The current status of T-lymphocyte apheresis (TLA) treatment of Crohn's disease.

After establishing criteria of patient selection, disease activity and, remission we performed lymphoplasmapheresis in seven patients with severely active chronic Crohn's disease. Five of the seven responded, but the results were unpredictable, not cost-effective, and had 100% morbidity. We then changed the protocol to selectively remove T-cells by differential ultracentrifugation. The initial goal was to remove 40 times 10(9) T-cells, but it was changed to 80 times 10(9) in order to increase the length of remission. We found that all patients with steroid-dependent chronically active Crohn's disease show evidence of protein calorie malnutrition. We used total parenteral nutrition with T-lymphocyte apheresis in the last 21 of 25 patients so treated. We have now completed a series of 54 patients, achieving a statistically valid remission, lasting an average of more than 18 months, in 48 of them. Criteria of remission included absolute zero steroid dosage. There has been no mortality or evidence of immunocompromise. The only morbidity (four patients) was the need for intravenous catheters during the apheresis procedure. This work has been confirmed elsewhere. Immune studies in active, untreated disease show low serum values of interleukin-2, as well as abnormalities of T-cell responsiveness to interleukin-2. The mechanism of how T-lymphocyte apheresis works is not clear, but it represents a promising new approach to the treatment of Crohn's disease.

Amiodarone-associated pulmonary toxicity. A clinical and pathologic study of eleven cases.

The new anti-arrhythmic agent, amiodarone, is increasingly recognized as a cause of pulmonary toxicity (APT). In the present series, 11 of 171 patients (6.4%) receiving the drug had APT develop. Clinical symptoms varied from mild cough and dyspnea to acute respiratory failure. Chest x-rays demonstrated alveolar and/or interstitial opacities in all 11 patients. The microscopic appearance of APT resembled that seen in lung injury from other drugs. The features were those of diffuse alveolar damage, ranging from the early acute to the organizing phase. Mural and intraalveolar foam cells were a prominent component. The epithelial origin of these cells was confirmed by positive immunoperoxidase staining for carcinoembryonic antigen. They were further identified as type II pneumocytes by electron microscopic examination. These findings support the concept that amiodarone is responsible for a drug-induced phospholipidosis. APT was clinically reversible in all patients; however, five patients (45%) died of arrhythmia shortly after discontinuation of amiodarone.

Thrombotic thrombocytopenic purpura in pregnancy: response to plasma manipulations.

We present three cases of thrombotic thrombocytopenic purpura (TTP) and one case of the hemolytic-uremic syndrome (HUS) occurring during pregnancy. All patients and their offspring survived, and none of the infants had TTP or HUS. Plasma manipulations (exchange and infusions) were the effective therapeutic measures in all patients. The most significant complication of therapy was posttransfusion hepatitis, which occurred in three patients, and from which recovery was complete.