[Methemalbuminnemia after massive hemolysis during blackwater fever]. / Methémmalbuminémie après hémolyse massive au cours d'une fièvre bilieuse hémoglobinurique.

We report a case of blackwater fever with brown plasma due to the presence of methemalbumin. The discovery of plasma with this color is a rare event at the laboratory. This compound appears during intravascular hemolysis or hemorrhagic pancreatitis when the ability of haptoglobin and hemopexin to bind free hemoglobin has been exceeded. In these cases some of heme is oxidized to hematin and taken up by serum albumin to form an albumin-hematin complex called methemalbumin. The major clinical problem is to evoke the diagnosis of methemalbuminemia and not confuse with methemoglobinemia. In our case, methemalbumin was detected and quantified using a scanning spectrophotometer. Its diagnostic and clinicals consequences are discussed.

Hematin is one of the cytotoxic factors in pancreatitis-associated ascitic fluid that causes hepatocellular injury.

BACKGROUND: We recently demonstrated that pancreatitis-associated ascitic fluid (PAAF) contains cytotoxic factor(s), inducing apoptosis in hepatocytes, and that PAAF induces hepatic adenosine triphosphate depletion, hepatocellular acidosis, and accumulation of hepatic intracellular sodium. Because ascitic fluid and serum from patients with hemorrhagic pancreatitis contain a lot of hematin, we aimed to test the hypothesis that hematin can induce hepatocellular injury, and then we compared its cytotoxicity with that of PAAF. METHODS: In vivo effects of intraperitoneal injection of hematin into the liver of healthy rats were evaluated with in situ nick-end labeling, blood biochemical analysis, and nuclear magnetic resonance spectroscopy. In vitro cytotoxic and apoptosis-inducing activities of hematin on rat primary culture hepatocytes were investigated with a cellular proliferation assay kit and DNA fragmentation enzyme-linked immunosorbent assay, respectively. Furthermore, PAAF was fractionated with Sephacryl S-300 gel column chromatography, and cytotoxic activities of its fractions on a human hepatoma cell line (HuH-7) were compared with those of hematin. RESULTS: Intraperitoneal injection of hematin into healthy rats caused apoptosis in the hepatocytes and elevated serum glutamate oxaloacetic transaminase and lactate dehydrogenase levels. Intraperitoneal injection of hematin also caused a significant decrease in the hepatic beta-adenosine triphosphate/inorganic phosphate ratio, severe hepatic intracellular acidosis, and a significant increase of hepatic intracellular sodium (Na(+)) concentration, similar to the effects of PAAF. In vitro, hematin decreased hepatocyte viability and increased the DNA fragmentation of hepatocytes, similar to the effects of 10% PAAF. Albumin reversed the cytotoxic effects of hematin and PAAF on HuH-7 cells nearly completely and partially, respectively. Fractionation of PAAF and hematin by gel column chromatography revealed that the first peak of cytotoxic activity of PAAF corresponded to that of hematin and that the cytotoxic activity was reversed by albumin nearly completely. CONCLUSIONS: These results suggest that hematin is one of the cytotoxic factors in PAAF that causes hepatocellular injury and that cellular injuries caused by hematin may be involved in the development of multiple organ failure associated with severe acute pancreatitis.

[Autoimmune hemolytic anemia with medullary erythroplasia and black serum with methemalbuminemia]. / Anémie hémolytique auto-immune avec érythroaplasie médullaire et sérum noir sur methémalbuminémie.

A patient with idiopathic autoimmune hemolytic anemia is described. On day 5 of therapy with corticosteroids, immunoglobulin and several plasmaphereses, a high level of methemalbumin was found while RBC lysis had ceased and bilirubin and haptoglobin had normalized. The hemoglobin and the reticulocyte count were still very low and a bone marrow aspirate showed erythroaplasia. Since the LDH was consistently elevated during the entire period of erythroaplasia, ongoing intramedullary hemolysis due to antibodies (IgG) was assumed. The patient received cyclophosphamide. After 15 days all symptoms, signs of hemolysis and aplasia resolved. The patient has not had any other hemolytic crisis without treatment (follow-up 18 months). The presence of methemalbumin is observed in intravascular hemolysis and also in association with hemorrhagic pancreatitis. Its diagnostic and prognostic value is discussed.

[The simultaneous establishment of the presence and classification of human (primate), bird and fish blood by electrophoresis]. / Odnovremennoe ustanovlenie nalichiia i prinadlezhnosti krovi cheloveku (primatam), ptitsam i rybam metodom élektroforeza.

Electrophoretic method of simultaneous determination of blood presence and its human (primates), bird and fish origin was developed. Method is based on detection of diagnostical characteristics possessing specific electrophoretic mobility and doesn't require use of precipitating sera. Diagnostical feature of human (primates) blood is methaemalbumin detectable in anodic part of electrophoregram and not detectable within the given test conditions in bloodstains of other animals. In bird and fish blood haemoglobin is determined in cathodic part of electrophoregram which differs from mammals blood by its electrophoretic mobility.

[Comparison of 2 methemalbumin measurements and of free hemoglobin in view of their value in the differential diagnosis of edematous and hemorrhagic pancreatitis]. / Vergleich zweier Methämalbuminbestimmungen und des freien Hämoglobins hinsichtlich ihrer Wertigkeit in der Differentialdiagnose der ödematösen und hämorrhagischen Pankreatitis.

Methemalbumin was estimated by means of electrophoresis and the method of Walberg, respectively in 59 patients (25 pat. with edematous, 34 patients with hemorrhagic pancreatitis) partially over three days. In addition the estimation of free hemoglobin in ascites has been carried out. By both approaches of methemalbumin estimation there was no differentiation of the two pancreatitis forms possible. Though the method of Walberg was much more sensitive especially in the serum its specificity was correspondingly lower. The tendency to a correlation of the methemalbumin-concentration to the severity of the course of the disease could be observed. Such a correlation has been proved statistically for the free hemoglobin.

Methemalbumin in acute pancreatitis: an evaluation of its prognostic value and comparison with multiple prognostic parameters.

Methemalbumin (MHA) and Ranson's prognostic parameters were measured in 90 patients with acute pancreatitis. Thirteen died (14.4%). The mortality rate was 36% in MHA-positive versus 6.2% in MHA-negative patients. Severe renal (56% vs 18.5%) and pulmonary (44% vs 10.2%) complications occurred more frequently in the MHA-positive as compared with the MHA-negative group. Hemorrhagic pancreatitis was found in all MHA-positive patients who were subject to surgery or postmortem examination. By way of comparison, the presence of more than four Ranson signs was associated with about the same risk of mortality and the development of complications as positive MHA findings. There was a good correlation between single and multiple prognostic factors for slight but not for moderate-severe or severe cases.

Diagnosis of acute pancreatitis.

The diagnosis of acute pancreatitis is still mainly based on the clinical signs and symptoms of the patients. Systemic organ failure, peritonitis and/or shock indicate severe disease, but to obtain optimal results of treatment the diagnosis of individual patients at high risk should be done before the development of systemic manifestations. A number of laboratory tests are valuable in the follow-up of the patients, but immediate onset of intensive therapy cannot be based on these tests. At present, contrast enhanced CT seems to be the most accurate method for the early detection of hemorrhagic/necrotizing forms of acute pancreatitis.

The presence of a meconium-like substance in second-trimester amniotic fluid.

Previous studies of the significance of meconium-stained second-trimester amniotic fluid have relied upon visual assessment of fluid color as the screening procedure followed by spectrophotometric analysis at 405 nm to confirm the presence of "meconium" (incidence of 1% to 3%). This assumes that in the absence of discolored fluid there is no "meconium." In the present study, prospective spectrophotometric analysis was performed on 123 serially obtained amniotic fluid specimens sampled at 15 to 19 weeks' gestation. The presence of an absorbing species peaking near 405 nm was observed in 91% of the samples. This substance is generally not present at term. Its presence does not correlate with pregnancy outcome and is of no prognostic significance. However, it is related to gestational age and placental implantation site. Further analysis supports the hypothesis that our tracings represent a variety of pigments derived from the metabolism of intra-amniotic hemoglobin resulting from the normal physiologic development of early pregnancy.

[Differential diagnostic and prognostic value of methemalbumin determination in acute pancreatitis]. / Differentialdiagnostischer und prognostischer Wert der Methämalbumin-Bestimmung bei der akuten Pankreatitis.

Methemalbumin (MHA) levels of serum or ascites were measured in a prospective study involving 40 patients with acute abdominal symptomatology suspected to have acute pancreatitis. MHA was demonstrated in 15 out of 18 cases, in whom a diagnosis of acute pancreatitis was established later on firm grounds. MHA was positive in all cases with necrotizing pancreatitis, in all cases with a severe course of the disease involving circulatory insufficiency, and, with values significantly higher, in all cases with renal or pulmonary complications. There was no correlation between pathologically increased serum levels of enzyme activity and MHA. In one patient with chronic pancreatitis MHA could be demonstrated in serum, in another one in ascites. In extrapancreatic abdominal disease MHA was falsely positive in 4 out of 15 cases; in no one of these cases were serum enzyme activities elevated. Measurement of MHA can be used in conjunction with measurement of serum enzyme activity as an additional diagnostic and prognostic parameter in acute pancreatitis.

Mechanisms of hemolysis.

I have reviewed hemolytic disease of the newborn to discuss with you the mechanisms by which red cell destruction occurs in the newborn and how such a process may be detected. I have introduced the concept of "minimal hemolytic disease" that manifests in ABO incompatibility disease and have suggested that this process may contribute significantly to the problem of idiopathic hyperbilirubinemia. There are many potential causes for this condition and they deserve study. The diagnosis of hemolytic disease in the newborn includes careful assessment of anemia and of all the factors unique to the newborn that affect its appearance and interpretation, as well as careful assessment of the erythrocytes themselves.

Haem-binding proteins in Gallus domesticus.

Genetic and physiological variations of the haem-binding proteins were studied in chickens by means of starch gel electrophoresis and other methods. No genetically controlled variability was found. Three electrophoretically different forms of the haem-binding proteins were observed. The permanent haem-binding protein (methaemalbumin) occurred from hatching until late age and was present in the blood serum and in some other organs. The juvenile haem-binding protein (haptoglobin) was present in the serum of hatchlings of both sexes and during sexual maturation it disappeared from the blood and was not renewed due to the physiological changes in the organism. The liver haem-binding protein is a fast migrating protein, having properties different from those of the permanent and the juvenile haem-binding proteins.

A compaative study of methods for the prediction of severity of attacks of acute pancreatitis.

Diagnostic peritoneal lavage was carried out in 79 patients with acute pancreatitis, at a mean time of 7 h after admission to hospital. The presence of more than 10 ml of free peritoneal fluid, brown-coloured free fluid or mid-straw-coloured lavage fluid was the criterion used for the prediction of a severe attack by lavage. Prior to lavage the attack was assessed as mild or severe by the clinician and reassessed by him at 24 and 48 h. All attacks were finally classified as mild or severe by means of a simple clinical grading scheme. There were 61 mild and 18 severe attacks (including 4 deaths). Initial clinical assessment correctly predicted only 39 per cent of the severe attacks compared with a 72 per cent succwss rate for diagnostic lavage. All the mild attacks were correctly predicted by clinical assessment but lavage was wrong in 3 out of 61 cases (95 per cent success rate). By 48 h after admission clinical assessment was comparable to systems using multiple criteria in its predictive value, success rates being 83 per cent and 82 per cent respectively for prediction of severe attacks. We did not find either the presence of methaemalbumin in the serum or the presence of hypocalcaemia to be of additional value. Diagnostic peritoneal lavage was the most accurate early guide to severity, and correctly predicted all patients who developed shock or died.

Determination of plasma or serum haemoglobin by peroxidase activity employing 2,2'-azino-di-(3-ethyl-benzthiazolinsulphonate-6) as chromogen.

A procedure is described for the determination of plasma or serum haemoglobin employing the peroxidase activity of the haemoprotein using 2,2'-azino-di-(3-ethyl-benzthiazolinsulphonate-6) as chromogen. The method gives equal results for free haemoglobin, methaemoglobin and haemoglobin complexed to haptoglobin. It is designed to measure haemoglobin in the range 0--12 mumol/l. The peroxidase activity of myoglobin is similar to that of haemoglobin, whereas haemin in free solution, bound to haemopexin or to albumin (methaemalbumin) shows much lower activity. The precision within run is satisfactory, +/- 5%.

Evaluation of methaemalbumin in acute pancreatitis.

Methaemalbumin (MHA) was measured in 62 patients with acute pancreatitis. In 26 MHA-positive patients the occurrence of renal and pulmonary complications was 65% and 58%, respectively, compared with 3% and 6% in 36 MHA-negative patients. Fatality rate was 54% in MHA-positive and 6% in MHA-negative patients. In 17 MHA-positive cases haemorrhagic pancreatitis was proven at laparotomy or postmortem examination. Thus MHA determination proved to be a valuable diagnostic and prognostic parameter in acute pancreatitis.