Haemolytic anaemia caused by piperacillin-tazobactam.

We report a case of haemolytic due to the use of piperacillin-tazobactam in a 50-year-old woman. Since 2002 4 other cases were reported. Either the presence of piperacillin as tazobactam can induce haemolysis. In all cases discontinuating the drugs resolves the haemolysis. Although drug-induced haemolytic anaemia due to piperacillin-tazobactam is rare, the common use of this antibioticum in the critical care setting should alert the physician as a possible culprit in cases of haemolytic anaemia.

An active haemovigilance programme characterizing the safety profile of 7437 platelet transfusions prepared with amotosalen photochemical treatment.

BACKGROUND: An active haemovigilance programme was implemented to survey adverse events (AE) associated with transfusion of platelets photochemically treated with amotosalen and ultraviolet A (PCT-PLT). The results of 5106 transfusions have already been reported. Here we report the results of an additional 7437 PCT-PLT transfusions. METHODS: The focus of this ongoing haemovigilance programme is to document all AEs associated with PCT-PLT transfusion. Data collected for AEs include: time of event after starting transfusion, clinical descriptions, vital signs, results from radiographs and bacterial cultures, event severity (Grade 0-4) and causal relationship to PCT-PLT transfusion. RESULTS: One thousand four hundred patients (mean 60 years, range 1-96) received PCT-PLT transfusions. The majority of the patients (53.4%) had haematology-oncology diseases and required conventional chemotherapy (44.8%) or stem cell transplantation (8.6%). Sixty-eight PCT-PLT transfusions were associated with AE. Acute transfusion reactions (ATR), classified as an AE possibly related, probably related, or related to PCT-PLT transfusions were infrequent (n = 55, 55/7437 = 0.7%) and most were of Grade 1 severity. Thirty-nine patients (39/1400 = 2.8%) experienced one or more ATRs. The most frequently reported signs/symptoms were chills, fever, urticaria, dyspnoea, nausea and vomiting. Five AEs were considered severe (> or = Grade 2); however, no causal relationship to PCT-PLT transfusion was found. Repeated exposure to PCT-PLT did not increase the likelihood of an ATR. No cases of transfusion-related acute lung injury and no deaths due to PCT-PLT transfusions were reported. CONCLUSIONS: Routine transfusion of PCT-PLT is well-tolerated in a wide range of patients. ATRs related to PCT-PLT transfusion were infrequent and most were of mild severity.

Earlier occurrence of severe alopecia areata in HLA-DRB1*11-positive patients.

BACKGROUND: Alopecia areata (AA) is a polygenic immune-mediated disorder affecting the hair follicle for which an association with human leukocyte antigen HLA-DRB1*11 has been described. OBJECTIVE: Two parameters including age of onset and extent of the disease (patchy AA and AT/AU forms) were correlated with the presence or absence of HLA-DRB1*11 and its alleles in 88 severe AA patients. METHODS: Patients and healthy controls were typed for HLA-DR and -DQ by molecular method. RESULTS: Among AA patients, 37.5% (a proportion rising to 72% when taking patients who began their first patch before the age of 20 years) were positive for HLA-DRB1*11 compared to 21.2% healthy controls (p = 0.004, RR = 2.1). DRB1*11-positive status was associated with earlier development of the first AA patch, at the mean age of 16 years compared to 27 years (p = 0.003) in DRB1*11-negative patients. Among the DRB1*11 alleles, the presence of DRB1*1104 was associated with the earliest occurrence of AA. CONCLUSION: Our data indicate that the HLA system largely through DRB1*1104 allele influences AA onset rather than extension considering patchy AA and AT/AU.

CD52 antibodies for prevention of graft-versus-host disease and graft rejection following transplantation of allogeneic peripheral blood stem cells.

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity after allogeneic bone marrow transplantation, but can be avoided by removing T lymphocytes from the donor bone marrow. However, T cell depletion increases the risk of graft rejection. In this study, two strategies are used to overcome rejection: (1) use of high doses of stem cells obtained from peripheral blood (PBSC), (2) admixture with a CD52 monoclonal antibody in order to deplete both donor and residual recipient lymphocytes. Two antibodies are compared: CAMPATH-1G (rat IgG2b) and its humanized equivalent CAMPATH-1H (human IgG1). A total of 187 consecutive patients at six centers received PBSC transplants from HLA-matched siblings between 1997 and 1999. A wide spectrum of diseases, both malignant and non-malignant, was included. The recovery of CD34+ cells after antibody treatment was close to 100%. The risk of acute GVHD (grade 2 to 4) was 11% in the CAMPATH-1G group and 4% in the CAMPATH-1H group (P = NS). The risk of chronic GVHD (any grade) was 11% in the CAMPATH-1G group and 24% in the CAMPATH-1H group (P = 0.03) but the risk of extensive chronic GVHD was only 2%. The overall risk of graft failure/rejection was 2%, not significantly different between the two antibodies. Antibody treatment was equally effective at concentrations between 10 microg/ml and 120 microg/ml and it made no significant difference to the outcome whether the patients received post-transplant immunosuppression or not (87% did not). Transplant-related mortality in this heterogenous group of patients (including high-risk and advanced disease) was 22% at 12 months. It is proposed that treatment of peripheral blood stem cells with CAMPATH-1H is a simple and effective method for depleting T cells which may be applicable to both autologous and allogeneic transplants from related or unrelated donors. Special advantages of this approach are the simultaneous depletion of donor B cells (which reduces the risk of EBV-associated lymphoproliferative disease) and the concomitant infusion of CAMPATH-1H to deplete residual recipient T cells and thus prevent graft rejection.

DPB1*7601, a novel DPB1 variant in the Caucasoid population.

A new DPB1 allele has been identified in a Caucasoid individual, DPB1*7601. The sequence of the complete second exon has been confirmed by cloning and subsequent sequencing. This allele differs by one amino acid, at codon 36, from DPB1*1401, as indicated by SBT and PCR-SSP analysis. The amino-acid motif introduced by the change is shared by DPB1*0401 and some rare alleles. It remains unclear whether the change is due to interallelic microgen conversion or a single point mutation.

Relationship between nuclear morphology and DNA content in large cell lymphomas.

The relationship between DNA content and nuclear morphology in large cell lymphomas (LCLs) was investigated on lymph node imprints. Mean maximum nuclear diameter (mean MND), nuclear shape and chromatin pattern were evaluated microscopically on May-Grünwald-Giemsa-stained slides. DNA content and nuclear area were measured on Feulgen-stained slides by image analysis. Twelve of the 24 cases were DNA diploid and 12 tetraploid. The DNA diploid cases were characterized by medium large (mean MND 11.2-13.7 microns), round nuclei with a fine chromatin pattern. The DNA tetraploid cases had significantly (P < .01) larger (mean MND 13.0-19.1 microns) nuclei and a higher frequency of coarse chromatin pattern, nuclear irregularities and multilobation. One of the researchers, unaware of the DNA index, could predict the ploidy level in 80% of cases on morphology. The linear coefficient of correlation between mean MND and mean nuclear area was 0.84. We also found that nuclear area increased as the cell moved through the cell cycle. DNA content, related to ploidy and position in the cell cycle, is an important explanation for the variable nuclear morphology in LCLs.

Trisomy 12 is uncommon in typical chronic lymphocytic leukaemias.

The incidence of trisomy 12 was studied by conventional chromosome analysis in 111 patients referred as B-cell chronic lymphocytic leukaemia (B-CLL). Fluorescent in situ hybridization (FISH) was also applied in 34 of those patients with either a normal karyotype or no analysable mitoses. By karyotyping, trisomy 12 was present in 11.7% (13/111), whereas additional FISH increased the incidence to 14.4% (16/111). When subdividing our cases in either typical CLL (n = 90), fulfilling the FAB classification criteria, or atypical CLL (n = 21), with one or more variations from those criteria, the incidence of +12 by metaphase analysis was 3% and 48%, respectively. Additional FISH increased the incidence to 4% and 57%. The most common aberration in atypical CLL was FMC7 positivity (n = 11), followed by CD5 negativity (n = 8), strong surface immunoglobulin staining (n = 7) and atypical morphology (n = 6). Trisomy 12 could only be demonstrated in a small proportion of neoplastic cells in all positive cases. By FISH and/or karyotyping, all available samples at diagnosis of the disease were positive.

Leukaemic intermediate lymphocytic lymphomas: analysis of twelve cases diagnosed by morphology.

Twelve cases of leukaemic intermediate diffuse lymphocytic lymphoma (ILL), diagnosed by morphology, were analysed. The morphology of the ILL cells was so typical that it allowed ready distinction from chronic lymphocytic leukaemia (CLL) and other related B cell disorders. All cases were of B derivation, had strong mu and chi or lambda immunoglobulin (Ig) staining, were CD5 and FMC7 positive and CD10 negative. Cytogenetic abnormalities were found in 8 patients all having t(11;14)(q13;q32). DNA analysis revealed a relatively high incidence of hypoploidy. At diagnosis all the patients (9 males, 5 females; median age 68) had a low degree of absolute lymphocytosis but the disease was advanced and mostly widespread. The course of the disease appears to be aggressive and incurable with conventional combination chemotherapy.

Platelet activation and vascular damage in gestational hypertension.

Increased plasma fibronectin levels are a highly sensitive and specific predictor of gestational hypertension. Of a total of 105 apparently healthy normotensive primigravid women seen at the outpatient clinic, 10 with increased plasma levels of fibronectin (mean +/- 2 SD), were compared with 14 controls. Parameters of early vascular damage (laminin, preprocollagen III), platelet activation (beta-thromboglobulin, platelet factor 4), and coagulation (thrombin-antithrombin III complexes, fibrinopeptide A) were measured at regular (weekly or monthly) intervals. Abnormal values of laminin (p less than 0.005) and fibronectin (p less than 0.0001) were found up to 4 weeks before the onset of clinical disease. Levels of beta-thromboglobulin (p less than 0.0001) were also elevated at least 4 weeks before the appearance of clinical symptoms. Our results show that increased levels of laminin, fibronectin, and platelet activation, as indicated by beta-thromboglobulin levels, are preclinical features of gestational hypertension and indicate that vascular damage has occurred. Fibrin formation would appear to occur later.

Neonatal alloimmune thrombocytopenic purpura induced by anti-Bak(a): a case report and review of the literature.

We report a case of neonatal alloimmune thrombocytopenic purpura after an uneventful pregnancy. The baby had systemic purpura at birth and his platelet count was 6 X 10(9)/1. He was treated with maternal platelets and one week later his platelets were normalized. It was the second pregnancy of the mother; she received a blood transfusion after the delivery of her first child. The mother was HLA DR3 positive, an antigen frequently implicated in neonatal alloimmune thrombocytopenic purpura. The antibody reacted with both P1A1 positive and negative platelets which excluded anti-P1A1 type, the antibody most involved in neonatal alloimmune thrombocytopenia. This antibody reacted with platelets of 46 out of 53 random donors (87%); this approached the 90.8% frequency of Bak(a) reported in the Netherlands. Later this antibody was typed as anti-Bak(a). A discussion and a review of the literature is given.

Elliptocytosis and schistocytosis in myelodysplasia: report of two cases.

Marked elliptocytosis and schistocytosis are described as unusual manifestations of haematopoietic dysplasia in two patients. The first patient, whose history was negative for inherited haemolytic anaemias, presented these prominent features on his first admission; 22 months later he developed an acute myeloblastic leukaemia. In the second patient, followed since 4 years for an autoimmune thrombocytopenic purpura, elliptocytosis and schistocytosis appeared 17 months before a pancytopenia established. The patient is now on follow-up and is treated for a refractory anaemia. In both cases bone marrow examinations revealed the typical criteria for myelodysplasia and this diagnosis was confirmed by cytogenetic analysis.

Philadelphia-positive T-acute lymphoblastic leukemia.

A case of typical T-acute lymphoblastic leukemia (T-ALL) is reported in which, at diagnosis, 100% of bone marrow metaphases showed a Philadelphia (Ph) translocation, t(9;22). These cells completely disappeared following chemotherapy. The significance of the Ph chromosome in T and B leukemic cells is discussed.

Drug dependent red cell antibodies and intravascular haemolysis occurring in patients treated with 9 hydroxy-methyl-ellipticinium.

Eleven patients were treated weekly with a new cytostatic drug, 9-hydroxy-methyl-ellipticinium (9 HME). Eight were treated for longer than 4 weeks and three of these developed a drug dependent antibody reacting with normal red cells. In two of these patients acute intravascular haemolysis occurred, one with oliguric renal failure; in the third patient the drug was stopped as soon as the antibody was detected. In all three patients the antibody developed after 4 weeks of treatment. It was IgM, agglutinated normal red cells and bound complement only in the presence of the drug. No antibodies could be detected in the patient's serum reacting with normal platelets in the presence of the drug. The incidence of haemolysis with this drug is much higher than seen with other drugs causing immune-complex haemolysis. Studies done with closely related substances suggest that the antigenic site of the drug is related to the group attached to carbon atom 9.