Citations

Abstract The patient with multiple myeloma should be carefully evaluated from the standpoint of symptoms, physical findings, and laboratory data. If there are no symptoms or evidence of early or impending complications, the patient should not be treated. He or she should be followed and treatment delayed until progression of the disease occurs. If the patient is younger than 70 years, autologous peripheral blood stem cell transplantation should be considered. Hematopoietic stem cells should be collected before the patient is exposed to alkylating agents. If the patient is older than 70 years, chemotherapy is indicated. The two major shortcomings of autologous stem cell transplantation are: A) failure to eradicate myeloma, and B) contamination of autologous peripheral blood stem cells. Most physicians initially treat the patient with vincristine, doxorubicin (Adriamycin), and dexamethasone (VAD) for three to four months and then collect the peripheral blood stem cells. One can then proceed with transplant or treat the patient with alkylating agents and delay the transplant until the patient progresses. In a prospective trial comparing autologous bone marrow transplantation with conventional chemotherapy, five-year overall survival favored the transplant group (52% versus 12%). In a randomized trial of 400 patients from France, there was no difference in event-free or overall survival between double and single autologous stem cell transplant when evaluated at two years. In a subsequent evaluation, patients with a low β2-microglobulin value at diagnosis appeared to have better results with a double transplant. There is no evidence that combinations of chemotherapeutic agents are more effective than melphalan and prednisone. Allogeneic transplantation is associated with a high mortality. Depletion of T-cells or a mini-allogeneic transplant may be beneficial in an effort to reduce mortality. Thalidomide produces objective response in approximately 30% of refractory patients. The use of intravenous bisphosphonates is recommended for patients with skeletal lesions. Hypercalcemia and renal failure must be treated promptly.

Objective. Anaphylaxis after immunization, although rare, is serious and potentially life-threatening. Understanding risk factors for this reaction is therefore important. Gelatin is added to many vaccines as a heat stabilizer. Japanese researchers have demonstrated a strong association between immediate hypersensitivity reactions to measles, mumps, rubella, varicella, and Japanese encephalitis immunizations and subsequent detection of anti-gelatin immunoglobulin E (IgE) antibodies. They suggested that previous receipt by these patients of diphtheria-tetanus-acellular pertussis vaccines with trace amounts of gelatin was responsible for the sensitization. We aimed to assess whether a similar association exists for vaccinees in the United States who reported anaphylaxis after receipt of measles-mumps-rubella (MMR) or measles vaccines and to review recent trends in reporting of hypersensitivity reactions. Methods. We conducted a retrospective case-control study. Cases of anaphylaxis that met a predefined case definition were identified from the US Vaccine Adverse Event Reporting System (VAERS). Mayo Clinic patients who received MMR vaccine uneventfully served as controls. The study subjects were interviewed to obtain the history of allergies. Sera from study subjects and their matched controls were tested for IgE antibodies to gelatin, whole egg, and vaccine viral antigens using solid-phase radioimmunoassay. Data from the Biologics Surveillance System on annual numbers of doses of MMR and varicella vaccines distributed in the United States were used to evaluate possible changes in reporting of selected allergic adverse events. Results. Fifty-seven study subjects were recruited into the study and interviewed. Of these, 22 provided serum samples for IgE testing. Twenty-seven subjects served as a comparison group and provided a sample for IgE testing; 21 of these completed an allergy history questionnaire. Self-reported history of food allergies was present more frequently in the interviewed study subjects than in the controls, whereas the proportions of people with other characteristics were similar in both groups. None of the interviewed people had a history of food allergy to gelatin. The level of anti-gelatin IgE antibodies was significantly higher among study subjects than among controls, whereas the levels of IgE antibodies against egg and all 3 viral antigens did not differ significantly. Of 22 study subjects, 6 (27%) tested positive for anti-gelatin IgE, whereas none of the 27 controls did. The rate of anaphylactic reactions reported to VAERS after measles virus-containing immunization in the United States between 1991 and 1997 is 1.8 per 1 million doses distributed. No substantial increase in the number of reported allergic events after frequently used gelatin containing MMR and varicella vaccines could be observed during the first 4 years (1997–2000) since the introduction of diphtheria-tetanus-acellular pertussis vaccines for use in infancy. Conclusion. Anaphylactic reactions to MMR in the United States are rare. The reporting rate has the same order of magnitude as estimates from other countries. Almost one fourth of patients with reported anaphylaxis after MMR seem to have hypersensitivity to gelatin in the vaccine. They may be at higher risk of developing anaphylaxis to subsequent doses of other gelatin-containing vaccines. These people should seek an allergy evaluation before such immunization.

Abstract OBJECTIVE AND IMPORTANCE Heterotopic ossification (“neuritis ossificans”) is among the least frequently encountered reactive lesions in peripheral nerves. Only two cases have been described previously, one in the median nerve of a 34-year-old man, and the other in the ulnar nerve of an adult woman. The architecture of this lesion is distinctly zonal. Consisting of a central fibroblastic core, an intervening zone of osteoid production, and a peripheral layer of ossification, the pattern is remarkably similar to that of myositis ossificans. This similarity and the occurrence of the process in superficial nerves have led to speculation that trauma plays a role in its pathogenesis; this hypothesis remains unproved. We describe two additional cases of neuritis ossificans. CLINICAL PRESENTATION One patient, a 41-year-old man, experienced pain and numbness in the left leg for several months but had no history of local trauma. A mass was detected in the saphenous nerve. The second patient, a 16-year-old boy, noted subacute onset of pain in the popliteal fossa and decreased sensation in the distribution of the lateral sural cutaneous nerve. A mass was found within the tibial nerve at the knee level. INTERVENTION In each patient, resection of the mass required sacrifice of a segment of the nerve. CONCLUSION In each patient, the mass was composed of fibrovascular tissue with osteoid and bone deposition arranged in a zonal pattern. The ossifying process was intraneural but encased rather than directly involving nerve fascicles. These exceptionally intact examples of neuritis ossificans underscore its resemblance to myositis ossificans. Nerve-sparing resection of such masses is not always possible.