Cefotetan-induced hemolytic anemia: a case report and review of the literature.

Cefotetan disodium-induced hemolytic anemia has been reported previously, and some of these cases have been severe or fatal. We describe a case of severe hemolytic anemia that occurred in an 80-year-old woman who received cefotetan prophylactically after surgery for a small bowel obstruction. Eight days after the first dose of cefotetan, the patient developed a severe Coomb test-positive hemolytic anemia. Using flow cytometry, we demonstrated cefotetan-specific antibodies in her posttreatment serum, which were detectable at a serum dilution up to 1:10 000. The patient received corticosteroid therapy and blood transfusions, with improvement of her hematologic parameters, but died 54 days after admission for respiratory failure. To our knowledge, this is the first use of flow cytometry for the detection of cefotetan-induced red blood cell antibodies. This technique offers a sensitive, rapid, objective method for detecting drug-induced antibodies.

Ground squirrel model for cholelithiasis: role of epithelial glycoproteins.

The cholesterol-fed Richardson's ground squirrel (Spermophilus richardsonii) has proven to be an effective animal model in which to study factors that influence cholesterol gallstone formation and associated alterations in the gallbladder epithelium. Ground squirrels of either sex, fed a 2% cholesterol-enriched diet, exhibit cholesterol monohydrate crystal precipitation within 24 hours and macroscopically visible cholesterol stones by 3 weeks. Data on bile chemistry, biliary cholesterol precipitation, and various mucosal alterations occurring prior to, during, and after stone formation were collected using sampling intervals from 6 hours to 20 weeks on the diet. The results indicate that mucin hypersecretion appears to be more closely related to the initiation of nucleation than does either bile calcium of pH. Mucus hypersecretion begins within 18 hours of diet initiation and continues throughout the 20 week experimental period. Apical excrescences became more common and were larger in size during the early stages of cholelithiasis. Administration of aspirin during the experimental period demonstrated an inhibition of mucin synthesis and release. Gallstones were not formed in these aspirin-treated animals. A lectin-binding panel for 10 epithelial glycoprotein-related sugars indicated the mucin secreted by the gallbladder epithelium of 7 day experimental animals differed from that of controls. The most obvious difference was the abolition of WGA binding in the experimental animals, suggesting an absence of sialic acid expression in the mucin during the lithogenic process. Ultrastructural histochemistry indicated that both sulphomucin and sialomucin were present in the secretory granules and within the surface mucus layer of both experimental and control animals. Experimental animals, however, exhibited a significant predominance for sulphomucin. This pattern varies from that typically seen in other regions of the gastrointestinal tract where sialomucins predominate during pathologic processes.

Glomerulonephritis with associated hypocomplementemia and crescents: an unusual case of fibrillary glomerulonephritis.

Fibrillary glomerulonephritis is an unusual, but not rare cause of glomerulonephritis. Hypocomplementemia in association with fibrillary glomerulonephritis has been reported only once previously. A patient with hypocomplementemia and fibrillary deposits as demonstrated by electronmicroscopy is reported. The clinical and pathologic features of fibrillary glomerulonephritis and immunotactoid glomerulopathy are reviewed.

Retrospective evaluation of flow cytometry as a platelet crossmatching procedure.

We performed a retrospective analysis of flow cytometry as a platelet crossmatching procedure. Sera from 17 alloimmunized refractory patients were tested against 32 donor platelets, which had been stored as platelet-rich plasma for up to 36 months. Overall, 14/32 (44%) crossmatches were positive. The mean 1 h posttransfusion corrected count increments (CCIs) were 9,195 and 2,269 for a negative and a positive crossmatch, respectively. The predictive value of a positive crossmatch was 86%, whereas the predictive value of a negative crossmatch was 56%. When samples with low background fluorescence or with high panel-reactive antibody (PRA) levels were evaluated separately, the accuracy of the crossmatch improved from 69% to 80%. When compared to the platelet adhesion immunofluorescence test (PAIFT) and the standard and antiglobulin-enhanced lymphocytotoxicity tests for the detection of HLA antibodies, flow cytometry appeared to be more sensitive. We conclude that flow cytometry is a useful technique for platelet crossmatching, particularly for alloimmunized patients for whom HLA compatible platelets may not be readily available.

Contractile cells of the kidney in primary glomerular disorders: an immunohistochemical study using an anti-alpha-smooth muscle actin monoclonal antibody.

Mesangial cells of the renal glomerulus are thought to have contractile properties, resembling those of smooth muscle cells. Since actin synthesis in mesangial cells is increased in selected animal models of glomerulonephritis, we evaluated the expression of alpha-smooth muscle actin (ASMA), the principal actin isoform found in smooth muscle cells, in biopsy specimens from patients with primary glomerular disorders and in control tissues. Normal glomeruli and glomeruli in acute tubulointerstitial disorders showed few or no ASMA-positive cells in the glomeruli. In contrast, ASMA expression in mesangial cells was increased in minimal change disease, focal segmental glomerulosclerosis, mesangial proliferative glomerulonephritis, membranous glomerulonephritis, and immunoglobulin A nephropathy. In membranoproliferative glomerulonephritis and cryoglobulinemic glomerulonephritis both mesangial and capillary loop ASMA-positive cells were observed with a segmental distribution. In addition, ASMA-positive interstitial cells were seen in many biopsy specimens and often were increased in number in biopsy specimens showing early interstitial fibrosis and tubular atrophy. We conclude that ASMA synthesis in mesangial cells is upregulated in a variety of glomerular disorders, frequently associated with increased cell proliferation and mesangial matrix production. This phenotypic change may be an indicator of mesangial cell activation after injury and may have important pathophysiologic consequences.

Selection of platelets for refractory patients by HLA matching and prospective crossmatching.

A multi-site clinical study compared platelets chosen for refractory patients by prospective platelet crossmatching using stored donor platelets and HLA-based selection. Seventy-three patients who were refractory to random-donor platelets received two plateletpheresis components, one chosen by HLA-based criteria and the other by crossmatching. Patients were carefully evaluated to exclude nonimmune factors that could adversely affect transfusion results. Each of the five study sites used a crossmatch procedure with which it had experience. Results from this study indicate the following: 1) The overall rate of successful transfusion was similar when an HLA-based method of donor selection that includes all grades of matching and mismatching was compared to a crossmatch-based method of donor selection. 2) HLA-based selection that restricts recipients to grade A and BU matches was superior to a selection method based upon crossmatching alone. Donor selection based on HLA matching (grades A or BU) was also superior to selection based on any degree of HLA mismatching (grades BX, C, or D). 3) Selection of donors based on HLA-cross-reactive groups (defined by in vitro serologic crossreactivity) was no more successful than that based on grade C and D mismatches and was no more successful than selection by crossmatching alone. 4) Lymphocytotoxic and platelet antibodies were not detected in many of the enrolled patients, even though patients demonstrating nonimmune factors were eliminated from the study. It can be concluded that HLA-compatible (grades A and BU) platelets provide optimal support for refractory patients, but that crossmatch-selected platelets are acceptable as an alternative component.

Gross and histologic effects of topical misoprostol on canine gastric mucosa.

This study reports the histological effects of topical misoprostol, a synthetic PGE1 analog, administered in varying dosages on the resting canine gastric mucosa. Misoprostol did not macroscopically or microscopically damage the mucosa but its presumed permeability effects on the gastric vasculature induced marked edema of the mucosa and submucosa. Consistent features included increased thickness of both layers, dilated interglandular regions of the lamina propria, marked subepithelial edema, reduced depth and width of gastric foveolae, vasodilation of the vascular channels, reduced height of surface epithelial cells, swelling of their basolateral intercellular spaces, and increased amounts of surface adherent mucus. It is speculated that the mucosal edema, in addition to an increased mucus layer, may be important in the mechanism of gastric cytoprotection by increasing the distance of penetration or absorption for a mucosal-damaging agent, diluting its concentration, and disseminating any focal accumulations of red blood cells.

Lymphoproliferative disorder of granular lymphocytes. A heterogeneous disease.

Lymphoproliferative disorders of granular lymphocytes (LDGLs) represent a family of diseases that are morphologically similar but diverse with regard to immunophenotype, function, and clonality. In this article, we report three informative cases and propose a modification of the current classification of LDGLs. Our first case is an example of natural killer cell LDGLs (CD2+, CD3-, CD16+, CD57+/-). Based on a review of the literature, we suggest that natural killer cell LDGLs can be divided into two subgroups (types 1 and 2) according to the expression of CD57. Reduced expression of CD57 may distinguish between patients with a poorer prognosis. The remaining two cases illustrate examples of T-cell LDGLs (CD2+, CD3+, CD8+, CD57+) that differ mainly in their expression of CD16. The CD16+ T-cell LDGLs (type 1) usually show a clonal rearrangement of the T-cell receptor-beta chain gene, whereas CD16- T-cell LDGLs (type 2) may show a germline configuration, suggesting a reactive rather than a neoplastic process. Pathologists should differentiate LDGLs from other chronic lymphoproliferative diseases, since most cases evolve slowly and aggressive cytoreductive therapy is usually unwarranted.

The detection of platelet alloantibodies by flow cytometry.

A flow cytometric procedure was investigated for its ability to detect antibodies directed against blood group A, HLA, and PlA1 (HPA-1a) antigens. When type O sera were tested against platelets from blood group A donors, only 9 of 14 positive reactions were observed. Furthermore, the expression of blood group A varied more than 100-fold on platelets derived from individual donors. When anti-HLA-A2 and -B7 were evaluated, 11 of 11 individuals with HLA-A2 and -B7 antigens reacted. In contrast, when platelets from donors whose HLA antigens included HLA-B8 or -B12 were tested with anti-HLA-B8 or -HLA-B12, respectively, positive reactions were observed in only 3 of 7 instances, despite the fact that the lymphocytes reacted strongly. Platelets from 10 HLA-A2-positive donors, which had been stored for up to 20 months at -70 degrees C, were studied. In all cases, frozen-stored platelets reacted well with an anti-HLA-A2. Limited testing with an anti-PlA1 (anti-HPA-1a) showed equal reactivity with fresh and frozen platelets. Finally, the method was compared to a visual immunofluorescence assay using sera from patients who were refractory to platelet transfusions. The results agreed in 30 of 37 comparisons, and most discrepancies were resolved in favor of flow cytometry. It is concluded that flow cytometry is useful for detecting platelet alloantibodies and possibly for prospective platelet crossmatching, as HLA- and platelet-specific antibodies can be identified by using platelets stored frozen for several months.

Cobalt as a gastric juice volume marker: comparison of two methods of estimation.

We investigated the use of cobalt-EDTA, a novel, nonabsorbable liquid phase marker, in the estimation of secretory volumes during topical misoprostol (synthetic PGE, analog) administration in the canine chambered gastric segment. We compared atomic absorption spectrophotometry (AAS) and instrumental neutron activation analysis (INAA) in the estimation of [Co]. Mucosal bathing solutions containing cobalt-EDTA were instilled into and recovered from the chamber by gravity every 15-min period as follows: (i) basal--60 min; (ii) misoprostol periods--150 min (plus 0.1-, 1-, 10-, 100-, and 1000-micrograms doses of misoprostol for two periods per dose). The recovered solutions were analyzed for [Co] by AAS and INAA. Total cobalt recovery by AAS after chamber washout was 102.97 +/- 0.98%. Mean +/- SE volumes (12.14 +/- 0.33 and 13.24 +/- 0.60 ml/15 min) obtained respectively from AAS and INAA were significantly higher (P less than 0.001) than the recovered mean volumes (10.51 +/- 0.17 ml/15 min). The percentage error in volume collection increased (range: 9.3-52.7%) with the volume of secretion. Values of [Co] obtained by the two techniques were comparable and not significantly different from each other (P greater than 0.05). INAA-estimated mean +/- SE [Co] showed consistently higher coefficients of variation. Spectra obtained for all samples during INAA measurements showed significant Compton background activity from 24Na and 38Cl. Cobalt-EDTA did not grossly or histologically damage the gastric mucosa. We conclude that cobalt is not adsorbed, absorbed, or metabolized, and is a suitable and reliable volume marker in this model.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolymphocytic transformation of chronic lymphocytic leukemia: a case report of lengthy survival after intensive chemotherapy.

A case of prolymphocytic transformation of chronic lymphocytic leukemia (CLL) is presented in which complete peripheral morphometric remission and lengthy survival were observed after intensive chemotherapy. The case is discussed within the context of the reported therapeutic experience.

The dose-response of canine focal gastric mucosal blood flow to misoprostol.

We studied the dose-response of focal gastric mucosal blood flow measured simultaneously by laser-Doppler flowmetry and hydrogen gas clearance in the canine chambered gastric segment to topical misoprostol (0.1, 1.0, 10, 100, and 1000 micrograms in 10 ml of 150 mM NaCl for two 15-min periods per dose). Simultaneously obtained mucosal blood flow values showed a highly significant linear correlation (r = 0.63, n = 20, p less than 0.01) in the basal but not misoprostol periods between the two techniques. Laser-Doppler flowmetry measured a dose-dependent increase in blood flow (Emax = 6.4 +/- 2.8 V at the 100-micrograms dose; equivalent to 92.8% increase above the basal mean blood flow value; ED50 = 1.0 micrograms). Peak increase in blood flow by laser-Doppler flowmetry after dosing was attained in 6.1 +/- 0.7 min and maintained for 1.9 +/- 0.3 min. In contrast, hydrogen gas clearance showed a gradual decline in blood flow after misoprostol administration throughout all experiments. The duration of each hydrogen gas clearance measurement was 13.1 +/- 0.1 min. In conclusion, misoprostol dose-dependently and transiently increases focal gastric mucosal blood flow. However, only laser-Doppler flowmetry is sensitive enough to detect it. Although it can measure steady-state blood flow, owing to the duration of one measurement, hydrogen gas clearance is incapable of detecting rapid flow changes.

Ionic fluxes induced by topical misoprostol in canine gastric mucosa.

We studied the dose response of ionic fluxes in canine chambered gastric segment mucosa to increasing doses of topical misoprostol (0.1, 1, 10, 100, and 1000 micrograms). The fluxes were also correlated with the simultaneous changes in focal gastric mucosal blood flow measured by laser-Doppler flowmetry. After misoprostol administration, there was a dose-dependent increase in focal gastric mucosal blood flow (Emax = 8.23 +/- 3.25 V at 10 micrograms; ED50 = 1.05 micrograms), pH, and the outputs of ions (Na+, K+, Cl-, and HCO3-) and fluid (Emax for pH and fluxes greater than or equal to 1000 micrograms). ED50 values for these outputs ranged from 215.40 to 340 micrograms (mean +/- SE = 279.08 +/- 24.27 micrograms). H+ output showed a dose-dependent decrease to zero at the 10-micrograms dose, the dose at and after which net HCO3- secretion became obvious. The slopes of the dose-response curves for the fluxes of fluid, Na+, K+, Cl-, and HCO3- were significantly different (p less than 0.01) from the slope of the curve for mucosal blood flow changes. There were no correlations between the changes in these fluxes and blood flow changes. Na+ and Cl- were the predominant cation (98.84%) and anion (98.19%), respectively, in the misoprostol-induced secretion. Misoprostol stimulates a composite alkaline gastric nonparietal secretion, predominantly Na+ and Cl-, but also containing K+ and HCO3-. Our results suggest different mechanisms for the effects on nonparietal secretion and focal gastric mucosal blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

HLA antibody formation within the HLA-A1 crossreactive group in multitransfused platelet recipients.

The formation of intragroup antibodies, HLA antibodies directed against antigens in the same crossreactive group (CREG) as those of the serum donor, may be an important cause of transfusion failures in patients receiving HLA-matched platelets. Twenty-two patients whose HLA types included at least one antigen in the HLA-A1 CREG were studied. Of the ten patients who formed HLA antibodies, six produced antibodies that reacted with one or more antigens in the HLA-A1 CREG. Five of 12 patients whose HLA types included HLA-A3 formed antibodies directed against HLA-A1-10-11 or HLA-A1-10. In contrast, only one of ten individuals whose phenotypes included HLA-A1, HLA-A11, or both produced anti-HLA-A3. Eleven incompatible retrospective crossmatches were observed in recipients of HLA-matched platelets attributable to intragroup antibodies. Patients receiving incompatible platelets had unsatisfactory post-transfusion platelet count increments. It is concluded that intragroup antibodies, such as those directed against antigens in the HLA-A1 CREG, are an important cause of platelet transfusion failures in patients requiring long-term platelet transfusion support. These antibodies can be identified by routinely screening recipient sera for HLA antibodies and performing retrospective crossmatches using the lymphocytotoxicity technique.

Focal segmental glomerulosclerosis in patients receiving lithium carbonate.

Lithium carbonate is a commonly used psychiatric medication with a number of toxic renal effects, which include nephrotic-range proteinuria. A review of the literature concerning lithium-induced proteinuria is presented and three cases of nephrotic-range proteinuria are described in association with lithium therapy. The pathology in these three cases was focal segmental glomerulosclerosis, a finding not previously described.

Gastric mucosal blood flow in misoprostol pretreated aspirin-induced ulceration.

To determine whether topical misoprostol (a synthetic PGE analog) pretreatment will increase or prevent a decrease in gastric mucosal blood flow (GMBF) during topical aspirin administration, we studied focal GMBF simultaneously by hydrogen gas clearance in a split canine gastric chamber model with one side as control. In the test chamber, immediately after topical misoprostol, there was a transient and significant increase (18%) in GMBF (55.71 +/- 7.80 to 65.84 +/- 6.12 mL/min/100 g; p less than 0.05). After 15 minutes, GMBF returned to premisoprostol levels and then showed a graded drop throughout the aspirin and postaspirin periods. No grossly visible mucosal lesions were observed. In the control chamber, mucosal lesions were observed 45 minutes after aspirin administration accompanied by a graded drop in GMBF throughout the experiments. Misoprostol neither produced a sustained increase in GMBF nor prevented the subsequent reduction in GMBF induced by aspirin. Therefore, maintenance of GMBF may not be important in cytoprotection by misoprostol. The sustained nonparietal secretion induced by this synthetic PGE1 analog may be important in gastric cytoprotection.

Characterization of lipid accumulation in the gallbladder mucosa of the ground squirrel fed a lithogenic diet.

Richardson's ground squirrels (Spermophilus richardsonii) of both sexes were fed a 2 per cent cholesterol-enriched diet for intervals of 12, 18, and 24 h; 3, 5, and 7 days; and 2, 3, 10, and 20 weeks. It was shown that free (unesterified) cholesterol, phospholipid, and cholesterol ester accumulated in specific regions of the gallbladder mucosa during cholelithiasis. Electron microscopy revealed the presence of lipids inter- and intracellularly as early as 12 h after ingestion. By 7 days, lipids were seen in dilated endoplasmic reticulum, as well as in supranuclear and basal regions of epithelial cells. Histochemical localization revealed free cholesterol in dilated endoplasmic reticulum and residual bodies at the ultrastructural level. Neutral lipid was observed by light microscopy in the supranuclear and basal regions of the cells. In 10- and 20-week treated animals, lipid droplets were also seen in the lamina propria and macrophages. The lesion induced by cholesterol ingestion persisted throughout the experimental period, and while different from that in human tissue, it was similar to those observed in experimental canine cholesterosis.

Mucus hypersecretion in the gallbladder epithelium of ground squirrels fed a lithogenic diet for the induction of cholesterol gallstones.

This study identified mucus granules, determined mode of release and quantified their volume in the gallbladder epithelium of Richardson's ground squirrels (Spermophilus richardsonii) fed a lithogenic diet of 2% cholesterol to experimentally induce gallstone formation. Tissue was examined using light microscopy histochemistry, scanning and transmission electron microscopy, as well as autoradiography and morphometry at the electron microscopic level. Autoradiography demonstrated incorporation of a glycoprotein precursor, [3H]galactose, within the membrane-bound granules localized in the supranuclear region of the epithelial cells. Exocytosis of granule contents was by merocrine secretion. Morphometry indicated a significant increase in the amount of intracellular mucin granules as early as 18 hr on the lithogenic diet, a feature that continued throughout the experimental period of 20 weeks. Mucus synthesis/secretion rates returned to control values within 3 weeks after removal from the diet. Scanning electron microscopy observations revealed a thick sludge-like layer overlying the epithelium at a time in the chronology of the cholelithiasic model that correlated well with the initial phases of stone formation. Histochemistry showed this layer to be a mixture of acidic mucins. Neutral mucins were not observed. The hypersecretion of mucus and formation of this sludge-like layer appear to be critical nucleating factors in the formation of cholesterol gallstones.

Morphological observations on the gallbladder of ground squirrels fed a lithogenic diet.

Richardson's ground squirrels (Spermophilus richardsonii) of both sexes were fed a 2 per cent cholesterol-enriched rat chow diet for intervals of 1, 2, 10 and 20 weeks. Light microscopy and 3H-thymidine autoradiography revealed an increase in cell proliferation prior to the occurrence of macroscopically visible stones, but in the presence of crystals and microliths. Transmission electron microscopy studies showed that columnar epithelial cells undergo mitosis rather than basal cells and that oedematous cells were extruded from the epithelial sheet. Transmission and scanning electron microscopy studies on gallbladders of animals fed the lithogenic diet for 10 and 20 weeks revealed damaged epithelial cells either singly or in groups. Neighbouring cells often slide under the basal aspects of cells being extruded. Hypertrophy, hyperplasia, Rokitansky-Aschoff sinuses, thickening of the lamina propria around the muscle bundles and inflammatory cells in the lamina propria began to occur about the time macroscopically visible stones were present. The epithelium of the Richardson's ground squirrel gallbladder is damaged more slowly than that of other animal models by a cholesterol-enriched, lithogenic diet and may more accurately reflect changes occurring in human cholecystitis.