Background: Although a second allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be a curative treatment for patients with acute leukemia who have relapsed after the first allo-HSCT, its disadvantages for patients may be too great given the high rate of transplantation-related morbidity and mortality. We aimed to identify the risk factors predicting early mortality after a second/third allo-HSCT.
Methods: We retrospectively analyzed the medical records of patients with acute leukemia who underwent allo-HSCTs twice or more in Tenri Hospital between December 1998 and April 2012.
Results: Eighteen patients, consisting of 12 with acute myeloid leukemia and 6 with acute lymphoblastic leukemia, were included. Six patients survived for >1 year, while 6 patients died within 60 days after the second allo-HSCT, and 17 patients finally died. The median overall survival time was 178 days. Concurrent infection, moderate/severe liver injury, and higher H(S)CT-specific comorbidity index (CI) score were significantly associated with mortality within 60 days. The median survival times of patients with HCT-CI scores 0, 1/2, and >3 were 335, 313, and 26 days, respectively, and the survival of the last was significantly worse than that of the former two groups. Three patients who underwent a third allo-HSCT for relapsing/refractory leukemia died within 60 days after the transplant. A total of nine patients who died <60 days after the second/third allo-HSCT developed significant morbidities of the lung, gastrointestinal tract, and central nervous system.
Conclusion: Second allo-HSCT recipients with concurrent infection, moderate/severe liver injury, and higher HCT-CI scores have a greater likelihood of early mortality and are unlikely to benefit from the transplant.

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 A 69-year-old man who had been treated for chronic obstructive lung disease presented with microcytic and hypochromic anemia. His hemoglobin level was 7.6 g/dL, mean corpuscular volume 70 fL, mean hemoglobin concentration 21.1 pg, and mean corpuscular hemoglobin concentration 30.3%. Iron overload was evident by increased serum iron of 233 μg/dL, reduced total iron binding capacity of 265 μg/dL, increased transferrin saturation of 87.9%, and increased serum ferritin of 552 ng/mL. The bone marrow showed 60 to 70% cellularity including siderocytes (7% erythrocytes) and ring sideroblasts (45% erythroblasts) containing iron deposits, which fulfilled the diagnostic criteria of sideroblastic anemia (SA). He had reportedly drunk a 4-liter bottle of shochu every few days for over 5 years; however, he now abstained from alcohol, as he was no longer able to drink owing to respiratory distress. Although anemia initially progressed so that a blood transfusion was required, the hemoglobin level steadily increased during the follow-up period; 8 months after the initial presentation, the hemoglobin value was 14.6 g/dL with normal erythrocyte indices. We first considered that the patient had a subtype of myelodysplastic syndrome (MDS), in which the presence of ring sideroblasts was predominant. The clinical course, however, indicated that the disease was acquired and reversible SA associated with alcoholism. This case report reminds us that MDS with ring sideroblasts must be carefully differentiated from non-neoplastic conditions.

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 We encountered a 66-year-old woman with fever, night sweats, and abdominal distension for 3 weeks. On examination, the liver was enlarged to the pelvic cavity and the spleen was felt 3 finger-breadths below the left costal margin. There was no superficial lymphadenopathy. Her hemoglobin level was 10.7 g/dL,white blood cell count was 4,600/μL, including 23.0% lymphoma cells, and platelet count was 82.0×10³/μL. Lactate dehydrogenase was 1,320 IU/L, soluble interleukin-2 receptor was 334 U/mL, and ferritin was 64 ng/mL. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography revealed the diffuse accumulation of FDG within the liver and spleen in addition to the bone marrow in the central skeleton. The bone marrow had 80% cellularity, including 90.2% lymphoma cells with CD5⁺, CD10^-, CD19⁺, CD20⁺, CD21^-, CD22⁺, and CD23^- immunophenotypes and expressed μ/κ immunoglobulins. There were no hemophagocytic findings. Biopsies of the bone marrow revealed large lymphoma cells that were clustered or formed cellular nests within the sinusoids. The karyotype had multiple numerical and structural abnormalities, including trisomy of the long arm of chromosome 3 and tetrasomy of the long arm of chromosome 18. Although the present case exhibited features that overlapped with CD5-positive diffuse large B-cell lymphoma and intravascular large B-cell lymphoma, both of which have been shown to have poor clinical outcomes, the lymphoma responded very well to cyclophosphamide, doxorubicin, vincristine, and prednisolone in combination with rituximab, and long-term disease-free survival was expected.

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 We report the case of a schoolgirl with long QT syndrome (LQTS) who was suspected of having epilepsy. She had a seizure with convulsion and loss of consciousness lasting for a few minutes early in the morning at the age of seven years. Ten months later, she had another similar seizure attack. Her electroencephalogram showed only minor abnormality. Her brain MRI and SPECT study showed borderline abnormalities. Therefore, she was suspected of having had epileptic seizures and was observed without medication. At the age of eight years, a third seizure attack occurred immediately after an alarm clock rang in the morning. When detailed clinical history was taken after the third attack, it was revealed that, in a school medical check at the age of six years, an electrocardiogram (ECG) had shown suspicion of LQTS. Then another ECG was taken and prolonged QTc lasting 0.500 seconds was confirmed. Later, gene analysis showed HERG mutation, leading to the definitive diagnosis of LQTS type 2. She is now under observation on beta-blocker medication without seizure attacks. Cardiogenic diseases including LQTS must be considered in the differential diagnosis of loss of consciousness and/or convulsion.

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