Cefotetan-induced immune hemolytic anemia following prophylaxis for cesarean delivery.

Second- and third-generation cephalosporins, notably cefotetan, are increasingly implicated in severe, sometimes fatal immunemediated hemolytic anemia. We describe a 26-year-old woman who developed severe hemolytic anemia 2 weeks after receiving a single prophylactic dose of cefotetan during cesarean delivery. The patient's DAT was weakly reactive for IgG and her serum reacted with cefotetan-coated RBCs. The antibody had a titer of 4,096 by antiglobulin testing. The patient required treatment with two units of PRBCs and experienced gradual resolution of hemolysis. Our case emphasizes the need for increased awareness of delayed onset hemolytic anemia following prophylactic use of cefotetan.

Therapeutic plasma exchange in recurrent focal segmental glomerulosclerosis following transplantation.

Focal segmental glomerulosclerosis (FSGS) recurs in 30% of renal allograft transplants with graft loss in half of the cases. A humoral factor may be implicated. We report on the use of therapeutic plasma exchange (TPE) in 11 patients with recurrent FSGS post transplantation. Medical records from 1989-2000 were reviewed for 11 adults transplanted for biopsy proven FSGS. Ten patients developed proteinuria (x: 6.1 g; range: 3-40 g/24 h) within 2 months of transplantation. In 1 patient, proteinuria (4 g) occurred 2 years post transplantation. Biopsy in six patients revealed early recurrent FSGS, while in five, suspected recurrence was based on clinical findings. Each patient received 5-11 TPEs (x: 6) with the COBE Spectra, daily or on alternate days with 2.5-3.5 L 5% albumin as the replacement fluid. In four, FFP was included because of coagulopathy. All received immunosuppression (IS) during and after TPE. A persistent drop in 24 h urine protein (U.P.) was observed in 10/11 patients. Seven had >70% drop in 24 h U.P. following the course of TPE, while three had a reduction of 45-50%. No change occurred in 1 patient. Follow-up (9 months-5 years) of seven patients has shown a persistent U.P. of <1 g with successful allograft survival. In these patients, TPE appeared effective in early recurrent FSGS. The decrease in U.P. may result from combined TPE and IS. Although the disease is designated in category III by the ASFA, TPE should be considered early when FSGS recurrence is established.

Plasma exchange in stiff-man syndrome.

Stiff-man syndrome (STS) is a rare neurological disorder characterized by involuntary axial and proximal limb rigidity and continuous motor unit activity on electromyography (EMG). Autoantibodies to glutamic acid decarboxylase (GAD) present in 60% of the patients are implicated. We report on the use of plasma exchange (PE) in 2 patients with STS whose serum and cerebrospinal fluid were negative for GAD autoantibodies. One patient showed minimal clinical improvement following PE while the second reported subjective improvement, but not any different from that with medications. Based on the results of PE in our patients, it seems that those who are autoantibody negative are less likely to respond. Whether a more aggressive approach to PE will be beneficial remains speculative.

Femoral vascular access for large-volume collection of peripheral blood progenitor cells.

Central venous catheters are used frequently in large-volume leukapheresis to provide high flow rates for peripheral blood progenitor cell (PBPC) collection. In a retrospective study, we evaluated the safety and efficacy of short-term use of large-bore femoral venous catheters for the collection of PBPCs in 63 patients with hematologic and solid organ malignancies. All catheters were placed in an outpatient setting on the day of apheresis and remained in site if subsequent collections became necessary. A total of 101 procedures were performed. Thirty-five patients (56%) reached target levels after 1 collection. Twenty-four patients (38%) had 2 consecutive day collections while 4 patients (6%) required more than 2 collections. In this latter group, 2 patients did not have consecutive day collections. One had 2 consecutive day collections followed by a third collection 48 hours later. In the other, leukapheresis was performed for 2 consecutive days and then resumed 3 days later with 2 subsequent collections. The longest duration the catheter remained in site was 6 days. Catheter care was provided by the apheresis staff. All patients who had more than 1 collection were given instructions on how to care for their catheters at home. Only 1 patient had oozing at the catheter site during the collection. Thrombosis, mechanical, and infectious complications were not encountered. The short-term use of femoral venous catheters appears safe and effective for the collection of PBPCs.