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`Processed: 11/23/15
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`HSRS
`
`* Haematologica - RESEND
`
`Journal Title: Haematologica.
`
`Volume: 84
`Issue: 8
`
`MonthlYear: August1999
`
`Pages: 767—8+TOC+cvrw/acq
`datestamp
`
`Article Author: Carrasco et al.,
`
`Article Title: Acute megaloblastic
`anemia: homocysteine levels are useful
`for diagnosis and fo||ow—up.+TOC+acq
`date stamp on cover
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`ll Pensiero Scientifico,
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`Imprint: Roma :
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`
`Scientific correspondence
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`Figure 1. Light scatter properties of analyzed cells (top).
`The flow cytometric dot plots clearly show that virtually all
`CD19* cells are positive for CD5 antigen and there are two
`cell populations with different HLA—DR antigen expression
`pattern. CD33 antigen ls found to be the only antigen that
`expressed more than 50% of the ‘cells and most of them are
`negative for HLA-DR antigen.
`
`nosis but we do not have any doubts about the diag-
`nosis because more then 10><10°/L cells expressed
`CD5, CD19, CD20 and CD22 (Figure 1).
`The concomitant presentation OFAML and CLL is
`extremely rare and the use olrtwo-color flow cytom—
`etry to diFFerentiate the cell populations demon-
`strates the utility otthis technology in the diagnosis
`ofunusual hematologic malignancies.
`Mustafa Nuri Yenerel, * Ibrahim Hatemi, ° Hiiseyin Keskin*
`*IstanbuI University, Istanbul Medical School, Department of Inter-
`nal Medicine, Divisian of Hematology, Capa, Istanbul; °HasekI
`State Hospital, Hasekl, Istanbul, Turkey
`
`Key words
`CCL, AML, flow cytometry.
`.
`correspondence
`Mustafli Nuri Yenerel, MD, Istanbul University, Istanbul
`Medical School, Department of/nternal Medicine, Division
`of Hematology, Capri, Istanbul, Turkey. Fax." international
`+902 72. 637 7263.
`
`ll‘
`Ifl
`yr
`
`
`
`I I
`
`References
`
`1. Caballero MD, Gonzalez M, Canizo MC, Orfao A,
`Nieto M], San-Miguel_lF. Concomitant chronic lym-
`phocytic leukemia (CLL) and acute myeloid leukemia.
`Complete remission of CLL achieved with high-dose
`cytosine arabinoside. Leukemia 1992; 62856-8.
`2. Conlan MG, Mosher DF. Concomitant chronic lym-
`phocytic leukemia, acute myeloid leukemia, and
`thrombosis with protein C deficiency. Case report and
`review otthe literature. Cancer 1989; 63:1398—401.
`3. Rai KR, Patel DV. Chronic lymphocytic leukemia. In
`HoITman R, Benz Ej.Jr, Shattil SJ, Furie B, Cohen HJ,
`Silberstein LE (eds): Hematology: Basic Principles and
`Clinical Practice. 2nd ed. Curchill Livingstone, New
`York, 1995, p 1308.
`4. Lima M, Porto B, Rodrigues M, et al. Cytogenetic find-
`ings in a patient presenting simultaneously with chron-
`ic lymphocytic leukemia and acute myeloid leukemia.
`Cancer-Genet Cytogenet 1996; 87:38-40.
`5. Mateu R, Bellido M, Sureda A, et al. Concomitant
`chronic lymphocytic leukemia and acute myeloid
`leukemia with an uncommon immunophenotype. Am
`J Hematol 1997; 56:281.
`6. Tamul KR, Meyers DC, Bentley SA, FoldsjD. Two col-
`or flow cytometric analysis of concomitant acute
`myeloid leukemia and chronic lymphocytic leukemia.
`Cytometry1994; 18230-4.
`
`Acute megaloblastic anemia: homocysteine
`levels are useful for diagnosis and follow-up
`
`Sir,
`Vitamin B12 (cobalamin) and Folic acid deficiencies
`lead to megaloblastic anemia (MA), and induce
`accumulation of methylmalonic acid (MMA) and
`homocysteine (HCY).l The most common presenta-
`tion OFMA is classical macrocytic anemia. Other pre-
`sentations are acute megaloblastosis (AM) and
`masked megaloblastosis.” In this report, we present
`a case OFAM diagnosed and Followed up by evalua-
`tion oFHCYlevels.
`
`A 45-year old male was diagnosed as having
`Philadelphia—positive chronic myelogenous leukemia.
`Three years aicter diagnosis the patient developed a
`lymphoid blast crisis and was started on a chemo-
`therapy protocol. The first consolidation treatment
`consisted oF6—mercaptopui'ine, methotrexate (MTX),
`VM—26 and cytarabine. MTX rescue with Folinic acid
`was performed Following standard guidelines. On day
`+14 a platelet count oF9><1 O9/L was Found. Hb was
`99 g/L, mean corpuscular volume (MCV) 92 ll and
`leukocyte count was 7.O6><1O9/L with 84% of neu-
`trophils with hypersegmentation. Reticulocyte count
`was 0.053><10‘Z/L (1.66%). Vitamin B12 levels and
`red cell Folate were 322 pmol /L (normal 150-1200)
`and 938 nmol/L(normal 441-1285), respectively. A
`BM aspirate revealed 30% of erythroid precursors
`with megaloblastic features and a 55% of myeloid
`precursors with increased size and no blast cells.
`Serum HCYlevels were 38 pmol/L(normal<16).The
`
`l'liaien)atoi|ogiica”vo|i. 84(8):August 1999
`
`Teva — Fresenius
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`Exhibit 1038-00002
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`

`
`
`
`768
`
`Scientific correspondence
`
`Table 1. Evolution of analytical parameters during folinic
`acid and vitamin B12 treatment.
`
`Pre-treatment Onset
`Day -9
`Day 0
`
`Post-treatment
`Day +9
`
`Platelets (x109/L)
`Leukocytes (X109/L)
`Hemoglobin (g/L)
`MCV (fL)
`Reliculocytes (X1011/L)
`Homocysteme (tlm0l/L]
`
`134
`6.76
`91
`93
`0.037
`—
`
`9
`7.06
`99
`92
`0.053
`38
`
`112
`5.72
`95
`95.3
`0.163
`9
`
`AM, aculc mugaiobiastosis: MCl/T,mean corpuscular volume.
`
`patient was diagnosed as having AM and began
`treatment with folinic acid 12 mg iv in one single dose
`and folic acid 5 mg/day po for 14 days and par-
`enteral vitamin B12 2 mg/day for 4 consecutive days.
`After 10 days of treatment
`the platelet count
`increased to 112><1O9/L and reticulocyte count to
`O.163><10‘3/L (5.41%). Vitamin B12 level was 716
`pmol/L, red cell folate level 1,506 nmol/L and serum
`HCY level decreased to normal value (9 umol/L)
`(Table 1).
`Four different clinical forms of megaloblastosis
`have been described.“ The classical form has an
`
`insidious onset with Frequent neurologic symptoms
`and macrocytic anemia. Vitamin B12 and/or red cell
`folate levels are decreased. The second form is the
`
`subtle MA anemia with ill—defined clinical symptoms
`and decreased or borderline vitamin B12 and folic acid
`levels with other abnormalities (dUST, HCY, MMA)?
`Masked megaloblastosis coexists with other defi-
`ciencies; MCV is normal or decreased.” MA ofacute
`onset is the rarest form? There are two clinical pre-
`sentations; the masked undiagnosed classical MA
`with cytopenias of abrupt onset and the so-called
`AM.“ In AM severe thrombocytopenia develops in 1
`to 3 weeks, MCV is normal or only moderately
`increased. This presentation is more Frequent
`in
`patients with risk Factors: parenteral nutrition, infec-
`tion, dialysis or treatment with some antifolate drugs.
`Mortality is high.’ The reticulocyte count is low. Vit-
`amin Bu and red cell folate levels are normal. BM
`aspirate shows megaloblastic changes. Classically,
`dUST is used as a diagnostic test. Nevertheless, HCY
`serum assays provide a sensitive test for the diagno-
`sis ofAM, especially in its early stages.“ in vitamin B12
`deficiences both HCY and MMA levels are high.
`In
`
`folate deficiencies only HCY concentration is
`increased?” HCY levels are also useful forAM follow-
`up ofAM; levels return to normal after starting treat-
`ment with vitamin B12 or folic acid. The evaluation of
`serum HCY levels is an easy and non—invasive test for
`the diagnosis and follow—up OFAM.
`Marina Carrasco, Angel Remacha, Anna Sureda,
`Pilar Sarda, Rodrigo Martino, Jorge Sierra
`Department of Hematology, Hospital de la Santa Creu i Sant Pau,
`Barcelona, Spain
`
`Key words
`Acute megaloblastosis, fin/ic acid, cobalamin, homocysteine
`Correspondence
`Angel Remaclia Sevilla, MD, Laboratorio de Hematolog/a,
`Hospital de la Santa Creu i Sant Pan, Antoni Maria i Claret,
`767, 08025 Barcelona, Spain. Phone: international +34-
`93-2979290 — Fax: international +34-93-2919792 —— E-
`mail: 2107@hsp.santpau.e5
`
`References
`
`1. Green R. Metabolite assay in cobalamin and folate
`deficiency. Bailliére Clin Haematol 1995; 8:533-66.
`2. Carmel R. Subtle cobalamin deficiency. Ann intern
`Med 1996; 124:338-40.
`3. Remacha A, Gimferrer E. Las megaloblastosis agudas:
`revision y reconsideracion conceptual de las distintas
`formas de presentacion de las megaloblastosis. Biol
`Clin Hematol1984;6:167—82.
`4. Carmel R. Pernicious anemia. The expected findings of
`very low serum cobalamin levels, anemia, and macro-
`cytosis are often lacking. Arch intern Med 1988;
`'l48:17'l2-4.
`5. SpivakJL. Masked megaloblastic anemia. Arch Intern
`Med 1982; 142121114.
`6. Bennett M, Koren A, Ludacer E. B12 deficiency in (X-
`thalassemia. N Englj Med 1984; 31021058-9.
`7. Martinez E, Remacha A, Roca-Cusachs A. Acute exac-
`erbation offolate—dependent chronic megaloblastosis.
`Biol Clin Hematol. 1992; 14:223~9.
`8. Vester B, Rasmussen K. High performance liquid chro-
`matography method for rapid and accurate determi-
`nation of homocysteine in plasma and serum. Eur]
`Clin Chem Clin Biocherm. 1991; 291549-54.
`9. Allen RH, StablerSP, Savage DG, Lindenbaumj. Diag-
`nosis of cobalamin deficiency: I: usefulness ofserum
`methylmalonic acid and total homocysteine concen-
`trations. Amj Hematol 1990; 34: 90-8
`10. Lindenbaumj, Savage DC, Stab|erSP,Allen RH. Diag-
`nosis ofcobalamin deficiency: ll: relative sensitivities
`of serum cobalamin, methylmalonic acid and total
`homocysteine concentrations. Am] Hematol 1990,
`34299-107.
`
`Haematologica vol. 84(8):August 1999
`
`Teva — Fresenius
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`
`Haematologica 1999; vol. 84, no.8
`
`Contents
`(indexed by Current Contents/Lite Sciences and in Faxon Finder and Faxon XPRESS. also available on diskette with abstracts)
`
`editorial, comments and views
`
`Favorable impact of low-dose fludarabine plus
`epirubicin and cyclophosphamide regimen (FLEC) as
`treatment for low-grade non-Hodgkln’s lymphomas
`Monica Bocchia, Catia Bigazzi, Silvia Marconcini,
`Francesco Forconi, Giuseppe Marotta, Renato Algeri,
`Francesco Lauria .
`.
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`.
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`. 716-720
`
`Effect of adenoslne derivatives on thrombus formation
`in vitro induced by shear stress
`Marzla Menegatti, Gloria Cristalli, Luciana Ga/lo,
`Pier Mannuccio Mannucci, Francesco l. Pareti . 721-725
`
`Lipoprotein(a) concentration is not associated with
`venous thromboembolism in a case control study
`Giuseppe Lippi, Antonella Bassi, Giorgio Brocco,
`Franco Manzato, Maddalena Marini,
`Giancesare Guidi .
`.
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`. 726-729
`
`decision making and problem solving
`
`Long-term cost-effectiveness of low molecular weight
`heparin versus unfractionated heparin for
`the prophylaxis of venous thromboembolism
`in elective hip replacement
`Monia Marchetti, Nicola Lucio Liberato, Nicola Ruperto,
`Giovanni Barosi .
`.
`.
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`. 730-737
`
`trends in hematology
`
`Placental/umbilical cord blood transplantation
`Girolamo Sirchia, Paolo Rebulla .
`.
`.
`.
`.
`.
`.
`.
`.
`.
`. 738-747
`
`the irreplaceable image
`
`Homozygous form of the Pelger-Huét anomaly
`Jesus Gastearena Erice, Jose Maria Arguifiano Pérez,
`Francisco Sala Pericas .
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`. 748
`
`Bllobulated clrculatlng lymphocytes In persistent
`polyclonal B-cell lymphocytosis
`Sole-dad Woessner, Lourdes Florensa,
`Blanca Espinet .
`.
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`. 749
`
`Atypical clinical presentation of visceral leishmaniasis
`José-Ange/ Hernandez, Maria Alba Bosch,
`Goretti Sauca .
`.
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`.
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`. 750
`
`{
`
`Teva — Fresenius
`
`Exhibit 1038-00004
`
`How safe is hydroxyurea in the treatment
`of polycythemia Vera? .
`.
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`. 673-674
`
`I A
`
`utologous bone marrow transplantation
`for chronic myeloid leukemia .
`.
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`.
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`. 674
`
`original papers
`
`Short-term, serum-free, static culture of cord blood-
`derived CD34‘ cells: effects of FLT3-L and MIP-1a
`on in vitra expansion of hematopoietic progenitor cells
`Gemma Capmany, Sergi Querol, Jose Antonio Cancelas,
`Joan Garcia .
`.
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`. 675-682
`
`Peripheral T lymphocyte cytokine profile (IFN'y, IL-2,
`IL-4) and CD30 expression/release during measles
`infection
`Fabrizio Vinante, Mauro Krampera, Lorella Morosato,
`Antonella Rigo, Sergio Romagnani.
`Giovanni Pizzolo .
`.
`.
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`. 683-689
`
`3q21 and 3q26 cytogenetic abnormalities in acute
`myeloblastic leukemia: biological and clinical features
`Nicoletta Testoni, Gabriela Borsaru, Giovanni Martinelli,
`Cristina Carboni, Deborah Ruggeri. Emanuela Ottaviani,
`Susanna Pelliconi, Paolo Ricci, Rocco Pastano, Giuseppe
`Visani, Alfonso Zaccaria, Sante Tura .
`.
`.
`.
`.
`.
`.
`. 690694
`
`Cleavage of the ALL1 gene in acute lymphoid
`leukemia before treatment disappears in relapse
`Eduardo Anguita, Ana Villegas, Anna Serra,
`Fernando Ataulfo Gonzalez, Paloma Ropero,
`Trinidad Contra, Giuseppe Saglio .
`.
`.
`.
`.
`.
`.
`.
`
`.
`
`. 695-698
`
`Outcome of biphenotypic acute leukemia
`Sally Killick, Estella Matures, Ray L. Powles.
`Mike Hamblin, John Swansbuiy. Jennifer G. Treleaven,
`Athanasios Zomas, Ayad Atra, Daniel Catovsky . 699-706
`
`A prospective study of or-interferon and autologous
`bone marrow transplantation in chronic myeloid
`leukemia
`The Italian Cooperative Study Group on Chronic Myeloid
`Leukemia. Writing committee: Giovanna Meloni,
`Domenico Russo, Michele Baccarani. Nicoletta Testoni,
`Giovanni Martinelli, Renato Fanin, Eliana Zuffa,
`Gianantonio Rosti, Giuliana Alimena, Giuseppe Saglio,
`Franco Mancielli, Sante Tura .
`.
`.
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`.
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`. 707-715
`
`Teva – Fresenius
`Exhibit 1038-00004
`
`

`
`
`
`scientific correspondence
`
`lmmunosuppression due to MACOP-B does not seem
`to cure the antiphospholipid syndrome
`Piero Maria Stefani, Francesco Pietrograncle.
`Roberto Sartori, Antonio Girolami.
`.
`.
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`.
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`. 751-752
`
`New technology and changlng parameters
`of leukapheresis for blood cell transplantation
`Katharina Granzow, Roberta Schiavo, lnna Timofeeva,
`Gianalessandro Moroni, Armando Santoro,
`Salvatore Siena.
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`. 752
`
`.
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`.
`
`INR variability in anticoagulation with acenocoumarol:
`is it useful for identifying patients at risk of bleeding
`and thrombosis?
`Patricia Casais, Analia Sanchez Luceros,Susana
`Meschengieser, Emilse Bermejo,
`Maria Angela Lazzari .
`.
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`. 753-754
`
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`The frequency of allele 00”‘, a low expression allele of
`the gene encoding erythroid spectrin or-chain, in the
`Greek population
`lssldora Papassiderl, Marianna Antonelou,
`Fotlni Karababa, Afroditi Loutradi—Anagnostou_.
`Jean Delaunay, Lukas H. lvlargaritis .
`.
`.
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`. 754-755
`
`Acute myeloid leukemia occurring in a patient with
`polycythemia vera in treatment with hydroxyurea
`Emma Cacciola, Rossella Rosaria Cacciola,
`Patrizia Guglielmo, Fabio Stagno,
`Rosario Giustolisl .
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`. 755-756
`
`Absence of p53 mutation in 15 cases of myeloid
`malignancies with structural rearrangements of 3q
`Luz lvlufioz, Carnino Estivill, Anna Aventin,
`Conxa Boqué, Olga Lopez, Josep F. Nomdedéu 757-758
`
`Invasive cerebral aspergillosis in a patient
`with aplastic anemia.
`Response to liposomal amphotericin and surgery
`Dolores Lopez Rodriguez, Carmen Albo Lopez,
`Esmeralda Benitez Cobos, Aida Jimenez Blanca,
`Angeles Fernandez Fernandez,
`Luiz Francisco Araujo .
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`. 758-759
`
`Transient response of myeloma clone
`to pamidronate therapy
`Alessandro Corso, Cesare Astori, Ester Orlandi,
`Patrizia Zappasodi, Luca Arcaini,
`Carlo Bernasconi .
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`. 759-760
`
`A paradoxical side-effect of antiaggregating treatment
`with ticlopidine: the Moschowitz syndrome
`Fabrizlo Fabris, Guido Luzzatto, MariaTeresa Sartori.
`Ilia Zanella, Antonio Glrolaml .
`.
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`. 760-762
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`Flow cytometry of cell suspensions from lymph nodes:
`lmmunophenotype, DNA content and proliferative rate
`are strongly correlated with histopathology diagnosis
`Joaquin Sanchez, Josefina Serrano, Jose Manuel
`Garcia. Jose’ Roman, Javier Casafio,
`Antonio Torres .
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`. 762-763
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`Previous occurrence of llfe-threatening abdominal
`infection is not a contraindication to bone marrow
`transplantation
`Marco Picardi, Carmine Selleri, Gennaro De Rosa,
`Catello Califano, Andrea Camera. Bruno Rotoli . 764-765
`
`Splenic inflammatory pseudotumor mimicking
`primary splenic malignancy
`Yeouda Edoute, Ariel Roguin, Zahava Gallimidi,
`Ofer Ben-lzhak, Pradeep Nagachandran,
`Harm Ben—Ami
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`. 765766
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`Concomitant chronic lymphocytic leukemia and
`acute myeloid leukemia diagnosed by two color flow
`cytometric analysis
`Mustafa Nuri Yenerel. Ibrahim Hatemi,
`Hiiseyln Keskin .
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`. 766-767
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`Acute megaloblastic anemia: homocysteine levels are
`useful for diagnosis and follow-up
`Marina Carrasco, Angel Remacha, Anna Sureda.
`Pilar Sarda, Rodrigo Martino, Jorge Sierra .
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`. 767-768
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`Haematologica
`is a Latin adjective, neuter and plural,
`used in this context as a noun:
`
`it means “hematological subjects”.
`The appropriate English translation is therefore
`Journal of Hematology.
`
`On the cover.
`
` Bone marrow aspirate smear. Leishmania sp within reticula-
`
`endothelial macrophages. Note the platelet clump to
`compare with the sharper and stronger staining of
`Leishmania sp). (see p. 750).
`
`Teva — Fresenius
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