantation. In order to investigate the pattern of chromosomal and genomic abnormalities during bone marrow progression in FA and their association to MDS/AML, we analyzed bone marrow samples from FA patients using a wide panel of chromosomal and molecular techniques including DNA microarrays and oncogene sequencing. This series of FA patients was enriched in patients older than 18 year-old and/or with morphological or karyotypic abnormalities on the follow up BM aspirate. 57 FA patients were included, aged 4 to 57 yo (median 18); FA groups were FA-A (n=49), FA-G (n=1), FA-D2 (n=1), FA-D1 (n=1) and undertermined (n=5). Bone marrow morphology was hypoplastic/aplastic anemia (n=20), MDS (n=18, mainly RCMD and RAEB according to the WHO 2008 classification), AML (n=11), or no abnormality except the usual mild dyserythropoiesis of FA (n=8). Bone marrow samples were analyzed by karyotype, FISH, high density array-CGH and/or SNP-arrays with respect to the paired fibroblast DNAs, and by sequencing of selected oncogenes and tumor suppressor genes. A specific pattern of genomic abnormalities due to unbalanced translocations was found in the 29 MDS/AML, which included 1q+ (44.8%), 3q+ (41.3%), -7/7q (17.2%), and 11q- (13.8%). Moreover, cryptic abnormalities (translocations, deletions or mutations) of the RUNX1/AML1 gene were evidenced for the first time in FA, in 6 out of the 29 patients with MDS or AML (20.7%). By contrast, mutations of FLT3-ITD, MLL-ITD, and N-RAS, but not TP53, CBL, TET2, CEBPa, NPM1, and FLT3-TKD, were rarely found. Frequent homozygosity regions were evidenced by SNP-array in 11 patients, but the analysis of the paired fibroblast DNA and the constitutional FANC mutations demonstrated that they were not related to somatic copy-neutral loss of heterozygosity but to consanguinity. Importantly, the RUNX1/AML1 and other chromosomal/genomic abnormalities were found at the MDS and AML stages only, except for 1q+ which could be found at any stages including normal bone marrow morphology. In our experience 1q+ does not predict systematically a transformation into MDS/AML in the following years. These data have important implications, not only for the cytogenetic staging of the bone marrow cells in FA patients with an impact for therapeutic managing, but also as a basis to investigate the multistep clonal selection and related oncogenesis in patients with hypoplastic bone marrow and genomic instability, with potential relevance for non-FA patients. Disclosures:Gluckman:Cord-use: Membership on an entity's Board of Directors or advisory committees.

Idiopathic neutropenia with fewer than 5% dysplasia may be a distinct entity of idiopathic cytopenia of undetermined significance

Dear Editor, A condition marked by fewer than 10% of dysplastic cells and fewer than 5% of blasts in the bone marrow (BM) is now categorized as idiopathic cytopenia of undetermined significance (ICUS); if clonal cytogenetic changes are detectable in ICUS patients, the diagnosis can be changed to myelodysplastic syndrome (MDS) [1]. This categorization is very practical and clear-cut in separating MDS from those with low-grade dysplasia [1], and it thus became possible to analyze the clinical and hematologic features to differentiate refractory cytopenia with unilineage dysplasia (RCUD) from ICUS. However, only a single report dealing with possible ICUS with dysplastic features in each cell lineage appears to exist, that by Wimazal et al. [2]. We therefore focused on cytopenia patients with fewer than 5% of BM blasts and reassessed the dysplastic features, in combination with the cytogenetic results, to shed light on low-grade dysplasia. From 1994 to 2008, we performed BM examinations with cytogenetic studies in 445 patients with cytopenia, 237 of whom were given diagnoses of MDS or suspected MDS. As well as we could, we used the initial BM examination to rule out the possibility of other underlying disorders inducing cytopenia, and as a result, 137 patients with fewer than 5% marrow blasts were enrolled in this study. Of these 137 patients, 56 who were followed for more than 6 months and for whom specimens were available for reanalyzable marrow films (200 cells being examined in each cell lineage) were used in this study [3, 4]; two patients with hypoplastic BM without cytogenetic changes were excluded from this study since we could not completely rule out the possibility of low-grade aplastic anemia. In this study, we reassessed the bone marrow films for 16 patients with ICUS (Electronic supplementary materials, File 1), 16 with RCUD (Electronic supplementary materials, File 2), and 22 patients with refractory cytopenia with multilineage dysplasia (RCMD; Electronic supplementary materials, File 3). No particular difference in the peripheral blood data was found among patients with ICUS, RCUD, and RCMD. RCUD patients had more dysgranulopoietic cells than those with ICUS (16.7± 19.4% vs 3.5±3.3%, P=0.0116) because of the presence of hypogranular neutrophils or pseudo-Pelger anomaly, while no significant difference in percentages of dyserythropoietic cells was noted (P=0.1809; Electronic supplementary materials, File 4). This indicates that ICUS patients can usually be diagnosed from the absence of prominent dysgranulopoiesis. We then separated the ICUS patients into two groups according to the percentages of dysplastic cells (Table 1). ICUS patients with fewer than 5% dysplastic cells in at least one cell lineage had a significantly lower absolute neutrophil count than those with 5% to 9% of dysplastic Electronic supplementary material The online version of this article (doi:10.1007/s00277-009-0845-0) contains supplementary material, which is available to authorized users. K. Ando : T. Iwabuchi :K. Ohyashiki (*) The First Department of Internal Medicine (Hematology Division), Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan e-mail: ohyashik@rr.iij4u.or.jp

妊娠初期に急性骨髄性白血病を発症し，増悪期に赤芽球症，無顆粒細胞症，骨髄低形成を伴った未熟児を出産した1例

妊娠初期に急性骨髄性白血病を発症し，増悪期に赤芽球症，無顆粒細胞症，骨髄低形成を伴った未熟児を出産した1例

The Favorable Outcome of Allo-HCT from MUD Following Treosulfan-Based Conditioning in Paroxysmal Nocturnal Hemoglobinuria

Although allo-HCT has a potential to cure patients with paroxysmal nocturnal hemoglobinuria (PNH), experience with allo-HCT from matched unrelated donors (MUD) is limited and favorable conditioning treatment for PNH has not been established. We report results of 8 allo-HCTs from MUD (matched in HLA-A,B,C,DR,DQ alleles) performed for PNH with treosulfan-based conditioning in years 2004–2008 in Katowice, Poland. Median age of recipients was 27 years (range 20–35) and donors 33(28–43), median time from diagnosis to transplantation was 20(15–36) months. Median size of PNH clone was 90% granulocytes (range 4%–95%), 4 donors were female and their recipients were male, AB0 incompatibility was minor in 5 pairs, major in 1 and bi-directional in 1 pair. Indication for transplantation despite severe refractory hemolysis with transfusion-dependency (observed in 6 pts) was aplastic or hypoplastic bone marrow and pancytopenia (5 pts), MDS (1 pt), severe course of PNH exacerbating with hemolytic crises (1 pt). Additional risk factors included thrombotic history with Budd-Chiari syndrome and hepatosplenomegaly (1 pt), history of renal insufficiency requiring hemodialyses (1 pt) and additional serological risk factors for hemolysis (1 pt). The preparative regimen consisted of treosulfan 3×14 g/m2 plus fludarabine 5×30 mg/m2 (7 pts) and treosulfan 2×10 g/m2 plus cyclophosphamide 4×40 mg/kg (1 pt). GVHD prophylaxis consisted of thymoglobuline 3×2 mg/kg pretransplant, cyclosporine-A 3 mg/kg/d since day -1 and methotrexate on days 1,3,6,(11). Transplanted cells were harvested from bone marrow (5 donors) and peripheral blood (3 donors) with median numbers 3.0 and 10.9 ×10(8)NC/kg, 3.0 and 6.9 ×10(6)CD34+ cells/kg, 27.5 and 427.7 ×10(6)CD3+ cells/kg, respectively. Myeloablation was complete in all pts with median 10 days (5–14) of absolute agranulocytosis <0.1 G/l. Median number of transfused RBC units was 7 (1–12) and of single-donor platelets units 9 (3–15). All pts engrafted, median granulocyte count of 1.0 G/l was achieved on day 17 (12–22), platelets 50 G/l on day 21 (9–30) and Hb 10 g/dl on day 30 (16–50). No serious acute GVHD was observed, grade I was transiently present in 4 pts and grade II in 3 pts. Transient limited chronic GVHD was observed in 2 pts. Hemolysis gradually decreased. 100% donor chimerism was present in the bone marrow on day +100 at latest in all pts. 1 previously hemodialysed pt died on day 102 in a consequence of nephrotoxicity complicating adenoviral/CMV haemorrhagic cystitis. Complications in survivors included FUO (2 pts), CMV reactivation (2), VOD (1), neurotoxicity (1), venal thrombosis (1), hemorrhagic cystitis (1) and mucositis (1). 7 pts (87.5%) are alive and are currently doing well under ambulatory control with no signs of hemolysis and without need for further hematological treatment, median follow-up is 23 months (2–44). Complete disappearance of PNH clone was confirmed by flow cytometry in all surviving pts. We conclude that MUD allo-HCT with treosulfan-based conditioning can be effectively and relatively safely used in PNH patients and thus it should be considered as a valuable therapeutic option in PNH.

90y-Ibritumomab Tiuxetan Treatment for Relapsed and/or Refractory B-Cell Non- Hodgkin'S Lymphoma. Multi-Institutional Argentinian Study. An Update

Background: 90Y-ibritumomab tiuxetan (Zevamab®; ZEV; Bayer-Schering Pharma- Argentina) has been approved for the treatment of relapsed, refractory and transformed (high grade) follicular lymphomas.Methods: Between Sep. 2005 and Feb. 2008, 45 patients (pts) [22 F & 23 M; median age 62 yrs (45–83)] with refractory/relapsed lymphoma were enrolled.Diagnoses: 37 follicular lymphoma (FL), 5 were mantle cell lymphoma (ML) and 3 transformed lymphoma (TL); 18 pts had bulky disease, 8 had bone marrow involvement and 21 had stage III–IV disease. Median time from diagnosis was 5 yrs (0.5– 29). Twenty two pts had received 1–2 previous treatments, and 23 pts had received 3–5 previous treatments including 5 pts with autologous bone marrow transplantation. All had previously received anti-CD20 monoclonal antibody therapy. Six pts received previous radiotherapy. ZEV was administered at 0.3 or 0.4 mCi, based on initial platelet count. Seven days before, and the same day of the ZEV administration, pts received standard rituximab 250 mg/m2. In 3 pt, ZEV was part of the conditioning regimen of autologous bone marrow transplantation.Results: Forty pts were evaluable for response: 34 (86%) pts responded – 19 CR (48%), 15 PR (38%). Overall survival and PFS for the entire group at 18 months was 63% and 37% respectively, with a median follow-up of 12 months (1–29 months). Of the 45 patients, 5 pts (11%) had died before third month and response was not assessed, 6 pts (13%) did not respond, 3 (7%) died with response from other causes, 14 pts (31%) responded and subsequently relapsed. Finally 17 pts (38%) continue to be in response, 9 (20%) lasting more than twelve months (long lasting responders). Slight differences in duration of response and survival were observed between FL vs ML and TL favouring FL (RR 2.047). Forty six per cent of pts required filgrastim for neutropenia, 24% required platelet transfusions, 22% had neutropenia plus fever and were admitted for complicated pancytopenia, and 20% required red blood cells transfusion. Two patient died 30 & 40 days after treatment with hypoplastic bone marrow complicated with sepsis in the post autologous bone marrow transplantation period. Four pts with previous bone marrow transplantation required filgrastim, transfusions and 2/3 had febrile neutropenia.Conclusion: Our experience with ZEV in relapsed and refractory FL shows 48 % CR. Even heavily treated pts that had previous bone marrow transplantation were able to receive ZEV, although they required extra support. Our experience supports the use of ZEV in relapsed and refractory lymphomas even after autologous bone marrow transplantation.

Rhabdomyolysis and pancreatitis associated with coadministration of danazol 600 mg/d and lovastatin 40 mg/d

Background: Danazol is a steroid analogue with anabolic and androgenic effects and is indicated for the treatment of endometriosis, fibrocystic diseases of the breast, and hereditary angioedema. Lovastatin has been prescribed to lower total cholesterol and low-density lipoprotein cholesterol, reducing cardiovascular-related morbidity and mortality in patients with hypercholesterolemia. As monotherapies, both danazol and lovastatin have been reported to induce myopathy and pancreatitis. Case summary: A 59-year-old Asian woman (height, 155 cm; weight, 54 kg; and body mass index, 22.5 kg/m2) presented to the outpatient neurology clinic with acute progressive quadriparesis and generalized myalgia (without focal sensory loss, numbness, dizziness, diplopia, dysarthria, dysphagia, or sphincter incontinence), lasting for 5 days. She was admitted to the National Cheng Kung University Hospital, Tainan, Taiwan. The patient's medical history revealed multiple comorbidities (eg, end-stage renal disease, hypertension, diabetes mellitus) for which she was receiving concomitant medication. Her medication history revealed that at the time the patient presented, she was also receiving calcium bicarbonate 1500 mg/d, labetalol 100 mg/d, and glipizide 10 mg/d in the treatment of her other comorbid illnesses. The patient was also receiving alprazolam 0.5 mg/d for insomnia. Her medical records also revealed that lovastatin 40 mg/d (a particularly high dose and not recommended) had been administered for 7 weeks, and danazol 600 mg/d was added (∼15 days later) to treat thrombocytopenia due to hypoplastic bone marrow. Laboratory findings revealed elevated creatine kinase (68,193 U/L), elevated pancreatic enzymes (amylase/lipase, 361/2788 U/L), and elevated liver enzymes (aspartate/alanine aminotransferase, 1496/1493 U/L), consistent with rhabdomyolysis and pancreatitis. After discontinuation of both drugs, the symptoms improved 5 days after admission and completely disappeared 1 month after admission. In addition, laboratory abnormalities completely normalized ∼2 months after admission.Danazol was resumed to treat persistent thrombocytopenia, while lovastatin was replaced with ezetimibe 10 mg QD to treat high cholesterol (dyslipidemia). Conclusion: The coadministration of high-dose lovastatin and danazol was probably associated with rhabdomyolysis and pancreatitis in this patient with multiple underlying comorbidities for which concomitant medications were being administered.