Overt immediate hemolytic transfusion reaction attributable to anti-Wr(a).

Wr(a) is a low-prevalence antigen. Anti-Wr(a) is a relatively common antibody present in approximately 1 in 100 healthy blood donors. Anti-Wr(a) is reported to cause different degrees of hemolysis in transfusion and in HDN, ranging from benign to severe. This report describes an acute overt hemolytic transfusion reaction in a patient whose serum contained anti-Wr(a) and who received a Wr(a+) RBC component.

Successful perinatal management of hydrops fetalis due to hemolytic disease associated with D-- maternal phenotype.

We report the successful management of a case of hemolytic disease and hydrops fetalis secondary to anti Rh 17 antibodies in a woman with the rare D-- phenotype. We discuss the efficacy of intravenous immunoglobulins in treating hemolytic disease of the newborn infant.

Ventricular free wall rupture in acute myocardial infarction.

Despite a progressive reduction in acute myocardial infarction mortality over the years, death related to ventricular free wall rupture has not changed. This is mostly related to the catastrophic presentation and death within minutes in the majority of these patients. Once rupture is suspected, bedside echocardiography should be performed immediately, followed by pericardiocentesis and repair of the rupture site as quickly as possible. Measures to prevent cardiac rupture include the administration of beta-blockers and angiotensin-converting enzyme inhibitors unless contraindications exist, and the avoidance of steroidal and nonsteroidal anti-inflammatory agents such as ibuprofen and indomethacin.

Low-grade endometrial stromal sarcoma with intracardiac extension. Evolution of extensive smooth muscle differentiation and usefulness of immunohistochemistry for its recognition and distinction from intravenous leiomyomatosis.

This case, a rare example of low-grade endometrial stroma sarcoma with extensive smooth muscle differentiation which extended to the inferior vena cava and cardiac chambers closely resembling intravenous leiomyomatosis grossly and microscopically, illustrates the importance of extensive sectioning and the usefulness of immunohistochemistry. Although spindle cell components arranged in interlacing bundles consistent with smooth muscle differentiation were recognizable in the primary tumor (on retrospective review), extensive smooth muscle differentiation in the recurrent tumors masked prototypical morphologic features of stromal sarcoma and only small neoplastic stromal components were preserved in limited areas, leading to initial failure to distinguish the lesion from intravenous leiomyomatosis. The immunophenotyping disclosed two distinct cell populations in the tumor: i.e. vimentin-positive and smooth muscle marker negative stromal cells, and vimentin-negative spindle-shaped desmin-positive smooth muscle cells. Our observation suggests that the predominance of a smooth muscle component in such a tumor can be misleading and does not always warrant a diagnosis of intravenous leiomyomatosis, nor does it predict a benign clinical course. This case also provides an insight into the relationship of the endometrial stroma and myometrium, and their cell of origin and the histogenesis of endometrial stromal sarcoma.

A cluster of transfusion-associated babesiosis cases traced to a single asymptomatic donor.

CONTEXT: The risk of acquiring babesiosis by blood transfusion is largely unknown since in areas where it is endemic it is often an asymptomatic infection. OBJECTIVE: To investigate and treat a cluster of blood transfusion-associated babesiosis cases. DESIGN: Case series and epidemiologic investigation. SETTING: Urban inner-city hospital. PATIENTS: Six persons who received Babesia microti-infected blood components from a donor. MAIN OUTCOME MEASURE: Diagnosis and successful therapy of babesiosis following transfusion. RESULTS: Six individuals (1 adult, 1 child, and 4 neonates) were exposed to products from a single blood donation by an asymptomatic Babesia-infected donor. Three of the 6 exposed patients became parasitemic. Polymerase chain reaction testing, animal inoculation studies, and indirect immunofluorescent antibody testing were used to confirm the presence of Babesia microti in the donor's blood and to establish the presence of infection in 3 of the 6 recipients. The 3 infected recipients and 1 additional recipient were treated without incident. CONCLUSION: Physicians should consider babesiosis in the differential diagnosis of a febrile hemolytic disorder after blood transfusion. Prompt diagnosis is important since babesiosis is responsive to antibiotic therapy and, untreated, can be a fatal disease in certain risk groups.

Exchange transfusion with red blood cells preserved in adenine clears a child of severe falciparum malaria.

Falciparum malaria may be associated with significant morbidity and mortality. The degree of mortality and morbidity usually corresponds to the degree of parasitemia. Quinine and other antimalarial drugs are relatively slow acting and not always effective owing to the presence of drug resistance falciparum. Rapid reduction of the number of circulating parasites may be required. Exchange transfusion has been used as a safe and quick approach to decreasing the parasitemia and antimalaria drugs used to eradicate the rest of the Plasmodium. In the present report, a case is described of a child with severe falciparum malaria who was successfully treated with exchange transfusion using the new adenine and mannitol enriched preservative media, Adsol.

Light chain cardiomyopathy. Structural analysis of the light chain tissue deposits.

Cardiomyopathy due to monoclonal light chain deposits is a complication of plasma cell disorders. The deposits may be either fibrillar as in light chain amyloid or nonfibrillar as in light chain deposition disease. The reasons for these structural differences are still unknown. We characterized the myocardial deposits by immunohistochemical examination of sections and extraction and biochemical analysis of the tissue deposits in a patient (MCM) who died of myeloma and systemic light chain deposition disease. Amino acid sequence analysis of the extracted nonfibrillar MCM kappa-light chain reveals that it belongs to the L12a germline subset of the kappa(I) protein and contains five distinctive amino acid substitutions (three in the framework region III and two in the complementarity-determining region III) that have not been reported previously in the same positions in other kappa(I) light chains. The theoretically determined isoelectric point (pI 8.21) of the MCM light chain is high compared with the low isoelectric point of other Bence Jones proteins from subjects without light chain deposition disease. The diffuse binding to basement membranes and the high isoelectric point of the MCM kappa-light chain suggest electrostatic interaction as a possible mechanism of tissue deposition. The spatial locations of the five distinctive residues and a sixth rare substitution of the MCM protein modeled on the backbone structure of REI, a kappa(I)-soluble Bence Jones light chain of known three-dimensional structure, may be responsible for protein destabilization, partial unfolding, and aggregation leading to tissue deposition.

Right atrial and right ventricular obstruction by recurrent stromomyoma.

A 30-year-old woman had a history of a uterine fibroid 6 years before admission. She had resection of a right atrial mass diagnosed as a leiomyoma 2 years ago and a second cardiac procedure for recurrent tumor 1 year ago. Pathologic examination at that time indicated that the tumor was a low-grade endometrial stromal sarcoma (stromatosis) with features of benign leiomyoma (intravenous leiomyomatosis). This time she was admitted with facial and lower extremity swelling as well as ascites. Transthoracic and transesophageal echocardiography revealed a large tumor entering the heart from the inferior vena cava and filling the right atrium and ventricle. Lower extremity ischemia from bilateral compartment syndrome due to severe edema developed, and she underwent successful surgical resection of the tumor that filled the right side of the heart, inferior vena cava, and mesenteric and renal veins.

Meconium testing for cocaine metabolite: prevalence, perceptions, and pitfalls.

OBJECTIVES: We determined the prevalence of prenatal cocaine use in a racially mixed sample of urban and suburban mothers and correlated its use with maternal demographics and newborn measurements. STUDY DESIGN: Meconium from 621 consecutive newborns delivered at two university-affiliated urban hospitals were assayed for benzoylecgonine. Maternal and infant characteristics were linked anonymously with the results. Statistical analysis included t test, Fisher's exact test, Duncan's multiple range analysis, and analysis of covariance, with a value of p < 0.05 considered significant. RESULTS: We found that 3.4% of meconium samples had benzoylecgonine levels exceeding 0.1 micrograms/ml. Its presence was statistically correlated with maternal and neonatal characteristics. A nurse's opinion of cocaine use was correct 22% of the time. CONCLUSIONS: Prenatal cocaine use was statistically associated with multiparity, multigravidity, late-onset and clinic-based prenatal care, public assistance, nonwhite race, and low academic achievement. A nurse's opinion was a poor predictor of maternal cocaine use. Cocaine-exposed infants were significantly smaller, and this correlated best with nonwhite background.

Immunological response to diphtheria/tetanus vaccine in Schistosomiasis mansoni patients.

The cellular and humoral immune responses of patients with S. mansoni infection were evaluated before and one month after each of two intramuscular doses of diphtheria/tetanus toxoid vaccine. Patients were divided into "responder" and "non-responder" groups based on anti-tetanus toxoid (anti-TT) IgG levels after vaccination. The specific anti-TT IgG1 response of the responder group was predominantly in the IgG, subclass. The lymphoproliferative response to PHA was also significantly higher in the responder group; this elevation was detectable before and after each vaccination. The responses to PWM and SPL were comparable in the two groups before vaccination, although the responder group had a higher response to SPL after vaccination. IgG antibodies for schistosome adult worm and egg antigens were significantly lower in the responder group prior to vaccination but not thereafter. Anti-diphtheria IgG antibodies were comparable in the two groups after vaccination at all times. Clinically, the non-responder patients had a higher incidence of splenomegaly (84.6% vs 44.8%) and were significantly older than the responder patients (mean 34.1 yrs vs 18.7 yrs). The cause for the reduced anti-tetanus IgG response in schistosomiasis patients is believed to be multifactorial. T cell or antigen presenting cell dysfunction, high levels of IgG antibodies specific for schistosome antigens, splenomegaly and age are factors that might lead to reduced anti-TT IgG response.

Serum and CSF levels of IL-2, sIL-2R, TNF-alpha, and IL-1 beta in chronic progressive multiple sclerosis: expected lack of clinical utility.

We measured interleukin-2 (IL-2), soluble IL-2 receptor (sIL-2R), tumor necrosis factor-alpha (TNF-alpha), and interleukin-1 beta (IL-1 beta) by ELISA in paired sera and CSF from 50 chronic progressive multiple sclerosis (CPMS) patients during worsening disability, 19 patients with other neurologic diseases (OND), and in sera from 40 healthy volunteers. In the CPMS patients, 28% (14/50), 10% (5/50), 16% (8/50), and 6% (3/50) had elevated serum levels of IL-2, sIL-2R, TNF-alpha and IL-1 beta, respectively, compared with healthy controls. The only analyte we detected in the CSF was IL-2 in 1 CPMS patient (1/50, 2%). We also saw elevated serum sIL-2R in 16% (3/19) of OND patients. We found no significant difference in mean levels of serum sIL-2R between the 3 groups. Our study, the largest to date of CPMS patients, shows that serum and CSF levels of IL-2, sIL-2R, TNF-alpha, or IL-1 beta are not sensitive for, and the serum sIL-2R level is not specific for, CPMS. Therefore, measurement of these analytes will not be clinically useful for therapeutic or prognostic purposes in the majority of CPMS patients.

IgG subclasses in human chronic schistosomiasis: over-production of schistosome-specific and non-specific IgG4.

IgG subclasses were determined quantitatively in sera from 63 Egyptian men who were infected with Schistosoma mansoni. Total and antigen-specific IgG was measured pre- and post-treatment. Total IgG subclass antibodies were determined by immunoradiometric assay (IRMA) using monoclonal antibodies (MoAbs). The anti-worm and anti-egg specific S. mansoni IgG subclass antibodies were quantitatively measured by ELISA using specific MoAbs and standards obtained by affinity chromatography. Our data show that total IgG of the patients was elevated in the range of two to three times above normal. The magnitude of increase differed markedly among the four subclasses of IgG. The IgG1, IgG2 and IgG3 concentrations were approximately two to four times higher than normal, whereas the IgG4 concentrations was 20 times normal (9000 mg/l). IgG1 and IgG4 tended to dominate the IgG subclass distribution of anti-soluble worm antigen preparation (SWAP) antibodies followed by IgG2 and IgG3. On the other hand, IgG1 and IgG2 dominated the IgG subclass distribution of anti-soluble egg antigen (SEA) antibodies. As with IgG1, IgG2 and IgG3, most IgG4 was non-specific. The role of IgG subclasses in the pathogenesis of schistosomiasis is not clear. However, the high concentration of IgG4 might act as IgE blocking antibody, possibly as anti-idiotypes that may play a role in down-regulation of the immune system when it is challenged with an excess of antigen.

Dot-ELISA for serodiagnosis of human infections due to Western equine encephalitis virus.

A standard dot-ELISA (enzyme-linked immunosorbent assay) was modified for use in detecting IgM and IgG class antibodies to Western equine encephalitis (WEE) virus in serum samples from humans infected with this virus. Nitrocellulose membranes were soaked in supernatant fluid from WEE virus-infected cell cultures, air dried, and blocked with bovine protein. Serum samples were pipetted onto sections of the nitrocellulose, incubated, and washed. Addition of antibody to human immunoglobulin conjugated to alkaline phosphatase and enzyme substrate were used to detect the antibodies. Of 13 samples positive for IgM antibody to WEE virus by IgM antibody capture ELISA, 12 were positive by IgM dot-ELISA. IgG antibody to WEE virus was detected by dot-ELISA in 7/8, 10/14 and 7/10 samples with neutralizing, hemagglutination-inhibiting, or complement-fixing antibodies, respectively.

Dot-enzyme-linked immunosorbent assay (dot-ELISA) for the rapid diagnosis of human fascioliasis.

A dot-enzyme-linked immunosorbent assay (dot-ELISA) was developed as a fast and field applicable antibody detection tool for the diagnosis of human fascioliasis. The assay is performed using partially purified antigens from a species of Fasciola at 180 ng protein/dot (2 microliters) and serum samples at 1:20 dilution (1 microliter). Dot-ELISA results completely agreed with those of micro-ELISA. Antigen-coated nitrocellulose sheets stored for 3 mo at -20 C showed results identical to fresh sheets. Sera from patients with fascioliasis (n = 30) and other parasitic or viral infections (n = 120) were compared with sera from healthy controls (n = 14). Ninety samples can be tested within 90 min. The sensitivity, specificity, and speed of the assay may justify its use in laboratory and field studies.

Seasonal differences in the rhythmicity of human male and female lymphocyte blastogenic responses.

To test the hypothesis that there are circannual differences in mitotic activity in males and females, normal human peripheral blood lymphocytes were stimulated with suboptimal concentrations of Phytohemagglutinin (PHA), Concanavalin A (Con A) and Poke weed mitogen (PWM) over two summer/winter cycles. Lymphocyte responses for the entire population were significantly higher in the summer than in the winter. The same results were observed when responses were compared between a summer and a successive winter. However, when male and child-bearing age female responses were compared, females showed a higher significant difference for PHA and Con A between summer and winter, but not for PWM. These different responses due to season may reflect a relationship between the neuroendocrine and immune systems. At the cell level, these results suggest that an inherent difference exists between female and male lymphocytes and that these lymphocytes are sensitive to seasonal changes.

Quantitation of IgG antibody to Streptococcus pneumoniae vaccine by ELISA and FAST-ELISA using tyraminated antigen.

We examined two ELISA methods for measuring antibodies to Streptococcus pneumoniae using tyraminated S. pneumoniae polysaccharide types 3, 7N, 9F and 14 as antigens. The ELISA has the usual format with a relatively long incubation time whereas the FAST-ELISA has a short incubation time and employs a different solid-phase configuration. We showed that both techniques can be used for the detection of antibodies to S. pneumoniae polysaccharides. Although its analytical sensitivity is about 1/10 of that of the ELISA, the FAST-ELISA is sufficiently sensitive to distinguish protective from unprotective levels of antibodies to the types of S. pneumoniae studied. In studying pre- and post-immunization response, we showed that type 3 is the most immunogenic.

Simplification and standardization of dot-ELISA for human schistosomiasis mansoni.

Dot-ELISA, a technique that shares the same principles as the enzyme immunoassay, is useful for detection of anti-Schistosoma mansoni antibodies in the sera of patients with Schistosoma mansoni infections. The antigens were fixed to the nitrocellulose strips, blocked with 1% bovine serum albumin in 0.05% Tween 20. Patient sera (40) and normal laboratory personnel sera (9) were applied to the sheet directly, without cutting the strips into small discs. The nitrocellulose sheets are kept in a humid chamber for 30 min and then washed. After incubation with peroxidase-conjugated goat anti-human antibody, washing, and addition of substrate, positive reactions appear as brown dots against the white background. The room temperature assay takes about 2 hr. The optimum antigen concentration is 20-80 ng per dot and the optimum serum dilution is 1:100-1:400. The sensitivity and specificity of the assay are 90-95% and 90%, respectively. The level of positivity of the dot-ELISA by an arbitrary scale compares with standard micro-ELISA. The single positive reaction in a normal serum sample in dot-ELISA is also positive in micro-ELISA. Cross-reactivity between the S. mansoni antigen and human fascioliasis sera was noticed in 2 out of 8 patient sera. Good correlation between the arbitrary level of dot-ELISA and the absorbance of standardized micro-ELISA shows that the dot-ELISA is useful both for laboratory and field studies.