HIV infection after autologous bone marrow transplantation despite HIV-antibody and HIV-antigen screening.

We report a 41-year-old woman who underwent ABMT for non-Hodgkin's lymphoma during her third CR. Her post-transplant course was complicated by interstitial pneumonitis, hemorrhagic cystitis, cytopenia and episodes of infection from herpes zoster virus and Staphylococcus aureus. She required prolonged blood product support and was later found to be seropositive for anti-HIV on day +191 despite HIV-antibody and HIV-antigen screening of blood donors.

A simple method for the elimination of platelets from the lymphocyte-platelet mixture by sucrose.

A method for the separation of lymphocytes from human blood by Ficoll-Hypaque density centrifugation, with removal of platelets by a single sucrose solution with a density of 65%, is presented. The Ficoll-Hypaque-sucrose method gives a good yield of lymphocytes, high viability and purity, and relatively low contamination with erythrocytes and platelets.

Histocompatibility antigens and dengue hemorrhagic fever.

Histocompatibility antigen (HLA) A and B typing on lymphocytes from 87 unrelated Thai children who had been hospitalized with dengue shock syndrome (DSS) and/or dengue hemorrhagic fever (DHF) was compared with that found in 138 controls who had not been hospitalized with clinical dengue infection. These data are presented as descriptive information; however, a statistical analysis was performed to identify potentially important relationships for future study. Several deviations (P less than 0.05) were detected in the distribution of four HLA-A and three HLA-B antigens. The prevalence of one HLA-A antigen and two HLA-B antigens appeared to relate to the development of DSS, with a positive association seen for HLA-A2 and HLA-B blank and a negative relationship for HLA-B13. These findings require confirmation, but they do suggest that genetic susceptibility may be important in the development of DHF/DSS and indicate that further broader studies of genetic markers might be rewarding.

Diffuse systemic sclerosis and related diseases in Thailand.

Diffuse systemic sclerosis and the related syndromes were diagnosed in 115 patients during 1977-1987. Sixty-nine patients were available for clinical evaluation and analysis. These included 46 patients with diffuse systemic sclerosis, 2 with limited cutaneous systemic sclerosis, 2 with linear scleroderma, 18 with overlap syndrome (OS), and one with primary Raynaud's disease. The major clinical manifestations among the diffuse scleroderma patients were the involvement of the following systems; cutaneous (93.3%), musculoskeletal (69.6%), gastrointestinal (54.3%), and pulmonary (43.3%) while renal involvement (4.3%) was less common. Antinuclear antibodies were found in 89.7% with predominating speckle pattern (86.2%) and anti Scl 70 antibody (40.6%). In contrast to the Western series, HLA-DR2 was significantly increased in our diffuse systemic sclerosis patients (p less than 0.01). Among the 18 OS patients, the involvement of pulmonary system (44.4%) was the major cause of morbidity and renal involvement (55.6%) was found frequently although it was clinically mild. In conclusion, our diffuse systemic sclerosis and related diseases patients seem to have milder clinical manifestations than those of the Western series.

Prevention of hepatitis B infection in infants born to hepatitis B carrier mothers: low dosage vaccination.

Two groups of newborn infants born to HBeAg positive carrier mothers were given HBIG (200 IU) immediately after birth. Subsequently, at age 2 days and at 1, 2 and 12 months, the first group received 5 microgram and the second group 2 microgram of HBV vaccines. There was no significant difference in the anti-HBs seroconversion rate (SR), and the protective efficacy rate (PER) at the age of 13 months in either group. The SR and PER of group 1 were 91.7% and 90.18%, and group II were 92.9% and 91.01%, respectively. Although the significant differences were observed in the geometric mean titers of anti-HBs in group I (526.3 mIU/ml) and group II (371.4 mIU/ml), both were above the protective level. The immune responses to the reduced dosage of HBV vaccines are satisfactory in preventing HBV in the newborn infants of HBeAg positive carrier mothers.

Evaluation of donor self exclusion program.

Donor self exclusion is a low technology procedure to avoid blood donations from the high-risk groups for HIV infection. This strategy has been widely used in western countries to reduce the risk of transfusion associated AIDS. At Ramathibodi Hospital, we conducted a study on donor self exclusion program during March-December 1991. It was found 2.60%-6.55% (mean = 4.59%) of a total of 4,286 units of blood that were from the donors who indicated that their blood may not be safe for transfusion while the rest of them declared that their blood was safe based on sexual behavior during the past 3 months and the history of intravenous drug use. Among 202 units of unsafe blood, there were 1 (0.49%) positive for HIV-Ag, 7 (3.46%) for anti-HIV, 5 (2.48%) for anti-HCV, 10 (4.95%) for HBsAg and 6 (2.97%) for VDRL while there was no HIV-Ag detected in 4,084 units of safe blood but 19 (0.46%) were positive for anti-HIV (p < 0.05), 65 (1.59%) for anti-HCV, 219 (5.36%) for HBsAg and 56 (1.37%) for VDRL. It was clearly demonstrated in this study that confidential self-exclusion or HIV-Ag testing would have eliminated this HIV-Ag reactive unit in the "window period" from transfusion, while the syphilis screening would not have had any value as a surrogate marker. However, self-exclusion programs are likely to prove too non-specific and need more time to educate the donors.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasmapheresis for the preparation of HIV free cryoprecipitate.

Single donor cryoprecipitate was prepared by blood cell separator for treatment of hemophilia A and von Willebrand patients to reduce a risk of transfusion associated HIV infection. A total of 7 plasmapheresis (range 1-1.5 plasma volume) was performed in 4 donors. Then fresh frozen plasma (FFP) was processed to cryoprecipitate and cryoprecipitate removed plasma (CRP). Donors were replaced with 0.9% normal saline solution (NSS) and 5% albumin for the first donation or their own CRP and 5% albumin for the second and third donation. After plasmapheresis total protein, albumin, IgG, IgA and IgM were below normal level in 71.43% (5/7), 14.3% (1/7), 28.57% (2/7), 14.3% (1/7) and 28.57% (2/7), respectively. All of these parameters returned to normal level within 3 days. Factor VIII:C was decreased after plasmapheresis in all donors and the low level of F VIII:C returned to normal within 24 hours. The donor was not exposed to any harmful effect. Donor reactions observed were mild. One donor was chilled due to unwarmed replacement solution. When this donor donated for the second time and was replaced with prewarmed replacement solution, no reaction was observed. We conclude that a preparation of single donor cryoprecipitate by plasmapheresis is safe and can reduce a risk of transfusion associated HIV infection. The donors are not at risk as the result of changes in the measured plasma protein and factor VIII:C level following plasmapheresis.

The value of HLA-ABC common typing tray in relation to bone marrow transplantation.

Bone marrow transplantation (BMT) is one of the most effective procedures to cure the previously uncured hematologic diseases. However, it is costly and HLA typing to select the compatible donors contributed to its cost. A total of 53 prospective patients for BMT and their 114 siblings were analyzed to evaluate the use of locally prepared HLA-ABC common typing tray (ABCCT) during Mar 1988-Mar 1992. The 16, 9, 7, 5, 5 and 12 patients were diagnosed as aplastic anemia, CML, thalassemia, ALL, ANLL and other blood diseases, respectively. It was found that 18 patients were HLA-identical (HLA-ID) with one of their siblings except one patient had 2 HLA-ID sibs. All of those who appeared to be HLA-ID were further tested for the HLA-ABCDR typings. It was observed that 16 (88.89%) of 18 patients and 17 (89.47%) of 19 sibs were confirmed as HLA-ID. After careful clinical screening, only 13 HLA-ID pairs were able to proceed to the mixed lymphocyte culture and confirmed their status of HLA-ID by this test. Finally, only 6 (46.15%) of 13 patients received BMT with a high rate of success, ie all patients have survived with bone marrow engraftment. Thus, ABCCT is very useful for related BMT. It was highly efficient to exclude HLA-non-ID and haplo-ID yet the cost and workload were greatly reduced.

HLA alloimmunization in patients receiving multitransfusions of red blood cells.

HLA antibodies were studied in 88 patients with chronic hemolytic anemia who received multitransfusions of red blood cells prepared by conventional (PRC-C), inverted centrifugation (LR-I) and leukocyte filter (LR-F) techniques. Their mean age was 8 years and 4 months with a duration of transfusion of 8 years. The patients were divided into five groups: group 1, receiving PRC-C (n=20); group 2, receiving LR-I (n=33); group 3, receiving LR-F (n=11); group 4, subsequently receiving LR-I and LR-F (n=10); and group 5, receiving PRC-C followed by LR-I and LR-F (n=14). The HLA class I antibodies were found in 30 out of 88 patients (34%). All were against HLA antigens commonly found in the Thai population. The patients receiving PRC-C exhibited HLA antibodies of 65%, which was significantly higher than those of patients receiving LR-I (24%) and LR-F (0%). Consequently, the transfusion reactions of fever, chill, rash and urticaria were also commonly found in patients receiving PRC-C (13.4%), which was significantly higher than patients receiving LR-I (0.4%) and LR-F (0%). The leukocyte filter technique has been shown to be effective in preventing HLA alloimmunization and transfusion reactions but the price is rather high. For the inverted centrifugation technique, only transfusion reactions were effectively prevented and the HLA alloimmunization continued to develop. A more effective and low-cost method for the removal of leukocytes should be investigated for these multitransfusion patients.

Risk of transfusion associated AIDS by seronegative blood in Thailand: a multicenter report.

Prevention of transfusion associated AIDS (TAA) in Thailand began in 1986 when the HIV infection started to be sharply increased among the general population. The retrospective anti-HIV screening in various blood donor populations by The National Blood Center (NBC) revealed a seroconverted prisoner. Then the use of prisoners, prisoners' blood was not recommended from 1986. In April 1987, the first case of TAA was disclosed. Five months later, anti-HIV screening in all units of blood was firstly introduced at Ramathibodi Hospital (RH) and NBC. From 1989, anti-HIV screening in all units of blood is mandatory nationwide by Ministry of Public Health. Despite the anti-HIV screening, TAA cases transmitted by seronegative blood were gradually reported. Among many Medical Centers, there were 9 and 18 cases of TAA recorded from Chiang Mai and Bangkok areas respectively, since 1985. In addition, several new seroconverters were observed among voluntary blood donors. All of this evidence indicates the existence of blood donation during the early stage of infection, the so-called "window period". At present, HIV-P24 antigen ELISA seems to be the only available technique for mass screening. In 1990, NBC successfully performed a retrospective study on HIV-Ag ELISA screening by obtaining the prevalence of 1/10,000 units of blood. At the same period of time, in RH prospective study, a unit of blood with HIV-Ag only was detected when 3432 units of blood were screened. The HIV-Ag ELISA screening was then performed on every unit of blood routinely since Aug 12, 1991 at RH.(ABSTRACT TRUNCATED AT 250 WORDS)

Response of hemophilia A with bleeding to fresh dry plasma.

Fresh dry plasma (FDP) is a lyophilized form of fresh frozen plasma (FFP) which can be stored at 4 degrees C for one year. One bottle of FDP is prepared from 220 ml of FFP and contains FVIII: C 0.75 +/- 0.3 U/ml (mean +/- 1 SD). This study describes the clinical and laboratory response in 7 severe and 4 moderate hemophilia A patients. The age ranged from 7-17 years (mean +/- SD = 11.7 +/- 2.9 years). Either 12.4 ml/kg. FDP or 12.2 ml/kg FFP was transfused to the patients when they had bleeding episodes such as hemarthrosis, hematoma. 16 episodes of FDP and 12 episodes of FFP transfusion were studied. The bleeding could be effectively controlled by FDP or FFP except one patient who had physical therapy at 8 hours post FDP transfusion. The increment of FVIII:C was 14.1 +/- 5.3% at 30 minutes after FDP transfusion and 12.1 +/- 3.7% at 30 minutes after FFP transfusion. The recovery rate was 83.2 +/- 32.6% in FDP and 65.3 +/- 22.7% in FFP transfusion. The FVIII:C was decreased to 78.9 +/- 12.3%, 55.6 +/- 13% and 16.3% of the initial level at 2, 8, 24 hours after FDP transfusion respectively which were not statistically significantly different from FFP transfusion. No serious complication was found. FDP will replace FFP for the treatment of coagulation disorders such as hemophilia A. It is an useful alternative therapy which can be provided to the hemophiliac patients in the rural area in developing countries.

HIV seroprevalence in hematologic patients other than hemophiliacs at Ramathibodi Hospital.

Recently there have been increasing reports of HIV infection acquired through transfusion of HIV seronegative blood in Thailand due to high incidence of HIV new infection in blood donors. Blood or blood components (BC) prepared from HIV seronegative blood donation pose significant hazards to recipients because of the risk of viremia during the "window period" of HIV infection. This paper presents the HIV seroprevalence in hematologic patients other than hemophiliacs who received multiple blood transfusion at Ramathibodi Hospital. The retrospective analysis was done on 167 patients: 132 thalassemia, 19 leukemia, 5 aplastic anemia, 5 ITP, 2 pure red cell aplasia, 2 congenital non spherocytic hemolytic anemia, 1 hereditary spherocytosis and 1 autoimmune hemolytic anemia patients, who received blood transfusion during January 1, 1987 till February 29, 1992 at the Department of Pediatrics, Ramathibodi Hospital. The number of blood or BC transfused in each patient was 1-154 units with the average of 23 units per patient per 5 years with a total 4,000 units. All were HIV sero-negative. Anti-HIV screening was performed periodically in these patients about 1-2 times per year or as necessary. The results were HIV seronegative in all cases. The reason for negative results cannot be explained clearly. It should be noted that our thalassemic patients receive leukocyte poor blood and avoid a hypertransfusion program. Patients with other blood diseases received both whole blood and BC. The HIV contaminated blood in the window period was estimated to be 1:10,000 in Thailand which showed HIV antigen positive but antibody negative. These patients may be fortunately received HIV non contaminated blood.

HIV seroconversion in Thai hemophiliacs up to 1991.

In Thailand, the anti-HIV screening in the donor blood was started in 1987 and was compulsory nationwide in February 1989. Sixty-six hemophilia A and 10 hemophilia B patients who received approximately six million units of factor VIII and IX in the form of fresh frozen plasma, frozen cryoprecipitate, cryoprecipitate removed plasma, fresh dry plasma and factor concentrate during 1976 to 1991 were tested for anti-HIV since 1987. The age ranged from 1-39 year (mean +/- SD = 15 +/- 7.3). The anti-HIV test was performed by ELISA and/or gel agglutination and confirmed by Western blot analysis. The patients would be checked 1-2 times per year and as necessary. A total of 174 tests for the first, second, third, fourth, fifth and sixth tests were studied in 76, 49, 27, 14, 5 and 3 patients respectively during 1987 to 1991. The prevalence of HIV seroconversion in the year 1987, 1988, 1989, 1990 and 1991 was 2.2% (1/45), 1.9% (1/53), 1.6% (1/63), 1.5% (1/67) and 3.9% (3/76) respectively. Three HIV seroconversion were found in the first, fourth and fifth anti-HIV test in 3 hemophilia A patients who received massive infusion of blood components during orthopedic corrective surgery. One case of HIV seroconversion found in 1987 was transmitted by HIV unscreened blood while 2 cases in 1991 by anti-HIV seronegative blood whose donors were in the window period of HIV infection. The prevalence of HIV seroconversion in Thai hemophiliacs is much lower than those in western countries.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical orthopedic correction of hemophilic hemarthrosis at Ramathibodi Hospital.

During 1982-1992, 15 major surgical orthopedic correction (SOC) were performed in 12 hemophiliacs. There were 11 synovectomy, 2 osteotomy, 1 currettage and suture wound, 1 release of multiple joint contracture and 1 removal of pseudotumour. During 1982-1989, frozen cryoprecipitate was entirely used for replacement therapy in 5 cases who had 7 SOC. During 1990-1992, 7 cases received SOC by using factor VIII concentrate (Emoclot or Profilate) alone or combined with cryoprecipitate in 8 SOC. Multiple surgical procedures could be performed by using factor VIII concentrates. The orthopedist could operate 3 joints in one setting ie right knee, left knee and right middle finger. There are many advantages of factor VIII concentrates over those of cryoprecipitate, especially in the aspect of HIV transmission by HIV seronegative blood products. The disadvantage is the extremely high cost of factor concentrates.

Bone marrow transplantation in Ramathibodi Hospital: progress report.

Bone marrow transplantation has become the accepted treatment for several hematologic disorders. We have done 3 autologous and 6 allogeneic bone marrow transplantations at Ramathibodi Hospital since July 1989 in patients with acute lymphoblastic leukemia, acute non-lymphocytic leukemia, chronic myeloid leukemia, non-Hodgkin's lymphoma and severe aplastic anemia. Only one patient with aplastic anemia had late graft rejection, but the rest of them engrafted and did well during the median follow up period of 317 days (range: 39 to 962 days) post transplantation. None of the allogeneic BMT had graft-versus-host disease. We use cyclosporin and short course methotrexate for post transplantation immunosuppression.

Anti-HIV seroconversion in hemophilia A patient after transfusion of anti-HIV negative blood components.

A Thai male hemophiliac A patient has been anti-HIV seroconverted in the hospital after a 2-year admission for a large infected retroperitoneal hematoma. The source of HIV is thought to be one or more of more than 20,000 units of blood components used during the admission. All were screened as anti-HIV negative. Although he received heat treated factor VIII concentrate before this admission, it was not thought to be the cause. Autologous blood transfusion and HIV antigen screening are suggested as a safer way of blood transfusion.

A*02 in southern Thai Muslims and central Thais.

UNLABELLED: The HLA-A*02 subtyping in Thais was conducted and included in the 12th International Histocompatibility Workshop (12WS). A total of 81 randomized individuals previously serologically or DNA typed as A2 were studied for A2 subtypings. The subjects consisted of 32 Southern Thai-Muslims (STM) and 49 Central Thais (CT). The 12WS HLA-A*02 subtyping DNA typing kit was employed. The most common A*02 subtypes in STM were A*0203,*0201 and *0207 while they were A*0203, *0207 and *0201 in CT. A*0202, *0204, *0208, *0209, *0212, *0213, *0214, *0215, *0216 and *0217 were not found in both STM and CT. The 12WS data indicated that A*0201 was also the most frequent allele of A*2 among North-East Asians. A2 subtype study in 32 STM revealed that 2 in 8 of A*0201 showed the absence of bands at 813 bp and 705 bp with primer mix number 03A and 517A and weak reaction band with primer mix number 33A. In addition, 3 subjects with A*0201 variations have one nucleotide difference in exon 2 by sequence base typing (by MGJ. Tilanus) which will be reported separately. CONCLUSION: More variations of A*02 were observed among STM compared to CT. The variations of reactions with the set of primer mix should be carefully observed and subjected to further analysis.

Lewis antigens on newborn red cells.

This study aimed to screen for Lewis antigens in Thai newborns. Although, these antigens are known to be weak or absent on the red cells of newborns, we encountered a case of a Le(a+) newborn baby when testing with monoclonal antibody and human anti-Le(a). Such a finding led us to conduct this study to explore further evidence of Lewis antigens in Thai newborn red cells. A total of 197 cord blood samples were tested with monoclonal anti-Le(a) and anti-Le(b). (Bioclone, Ortho Diagnostic Systems, USA). The tests were performed according to the manufacturer's recommendations. The results revealed that none of the cord red cells in this study group possessed Lewis antigens. This study showed that Lewis antigens were absent or were so extremely weak on the red cells of these newborn infants that they could not be demonstrated despite the use of potent monoclonal antibodies. However, further study should be done by using more cord blood samples, a more sensitive technique or even more potent antisera.

HTLV-I antibody screening in donated blood and thalassemic patients.

The HTLV-I antibody screening by passive partial agglutination test, Serodia HTLV-I (Fuji-rebio Inc) was performed in a total of 1,225 male and 468 female blood donors from September 1992 to March 1993. In addition, a total of 64 multitransfused thalassemic patients were also studied. All of the sera from donors and patients in both study groups showed no reactive results for HTLV-I antibody. This finding indicated that the HTLV-I infection is not yet a problem in blood transfusion in Thailand. However, the scattered reports of HTLV-I infections from our region should urge the national authority on the surveillance of this infection by epidemiological survey and occasional screening in blood donors.

Fetal red cell staining: method evaluation.

Acid elution methods have been extensively used for the identification of fetal red cells in pregnant women with fetomaternal hemorrhage. A number of methods have been described: Kleihauer-Betke, Boehringer Mannheim, Fetaldex, Nierhaus-Betke modification and Sanguansermsri amido black B. A comparative evaluation of these methods was performed in this study. The technique of Sanguansermsri using amido black B was found to be more advantageous than the others in terms of simplicity, accuracy, precision and time taken.