Direct antiglobulin test negative, non spherocytic autoimmune haemolytic anaemia.

We report a case of direct antiglobulin test (DAT) negative warm autoimmune haemolytic anaemia (AIHA). At initial presentation our patient had compensated haemolysis and was DAT positive for complement only. Severe haemolytic anaemia developed some years later with a negative DAT. Spherocytes were not a feature of the blood film and osmotic fragility studies were negative. Immune mediated haemolysis was confirmed by fluorescent activated cell sorter (FACS) analysis using antihuman IgG immunoglobulin. Response to immunosuppression was transient but a good response was achieved following splenectomy. Repeat FACS analysis post splenectomy demonstrated a marked rise in IgG coated red cells. Techniques used in establishing the diagnosis and possible mechanisms for this presentation are discussed.

Factitious proteinuria: diagnosis and protein identification by use of isoelectric focusing.

Factitious proteinuria is an unusual finding. We present a case in which clinical suspicion was aroused by the disparity between the clinical history and findings and the 24-h excretion of protein in urine. Electrophoresis of the patient's serum and urine confirmed the presence of an unusual protein. By isoelectric focusing we identified it as egg-white, a finding confirmed by immunofixation with antiserum to egg-albumen. In the past, confirmation of the identity of such a protein has required specific antiserum for immunofixation or immunodiffusion. Such antiserum may not always be available. However, isoelectric focusing gives sufficient resolution for positive identification of exogenous proteins, even in the presence of true proteinuria.

An audit of the investigation and use of anti-D immunoglobulin prophylaxis in Tayside.

OBJECTIVES: To audit the implementation of national guidelines on the investigation and management of RhD disease in Tayside. SETTING: Tayside region. DESIGN: An eight month retrospective audit. RESULTS: Two hundred and eighty eight completed pregnancies in RhD negative women were observed from a total of 1879 deliveries. Of these, 120 RhD negative and 169 RhD positive babies were delivered from women who had not previously been sensitised. At delivery, anti-D was used appropriately in all cases. Of those assessed to require anti-D (n = 168), 91% received it within 24 hours of delivery. In 59 RhD negative subjects, 75 potential sensitising events occurred antenatally. In 45 of these, the event occurred after 20 weeks gestation and 44 received appropriate anti-D. In 11 (23.7%) of these, no foetomaternal haemorrhage assessment was carried out. CONCLUSION: Despite a significant increase in awareness of antenatal prophylaxis since a previous audit in the region, there is still a significant failure to request FMH assessments following potential antenatal sensitising episodes and after delivery. During the audit period, an EDTA plasma gell-based antibody detection system was commissioned in the region. This has allowed the introduction of internal laboratory referral for FMH assessment. This has allowed accurate knowledge on the possible occurrence of FMH at delivery, but has not had a significant impact on antenatal events.

Malignant osteopetrosis: hypercalcaemia after bone marrow transplantation.

A 3 year old girl presented with malignant osteopetrosis, which was treated by allogeneic bone marrow transplantation. Successful engraftment was complicated by prolonged hypercalcaemia, which was controlled by a combination of a bisphosphonate, phosphate infusions, vigorous resalination, and salmon calcitonin. She was alive and well 16 months after the transplant.

The role of the Sysmex SE9000 immature myeloid index and Sysmex R2000 reticulocyte parameters in optimizing the timing of peripheral blood stem cell harvesting in patients with lymphoma and myeloma.

Peripheral blood CD34/45+ cell (CD34/45) enumeration is an expensive and labour-intensive investigation but remains the standard assay for optimizing yield and timing of peripheral blood stem cell harvesting (PBSCH). The present study examined the value of the Sysmex SE9000 parameters (WBC, neutrophil count, and immature myeloid index (IMI)) and Sysmex R2000 reticulocyte parameters (absolute, high and medium fluorescence reticulocytes) in predicting the optimum timing of PBSCH in comparison to peripheral blood CD34/45. Sixty-four PBSCH from 23 patients with haematological malignancies were assessed with a variety of mobilization regimes used. Reticulocyte parameters showed high interpatient variability and did not prove clinically useful. IMI did not consistently predict satisfactory PBSCH yield except when > 1000 x 10(6)/l. Peripheral blood CD34/45 was the most useful predictor of yield. IMI > 20 x 10(6)/l was, however, a useful surrogate for predicting a rise in peripheral blood CD34/45 from nadir and proved to be superior to WBC or neutrophil count. A rising IMI is a marker of early regeneration and has a role in determining when to initiate enumeration of peripheral blood CD34/45.