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A young man with a history of thrombocytopenia for seven years presented with splenomegaly and fever and rapidly evolved to disseminated intravascular coagulation (DIC) and hemorrhagic shock. Spontaneous rupture of the spleen was diagnosed. The critical patient underwent an emergency splenectomy. Pathological examination revealed splenic peliosis, an extremely rare disease with unknown etiology and pathogenesis. Despite the high mortality rate due to spontaneous splenic rupture with DIC, the patient was successfully treated and the details of the case are presented in this report.

Immune thrombocytopenia (ITP) is an acquired autoimmune hemorrhagic disorder characterized by persistent thrombocytopenia. It may be induced by different pathogenesis due to its heterogeneity, and the therapeutic effects vary on different patients. Bone marrow derived mesenchymal stem cells (BMMSCs) can modulate innate and adaptive immunity, thus resulting in a tolerant microenvironment. Functional defects and immunomodulatory disorders of BMMSCs are significant causes of ITP. Functional effects associated with the activation of the P53 pathway include decreased activity of the phosphatidylinositol 3 kinase/AKT pathway and activation of the TNFAIP3/NF-κB/SMAD7 pathway. Immune dysfunction appears to be correlated with an impaired ability of BMMSCs to induce various types of immune cells in ITP. An in-depth investigation into the pathogenesis of ITP facilitates the treatment of ITP, but larger-scale clinical trials are needed to verify the efficacy of exogenous BMMSCs in the clinical treatment of ITP.

The differential diagnoses of reactive arthritis presenting as arthralgia should be considered as diverse disorders, especially when the symptoms cannot be fully explained by some definite diseases. Do not ignore the indication of bone marrow aspiration. We reported a 50-year-old woman who complained of arthralgia, recurrent fever and rash 9 months ago. Laboratory exams showed mild leukopenia, anemia, thrombocytopenia and increased lymphocyte proportion. She was treated with glucocorticoid after the diagnosis of connective tissue disease was suspected. Until platelet count abruptly decreased to very low level, the final diagnosis of acute lymphoblastic leukemia was made through bone marrow morphology, flow cytometry, and chromosome examination. Therefore, a small number of leukemia is not easily diagnosed by routine operations. Thus when diagnoses are not determined with recurrent symptoms, cautious observation and further examination are required to avoid misdiagnoses or missed diagnoses of acute leukemia.

Objective: To explore the relationship between thrombocytopenia (TCP) induced by lipopolysaccharide (LPS) and coagulation or inflammatory response in mouse., Methods: Forty-eight C57BL/6 mice were divided into control group, low-dose, and high-dose LPS treatment groups by random number table method, and each group was subdivided into 4-hour and 24-hour subgroups randomly, with 8 mice in each subgroup. 0.5 mg/kg or 50 mg/kg LPS was injected intraperitoneally in low-dose or high-does group respectively, and equal amount of normal saline was injected in control group. Blood was collected from endocanthal vein at the specified time point, platelet count (PLT) was counted, and the levels of thrombin antithrombin complex (TAT), D-dimer, fibrinogen degradation product (FDP), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were determined by enzyme linked immunosorbent assay (ELISA)., Results: Compared with control group, PLT ( x 10(9)/L) at 4 hours and 24 hours in low-dose and high-dose LPS groups was significantly decreased (4 hours: 660.65 ± 180.48, 568.55 ± 117.99 vs. 1 199.13 ± 110.54; 24 hours: 505.63 ± 218.92, 256.33 ± 72.86 vs. 1 229.13 ± 1 189.37, all P < 0.05), and the changes were more obvious in high-dose LPS group compared with those of the low-dose LPS group (all P < 0.05). Factorial analysis showed that the changes in PLT were related with LPS dosage and time (F1 = 135.660, P = 0.000; F2 = 12.120, P2 = 0.001). It was also found that there was an interactive effect of the dose of LPS and time on PLT (F = 5.580, P = 0.007). Compared with control group, TAT, TNF-α, and IL-6 at 4 hours and 24 hours in low-dose and high-dose LPS groups were significantly decreased [TAT (ng/L) at 4 hours: 1.10 ± 0.59, 0.22 ± 0.13 vs. 3.47 ± 1.73; 24 hours: 1.18 ± 0.68, 0.39 ± 0.29 vs. 3.19 ± 1.27; TNF-α (nmol/L) at 4 hours: 87.35 ± 12.29, 93.70 ± 5.25 vs. 101.59 ± 10.96, 24 hours: 81.94 ± 8.26, 93.23 ± 4.71 vs. 102.84 ± 10.56; IL-6 (ng/L) at 4 hours: 81.78 ± 7.82, 78.59 ± 9.06 vs. 110.88 ± 9.66, 24 hours: 76.03 ± 9.85, 71.34 ± 3.69 vs. 110.88 ± 10.35, all P < 0.05]. TAT at 4 hours and 24 hours in high-dose LPS group was further decreased, and TNF-α at 24 hours was increased as compared with those of low-dose LPS group (all P < 0.05). TAT, TNF-α and IL-6 were influenced only by different dosage of LPS (TAT: F = 42.350, P = 0.000; TNF-α: F = 14.8 10, P = 0.000; IL-6: F = 81.910, P = 0.000), not time (TAT: F = 0.002, P = 0.967; TNF-α: F = 0.342, P = 0.562; IL-6: F = 2.973, P = 0.092). Changes in TAT was not found to be related with the dose of LPS and its time of action, or levels of TNF-α and IL-6 (TAT: F = 0.236, P = 0.791; TNF-α: F = 0.572, P = 0.569; IL-6: F = 0.774, P = 0.468). The dosage of LPS and time of admission showed no influence on D-dimer (F1 = 2.448, P = 0.099; F2 = 0.024; P2 = 0.877). The effect of different doses of LPS and time of administration showed no influence on FDP (F1 = 0.106, P = 0.900; F2 = 0.013, P2 = 0.908), and no interactive effects were found (D- dimer: F = 0.002, P = 0.998; FDP: F = 0.582, P = 0.563)., Conclusion: LPS can induce TCP in mouse, but this effect may not related to the activation of coagulation system and excessive inflammatory response.

The aim of this study was to explore the role of Toll-like receptor (TLR) 2 in primary immune thrombocytopenia (ITP) by detecting TLR2 expression in the peripheral blood lymphocytes of patients with ITP and evaluating the role of TLR2 activation on inflammatory cytokine secretion. A total of 39 ITP patients and 21 normal controls were enrolled in this study. The expression of TLR2 was detected by real-time PCR and flow cytometry, and the concentration of IL-6 and TNF-α in culture supernatant of PBMNC treated with pam3CSK4 for 48 hours were detected by ELISA. The results showed that the expression of TLR2 mRNA in active ITP patients (3.561 ± 0.741) was significantly higher than that in normal controls (1.750 ± 0.314) (P < 0.05), but there was no statistically significant difference between remission ITP patients (2.333 ± 0.448) and normal controls (P > 0.05) . Flow cytometry analysis found that the TLR2 was not expressed on T and B cells, but expressed on all monocytes both from ITP patients and normal controls. Further activation experiment showed that TLR2 activation in vitro could induce the expression of IL-6 (1644 ± 634.0 vs 4111 ± 525.2 pg/ml) and TNF-α (75.37 ± 22.31 vs 326.0 ± 109.9 pg/ml) in PBMNC from ITP patients (both P < 0.05), but just could promote IL-6 expression in normal controls (2119 ± 636.9 vs 4671 ± 315.9 pg/ml)(P < 0.05). It is concluded that the expression of TLR2 mRNA is up-regulated in PBMNC of ITP patients, and this increased TLR2 maybe participate in ITP through inducing secretion of inflammatory cytokines.

Objective: To study the clinical features and ABCG5/ABCG8 gene mutations of three pedigrees of phytosterolemia presented with macrothrombocytopenia and hemolysis., Methods: Erythrocyte and platelet morphology were examined under light microscope. Plasma sterol levels were measured by high pressure/performance liquid chromatography method. All of ABCG5 and ABCG8 exons and intron-exon boundaries were directly sequenced to identify mutations, the corresponding gene mutation sites of three families members and healthy individuals were detected., Results: All the patients presented macrothrombocytopenia, hemolysis, splenomegaly and xanthomas. The blood smears showed large platelets, some as large as erythrocytes, and abnormal erythrocyte shapes, such as stomatocytes. Plasma concentrations of phytosterols, especially sitosterol were markedly elevated (30 fold) in the affected patients. Four mutations were identified in these three pedigrees, ABCG5 C20896T (R446X) and A20883G, ABCG8 del43683-43724 and del1938C-1939G/ins1938T. The latter three were novel mutations reported for the first time., Conclusions: Phytosterolemia associated with macrothrombocytopenia and hemolysis is a new subtype of this disease. Plasma phytosterols and related gene analysis should be performed when ever an unexplained macrothrombocytopenia, especially combined with haemolysis or/and stomatocytosis.

Objective: to study the clinicopathological features, imaging characteristics, immunophenotypes and differential diagnosis of giant cell angioblastoma (GCAB)., Methods: a case of GCAB in the left middle-upper tibia and fibula was studied by light microscopy, X-ray and CT imaging, immunohistochemistry., Results: X-ray and CT imaging showed a clearer lesion in the left middle-upper tibia than in the ipsilateral fibula with enlarged ostealleosis and increased inhomogeneously medullary cavity density, irregular thickening of cortical bone, local cortical default at the inner edge, soft tissue swelling around the abnormal bone. Histologically, tumor tissue was located between the bone trabeculae by nodular, linear and plexiform aggregates of oval-to-spindle cells, large mononucleate cells and multinucleate giant cells with prominent nucleoli and abundant granular eosinophilic cytoplasm. Some aggregates had uncentain amount of discernible lumens, either empty or containing few erythrocytes. A concentric arrangement of oval-to-spindle Cells around small-caliber vascular structures together with collagen fiber contributed to a so-called 'onion-skin' arrangement. The background showed a loose mesenchymal stroma formed of some inconspicuous spindle-fibroblast-like cells, stellate-shape mesenchymal cells, a moderate mononuclear inflammatory cell infiltrate and scattered mast cells. Immunophenotype showed the tumor cells and giant cells strongly positive for vimentin. A good many oval-to-spindle cells stained markedly for CD31 and CD34, but weakly for FVIII, while the giant cells are highlighted instead by CD68, occasionally, very few giant cells showed positive focally for FVIII, a-SMA decorated notedly the cells surrounding the endothelium-like cells but weakly positive in some other tumor cells., Conclusion: GCAB is a rare, locally infiltrative but slow growing neoplastic angiogenesis with unique morphological characteristics during infancy, which may occur not only in the skin, mucosa, subcutis and deep soft tissue but also in the bone.

The study was purposed to investigate the expression and function of non-muscle myosin heavy chain-IIA (NMMHC-IIA) in Fechtner syndrome in order to explore the pathologic changes of kindy disease and the mechanism of granulocyte inclusion body formation. NMMHC-IIA levels in granulocytes were analyzed by Western-blot, the expressions of NMMHC-IIA, IIB in HEK-293 cells were detected by RT-PCR and were analyzed by co-immunoprecipitation. The results indicated that the IIA/beta-actin ratio for Fechtner syndrome granulocytes was (0.35 +/- 0.12), and obviously decreased as compared with that of normal control (0.87 +/- 0.18) (p < 0.01). The IIA and IIB expressed higher in HEK-293 cells. The interaction of IIA and IIB was confirmed by co-immunoprecipitation in HEK-293 cells. It is concluded that dominant-negative effect of NMMHC-IIA is involved in the formation of inclusion bodies. IIA and IIB show obvious interaction, IIB partly compensates the IIA defect derived from MYH9 mutations, and may delay or prevent the development of clinically relevant abnormalities.

Objective: To study the platelet morphology and function of an inherited macrothrombocytopenia disorder with abnormal large granules., Methods: Platelet size and structure were investigated by both light microscopy and electron microscopy. The platelet membrane expression of GP I b, GP II b, GPIII a, P-selectin and CD63 were analyzed by using respective monoclonal antibodies. Platelet 5-hydroxy-tryptamine was measured with spectrophotofluorometer., Results: Both the patient and her father had large granules in their platelets, with exocytosis being easily observed. The expressions of GP I b, GP II b and GP II a on the platelets were in normal range, while P-selectin and CD63 were somewhat increased. The abnormal large granules were not the alpha granules, lysosomes or dense bodies., Conclusion: Both morphological and functional abnormalities of the platelets from the patient are clearly distinguishable from other hereditary giant platelet disorders. It would probably represent a novel platelet disorder.

Objective: To study the changes of platelet in May-Hegglin anomaly (MHA) and the molecular pathogenesis mechanism., Methods: Peripheral blood was drawn from the MHA proband, her father and her uncle. Platelet count and morphology were examined by automatic blood cell counter and microscopy, respectively. The platelet membrane protein was examined by flow cytometry. Membrane antibodies were determined by ELISA. PCR was used to amplify the exons 25, 31 approximately 32, 38 and 40 of the MYH 9 gene in the MHA patient and her diseased father. Furthermore, PCR products were sequenced, a specific point mutation was identified and inclusions (Dohle's body) in the neutrophil was detected by indirect immunofluorescence technique., Results: It was proved that in MHA patients, platelet count was higher by cell counter than by microscope (P < 0.01). Giant platelet was 94% but platelet membrane proteins (CD41, CD61, CD42A, CD42b) were in normal range. Membrane antibodies was undetectable. An A5521G mutation (GAG-->AAG) in the exon 38 was found in the proband and her diseased father, resulting in a characteristic change of NMMHC-A1841 (Glutamic acid-->Arginine), which was not found in other members of the family and in normal controls. Spindle-like inclusions with fluorescence were clearly displayed in neutrophil cytoplasm., Conclusion: The molecular pathogenesis mechanism of May-Hegglin anomaly is the mutation in MYH 9 gene.

Objective: To observe the localization of inclusion and expression of nonmuscle myosin heavy chain-A (NMMHC-A) in cytoplasm of neutrophils of May-Hegglin anomaly (MHA) patients, and elucidate and identify the property of the inclusions in constitutional elements., Methods: Peripheral blood was drawn from the MHA proband, the proband's father, and a healthy control. White blood cells and platelets were isolated and smeared. Indirect immunofluorescence technique combined with propidium iodide (PI) nuclei staining technology was used to detect the inclusion and nonmuscle myosin in cytoplasm of neutrophils and platelet. Neutrophils were isolated. Protein in the neutrophils was extracted and underwent Western blot assay to examine the expression of NMMHC-A., Results: Spindle-like inclusions with yellow fluorescence were clearly displayed in the neutrophils of the MHA patient and her father, that matched very well in shape, size and localization with the inclusions, revealed by Wright-Giemsa's stain. In normal control, except a diffusive distribution of fluorescent spot in neutrophils cytoplasm, not any inclusion was detected. As for NMMHC-A expression, Western blot assay showed that NMMHC-A was upregulated in the neutrophils of the MHA patient (60.9) and her father (58.9)., Conclusion: A new method to display MHA inclusions and identify the major component of inclusions in the neutrophils, which was originated from a mutant of nonmuscle myosin, of MHA was set up. Immunofluorescence analysis is more sensitive than Wright-Giemsa's staining in detecting inclusions of MHA.

Objectives: To evaluate the relationship between cytopenia and cytogenetic response in Imatinib mesylate treated Ph-positive chronic myeloid leukemia (CML) in chronic phase patients., Methods: Fifty-four patients with Ph + CML in chronic phase received oral administration of Imatinib 400 or 600 mg once a day for 18 months., Results: In the early phase of Imatinib treatment, rates of severe leukopenia (leukocyte < 2.0 x 10(9) L-1), anemia (hemoglobin < 100 g.L-1) and severe thrombocytopenia (platelet < 50 x 10(9) L-1) were 14.8%, 37.0% and 27.8%, respectively. Hemocytes recovered in most patients with continued therapy. Treatment was interrupted or dosage reduced in a few patients. The lower the hemoglobin and higher the platelet before the regime, the lower the nadir of leukocytes and hemoglobin counts during the treatment. The lower the platelet count before the regime, the lower the nadir of platelets during the treatment. Risk factors for severe leukopenia were thrombocytosis (> or = 500 x 10(9) L-1) and basophilia > or = 5% before the treatment. Risk factors for severe thrombocytopenia were thrombocytopenia (< 100 x 10(9) L-1) and basophilia > or = 5% before the treatment. During the 12-month treatment with Imatinib, the statistically significant lower probabilities of cytogenetic response were observed at all checked points in patients with severe leukopenia, at the end of 3 and 6 months in patients with anemia, at the end of 3 months in patients with severe thrombocytopenia., Conclusion: Cytopenia is a common side effect in patients with CML in chronic phase treated with Imatinib mesylate. Severe leukopenia is associated with a sustained lower major cytogenetic response, whereas anemia and severe thrombocytopenia influence more for the first 6 months.

Objective: To evaluate the significance of reticulated platelets (RPs) in the diagnosis of thrombocytopenic disorders and the relationship between RPs and the proliferative degree of megakaryocyte (MK) in bone marrow., Methods: With thiazole orange as a fluorescent dye, RPs were measured by analyzing the RNA content in platelets with flow cytometry and the percent and absolute counts of RPs were calculated., Results: (1) The percent and absolute counts of the RPs in a normal group were (8.4 +/- 2.5)% and (16.8 +/- 6.8) x 10(9)/L respectively. (2) As compared with the normal group, the patients with idiopathic thrombocytopenic purpura (ITP) and hypersplenism had a significantly high percent and low absolute counts of RPs (P < 0.01). In patients with aplastic anemia, both the percent and absolute counts of RPs were at low levels (P < 0.05 and P < 0.01, respectively). There was no difference of RP percentage between the patients with acute leukemia or myelodysplastic syndromes and normal controls, but the absolute counts of RPs in the former was significantly lower than that in the latter. There was no difference between the percent and absolute counts of RPs among ITP patients with different proliferative degree of MK in bone marrow. (3) In all the diseases mentioned above, it was shown that RP percentage returned to normal in the effective cases after treatment, but no such change was found in the ineffective cases., Conclusions: Reticulated platelet counts contribute to the aetiology determination of the thrombocytopenia. It is also a valuable diagnostic method and a monitoring marker. There is no relationship between reticulated platelet counts and the counts of MK proliferation in bone marrow.