Use of anti-D in immune thrombocytopenic purpura as a means to prevent splenectomy: case reports from two University Hospital Medical Centers.

Presented here are 16 case studies of adults with immune (idiopathic) thrombocytopenic purpura (ITP); 5 were treated at Hackensack University Medical Center (HUMC), Hackensack, NJ, and 11 were treated at the Allegheny University Hospital (AUH), Medical College of Pennsylvania. Four of the 5 patients at HUMC had initial transient responses to intravenous immunoglobulin G (IVIg) therapy and required large doses of corticosteroids to maintain platelet counts over 50,000 microL. One elderly patient with systemic lupus erythematosus (SLE) had been treated unsuccessfully with corticosteroids and immunosuppressants to maintain her platelet count over 50,000 microL. All 5 patients were given 1 or 2 doses of anti-D at 50 microg/kg, leading to complete resolution of ITP. Following anti-D therapy, patients were tapered off corticosteroids and currently remain in complete remission with platelet counts over 100,000/ microL. The mechanism of action of anti-D in ITP remains unclear and requires further study. Treatment of the 11 patients at AUH began with corticosteroids, which resulted in no durable therapeutic response. Anti-D was then given at 50 microg/kg, and this provoked an excellent response with a prompt recovery of platelet levels to 100,000/ microL, after which active treatment was halted. Patients were monitored by direct office visit every 3 months unless a clinical indication required an earlier return. If the patient's platelets dropped below 100,000/ microL, they were first given prednisone. As of the last follow-up, all 11 patients remain stable and no patients have required splenectomy.

In situ endothelin in coronary artery disease.

Despite the significant advances made in the understanding and treatment of coronary artery disease much remains unclear about the pathogenesis of this complex atherothrombotic process. Atherogenesis may reflect a combination of multiple factors interacting with one another leading to coronary artery occlusion. One potential participant may be endothelin-1 (ET-1), a potent mitogenic vasoconstrictor. The presence of endothelin within saphenous veins before insertion and after removal during coronary artery bypass grafting (CABG) because of bypass closure, within internal mammary arteries before and after surgical intervention, and within native coronary artery segments resected during CABG was demonstrated immunocytochemically with an antiendothelin antibody and aminoethyl carbazole as the indicator chromogen. Increased amounts of ET-1 were observed in failed venous grafts, in damaged internal mammary artery grafts, and in vessels of the myocardium. These results suggest that ET-1 may play a significant pathophysiologic role in the evolution of coronary heart disease.

Interleukin-1 alpha as a factor in occlusive vascular disease.

The purpose of this study was to examine the recognized ability of interleukin-1 alpha (IL-1 alpha) to alter the functional properties of endothelial cells and to induce replication of smooth muscle and fibroblasts. Such changes could potentially link IL-1 alpha pathogenetically to the myointimal proliferation of vascular sclerosis. Using a peroxidase-immunoperoxidase immunohistochemical method, saphenous veins and internal mammary arteries were examined for the presence of IL-1 alpha before their implantation as aortocoronary bypass grafts. Occluded saphenous vein grafts requiring replacement because of recurrent angina pectoris also were similarly examined. Interleukin-1 alpha, deposited as a scarlet immunoprecipitate, was seen on the luminal surface, in the subintima, and on the spindle cells and infiltrating macrophages in the media of 13 phlebosclerotic veins before surgical insertion. The remaining 30 unchanged veins did not contain IL-1 alpha. Similarly, IL-1 alpha was not identified in any of the 43 sampled internal mammary arteries that were all considered structurally intact. All the 55 bypass grafts, which were examined by biopsy during revascularization and demonstrated diverse histopathologic abnormalities consisting of reduced luminal patency, myointimal proliferation, mononuclear cell infiltration, mural collagenization, and luminal-mural hemorrhage, also contained widely distributed IL-1 alpha. The observation that IL-1 alpha was absent in all of the internal mammary arteries concomitant with maintenance of normal microanatomic structure may help explain, in part, their recognized resistance to reduction in luminal patency and their improved clinical survival when used as coronary artery bypass grafts. Alternatively, the consistent presence of IL-1 alpha in all vessels with sclerotic histopathologic changes suggests that this cytokine may be an important in situ indicator of and a potential participant in vascular injury. Interleukin-1 alpha may be a pathogenetic factor in the complex processes leading to vascular occlusion.

Development of 5q- myelodysplasia in a patient with sarcoidosis.

Sarcoidosis has been observed in association with numerous blood dyscrasias including lymphoma, leukemia, and multiple myeloma. This report describes a patient with sarcoidosis and a refractory anemia whose bone marrow karyotype showed deletion of the long arm of chromosome 5, consistent with a myelodysplastic syndrome. Concurrent sarcoidosis and myelodysplasia may relate to the continued availability of cytokines as a consequence of repeated macrophage, T-cell, and B-cell interactions, with evolution to the 5q- abnormality. This association may merit specific attention in the future approach to the diagnostic evaluation in certain patients with sarcoidosis.

Immunocytochemical features of obstructed saphenous vein coronary artery bypass grafts.

The peroxidase-immunoperoxidase immunocytochemical method was used on 27 saphenous vein coronary artery bypass grafts, which had been resected because of recurrent angina, to identify in situ cellular and humoral elements possibly associated with graft occlusion. Immunostaining was performed on paraffin wax embedded control saphenous vein and graft sections incubated directly with primary antibodies against von Willebrand antigen (vWFAg), fibronectin, fibrinogen, leucocyte common antigen (LCA), lysozyme, vimentin, desmin, platelet factor 4, and thrombospondin. Antigens were visualised by a chromogen providing an orange-red immunoprecipitate at the site of epitope localisation. The intraluminal, amorphous exudate present in most grafts was not composed simply of fibrin or fibrinogen, as previously thought, but was a multiprotein complex including wWFAg, fibronectin, thrombospondin and platelet factor 4. Along with macrophages, these components probably enter the graft after haemodynamic, physical, and chemical injury to, and disruption of, the endothelial cell. Progressive myointimal proliferation and fibrosis of these grafts may be local repetitive responses to macrophages and platelets, cells previously known to participate in vascular disease.

Altered lymphocyte subsets during cardiopulmonary bypass.

Peripheral blood lymphocyte subsets were quantified by immunofluorescence in nine patients undergoing open heart surgery for coronary artery, valvular, and congenital heart disease. Compared with normal preoperative values, all patients developed an absolute lymphopenia, a reduction in T4 (helper) lymphocytes, and a statistically significant reversal of the T4/T8 ratio two hours after cardiopulmonary bypass (CPB). These changes could be caused by mechanical or immunogenic injury. A return to normal of the T4 subset and T4/T8 proportion occurred 24 hours after surgery. Whereas transient inactivation of immunoreactive lymphocyte clones may prevent unwanted immunization to blood products received during surgery, such temporary immune dysfunction could make certain patients liable to infectious sequelae. Viral-induced postperfusion syndromes, transmission of human T lymphotropic virus (HTLV) III by blood products, and reports of acquired immune deficiency syndrome after CPB foster a concern regarding postoperative infections under these circumstances.

Coronary artery deposition of factor VIII-related antigen in ischemic heart disease.

This study localized Factor VIII-related antigen (FVIIIRAg) directly in the intramural coronary arteries of patients with coronary artery disease (CAD). Assays were performed on myocardial autopsy sections from 17 patients with and 15 patients without CAD, using a monospecific FVIIIRAg antibody in the peroxidase-immunoperoxidase technic. FVIIIRAg was quantified by a FVIIIRAg index (FRI), as a numerical score based on distribution, thickness, and extension of immunostaining. The mean FRI for the CAD patients was 55 +/- 11 and that for the control patients 12 +/- 5 (P less than 0.001). The increased amounts of in situ FVIIIRAg suggest this glycoprotein may be involved in the pathogenesis of atherosclerosis.

Concentrations of factor VIII-related antigen and factor XIII during open heart surgery.

Plasma levels of factor VIII-related antigen (fVIIIRA) and factor XIII S and A subunits (fXIIIS, fXIIIA) were assayed by counterimmunoelectrophoresis before, during, and after cardiopulmonary bypass (CPB) in patients with coronary artery and valvular heart disease to define the basis for clinical and laboratory abnormalities of hemostasis occurring in this form of surgery. During CPB, concentrations of fXIIIA dropped in both patient groups but returned to preoperative levels promptly after pump removal. In contrast, fVIIIRA and fXIIIS, which are not incorporated into the clot, remained unchanged even during fluid administration. These data provide evidence of a transient consumption coagulopathy as a feature of CPB. Hemodilution probably plays a secondary role in these changes.

The behavior of antithrombin III, alpha 2 macroglobulin, and alpha 1 antitrypsin during cardiopulmonary bypass.

We serially measured concentrations of three protease inhibitors, antithrombin III, alpha 2 macroglobulin, and alpha 1 antitrypsin in patients with coronary artery and valvular heart disease during extracorporeal circulation. Assays for immunoreactive antiproteases and for functional antithrombin III were performed on plasma samples obtained at selected intervals before, during, and after cardiopulmonary bypass. Significant reductions of all protease inhibitors occurred at some time during cardiopulmonary bypass, although patterns of change were dissimilar for the two patient groups. A return toward preoperative levels was observed after cardiopulmonary bypass was discontinued, but antithrombin III remained diminished in the patients with coronary artery disease. The acute serial changes in this group of alpha globulins is evidence of their participation during the dynamic stress of extracorporeal circulation. Their timely intervention as serine protease antagonists deters sustained thrombogenesis and fibrinolysis during cardiopulmonary bypass.

von Willebrand syndromes and mitral-valve prolapse; linked mesenchymal dysplasias.

We searched for mitral-valve prolapse by two-dimensional echocardiography in 15 patients with von Willebrand syndromes to test the hypothesis that this bleeding disorder is actually a mesenchymal dysplasia that resembles the heritable disorders of connective tissue. This valvular abnormality was found in nine (60 per cent) of these patients, as compared with four (13.3 per cent) of 30 sex-matched and age-matched healthy controls. This difference was statistically significant (P less than 0.01). The association between these two disorders encourages a search for mitral-valve prolapse in persons with a von Willebrand syndrome. The complex of a von Willebrand syndrome and mitral-valve prolapse may be an example of a newly recognized category of related coagulation and cardiovascular disorders.

In vitro effects of single alkylating agents on normal peripheral blood lymphocytes.

The separate in vitro effects of HN2 and L-PAM on resting and stimulated peripheral blood lymphocytes were evaluated with biochemical and morphologic experimental endpoints. Both alkylating agents caused dose-dependent reduction of protein, RNA, and DNA synthesis, but the patterns of diminution differed. The number of cells staining with Erythrosin B, as a toxicity indicator, also rose with higher drug concentrations, but a large proportion of lymphocytes remained unstained even at the maximum drug dose. Stimulation with PHA partially nullified the suppression caused by HN2 but did not influence the effects of L-PAM. Exposure to PWM rendered the in vitro HN2 innocuous but L-PAM remained cytotoxic. Simultaneous lectin-induced blastogenesis proceeded unaltered. Finally, comparisons between 72 and 4 hr drug exposures imply that interference with intracellular synthesis occurs promptly, continues after drug removal, and is related quantitatively to drug concentration rather than to duration of contact.

Accumulation modes of alkylating agents on normal peripheral blood lymphocytes.

The in vitro uptake by normal peripheral blood lymphocytes of 14C-labeled cyclophosphamide and nitrogen mustard has been measured in a manner which parallels cell exposure to drugs used in the nitrogen mustard-oncovin-procabazine-prednisone (MOPP) and cyclophosphamide-oncovin-procarbazine-prednisone (COPP) clinical protocols. Accumulation of these alkylating agents occurs in two recognizable patterns. The first exhibits a saturation phenomenon, since radioactivity can be partially blocked by an equal concentration of unlabelled drug, reflects stereospecificity, and represents a minor fraction of total deposition. The second form, proportionately larger than the first, is dependent on drug concentration in the suspending medium, with radioactivity increasing in an apparently limitless linear fashion, uninfluenced by competitive inhibition. This part also is less tenaciously held by the lymphocyte. While the mere presence of drug on the lymphocytes does not necessarily imply injury or lethality, the fact that these peripheral lymphocytes are able to accumulate cytotoxic agents and are partially interchangeable with an analogous fixed lymphoid cell mass suggests that clinical immunosuppression and lymphocytopenia may be related, in part, to cell drug deposition.

Sickle cell trait and hematuria associated with von Willebrand syndromes.

A von Willebrand syndrome was present in four patients with sickle cell trait and hematuria. The first two patients had severe anemia and active bleeding and received cryoprecipitate, with prompt cessation of hemorrhage. All of the patients had repetitive laboratory and clinical features; that is, reduced, but detectable, factor VIII-related antigen, heterogeneity of, and incongruities within, the coagulation studies performed by consistently defective platelet aggregation to ristocetin correctable only with normal plasma. Bleeding outside the genitourinary tract never was observed. Because of the focal nature of the hemorrhage, the hematuria may not have been perceived as part of a general hemorrhagic disorder and the diagnosis not pursued. These observations suggest that when sickle cell trait and hematuria occur together, a von Willebrand syndrome should be a major diagnostic consideration that ultimately may point toward a rational, effective, easily administered, and clinicially acceptable form of treatment with cryoprecipitate.

Differential uptake of alkylating agents by normal and leukemic lymphocytes.

When 14C-labeled cyclophosphamide and nitrogen mustard were incubated separately with normal lymphocytes and lymphocytes from patients with chronic lymphocytic leukemia, the amount of radioactivity associated with the normal cells far exceeded that detected on the leukemic lymphocytes. This comparative diminution may be analogous to the impaired PHA response and excess surface immunoglobulin which serve as identifying markers of the malignant B cell. Cytotoxicity and neuraminidase experiments indicated that drug uptake by lymphocytes is not capricious and may occur in an optimum, predetermined fashion. Although surface uptake and therapeutic response are not necessarily directly interrelated, initial peripheral contact with an antineoplastic agent may be an essential step which modifies tumor sensitivity or resistance.

Serum alkaline phosphatase isoenzymes in sickle cell anemia.

Alkaline phosphatase isoenzymes in sera from patients with sickle cell anemia were separated by electrophoresis on starch gel. Physical and biochemical criteria identified bone alkaline phosphatase as the principal, although not necessarily the sole, enzyme fraction that increases during symptomatic sickle cell crises. Moreover, there appeared to be concordance between crisis severity, serum levels of alkaline phosphatase, and isoenzyme patterns; electrophoretic and biochemical abnormalities could be detected even when the patients were asymptomatic. The present data suggest that the serum alkaline phosphatase level may be an additional indicator of the degree, frequency, and persistence of tissue injuries that occur in sickle cell anemia.