Chronic cholestasis in patients after allogeneic bone marrow transplantation: several diseases are often associated.

From 1984 to 1991, 514 patients were treated by BMT in 1 center. 254 patients survived more than 3 months and, in 38 patients, 47 liver biopsies were performed for chronic liver dysfunction characterized by cholestasis. The aim of the present study was to evaluate the possible causes of liver disease at the time of biopsy. One clinician analyzed clinical data and was able to propose up to 3 diagnoses including GVHD, viral hepatitis, drug-related hepatitis, chronic veno-occlusive disease (VOD) or other. Two pathologists reviewed histologic sections and were also able to propose up to 3 diagnoses. Clinically, 1, 2 or 3 diagnoses were proposed in 30, 60 and 10% of cases, respectively. Pathologically, 1, 2 or 3 diagnoses were proposed in 13, 62 and 25%, respectively. Histologic changes of GVHD were present in 40 of 47 biopsies and concordance between the clinician and the pathologists on the presence of GVHD lesions was found in 77% of biopsies. Viral hepatitis was proposed 22 times by the clinician and 19 times by pathologists. Viral hepatitis, usually hepatitis C, was associated with GVHD in 16 cases. Diagnoses of chronic VOD and drug-related hepatitis were proposed less often. In summary, more than 1 diagnosis was suggested for many of the patients studied, GVHD being the most frequent. The simultaneous presence of GVHD, viral diseases, chronic VOD and drug-induced diseases could explain the high incidence of cholestasis in the long-term post-BMT.

Long-term study of chimaerism in bone marrow transplantation recipients for severe aplastic anaemia.

We used minisatellite probes to analyse by DNA fingerprints the long-term engraftment (median 4.3 years, range 1-2) of 21 bone marrow transplantation recipients for severe aplastic anaemia. Patients received their graft from histocompatible siblings. They were conditioned with cyclophosphamide (150 mg/kg) and a 6GY thoracoabdominal irradiation and did not have ex-vivo T cell depletion of marrow donor. DNA was extracted peripheral mononuclear cells and analysed by Southern blotting with 32P-labelled single-stranded RNA probes. Seven out of 21 donor-recipient pairs were sex-mismatched and additionally studied with a probe detecting a male specific repeated sequence on the Y chromosome. Red cell surface phenotype was also used as marker of engraftment in most cases. Long-term engraftment appeared complete for all patients studied with respect to the three methods.

Fulminant hepatitis due to reactivation of chronic hepatitis B virus infection after allogeneic bone marrow transplantation.

A case of hepatitis B reactivation following bone-marrow transplantation for leukemia in a previously healthy HBsAg carrier is reported. A number of changes in HBV serum markers were contemporary to the acute episode. All of them (increase of HBsAg concentration, conversion from anti-HBe to HBeAg, appearance of anti-HBc IgM and of serum HBV-DNA) were suggestive of a "switching-on" of viral replication. Institution of corticosteroid treatment at the onset of the acute phase did not prevent the fatal outcome.

Anti-RH immunoglobulin therapy for human immunodeficiency virus-related immune thrombocytopenic purpura.

The potential hazards of steroids in human immunodeficiency virus (HIV)-infected patients led us to evaluate the effectiveness and safety of anti-D and anti-c Ig in 17 adults with severe HIV-related immune thrombocytopenic purpura (platelet count less than 20 x 10(9)/L). The 14 Rh+ patients received 12 to 25 micrograms/kg of anti-D IgG intravenously on two consecutive days. A significant platelet rise above 50 x 10(9)/L was obtained in nine patients. Repeated boosters were performed in six cases and were effective in all cases. The 3 Rh- patients had a good response after they were given 20 mL x 2 of plasma containing potent anti-c antibodies. Therapy was well tolerated, and only one patient had significant hemolysis. These data suggest that anti-Rh IgG can be effective and safe in HIV-related thrombocytopenic purpura and that a specific interaction between the RBC antigens and the anti-Rh antibodies is required.

Long-term complete autologous reconstitution following cyclophosphamide and allogeneic marrow infusion in a case of severe aplastic anemia.

A 23 year old man with severe idiopathic aplasia, who had previously been unsuccessfully treated with oxymetholone for a period of 6 months, received two intravenous (IV) infusions of bone marrow cells from his HLA identical brother. He was given 200 mg/kg anti-lymphocyte globulins (ALG) IV, followed by a first infusion of 13 X 10(9) nucleated cells IV, but no improvement was observed. Three months later, he was treated with cyclophosphamide (25 mg/kg over 4 days) followed by a second infusion of 18 X 10(9) nucleated cells IV of the same donor. Within a four month period there was evidence of complete marrow reconstitution, and the patient has experienced no relapse of the disease during the subsequent 13 years follow up period. The mechanism of the recovery is unclear: no evidence of graft acceptance could be established. The respective roles of ALG, cyclophosphamide and/or bone marrow infusions are discussed.

[Determination of plasma hemoglobin in fresh plasma for therapeutic use by the TMB (3,3',5,5'-tetramethylbenzidine) method]. / Dosage del'hémoglobine plasmatique dans les plasmas frais à utilisation thérapeutique par la méthode à la T.M.B. (3,3'-5,5 tétraméthylbenzidine).

The maximum level of plasma hemoglobin in standard fresh frozen plasma before freezing has been mixed at 50 mg/l by french regulations. As no reference method is specified by the standards, we have adapted a technique where pseudo-peroxydasic activity of the hemoglobin is revealed by 3,3'-5,5', tetramethylbenzidine, a non carcinogenic chromogen derivate from benzidine. A 4 points reference scale is plotted for each plasma to be tested, thus reducing eventual interferences between pseudo-peroxydasic activity of the hemoglobin and other plasma proteins. We compared our modified technique to other existing ones: Vanzetti's extraction technique [8] whose main drawbacks are the use of flammable solvents and carcinogenic chromogen. Standefer's technique [10] involving plasma preincubation in H2O2 solution, which reveals protein interferences but is imprecise as it relies on only one reference point and does not show whether chromogen saturation is present. The level fixed by regulations is higher than the mean level indicated by our method, based on 118 samples of fresh plasma obtained by double centrifugation of whole blood collected on CPD as anticoagulant. It is also higher than the level indicated by the same method for plasma samples drawn from continuous or discontinuous flow cytapheresis (IBM 2997; Haemonetics V 50) using ACD - A or ACD - AA 16 as anticoagulant. Our method measures with precision low levels in plasma. Furthermore it is cheap, simple and easy to run in a blood transfusion center.

Chronic hemolytic anemia due to a monoclonal IgG cold agglutinin with anti-Pr specificity.

Immunologic studies performed in a case of autoimmune chronic hemolytic anemia with low titer cold agglutinins (1/16) demonstrated that the cold agglutinins corresponded to monoclonal IgG with anti-Pr specificity. This antibody had a large thermal amplitude, being active at 37 degrees C. These unusual characteristics may define a distinct subset of chronic cold agglutinin disease.

Somatic segregation and Fanconi anemia.

A case of Fanconi anemia with terminal acute leukemia is reported. Clones with chromosome abnormalities were observed in bone marrow cells. The patterns of marker chromosome distribution in these clones suggests the occurrence of a somatic segregation mechanism.

[Cytogenetic studies in four cases of Fanconi's anemia (author's transl)]. / Anomalies chromosomiques et anémie de Fanconi. Etude de 4 cas

In two sibships, four patients with Fanconi's anaemia were studied cytogenetically. Interfamilial variations of the frequency of chromosome breakage and rearrangements were found, suggesting the heterogeneity of the disease. Variations of chromosomal abnormalities have also been found during the course of the disease. An abnormal 47 chromosomes clone has been observed in the bone marrow cells from one patient. A mechanism of somatic segregation is probably involved in the constitution of that clone.

[Somatic segregation and Fanconi's anemia]. / Ségrégation somatique et anémie de Fanconi

The chromosome marrow cells of two patients suffering from Fanconi's anemia were studied. Abnormal clones were found, pseudodiploid in one case, aneuploid in another. The analysis of these clones showed that somatic segregation occurred, resulting in partial homozygosity.