Hypotension and acute pulmonary insufficiency following transfusion of autologous red blood cells during surgery: a case report and review of the literature.

Transfusion of autologous blood is associated with fewer complications, although all untoward events of transfusion may not be negated with this strategy. We report a case of acute pulmonary insufficiency and hypotension following transfusion of autologous packed red blood cells (PRBCs) in a patient, who was undergoing major surgery. Anti-HLA class-I and class-II and anti-granulocyte antibodies were measured in the unit and in the recipient. Neutrophil (PMN)-priming activity was measured as the augmentation of the formyl-Met-Leu-Phe-activated respiratory burst. No immunoglobulins were identified; however, significant lipid-priming activity was present in the implicated, autologous PRBC unit that primed PMNs from both healthy people and the recipient. In addition, lipids, identical to those that accumulate during PRBC storage, caused significant hypotension when infused into rats at similar concentrations found in stored PRBCs. We conclude that the observed transfusion-related acute lung injury reaction with significant hypotension may be the result of two independent events: the first is related to inherent host factors, in this case major surgery, and the second is the infusion of lipids that accumulate during the routine storage of PRBCs.

Upper-extremity deep venous thrombosis complicating whole-blood donation.

BACKGROUND: Up to 36 percent of blood donors may experience a donation-related complication. Fatigue, bruises, hematomas, and vasovagal reactions comprise the great majority of donor reactions and injuries. Serious complications are rare. CASE REPORT: A 20-year-old female taking the third-generation oral contraceptive desogestrel/ethinyl estradiol and ethinyl estradiol (Mircette) developed bruising and increased pain and swelling of her right arm over a 5-day period after whole-blood donation. She was a first-time donor and the venipuncture was reported as being mildly traumatic. There was no personal or family history of thrombosis. RESULTS: Ultrasound examination of her upper extremity revealed the presence of a deep venous thrombosis that required treatment with enoxaparin sodium for 5 days and warfarin for 6 months. Evaluation for thrombophilia was negative. The only risk factor for thrombosis was use of oral contraceptives. CONCLUSION: Although serious complications from whole-blood donation are rare, they may occur. Deep venous thrombosis should be considered in a donor presenting with increasing pain and swelling after blood donation.

Acute hemolytic transfusion reaction caused by anti-Coa.

Coa is a high-frequency blood group antigen in the Colton blood group system expressed on red blood cells (RBCs) of approximately 99.8 percent of random persons. Anti-Coa has been reported to cause delayed hemolytic transfusion reactions, hemolytic disease of the newborn, and accelerated clearance of RBCs in vivo. Acute hemolytic transfusion reactions (AHTRs) have not previously been reported. A 58-year-old man was hospitalized for vascular surgery. Initial blood bank evaluation revealed anti-Fya. The patient received six units of RBCs during his initial hospitalization and developed anti-E. A subsequent sample was sent to the reference laboratory when all units of RBCs appeared incompatible. Additional studies, including alloadsorptions, revealed the presence of anti-E, anti-Fya, and an apparent warm autoantibody. One unit of least-incompatible RBCs was transfused during surgery. The patient had an increase in temperature. Hemoglobinuria and a decrease in hematocrit were also noted. Due to the clinical impression of an AHTR, the pre- and postreaction samples were reevaluated in the reference laboratory and demonstrated the presence of anti-Coa in both. Based on clinical and laboratory evaluation this patient appears to have had an AHTR due to anti-Coa. This is the first known reported case of an AHTR caused by anti-Coa.

Altered expression and localization of 5-lipoxygenase accompany macrophage differentiation in the lung.

The alveolar macrophage (AM) exhibits a greater capacity to synthesize bioactive leukotrienes from arachidonic acid than does its circulating precursor the peripheral blood monocyte. Macrophage differentiation in the lung entails cellular residence within both the pulmonary interstitial and alveolar compartments. In the present study, we sought to determine 1) whether this enhanced metabolic activity was acquired during maturation within the alveolar space and 2) the underlying mechanisms responsible for this upregulation. Rat AMs were separated by Percoll gradient centrifugation into four density-defined subpopulations thought to reflect their degree of maturation. On stimulation with a calcium ionophore, synthesis of leukotriene B4 increased with the degree of maturation, although it was diminished in the oldest subpopulation. This maturation-dependent upregulation was not explained by increases in arachidonic acid release but was associated with increased expression of 5-lipoxygenase (5-LO) protein as determined by immunoblot analysis. Whereas 5-LO is primarily cytosolic in monocytes, it is known to be primarily intranuclear in unfractionated AMs. Here, the localization of 5-LO was investigated by immunofluorescence microscopy and was found to be predominantly nuclear in all AM subpopulations; by contrast, the protein was cytosolic in interstitial macrophages isolated by mechanical and enzymatic lung digestion. These divergent localization patterns in AMs and interstitial macrophages were verified in situ by immunohistochemical staining of sections of normal rat lung. When unfractionated AMs were isolated and maintained in culture for 3 days, a shift in 5-LO distribution from nucleus to cytosol was observed. We conclude that 1) nuclear import of 5-LO occurs within the alveolar space and is reversible on removal from the alveolar milieu and 2) leukotriene synthetic capacity increases further during AM residence within the alveolar space as a result of a progressive increase in the amount of 5-LO protein.

Wegener's granulomatosis in the elderly.

STUDY OBJECTIVE: To determine if elderly patients with Wegener's granulomatosis (WG) exhibit distinctive clinical features or outcomes compared with patients whose conditions were diagnosed at younger ages. DESIGN: Retrospective cohort study. SETTING: University medical center. PATIENTS: Thirty-three patients with WG diagnosed when 60 years old or older and 34 patients with WG diagnosed at age younger than 60 years, identified by record review of all WG patients seen over an 11-year period. RESULTS: The prevalence of specific clinical features, progression to end-stage renal disease, mortality rate, and infectious and noninfectious complications of therapy were examined. The prevalence of upper respiratory tract involvement (rhinitis, sinusitis, otitis, epistaxis) and hemoptysis were significantly less common as initial manifestations in the elderly patients, although pulmonary infiltrates were seen more commonly during the course of their disease. Renal insufficiency was more common at the time of diagnosis in the elderly patients (64% vs 35%; p < 0.05). Most notably, CNS involvement was 4.5-fold more common in elderly patients (27% vs 6%; p = 0.02). The overall incidence of infectious and noninfectious complications of therapy was similar between the groups, although the mortality rate was markedly higher in the elderly patients (54% vs 19%; p < 0.01). Almost all deaths were due to overwhelming infection. CONCLUSIONS: Elderly patients with WG present with distinctive clinical features, particularly a relatively low incidence of upper respiratory tract complaints and a high incidence of CNS involvement. The mortality risk from infectious complications of WG is substantially higher in elderly patients, although this cannot be attributed directly to adverse affects of therapy.