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Anti-D in individuals with a weak D phenotype is an unexpected finding that may require additional investigation to determine whether the anti-D is an autoantibody or alloantibody. Further investigation may also include assessment of the patient's RHD genotype and exclusion of anti-G. We present a case of an 84-year-old man with the weak D type 2 genotype who developed an unexpected anti-D along with anti-C. Individuals with the weak D type 2 genotype are thought not to be at risk for developing alloanti-D, although the distinction between alloanti-D and autoanti-D may be difficult to ascertain. Furthermore, investigations may affect transfusion recommendations. This patient was restricted to crossmatch-compatible, D-C- red blood cells even though the clinical significance of the anti-D was uncertain. This report is one of a few reported cases of an individual with the weak D type 2 genotype with demonstrable anti-D but without evidence for alloanti-D.

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First described in the United States in the late 1990s, West Nile virus (WNV) infection following solid organ transplantation is a rare but life-threatening complication. The many ways in which WNV may be acquired, patient specific risk factors, and variability in clinical severity present challenges to health care providers caring for these patients.

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Post-transfusion purpura (PTP) is a rare disorder characterized by severe thrombocytopenia developing seven to 10 days following transfusion of platelet-containing blood components, in a person who was previously sensitized via transfusion or pregnancy. Although most cases of PTP are caused by alloantibodies directed against HPA-1a[(Pl(A1))], this case represents the second example of anti-HPA-5a-associated PTP. A 61-year-old female was diagnosed with acute myocardial infarction and gastrointestinal bleeding and, after receiving six units of packed red cells over 5 days, developed PTP as a result of HPA-5a [Br(b)] antibodies with severe thrombocytopenia (5000/microl). She was successfully treated with intravenous immunoglobulin (IVIG), suggesting that this is a highly effective mode of treatment for PTP, regardless of the antibody implicated.

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Plasma exchange (PE) is considered first-line treatment for thrombotic thrombocytopenic purpura (TTP) to the point that many clinicians regard it as definitive therapy. Studies have reported response rates to PE ranging from 39% to 78%. In our experience, a minority of patients have been cured solely by PE. While adjuvant therapies (e.g., vincristine, splenectomy) have proved effective in anecdotal reports, protocols using these therapies in the treatment of TTP have not been established. Management of TTP over a 15-year period was reviewed to evaluate (1) the rate of cure accomplished by PE alone, and (2) the potential benefit of additional therapies. The records of 29 consecutive patients with TTP treated by PE were reviewed and classified according to response to PE alone and the need for adjuvant therapy. Eight patients (28%) achieved remission and long-term survival with PE alone. With the addition of adjuvant therapy another 13 patients survived, bringing the total survival to 72%. Fifteen patients were treated with vincristine in addition to PE. Only three of seven patients receiving vincristine after failing to respond completely to PE survived, but survival increased to 88% (7 of 8) when vincristine was administered within 3 days of beginning PE. These data suggest that PE alone may not be sufficient therapy for most patients with TTP. Additional therapy is often needed to achieve long-term survival. While controlled trials will be necessary to prove the efficacy of vincristine, we believe that, given the minimal risk of vincristine toxicity and the grave consequences of ineffective therapy, routine administration of vincristine early in the course of PE should be considered.

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BACKGROUND: Though earlier investigations have demonstrated the efficacy of autologous blood transfusion in reducing allogeneic blood exposure in patients undergoing heart or lung transplantation, questions remain regarding the safety of blood donation by patients with severe heart or lung disease. METHODS: Response to autologous blood donation by candidates for heart and lung transplantation and a group of age- and gender-matched control subjects was studied. Heart rate, blood pressure, oxygen saturation, and cardiac rhythm were examined before and after phlebotomy, and response to orthostatic challenge was evaluated. Patients were also questioned regarding impressions of changes in subjective sense of well being. Differences between patients and control subjects were evaluated by the paired t test and Fisher's exact test. An alpha of 0.05 was used in all testing to determine statistical significance. RESULTS: Eighteen candidates for heart transplantation, 16 candidates for lung transplantation, and their matched control subjects were studied. Though patients and control subjects differed with respect to baseline hemodynamic measurements, significant differences between the groups' responses to phlebotomy were not observed. After whole blood donation, orthostatic challenge resulted in a mean change in mean arterial pressure of -2.1 mm Hg in candidates for heart transplantation compared with a mean of +3.6 mm Hg in their control subjects (p = 0.062). In candidates for lung transplantation there was a mean change of +2.2 mm Hg after orthostatic challenge versus a mean change of +8.5 mm Hg in their control subjects (p = 0.052). Furthermore, no changes in cardiac rhythm or arterial oxygen saturation were detected. CONCLUSIONS: The hemodynamic effects of autologous blood donation in a group of patients with significant cardiac or pulmonary disease were not different from those observed in patients considered acceptable candidates for autologous blood collection. On the basis of these objective findings, we believe that patients with less severe degrees of heart or lung disease should not be excluded from participation in autologous blood donation programs.

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Granular cell tumors (GCT) are rare benign neoplasms of Schwann cell origin which have been found in virtually every location in the body. Their location in the biliary system is unusual, and typically occurs in black females during the fourth decade of life. Forty-eight cases have been reported since 1952. We present two patients treated for obstructive jaundice caused by GCT of the extrahepatic biliary tree. The literature on biliary GCT is reviewed and their management is outlined. Local excision with Roux-y-hepaticojejunostomy was performed in one patient with GCT obstructing the common bile duct at the level of the cystic duct. Pancreaticoduodenectomy was performed on one patient for GCT of the common bile duct involving the ampulla and adjacent pancreas. GCT of the extrahepatic biliary system are rare but should be considered in black females who present with obstructive jaundice in the fourth decade of life. Local excision with cholecystectomy and reconstruction of the biliary remnant is indicated. Primary biliary anastomosis is desired but choledochojejunostomy or hepaticojejunostomy may be necessary. Rarely, pancreaticoduodenectomy may be indicated in GCT of the distal common bile duct.

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Many patients are, perhaps inappropriately, denied the benefits of autologous blood transfusion, because they are thought to be too ill to donate blood safely. The safety and efficacy of autologous blood donation by selected patients with end-stage heart or lung disease who are awaiting organ transplantation were studied to determine if even these critically ill patients could be suitable candidates for autologous blood donation. Seventy-two adults awaiting heart or lung transplantation were evaluated for autologous blood donation in a hospital-based blood collection facility. Phlebotomy was performed if the patient met the required medical eligibility protocol, and if he or she consented to participate. Units of blood were separated into packed red cells and plasma and stored in a frozen state. Of 48 heart transplant candidates, 31 (65%) were each able to donate 1 to 8 units of blood. The median number of exposures to allogeneic components was 1 for patients who donated and 7 for nondonors (p = 0.0141). Among patients who donated, 54 percent required allogeneic components, as compared to 88 percent of nondonors (p = 0.0968). Of 24 lung transplant candidates, 15 (63%) made 1 to 6 donations each. The median number of exposures to allogeneic components was 0 for donors and 2 for nondonors (p = 0.1871), but only 45 percent of donors required allogeneic components, as compared to 100 percent of nondonors (p = 0.0418). No serious complications during or following phlebotomy were observed. It is concluded that autologous blood donation by patients with end-stage heart or lung disease may be safe.(ABSTRACT TRUNCATED AT 250 WORDS)

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Babesiosis is a malaria-like parasitic disease causing subclinical or mild illness in most cases. Splenectomized patients, however, may experience a more severe course. Although generally responsive to antibiotic therapy, several cases of severe babesiosis refractory to appropriate antibiotic therapy have been reported to respond promptly and dramatically to red blood cell (RBC) exchange transfusion. Although the role of HIV coinfection in babesiosis is uncertain, two previously reported cases raise a concern that it may predispose to a more severe clinical course. We report a third case of severe babesiosis in an HIV-positive splenectomized man, following travel to an endemic area. Antibiotic therapy, though initially effective, ultimately failed to prevent severe disease. RBC exchange transfusion resulted in prompt clinical improvement, which has been sustained during 26 months of follow-up. Although the patient has since developed various sequelae of HIV infection, including disseminated Kaposi's sarcoma, CMV retinitis, and enteritis, there has been no recurrence of observable parasitemia. In severe babesiosis, RBC exchange transfusion, combined with appropriate antibiotic therapy, appears to be a rapidly effective therapeutic modality which can induce sustained remissions.

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Transfusion medicine is a rapidly evolving specialty, and efforts are ongoing to improve the safety and quality of blood component therapy. Leukocytes are known to be the cause of numerous adverse effects of transfusion therapy, and their removal from red cells and platelet components may be desirable in a variety of clinical settings. The various complications of transfusion that can be attributed to contaminating leukocytes and the benefits of leukocyte depletion are addressed in this article. Laboratory as well as clinical data are summarized.

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The diagnostic value of barium enema in staging of carcinomas of the corpus uteri was evaluated in a retrospective study of 218 patients. The primary treatment in all patients was surgical. Barium enema was performed preoperatively in 48 (22%) of the patients and postoperatively in 106 (49%); 64 (29%) of the patients were not subjected to this investigation. Barium enema revealed changes possibly due to tumor in five patients (3%): two patients exhibited stenosis of the sigmoid colon due to a stromal sarcoma (Stages III and IV), and in one patient there was evidence that the primary tumor was in fact a carcinoma of the sigmoid colon. The suspicion of bowel involvement in the two other patients (both at Stage I) proved to be unfounded. These results show that barium enema is unnecessary in carcinoma of the corpus uteri at Stages I and II, and that in Stages III and IV the necessity for this investigation should be considered for each patient on an individual basis.

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The authors present experimental technics for the diagnosis of non-Hodgkin's lymphomas, based on instrumental classification of nuclear profiles using a video-based system for computerized interactive morphometry (CIM). In their system, the real time video image of a specimen is superimposed to a graphics overlay generated by a computer, consisting of a test area with four visual markers for random sampling of cells and a menu with several options to send direct commands to the system. Using a touch-sensitive screen mounted on a video monitor as an interactive peripheral, a trained observer traces 100 randomly selected lymphoid cells, counts mitoses in 25 microscopic fields, and categorizes the lesion as diffuse or nodular. Each cell is instrumentally classified into either small cell noncleaved, small cell cleaved, or large, based on the length of their nuclear profiles, their enclosed nuclear area, and a circularity factor. Thereafter the computer provides a "diagnosis," based on hierarchic analysis of the data. The morphometric data are also interpreted by alternate statistical methods of discriminatory classificatory analysis that provide a diagnosis and a probability statement derived from matching unknown cases with a data base. Forty-two lymphoid lesions have been categorized with the CIM system. Studies of interobserver and intraobserver variations in data collection are discussed. The potential advantages of CIM for the objective classification of non-Hodgkin's lymphomas are discussed.

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