Use of a mildly restrictive administrative protocol to reduce orders for manual blood film examination from the emergency department.

In order to conserve laboratory resources, we instituted a mildly restrictive administrative protocol requiring a telephone request by emergency physicians or their designees in order to obtain a manual blood film examination (BFE). This test includes a manual differential leukocyte count (DLC), examination of red cell morphology, and platelet estimate. The protocol resulted in a marked reduction of the number of BFE's performed on emergency department patients from the previous level of one for every complete blood count (CBC). Retrospective chart review of a sample of patients not receiving manual BFEs indicated no apparent adverse effect on patient care. We speculate that the availability of an electronic partial differential count, providing enumeration of lymphocytes and neutrophils along with the CBC, facilitated in part the reduced ordering of manual BFEs.

Failure of high-dose i.v. gammaglobulin in the treatment of spontaneously acquired factor VIII inhibitors.

Two patients with spontaneously acquired factor-VIII-C inhibitors were treated with high-dose i.v. gammaglobulin. Minimal inhibition of anti-VIII-C activity was demonstrated in vitro in one patient when i.v. gammaglobulin was mixed directly with his plasma. In neither patient, however, was there any significant reduction in titer of antifactor VIII-C after i.v. gammaglobulin administration, nor was there any shortening of the aPTT or reduction in bleeding. The possible mechanisms of the previously reported salutary benefits of high-dose i.v. gammaglobulin in patients with spontaneously acquired factor-VIII inhibitors as well as the potential reasons for failure in our patients are discussed. Our cases demonstrated that high-dose i.v. gammaglobulin is not uniformly successful in the treatment of patients with acquired factor-VIII-C inhibitors. The true frequency of clinically significant responses will require further clinical trials.

Procainamide-induced lupus anticoagulant.

The lupus anticoagulant, with or without other symptoms or signs of lupus, has been described in patients taking procainamide. Screening all such patients for the presence of these anticoagulants may be warranted (despite the rarity of episodes of bleeding) in view of the potentially increased risk of thrombotic events in patients who may already be predisposed. A prospective study to determine the incidence of lupus anticoagulant in procainamide-treated patients and the true frequency of thrombosis in these patients would be helpful in determining appropriate management.

Reacting appropriately to thrombocytopenia in pregnancy.

The lower limit of normal for the platelet count is considered to be 150,000/cu mm in both pregnant and nonpregnant normal adults. In the absence of preeclampsia, sepsis, drugs, or other apparent causes, the finding of asymptomatic mild thrombocytopenia in pregnant women is compatible with previously unrecognized immune thrombocytopenic purpura (ITP). Because of the risk of fetal/neonatal thrombocytopenia and the subsequent risk of neonatal intracranial hemorrhage in infants born of mothers with ITP, the optimal mode of delivery for an asymptomatic but thrombocytopenic mother is problematic. Conceivably, those gravidas with mild previously unrecognized thrombocytopenia may not have ITP and thus could be spared cesarean section. From the platelet counts of 730 antepartum patients, we found a mean value of 263,900/cu mm with a standard deviation of 66,000/cu mm, yielding 95% confidence limits of 134,500 to 393,300/cu mm. The distribution is statistically indistinguishable from a normal distribution. Of 26 asymptomatic thrombocytopenic patients with no hematologic history, none had infants with hemorrhage or platelet counts less than 100,000/cu mm. Only one patient subsequently had severe glucocorticoid-resistant thrombocytopenia requiring splenectomy several months after delivery. The remaining patients continue to be asymptomatic to date, with platelet counts greater than 100,000/cu mm. We suggest a plan for managing less than normal platelet counts in asymptomatic gravidas without a history of hematologic abnormality.

Uneventful plasma exchange with albumin replacement in a patient with a previous anaphylactoid reaction to albumin.

A patient who had a previous anaphylactoid reaction to albumin required plasma exchange for myasthenia gravis. She was rechallenged with albumin from a different manufacturer after premedication with diphenhydramine. No adverse reaction occurred during five exchanges over a 10-day period. Possible pathogenic mechanisms and prevention of such reactions are discussed.

Microgranular acute promyelocytic leukemia--a case with multiple Auer rods demonstrable only after staining for chloroacetate esterase.

In the past several years there has been increasing recognition of the microgranular variant of acute promyelocytic leukemia (APL). This variant is easily mistaken for other types of acute non-lymphocytic leukemia. Its recognition is important because it carries the same high risk of disseminated intravascular coagulation as typical APL. An important clue to the correct diagnosis is the recognition of small numbers of characteristic cells containing multiple Auer rods. This report presents a case in which such Auer-body-containing cells were demonstrable in the marrow only after staining for chloroacetate esterase. They were not apparent with Wright's stain or Sudan black B. The case also highlights the occurrence of variant APL in children and adolescents.