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.

Low cost locally prepared fibrin glue for clinical applications: reported of 145 cases. Committee of Bangkok International Hemophilia Training Center.

Fibrin glue (FG) is one of the blood products known to be very useful for local hemostatic measure and as a medically valuable tool for adhesion, sealing, anastomosis, repair microvascular and nerve grafts in medical and surgical procedures. Before 1996, FG was used to a limited extent in Thailand due to the high cost. Technology for locally prepared FG was transferred to Bangkok International Hemophilia Training Center of the World Federation of Hemophilia (IHTC-WFH) in July 1996 by Prof. Uri Martinowitz and the late Prof. Henri Horoszowski. Since then FG has been widely used and proved to be very useful in Thailand. This paper reports 145 cases using low cost locally prepared FG at Ramathibodi Hospital during November 1996 to December 1997. A total of 145 cases with age range from 5 months to 73 years, which included 55 pediatrics and 90 adults, 100 males and 45 females. The amount of FG used was 1-80 ml per case. Clinical procedures included dental surgery (46), open heart surgery (35), ENT (28), orthopedic (13) including 2-3 joint correction in one session in 2 hemophiliacs, neurology (11), plastic repair (7), liver (2) and severe bleeding in dengue hemorrhagic fever (3). Forty-seven cases had hemostatic disorders. The result of local hemostatic, adhesive and sealant effect of FG was satisfactory with no complications. In open heart surgery, the amount of content in chest drain decreased and none required reopen-surgery to stop bleeding. Dental surgery was performed in 43 patients with bleeding disorders i.e. hemophilia, idiopathic thrombocytopenic purpura, leukemia, severe thrombocytopenia, patients on anticoagulant, etc. Only 3 cases (7%) required blood component compared to all of the 50 no-FG controlled cases (100%) that required blood component therapy. FG has proved to be very useful in many aspects i.e. minimizing blood product usage, decreasing medical workload, reducing medical cost and increasing patients' convenience and satisfaction in particular.

The efficacy and safety of lyophilized cryoprecipitate in hemophilia A.

This prospective study of assessing the efficacy and safety of lyophilized cryoprecipitate (LC), which was heat-treated at 60 degrees C for 25 hours, was conducted in 23 patients with hemophilia A (severe 13, moderate 9, mild 1) at the International Hemophilia Training Center, Bangkok from 1997 to 1998. A total of 223 infusions of LC were given. The status of the patients could be classified into 4 groups: group I, non-bleeding (n = 13); group II, severe bleeding requiring hospitalization (n = 9); group III, appendectomy (n = 1) and group IV, early bleeding controlled by modified home treatment (n = 200). Pharmacokinetic studies were conducted in groups I and II. The mean in vivo half-life of factor VIII clotting activity (F VIII:C) was 12.6 hours and the mean in vivo incremental recovery at baseline was 2.1 per cent/unit/kg. The mean clearance was 3.22 ml/kg/h. There was no statistically significant difference in these parameters between groups I and II (p > 0.05). The hemostasis was successfully achieved and 1 to 2 small urticarial wheals were observed in only 2 infusions. In addition, 9 out of 23 patients received LC exclusively for 1 year. None of them developed inhibitor to F VIII:C nor did any contract additional transfusion-transmitted infection except one who developed anti-hepatitis C virus seroconversion after receiving 16 bottles of LC in 4 months. Therefore, the more efficient virus-inactivation in the preparation of LC should be established.

Home treatment for patients with congenital bleeding disorders in a developing country.

Ninety-six patients with congenital bleeding disorders were enrolled in a home treatment program from 1979 to 1997. The diagnosis included severe and moderate hemophilia A and B (n = 63), mild hemophilia A (n = 18), von Willebrand disease (vWD) (n = 12) and congenital factor VII deficiency (n = 3). The median age was 9 years and the median duration of follow-up was 4 3/12 years. The home treatment was modified 4 ways: (1) Using locally-prepared single units of fresh dry plasma in the majority of the patients while mild hemophilia A and vWD patients received 1-deamino 8D-arginine vasopressin. (2) Recruiting local health personnel as the primary care providers. (3) Teaching and training patients and parents intensively. (4) Maintaining an effective control system. The heartful effort of the health personnel was not in vain; the patients learned to take good care of themselves. Twenty patients and 20 parents or relatives were able to perform venipuncture properly and no adverse effect was observed. Since the hemorrhage was treated very early, the severity and sequelae of bleeding were decreased. The utilized blood components and days of hospitalization were reduced. Impressively, the absenteeism from work or school was minimized so that the patients could enjoy a near normal life in their family, school and society.

Vitamin K deficiency bleeding in Thailand: a 32-year history.

Vitamin K deficiency bleeding cases in Thailand from 1963 to 1995 were extensively studied. From 1963 to 1987 there were 499 reported cases from 10 papers including 102 cases of the authors' series. From March 1994 to April 1996, two subsequent nationwide surveys were conducted where questionnaires were sent to 714 and 732 hospitals located throughout Thailand. The responding rate was 58.2% and 67% respectively. 331 cases were found during 1988 to 1995. The total number was 830 cases of which 799 were idiopathic vitamin K deficiency in infancy (IVKDI) and 31 were secondary types. IVKDI was found exclusively breast-fed infants (92%) who did not receive vitamin K prophylaxis at birth (90%). Bleeding and pallor were the common features. The occurrence of intracranial hemorrhage was strikingly high (82%); the fatality rates was 24%. However, the fatality rate among patients receiving either 1 mg of vitamin K, intramuscularly, (17%) or 2 mg, orally, (18%) were lower than those not receiving vitamin K prophylaxis (36%). The incidence of IVKDI significantly declined to 4.2-7.8 per 100,000 births between 1988 to 1995 which was in reverse proportion to the coverage of vitamin K prophylaxis (r = -0.94, p < 0.05).

Eluding transfusion-transmitted HIV infection: report of two cases.

Two hemophilia A boys (FVIII: C < 1% and 2.2%), whose ages were 12 and 14 years. old, received fresh frozen plasma of 140 ml and 210 ml, respectively, in 1989. It was the 27th and 13th donation for each regular donor who was negative for anti-HIV testing. However, both donors had HIV seroconversion within 95 to 110 days after the last donation. They might have contracted HIV infection shortly after the last donation. Luckily, the two hemophiliac recipients are still in good health and negative for anti-HIV and HIV-antigen testings for 7 years.

Prophylactic treatment for hemophilia A patients: a pilot study.

Prophylactic treatment with factor VIII concentrate was given to six hemophilia A boys whose factor VIII:C ranged from 1% to 3.5% at Ramathibodi Hospital. The age ranged from 11 to 16 years with the median age of 12 years old. Each patient received factor VIII concentrate twice a week in the dosage of 8-10 unit per kg for one year. During the prophylactic period, bleeding episodes seldom occurred. They did not need hospitalization. The absence from school was reduced. They became muscular from regular daily exercise. They could join the activity at school and lived a near normal life. The patients and family were very happy since they did not have to worry about bleeding. No adverse effect was found. The only constraint was the cost. It cost 180,000 baht (US$ 7,200) per year or 15,000 baht (US$ 600) per month for a 25 kg hemophiliac boy.

Disseminated Burkitt's lymphoma in a child with AIDS.

Rarity of HIV-associated disseminated lymphomas in children initiated this report. The patient was an 18-month-old girl who had a history of chronic cervical lymphadenopathy since 6 months of age. She was first seen because of rapid enlargement of an inguinal lymphnode. The bone marrow aspirate was compatible with Burkitt's lymphoma, L3 cell-type. She was treated with chemotherapy without satisfactory success. She developed neurological involvement of lymphoma. Accidental sharp injury which contaminated her blood, in a medical personnel leaded to having her blood tested for anti-HIV and it was found positive. Her mother had positive anti-HIV presumably acquired from blood transfusion after an abortion in early 1988. It occurred before the donated blood was compulsively tested for anti-HIV. She died at the age of 24 months.

Transmission of HIV infection by seronegative blood in Thailand.

In Thailand, the prevalence of HIV infection in the general population and in donor blood (DB) has sharply increased since 1987. The HIV seropositive rate in DB was increased from 0.0065 per cent in 1987 to 0.95 per cent in 1993 (150 times in 6 years). Heterosexual transmission is the major route of spreading. Therefore, HIV seronegative blood (SNB) poses significant hazard to the recipients because of the risk of viraemia during the window period of early HIV infection. In Thailand HIV Ab screening in all units of blood was started in 1987 and was compulsory nationwide in early 1989. Donor self exclusion (DSE) has been implemented since 1990. It is not fully effective in the prevention of transfusion associated AIDS (TAA) because of many limiting factors. However, DSE should be promoted to practice in every blood bank particularly those that can not do HIV Ag screening. During 1990-1992, there were 30 reported cases of TAA by SNB. The study of risk figure (HIV Ag positive-neutralization with HIV Ab negative) in DB was 1:3,400 and 1:10,000 in two reports in 1991. Under all these circumstances, the national AIDS committee has documented the policy to do HIV Ag screening in every unit of blood from August 1991 and allocated a 10 million baht budget (year 1992) for Ag testing. Several hospitals and NBC reported the risk figures which varied from 1:3,400 to 1:25,000. A certain amount of blood is processed to 2-4 blood components given to 2-4 patients which will increase the number of TAA by SNB.(ABSTRACT TRUNCATED AT 250 WORDS)

Histiocytoses in children: analysis of 120 cases and the bone marrow findings in infection-induced hemophagocytic syndrome vs malignant histiocytosis.

Retrospective analysis of childhood histiocytoses treated at the Department of Pediatrics, Ramathibodi Hospital from May 1970 till June 30, 1992 to verify the prevalence according to the recent classification, course and prognosis was conducted. Among 120 cases, 54 were Class I or Langerhan Cell Histiocytosis (LCH, previously called Histiocytosis-X). Nineteen cases were Class II: Infection-Associated Hemophagocytic Syndrome (IAHS) and Sinus Histiocytosis. Forty-seven cases were class III which included acute monocytic leukemia, juvenile CML; malignant histiocytosis, HMR, and histiocytic lymphoma. Excellent prognosis (cure) was seen in all cases of Hand-Schuller Christian Disease, eosinophilic granuloma, sinus histiocytosis with massive lymphadenopathy and many cases of Class II (except IAHS). The worse prognosis (100% mortality rate) was seen in HMR and juvenile CML. The intermediate prognosis (50%, 54%, 58.8% and 66.7% mortality rate) was seen in MH, HL, LSD and IAHS respectively. To differentiate between IAHS and MH/HMR, the prominent bone marrow findings in 12 cases of IAHS revealed that every case showed prominent hemophagocytosis by the promono-histiocytes/histiocytes, the maximal total erythroblasts (TE) were only 7.5 per cent except for 3 cases; in which one case with agranulocytosis from co-trimoxazole had 84 per cent erythroid cells, one case with prior co-trimoxazole treatment had 37 per cent TE, the last one had 40 per cent TE with massive GI bleeding while in the recovery stage of DHF. All 5 cases of HMR had prominent hemophagocytosis and increased TE (> 22%).(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombotic risk of children with thalassemia.

Pulmonary microthromboembolism is one of the serious complications found in patients with thalassemia. The pathogenesis is undetermined. The thrombotic risk in 44 patients (26 males, 18 females) with beta-thalassemia/hemoglobin E disease and without clinical symptoms of thrombosis were studied. The age ranged from 3-19 yr (X +/- SD = 10 +/- 4). Neither of them had chronic hepatitis B infection. They were divided into three groups according to clinical manifestations as follows: (1) Mild form (n = 12). They did not require blood transfusion. The mean +/- SD of hematocrit was 23.3 per cent +/- 2.3; (2) Severe form (n = 19). They required frequent blood transfusion. The mean +/- SD of hematocrit was 17.7 per cent +/- 1.5; (3) Severe form with splenectomy (n = 13). They seldom required blood transfusion. The mean +/- SD of hematocrit was 21.8 per cent +/- 3.5. Most of the patients had delayed growth. They had high serum ferritin reflecting iron overload status which was prominent in the severe groups (group 2 & 3). The prothrombin time and serum albumin were slightly decreased, and the serum alanine transaminase were slightly increased; all of which reflected mild alteration of liver function. The plasma AT III, PC and PS antigen in the three groups were similar. The mean +/- SD of AT III antigen was 106.7 per cent +/- 22.2 which is normal. The mean +/- SD of PC antigen was 44.2 per cent +/- 14.2 and PS antigen level was 77.2 per cent +/- 17.8.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatopathy-thrombocytopenia vs infection-induced hemophagocytic syndrome in Wilms' tumor: a case report.

A 3-year-old boy with Wilms' tumor, post operative left nephrectomy stage, had HTS on day 99 of the combined chemotherapy which lasted for more than 20 days. He had severe respiratory distress due to a moderate amount of ascites and marked pleural effusion. Because of high fever, thrombocytopenia and marked hemphagocytosis in the bone marrow, he received IVIG for 2 days. Normal platelet count and markedly decreased pleural fluid were attained within 3 days. He subsequently tolerated full doses of combined chemotherapeutic agents with an additional one (doxorubicin). In cases of HTS, IAHS should be suspected. The bone marrow should be done and treatment accordingly so that there is no need to decrease, the dosage of chemotherapeutic agents afterwards.

Chemotherapy in patients with retinoblastoma.

Chemotherapy composed of vincristine, cyclophosphamide, procarbazine and intrathecal thiotepa/methotrexate (in the indicated ones) were given for 1.5 years in the doubtful and very unfavorable (Reese-Ellsworth classification) cases of retinoblastoma. There were 58 new cases treated at the Department of Ophthalmology and the Department of Pediatrics, Ramathibodi Hospital from October 1, 1985 to December 31, 1991. Eight cases had refused the surgery prior to admission. Nine cases were not given chemotherapy due to the very advanced cases and refusal. Forty-nine cases received chemotherapy. Eighteen cases were not followed. Among 31 evaluable cases, three cases had progression of the disease. Twenty-eight cases (90%) were clinically well 2 months-6 years after discontinuation of chemotherapy. The good result could be attributable to spontaneous regression (minimal percentage), surgery, radiation therapy or chemotherapy. However, obvious chemotherapeutic effects were seen in some cases. Even though 28 cases seemed to have good result including three of the 8 cases who had refused surgery before admission, we should stress that retinoblastoma is a curable disease provided that early diagnosis and treatment are rendered. Ophthalmologic examination in first degree relatives should be done in the bilaterally involved cases.

A new method for factor VII deficient substrate preparation and coagulation studies in malaria.

A simplified technique using DEAE-cellulose chromatography for the preparation of factor VII deficient substrate was developed in order to reduce the high cost of individual factor VII assay in the routine coagulation laboratory. The substrate prepared from cryo-removed human and bovine plasma had a high correlation (r = 0.9929) with two of the most popular imported commercial substrates available (DADE, Ortho). When compared several other imported commercial substrates of equal quality, the prepared substrate was 3,000 to 6,000 times cheaper. Using the prepared factor VII deficient substrate along with other commercial substrates available, two hundred and fifty patients with malaria (fifty cases of P. vivax and two hundred cases of P. falciparum) were studied for coagulation and fibrinolysis abnormalities. Only P. falciparum infections showed prolonged PT and aPTT which correlated with the degree of parasitemia (r = 0.0972). Factors V, VII, and IX were the most sensitive parameters in the expression of coagulation defects and most coagulation abnormalities were due to liver involvement. Plasmin activity was normal in P. vivax patients but it was significantly increased in P. falciparum patients with > 5% parasitemia. Only two of the complicated cases of P. falciparum patients showed the evidence of DIC.

Abnormal hemostasis in dengue hemorrhagic fever.

Abstract. Abnormal hemostasis in dengue hemorrhagic fever includes:- 1. Vasculopathy which occurs during the early febrile to pre-shock and shock phase. The evidences support are: 1.1 Increased anaphylatoxin, released by complement activation causing leakage of intravascular fluid in to serous space. 1.2 Positive tourniquet test, some of which occur preceeding thrombocytopenia in the acute phase of DHF. 1.3 Excessive increased in PGI2 which is the most potent vasodilator and platelet aggregation inhibitor. 2. Platelets: 2.1 Thrombocytopenia due to 2.1.1 The bone marrow hypocellularity with increased in all forms of megakaryocytes but the vacuolated and disintegrated ones. 2.1.2 Destruction by the liver and spleen. 2.1.3 Immune-mediated injury as demonstration of dengue antibody complexes on the platelet surface. 2.1.4 The in vitro spontaneous aggregation to vascular endothelial cell pre-infected by dengue virus inducing platelet aggregation, causing lysis and platelet destruction. 2.2 Dysfunction shown by 2.2.1 Increased release of betathromboglobulin (BTG), PF4 and PGI2. 2.2.2 In vitro hypoaggregation stimulated by ADP and defect in ADP-releasing ability. 3. Coagulopathy including: 3.1 Prothrombin complex deficiency due to liver damage. 3.2 Consumptive coagulopathy due to the activation by mononuclear phagocytes, PF3 released from platelet aggregation. DIC is seen in prolonged shock cases of DSS.

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.

Platelet counts in thalassemic children before and after splenectomy.

Even though thrombotic risks in thalassemia patients from standpoints of platelet dysfunction and coagulation factors are controversial, they are in favor of thrombosis due to thrombocytosis. From the study of 74 cases of thalassemia in children, marked thrombocytosis occurred during day 8 to 4 months during which one should be aware of the thrombosis. However, none of thalassemia children had acute thrombosis even at platelet counts of 1.6 million/microliters.

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.

Immunoglobulins in acquired platelet dysfunction with eosinophilia.

Acquired platelet dysfunction with eosinophilia (APDE) is acquired bleeding diathesis associated with platelet dysfunction causing prolonged bleeding time. Most of them had eosinophilia. Various reports of the isolated cases had normal level of immunoglobulins but few had increased IgE. This report is different from others in that among 41 cases of APDE, it was found that most of them had normal levels of IgG, IgA, IgE but there was increased IgM in 95.1% of the cases. Increased in IgE was noticed in 7/24 cases (29.2%) and only half (3/6 cases) corresponded with eosinophilia.