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Korrektur zu 10.1038/s41375-020-0826-9

Zusammenfassung Es wird uber zwei Falle von Afibrinogenamie beim Hund berichtet. Im einen Fall (11jahrige Schaferhundin) lag eine Verbrauchskoagulopathie (Fibrinogenmangel zufolge intravasaler Gerinnung) mit Verminderung von Faktor 1, II, V, VII und VIII und der Thrombozyten vor. Das Tier hatte ein metastasierendes Mamma-Karzinom. Beim zweiten Patienten (6jahriger Durrbachler-Rude) fehlte selektiv das Fibrinogen. Obwohl er an einer generalisierten Retikulo-Histozytose litt, wird — auf Grund des Gerinnungsstatus und der Familienanamnese — auch das Vorliegen einer hereditaren Afibrinogenamie diskutiert. Summary Afibrinogenaemia in the dog Two cases of absence of fibrinogen in the blood in the dog are reported. In one case (11-year-old Alsatian bitch) there was a usage coagulopathy (lack of fibrinogen as a result of intravascular clotting), with reduction of factors 1, 2, 5, 7 and 8 and of platelets. The animal had a metastasising mammary carcinoma. The second case was a 6-year-old Durrbach male with selective failure of fibrinogen. Although the animal had a generalised reticulo-histiocytosis, the question of a hereditary afibrinogenaemia is discussed on the basis of the clotting status and the family history. Resume Afibrinogenemie chez le chien On rapporte deux cas d'afibrinogenemie chez le chien. Dans un des cas, (une chienne berger de 11 ans), on observe une coagulopathie de consommation (deficience en fibrinogene a la suite d'une coagulation intravasculaire), avec diminution des facteurs I, II, V, VII et VIII et des thrombocytes. L'animal presentait un carcinome mammaire a metastases. Dans le deuxieme cas, (un chien de Durrbach mâle de 6 ans), le fibrinogene faisait defaut de maniere selective. Bien que l'animal fut atteint d'une reticulo-histiocytose generalisee, on discute cependant l'eventualite d'une afibrinogenemie hereditaire, en vertu des resultats de la coagulation et de l'anamnese familiale. Resumen Afibrinogenemia en el perro Informase sobre dos casos de afibrinogenemia en perros. En un caso (perra pastor de 11 anos de edad) se hallo una coagulopatia de consumo (carencia de fibrinogeno como consecuencia de coagulacion intravasal) con disminucion de los factores I, II, V, VII y VIII y de los trombocitos. El animal tenia un carcinoma mamario que producia metastasis. En el paciente segundo (macho Durrbach de 6 anos de edad) faltaba selectivamente el fibrinogeno. Aunque padecia una reticulo-histocitosis gene-ralizada, se discute — en virtud de la situacion de coagulacion y de la anamnesis familiar — tambien la presencia de una afibrinogenemia hereditaria.

The Infectious Diseases Working Party of the European Blood and Marrow Transplant Group conducted a survey to obtain information about the frequency, presentation, and treatment of mycobacterial infection (MBI) in stem cell transplant (SCT) recipients. Among 29 centers, MBI was diagnosed in 0.79% of 1513 allogeneic and 0.23% of 3012 autologous SCT recipients during 1994-1998 a median of 160 days after transplantation. The mean interval between first symptoms and diagnosis was 29 days and was still longer for patients with atypical MBI or recipients of corticosteroid therapy. The prevalence of MBI was highest among those who received matched unrelated or mismatched STCs from related donors. Of 31 patients, 20 had tuberculosis, 8 had atypical MBI, and 3 had diagnoses based on histological findings only. Five patients (16%) died, all of whom had received an allogeneic SCT. Because of the increased numbers of unmatched donors and transplantation programs in countries with a high prevalence of tuberculosis, constant vigilance is required to early detect MBI in SCT recipients.

The use of granulocyte colony-stimulating factor (G-CSF) has been established to improve hematological recovery after allogeneic bone marrow transplantation (BMT). The optimal timing to start with G-CSF has not been determined. This study investigates whether delayed use of G-CSF starting on day 6 is as safe and efficient as starting treatment with G-CSF immediately after BMT. Thirty-eight patients undergoing allogeneic BMT were randomized to either receive post-transplant G-CSF treatment starting at day 1 or at day 6. The time to hematological recovery was monitored and the groups were compared with respect to peritransplant morbidity and mortality. Recovery of the neutrophil granulocyte counts (PMN) to100/microl,500/microl and1000/microl was comparable in both groups. The nadir of the PMN counts after stopping G-CSF was also similar. There was no difference in the recovery of red blood cells and platelet counts and no difference between the two groups with respect to the number of febrile episodes, number of days with antibiotics or number of documented bacterial, fungal or viral infections. Delayed treatment with G-CSF resulted in a reduction of G-CSF treatment from 19 days to 14 days (P = 0.0017). Reducing the length of treatment by 5 days lowered G-CSF treatment costs by 26.3%. Therefore, postponing treatment with G-CSF has no influence on the hematological recovery after allogeneic BMT. There is an economical benefit of postponing G-CSF use without any clinical disadvantages.

The best treatment of CMV gastrointestinal disease has been controversial, with some centers adding intravenous (i.v.) Ig to antiviral chemotherapy. The aim of this retrospective survey was to compare the outcome of antiviral chemotherapy with or without i.v. Ig. A questionnaire was sent to centers belonging to the EBMT. Thirty-three patients with CMV gastrointestinal disease were reported, 22 patients were given antiviral chemotherapy alone and 11 patients a combination of antiviral chemotherapy and i.v. Ig. Eighteen of 33 (55%) patients responded to therapy, 13 of those treated with antiviral chemotherapy alone and five (45%) of those treated with the combination (P = NS). Patients with acute GVHD of grades II-IV had significantly worse outcomes than patients with acute GVHD grades 0-I. In a Cox proportional hazards model corrected for acute GVHD there was no difference in outcome of CMV gastrointestinal disease with or without addition of Ig. Survival at 100 days after diagnosis of CMV gastrointestinal disease was 64%. There was no difference in survival in patients treated with or without i.v. Ig. The results of this retrospective survey indicate that addition of i.v. Ig to antiviral chemotherapy might not improve outcome in patients with biopsy-proven CMV gastrointestinal disease.

We describe the phenomenon of waning of focal hepatic and/or splenic lesions on abdominal computed tomographic (CT) scan during neutropenia in patients with chronic disseminated candidiasis. After observation of the phenomenon in one patient, a total of five cases were prospectively monitored with serial CT scans. After the diagnosis of disseminated candidiasis, hepatic lesions decreased in size and conspicuousness in three patients, while in two others they disappeared completely during a subsequent chemotherapy-induced neutropenia. After recovery of the neutrophils, the lesions reappeared or increased in conspicuousness in all five patients. Of three patients treated with a second cycle of myeloablative chemotherapy, lesions again decreased in two patients during neutropenia and increased again in one patient after neutrophil recovery. In all five patients, candidiasis eventually resolved after prolonged antifungal treatment. In chronic disseminated candidiasis, hepatic or splenic lesions may transiently disappear during neutropenia. Thus, antifungal therapy should not be discontinued on the basis of radiologic findings alone.

Deletions of sequences centromeric to the p-arm breakpoint have been described in a subset of patients with inv(16) and acute myeloid leukemia (AML) and reported to be associated with a relatively good prognosis. We have investigated 16 p deletions in a cohort of 15 patients with AML and inv(16) or t(16;16) and compared non-deletion and deletion patients in terms of clinical course. Patients were studied by fluorescence in situ hybridization (FISH) using cosmid zit14 as a probe to detect the presence of 16 p deletions in metaphase chromosomes of leukemic cells. While seven patients (47%) revealed no evidence of a deletion, five patients (33%) presented 16 p deletions, thus bringing further support to the relatively frequent occurrence of this event in inv(16) patients. Remarkably, two patients with inv(16) and one patient with t(16;16) showed a mosaicism of deletion and non-deletion metaphases suggesting the presence of two distinct leukemic cell populations. Results let us assume that 16 p deletions are not restricted to inv(16) and may occur subsequently to inv(16) or t(16;16). The presence of a 16 p deletion in a case of inv(16) associated with CBFB-MYH11 transcript type E indicates that deletions are not limited to CBFB-MYH11 transcript type A rearrangements. Survival of deletion patients was compared with that of non-deletion and mosaic ones. No significant differences were observed. The advantage of FISH for enumerative and quantitative assessment of submicroscopic rearrangements of clinical significance is further emphasized.

Intravenous immunoglobulins (IvIgG) are often used in patients receiving a basic immunosuppressive therapy with CsA either for prevention of infectious complications or as an additional prophylaxis of graft versus host disease in clinical bone marrow transplantation. As far as we know, the combined in vitro immunosuppressive effects of these 2 drugs have not been investigated yet. In this study, we compared the effect of CsA, IvIgG, and CsA combined with IvIgG on the proliferative capacity of peripheral blood mononuclear cells in a mixed lymphocyte culture system. The concentration-dependent inhibition of peripheral blood mononuclear cell proliferation in the mixed lymphocyte culture system by CsA is a well established phenomenon. By adding IvIgG to the cultures (n=20) containing CsA, we were able to show a significantly (P

Effective granulocyte transfusion (GT) therapy has been hampered by the low yield of neutrophil granulocytes (PMN) obtainable from normal donors even by use of corticosteroid prestimulation, hydroxyethyl starch (HES), and modern leukapheresis (LA) techniques. To increase the PMN yield we performed LA in 22 healthy volunteer donors after a single subcutaneous administration of 300 micrograms of granulocyte colony- stimulating factor (G-CSF) 12 to 16 hours before LA. Five to 7 L of blood was processed within 1.9 to 3 hours using the standard CS- 3000Plus (Baxter, Deerfield, IL) LA protocol including HES. The mean number of PMN harvested was 44.32 +/- 15.5 x 10(9), corresponding to 6.88 +/- 2.1 x 10(9)/L of blood processed. In the final product PMN functions (in vitro: chemotaxis, phagocytosis, chemiluminescence, superoxide anion production; in vivo: chemiluminescence, half-life) were at least normal. In all donors G-CSF induced a consistent increase of white blood cell (mean 16.46 +/- 3.8 x 10(9)/L) and PMN counts (15.94 +/- 3.6 x 10(9)/L). No G-CSF-related side effects were observed and LA was well tolerated. G-CSF prestimulation allows to harvest three to five times higher numbers of functionally normal PMN by LA compared with corticosteroid pretreatment. This may help to overcome one of the major limitations of an effective PMN support.

Transient pure red cell aplasia (PRCA) in three consecutive patients receiving ATG for management of kidney graft rejection prompted a systematic study of the effects on erythropoiesis of the ATG preparation used at our institution. We found that 90% of patients treated with rabbit anti-T lymphoblast globulin developed reticulocytopenia (less than 17,000 reticulocytes/mm3), with complete disappearance of reticulocytes in 65% of patients and increased requirement for red cell transfusion. PRCA, with selective aplasia of erythroblasts was confirmed by bone marrow aspiration in 4 patients volunteering for aspiration, and by the kinetic of the disappearance of blood reticulocytes in relation to the beginning of ATG treatment. The nadir of thrombocytes and lymphocytes, blood cells directly destroyed by ATG in circulation, followed the start of ATG treatment within 1 to 4 days. In contrast the nadir of reticulocyte counts occurred later, between day 7 and 13 after ATG was begun, reflecting the fact that toxicity was directed against red cell precursors rather than mature circulating cells. In agreement with these clinical findings ALG was found to be cytotoxic in vitro for erythroid precursors. Analogously to autoimmune PRCA caused by autoantibodies to erythroblasts, this type of PRCA could be viewed as "heteroimmune disease."

The major risk factor associated with repeated platelet transfusions is alloimmunization. Its management represents one of the greatest remaining clinical and research challenges in the field of platelet transfusion therapy. This is particularly true because current approaches to the treatment of leukemias and various solid tumors are now focussed on the administration of intensive, repetitive courses of postremission chemotherapy necessitating successful platelet support for a prolonged time. Moreover, once alloimmunization has supervened and histocompatible donors cannot be identified there are no proven approaches for the management of bleeding complications in thrombocytopenic patients. Thus, any practical means by which the rate or the speed of alloimmunization could be minimized would be of considerable clinical importance.

In 3 of 15 consecutive patients receiving a human leukocyte antigen (HLA)-identical but major ABO incompatible bone marrow transplant (BMT), pure red cell aplasia (PRA) lasting 5 to 8 months was observed. Titers of the incompatible anti-A agglutinin before infusion of the red blood cell (RBC)-depleted BMT was very high in one, and in the usual range in two patients. Decrease of agglutinin titers during the first 4 weeks after BMT were comparable between PRA patients and those of ABO- incompatible BMT recipients with timely RBC recovery. However, in PRA patients, agglutinin titers rose again and remained elevated for 19 to 28 weeks. RBC engraftment and reticulocyte recovery ultimately occurred spontaneously and coincided with the decrease of agglutinin titers below 16. These observations indicate that PRA is antibody-dependent in this setting. Furthermore, it is conceivable that cyclosporine facilitates recipient-derived antibody synthesis after major ABO- incompatible BMT.

Common variable immunodeficiency (CVIS) is a condition associated with a deficiency of humoral immunity. The typical patient is an adolescent or adult with a history of recurrent upper respiratory tract infections over many years. Despite the long history the illness is not readily recognised and diagnosis is usually delayed until the patient is admitted to hospital for a severe respiratory tract infection and is being worked up for causes of immunodeficiency. The diagnosis of CVIS is based on the finding of an immunoglobulin deficiency in immunoelectrophoresis or documentation of reduced IgG subclasses. Typically this leads to upper respiratory tract infections and malabsorption, as illustrated by the case reports. Pathophysiologically this disease is characterised by malfunction of B cells with defective gammaglobulin production or secretion. 7 patients were substituted with IgG, leading to decreased susceptibility to infection and a reduction in hospital admissions due to severe infections.

DNA-based methods can type for HLA antigens with no or very low cell surface expression. The role of such serological blank antigens in bone marrow donor selection is unknown.HLA-A serological blank antigens detected in two leukemic patients were cloned and sequenced from genomic DNA. mRNA expression and exon 3 splicing were determined by reverse transcriptase-polymerase chain reaction (PCR).Two patients typed A2/x and A3/x by serology were revealed to be A*01/A*0201 and A*03/A*24 by DNA typing. The HLA-A*O1 blank antigen was identified as the A*0104N allele with a C insertion in exon 4, which results in a stop codon. The HLA-A*24 blank antigen was identified as the A*2402102L allele characterized by a mutation in intron 2 leading to impaired splicing of mainly exon 3. As a consequence, functional A24 mRNA was reduced to less than 5% compared with the other HLA-A allele. For both patients, a search for an unrelated donor was initiated on the basis of the functional absence of the serologically blank allele. The second patient with the A*24 blank antigen could undergo transplantation with marrow from a "fully A/B/C/DRB1/DRB5/DQB1-compatible" donor, homozygous for the A antigen. Donor T cells did not react against the patient in a pretransplantation cytotoxic T lymphocyte precursor frequency test known to detect all class I incompatibilities. However, despite this functional pretransplantation compatibility, the patient died 44 days after bone marrow transplantation, suffering from graft-versus-host disease grade IV. The presence of potentially functional A*2402 mRNA could be demonstrated by reverse transcriptase-PCR and sequencing: 50% of the A24 mRNA molecules were estimated to contain exon 3 with a correct splice site.These findings show that serological blank antigens with low mRNA expression might still be recognized after bone marrow transplantation. The determination of such alleles by molecular methods and the assessment of mRNA expression should therefore be included in the unrelated bone marrow donor search protocol.

The threshold for prophylactic platelet transfusions in patients with hypoplastic thrombopenia generally recommended in the standard literature is 20,000 platelets/μL. A more restrictive transfusion policy may be indicated in patients with chronic severe aplastic anemia (SAA) in need of long-term platelet support. We evaluated the feasibility and safety of a policy with low thresholds for prophylactic transfusions (≤5,000 platelets/μL in stable patients; 6,000 to 10,000 platelets/μL in cases with fever and/or hemorrhagic signs) combined with progressive lengthening of transfusion intervals (up to at least 7 days irrespective of the interim course of platelet counts). The study was based on a retrospective analysis of a total of 18,706 patient days with platelet counts ≤10,000/μL in patients with chronic SAA treated (for more than 3 months) on an outpatient basis. Altogether, 1,135 platelet transfusions were given, 88% at counts ≤10,000/μL and 57% at counts ≤5,000/μL. The mean transfusion interval was 10 days. During the period of observation, three major nonlethal bleeding complications occurred, which could be well controlled. We conclude that the restrictive policy with low transfusion thresholds and prolonged transfusion intervals proved feasible and safe in chronic SAA patients.

We describe the phenomenon of waning of focal hepatic and/or splenic lesions on abdominal computed tomographic (CT) scan during neutropenia in patients with chronic disseminated candidiasis. After observation of the phenomenon in one patient, a total of five cases were prospectively monitored with serial CT scans. After the diagnosis of disseminated candidiasis, hepatic lesions decreased in size and conspicuousness in three patients, while in two others they disappeared completely during a subsequent chemotherapy-induced neutropenia. After recovery of the neutrophils, the lesions reappeared or increased in conspicuousness in all five patients. Of three patients treated with a second cycle of myeloablative chemotherapy, lesions again decreased in two patients during neutropenia and increased again in one patient after neutrophil recovery. In all five patients, candidiasis eventually resolved after prolonged antifungal treatment. In chronic disseminated candidiasis, hepatic or splenic lesions may transiently disappear during neutropenia. Thus, antifungal therapy should not be discontinued on the basis of radiologic findings alone.

A 45-year-old male with acute lymphoblastic leukemia in first remission was successfully transplanted with G-CSF (filgrastim)-mobilized syngeneic PBPC (peripheral blood progenitor cells). Conditioning regimen consisted of high-dose etoposide, cyclophosphamide and total body irradiation. For PBPC mobilization the patient's healthy syngeneic brother was subcutaneously stimulated with 16 micrograms/kg/day G-CSF for 5 consecutive days. Only mild adverse effects (myalgia, transient changes of laboratory test) were observed. PBPC-apheresis was performed three times without complications on days 4, 5 and 6 after the start of G-CSF application. The unmanipulated PBPC (total 5.75 x 10(8)/kg mononucleated cells) were transfused immediately after each collection. Engraftment under administration of G-CSF (5 micrograms/kg/day subcutaneously) from day 0 to +12 was very rapid. Neutrophils exceeded 1.0 x 10(9)/l on day +9, platelet counts reached 50 x 10(9)/l on day +13. On day +27 the patient was discharged from the hospital with normal blood counts except mild anemia (Hb 9.5 g%). Bone marrow aspiration was repeatedly normocellular with normal differential count and no leukemia. We demonstrate that G-CSF-mobilized syngeneic PBPC transplantation after myeloblative chemoradiotherapy results in rapid and so far stable hematologic reconstitution with an actual follow-up of more than 15 months. This experience may be of relevance for future allogeneic G-CSF-mobilized PBPC transplantation.

In the last two decades complete remission [CR] rates for adults with acute leukemia has increased to 60 to 80%. In acute myelogenous leukemia [AML], this is due to the application of intensive induction therapies, comprising an anthracycline and a cytarabine. In acute lymphoblastic leukemia [ALL], the introduction of intensive early consolidation and CNS prophylaxis played an additional important role. These myeloablative treatments became feasible because of considerable improvements in the management of infectious and bleeding complications. The standard induction for AML further on remains the '3 + 7' schedule [daunorubicin 45 to 60 mg/m2/day x 3, I.V. and Ara-C 100 to 200 mg/m2/day x 7, 24-h infusion]. In ALL, prednisone, vincristine, L-asparaginase and an anthracyeline are the backbone of the induction therapy. Unfortunately, there has been less improvement for overall long-term survival, which is about 15 to 20% in AML and 20 to 35% in ALL beyond 5 years. More intensive post-remission regimens which include high-dose Ara-C in AML and intermediate-dose methotrexate and cyclophosphamide in ALL seem to improve these results to some extent. Allogeneic bone marrow transplantation has the most powerful anti-leukemic potential; however, because of the high peritransplant mortality [20 to 25%], its use in first CR tends to be restricted to patients with adverse prognostic features predicting early relapse, while good-risk patients are transplanted at the first signs of relapse or in second CR. In both AML and ALL, the optimal form of post-remission treatment needs to be defined.

139 patients with newly diagnosed acute leukemia were admitted to our institution from 1984 to 1990. More than 70% developed severe infections during cytotoxic chemotherapy. Septicemia accounted for 40.1%. The two most frequent organisms isolated from the blood were Staphylococcus epidermidis and E. coli. A prominent finding were the soft tissue infections (23.4%). They often occurred in the anorectal area and at the exit of an intravenous catheter. Pneumonia (17.8%) was of fungal origin in 22.9%. 66% of the infections occurred when the neutrophils were below 100/microliters.

Posttransplant hemolytic uremic syndrome (P-HUS) is a rare complication following kidney transplantation and is due to thrombotic microangiopathy. The aim of the present study was to determine patients at risk for this condition and to describe the follow-up in patients who developed P-HUS. The study is based on 557 consecutive patients who underwent either renal or combined renal and pancreatic transplantation in the cyclosporin era. P-HUS occurred in 19 out of 557 patients (3.4%). The reasons for developing P-HUS were: vascular rejection in 10 patients, association with cyclosporin in 5 patients, recurrence of an original HUS in 3 patients, and a transplanted shock-damaged kidney in 1 case. Patients with retransplants, grafts procured from non-heartbeating donors, high levels of anti-HLA antibodies, high HLA-DR mismatch, and HUS or Alport syndrome as the original disease, were found to be at increased risk for developing P-HUS. One-year graft survival for the P-HUS group was 42% and 88% for patients without this complication. Despite full therapy the prognosis of a P-HUS remains poor. Therefore, prevention of P-HUS, which consists in avoidance of the combination of the risk factors mentioned above, is emphasised.

The chance of finding an unrelated bone marrow donor depends on the size of the donor registry, the frequency of the patient's HLA phenotype and the degree of histoincompatibility considered acceptable. We have studied 60 unrelated bone marrow donor searches and the probability of finding a donor when increasing HLA-compatibility requirements were applied. For 21 (35%) of the patients no donor could be identified who was (serologically) matched for all six ABDR antigens. For the remaining 39 (65%), a median of two (range 1-20) blood samples from serologically-matched potential donors was obtained for further analysis. Eighteen (30%) patients appeared to be mismatched with all the pre-selected donors because of DR (sub-)type mismatches detected by oligotyping. A further 7 (12%) patients did not have an MLC and/or cytotoxic T lymphocyte precursor (CTLp) negative donor. Thus, a 'perfectly matched' donor was found for 11 (18%) patients. To find a suitable donor for more patients we propose that many or all the potential donors identified in the various registries for a particular patient are simultaneously evaluated as many of the serologically ABDR-matched donors will appear to be incompatible after high resolution HLA-typing. This strategy will not only allow selection of the best matched donor more rapidly but the consequent use of high resolution typing might also lead to the definition of a certain number of acceptable mismatches.

Maintenance chemotherapy for up to 3 years is traditionally given to patients with acute lymphoblastic leukaemia (ALL) achieving complete remission. We questioned the value of such maintenance therapy in adult patients treated with intensive induction/consolidation. In a phase II study (SAKK 33/86) 63 patients between 17 and 72 years of age (median 27 years) with newly diagnosed ALL were treated with three intensive cycles of marrow-ablative chemotherapy. All subtypes were included. No maintenance phase was added. 53 patients (84%) entered a complete remission (CR) and 21 (33%) continue to be in unmaintained remission for 11-69 months (median 21 months). The disease-free survival of patients achieving CR and completing all three cycles is 40% at 3 years, with a 95% confidence interval of +/- 19%. These findings are comparable to the results of conventional studies. We conclude that maintenance therapy might not be needed in all adult ALL patients. Its value should be tested in a randomized trial. For patients failing, novel approaches are needed to improve outcome in adult ALL.

We report on a patient with very severe aplastic anemia (SAA) unresponsive to immunosuppressive therapy (cyclosporine A, ATG). Because no HLA-identical family or unrelated donor could be found, a trial with recombinant human granulocyte stimulating factor (G-CSF) was started. This was followed by a rapid 3-lineage response with near-normal blood counts and transfusion independence. A similar response was obtained by 2 further G-CSF cycles which were given for relapsing SAA after G-CSF withdrawal. Following the third cycle, an acquired platelet function disorder was observed which preceded a myelodysplastic syndrome.

Alloimmune thrombocytopenia (AIT) in fetuses and newborn, a disease resembling Rh incompatibility, is caused by transplacental transfer of an IgG-class antibody against fetal platelets. In humans five different platelet antigen systems are so far known which lead to AIT. The disease occurs in 1:2000-1:5000 deliveries. In contrast to Rh disease, immunization occurs in the first pregnancy in the majority of cases. The main significance of AIT lies in the occurrence of fetal (-10%) and neonatal (-20%) intracranial hemorrhage. Newborns are treated with compatible platelets, if necessary in combination with immunoglobulins. The high rate of fetal intracranial hemorrhage justifies therapy during pregnancy as well. Antenatal measures include treatment of the mother with high-dose immunoglobulin, treatment of the fetus with immunoglobulin by cordocentesis, and fetal platelet transfusions. However, all therapeutic measures involving the fetus remain in the experimental stage at present. International cooperative studies are necessary to evaluate cost-benefit of intervention during pregnancy.

Effective granulocyte transfusion (GT) therapy has been hampered by the low yield of neutrophil granulocytes (PMN) obtainable from normal donors even by use of corticosteroid prestimulation, hydroxyethyl starch (HES), and modern leukapheresis (LA) techniques. To increase the PMN yield we performed LA in 22 healthy volunteer donors after a single subcutaneous administration of 300 micrograms of granulocyte colony-stimulating factor (G-CSF) 12 to 16 hours before LA. Five to 7 L of blood was processed within 1.9 to 3 hours using the standard CS-3000Plus (Baxter, Deerfield, IL) LA protocol including HES. The mean number of PMN harvested was 44.32 +/- 15.5 x 10(9), corresponding to 6.88 +/- 2.1 x 10(9)/L of blood processed. In the final product PMN functions (in vitro: chemotaxis, phagocytosis, chemiluminescence, superoxide anion production; in vivo: chemiluminescence, half-life) were at least normal. In all donors G-CSF induced a consistent increase of white blood cell (mean 16.46 +/- 3.8 x 10(9)/L) and PMN counts (15.94 +/- 3.6 x 10(9)/L). No G-CSF-related side effects were observed and LA was well tolerated. G-CSF prestimulation allows to harvest three to five times higher numbers of functionally normal PMN by LA compared with corticosteroid pretreatment. This may help to overcome one of the major limitations of an effective PMN support.

Clinical results of the treatment of malignant lymphomas with a high risk of relapse by dose intensification and autologous bone marrow transplantation are reported. Since 1988, 68 patients with a median age of 34 years (range 16 to 56 years) received dose intensification, including 25 non-Hodgkin's lymphomas in first remission (12 lymphoblastic or Burkitt's lymphomas and 13 large cell lymphomas with risk factors), 20 aggressive non-Hodgkin's lymphomas in chemosensitive relapse, and 23 Hodgkin's lymphomas in chemosensitive relapse. The calculated 3-year overall survival and relapse-free survival was 72% (CI: 57-82%) and 61% (CI: 47-73%) respectively. Treatment related deaths were seen in 4.4%. The median duration of hospitalization was 30 days (range 19-51 days). The relapse-free 3-year survival for the separate treatment groups was 80% for lymphoblastic and Burkitt's lymphomas in first remission, 77% for large cell lymphomas with clinical risk factors in first remission, 39% for aggressive non-Hodgkin's lymphomas in chemosensitive relapse, and 59% for Hodgkin's lymphomas in chemosensitive relapse. These excellent results were obtained with acceptable toxicity and justify the use of dose intensification for a group of young patients with high risk lymphomas.

The growing number of BMTs has increased interest in safe and standardized in vitro bone marrow processing techniques. We describe our experience with a rapid automated method for the isolation of mononuclear cells (MNC) from large volumes of bone marrow using a Fenwal CS-3000 cell separator without employing density gradient materials. Forty bone marrow harvests with a mean volume of 1650 +/- 307 ml were processed. A mean of 75 +/- 34% (50 percentile range 54-94%) of the original MNCs were recovered in a volume of 200 ml with only 4 +/- 2% of the starting red blood cells (RBC). Removal of granulocytes, immature myeloid precursors and platelets proved to be sufficient to permit safe cryopreservation and successful autologous BMT (n = 25). Allogeneic BMT (n = 14, including three major ABO-incompatible) could be performed without additional manipulation. In both groups of patients timely and stable engraftment comparable to historical controls receiving Ficoll gradient processed autologous (n = 17) or unprocessed allogeneic BMT (n = 54) was observed. Moreover, 70 +/- 14% of the RBC could be recovered from the grafts. They were used for autologous RBC support of donors, rendering unnecessary autologous blood pre-donations.

Bone marrow transplantation from the unrelated volunteer donor is today a realistic possibility for patients lacking an HLA-identical family donor. In 1988, the Swiss Unrelated Bone Marrow Donor Registry was founded to coordinate such bone marrow transplants and create the Swiss volunteer donor registry. Thus for a search has been initiated for 71 patients and 16 transplants have been performed. Donor and recipient were HLA-A-, -B- identical by serology and HLA-Dr-identical by DNA-oligotyping. 10 of the 16 patients are alive without signs of basic disease 2 weeks to 2 years and 4 months after the transplant. These results illustrate that unrelated donor transplantation, using careful selection criteria, is a realistic new therapeutic modality.

We report a rare disease of skin and oropharyngeal mucosa in a 28-year-old patient occurring 2 years after an allogeneic bone marrow transplantation. The dermatologic diagnosis was unambiguously epidermolysis bullosa acquisita according to the immunofluorescence and clinical presentation. Treatment with cyclosporin A and prednisone resulted in resolution. This autoimmune skin disease may be a manifestation of graft-versus-host disease, but the relationship must remain speculative.

In bone marrow transplantation (BMT) the main reason for early treatment failure is transplant-associated mortality (TAM) due to GvHD, interstitial pneumonia, veno-occlusive disease and infections. Since 1981, 84 consecutive HLA-identical BMT have been performed (13 aplastic anemia, 61 leukemia/lymphoma, 3 genetic diseases; mean age 28 [5-51] years) according to a standardized protocol designed to reduce TAM: fractionated, low dose rate irradiation; strict laminar air flow isolation plus complete intestinal decontamination; cyclosporine therapy for 4 months and CMV prophylaxis (hyperimmune plasma infusion, CMV-negative blood products). 11 patients (13%) died in TAM. Continuous complete remission was obtained in 78% of standard risk patients (n = 55) and 28% of high risk patients (n = 29). Mean observation time was 42 (3-116) months post transplantation. This result points to the necessity of a liberal indication for BMT early in the course of acute or chronic myelogenous leukemia, in the course of acute or chronic myelogenous leukemia, severe aplastic anemia and other eventually lethal hemato-oncological diseases.

Refsum's disease (Heredopathia atactica polyneuritiformis) is caused by accumulation of phytanic acid in all body tissues due to an inherited failure of alpha-oxidation of branched chain fatty acids. Plasmapheresis has been reported to be beneficial by removal of phytanic acid from the blood. We describe a patient with Refsum's disease in whom long-term plasmapheresis did not improve clinical, biochemical or electrophysiological parameters.

Severe hemolysis occurred in a 51-year-old female after a 17-day course of intravenous amoxicillin. A strongly positive direct antiglobulin test (anti-IgG titer 1:2,000) ensued which disappeared after withdrawal of the drug. Both the patient's serum and eluate obtained from the patient's red cells contained an IgG antibody which reacted with red blood cells coated in vitro with amoxicillin, but not with uncoated cells. In addition, high-titer antipenicillin, antiampicillin and antiamoxicillin IgG antibodies could be demonstrated in her serum by a RAST-based solid-phase radioimmunoassay. The patient's hemolysis gradually subsided within 1 week after discontinuing the drug. This is the first report of amoxicillin-induced immune hemolytic anemia.

Twenty-four thrombocytopenic patients refractory to random-donor platelet support were given 106 platelet transfusions obtained from 57 different HLA-typed single donors. For critical evaluation of the transfusion responses, “fullhouse” HLA typing of donors and a precise measurement of the number of infused platelets were performed. Posttransfusion platelet increments were related to the HLA matching of donor-recipient pairs and to leukocyte crossmatch tests in vitro. The transfusion response displayed a striking difference depending on the absence (type-0 match) or presence (type-1 or-2 match) of donor HLA antigens differing from the recipient. Whereas 95% of transfusions from type-0 match donors resulted in a compatible platelet increment, only 20% successful transfusion responses could be achieved with type-1 or -2 match donors. In 77% of type-1 or -2 match transfusions with poor posttransfusion platelet increments, the lymphocyte cytotoxicity test (incubation time 180 min at room temperature) was positive. This test therefore seems to be a useful tool in predicting the outcome of transfusion responses in type-1 and -2 match pairs. In contrast, the lymphocyte cytotoxicity tests were of no predictive value in type-0 match pairs. The influence of specific antigranulocyte antibodies on type-0 match platelet transfusions was assessed in four recipients. Although severe transfusion reactions were observed, no detrimental influence on platelet increments could be observed, at least following the initial transfusion.

A 26-year-old man with severe aplastic anemia was treated with high-dose Cyclophosphamide followed by the infusion of bone marrow cells from his HLA-identical sister. After initial intake of the graft, rejection ensued by day 46 which was followed by a permanent complete aplasia. After 4 months, bone marrow retransplantation with the same donor was attempted after a more intensive conditioning regimen. This led to permanent engraftment with rapid normalization of the blood counts lasting now for over 12 months. The patient has since remained in excellent clinical condition without signs of graft-versus-host disease.

A randomized study was performed in 54 thrombocytopenic patients with acute leukemia. Alloimmunization of recipients of random multiple-donor platelet concentrates (MD group) was compared to that of patients receiving random single-donor platelets (SD group). In the SD patients, formation of alloantibodies (mostly anti-HLA) occurred less frequently (p less than 0.002), after a longer time period (p less than 0.002), and after a higher number of transfusions (p less than 0.005) as compared to MD patients. SD patients also became refractory to random platelets less frequently (p less than 0.005), after a longer time period, and after a higher number of transfusions (p less than 0.02). In SD patients, the increments after the first and the last transfusion were in the same range, whereas in MD patients, the 1-hr (p less than 0.001) and the 24-hr (p less than 0.025) increments decreased from the first to the last transfusion. Thus, the use of random SD platelet transfusions postponed alloimmunization.

A 17-year-old woman with severe aplastic anemia was treated with high-dose cyclophosphamide followed by infusion of bone marrow cells from her HLA-identical, ABO-incompatible brother. The marrow graft failed to take. Subsequently, the patient revealed an autologous marrow reconstitution leading to a near-complete hematologic recovery which is now persisting for over 20 months.

ZusammenfassungEs wurde die Blutgerinnung und Fibrinolyse in dem durch Punktion der Nabelschnurvene gewonnenen Blut von 140 Neugeborenen untersucht und die Resultate denjenigen zahlreicher früherer Arbeiten gegenübergestellt.1. Fibrinogen- und Faktor-V-Spiegel lagen praktisch immer im Erwachsenen-Normalbereich.2. Die Thrombinzeit war bei 85% der Neugeborenen verlängert. Eine Erhöhung des endogenen Heparins konnte als Ursache ausgeschlossen werden. Die Thrombinzeit-verlängerung der meisten Neugeborenen dürfte auf eine fibrinolytische Alteration des Fibrinogens zurückzuführen sein. Bei einigen Neugeborenen konnte aber die Existenz eines funktionell andersartigen, »fetalen« Fibrinogens nicht sicher ausgeschlossen werden.3. Die fibrinolytische Aktivität – bestimmt durch die Euglobulinlysezeit, die bovine, nicht erhitzte Fibrinplatte und die Immunelektrophorese auf Fibrinogenabbaupro-dukte – war bei rund 60% der Neugeborenen erhöht. Die Vollblutfibrinolyse und die Parakoagulation durch Protaminzugabe im Serum erwiesen sich hingegen als zu wenig empfindliche Methoden zur Erfassung der Fibrinolyse im Nabelschnurblut.

Summary. Reptilase®-R, a purified thrombin-like snake-venom enzyme from Bothrops atrox, has been tested for its usefulness as a substitute for thrombin in two coagulation assay systems. Reptilase was found to be more stable than thrombin and not to be inhibited by heparin and hirudin. Performance of the Reptilase time allows the rapid exclusion of heparin contamination in plasma samples with prolonged thrombin times. In the presence of fibrinogen/fibrin split products, the Reptilase time is less prolonged than the thrombin time, whereas in patients with prolonged thrombin times because of congenital dysfibrinogenaemia the inverse is found. Thus, performance of both Reptilase time and thrombin time allows the rapid identification of three major causes for a prolongation of the thrombin time. In patients on heparin therapy because of a defibrination syndrome, the Reptilase time may replace the thrombin time as a guide for the degree of coagulation inhibition by FDP, although our results show that it is somewhat less sensitive. Reptilase can also be substituted for thrombin in the rapid chronometric fibrinogen assay. Unfortunately the advantages of reagent stability and insensitivity to heparin are balanced by a lesser reproducibility, especially in the presence of FDP.

Splenic function was evaluated after subcutaneous epinephrine injection (0.5 mg/m2) in 15 bone marrow transplant (BMT) recipients, 10 healthy volunteers and 5 healthy asplenic men. Healthy volunteers and BMT recipients with minor primary induction chemotherapy (mRx) showed similar rise in platelet (plt) and neutrophil granulocyte (PMN) counts and similar contraction of spleen. Patients with intensive primary induction chemotherapy (MRx), however, had significantly smaller spleens and spleen contraction (p less than 0.02) and no plt increase (p less than 0.05) when compared with healthy volunteers. 2 patients with MRx even exhibited a decrement of plt count after epinephrine, similar to that observed in all 5 healthy asplenic subjects tested. Our results suggest that mRx and conditioning for BMT including total body irradiation (TBI) does not alter the splenic function, but that the combination of MRx and conditioning regimen including TBI may cause functional hyposplenism, sensitively revealed by reduction in plt count after epinephrine stimulation.

Thrombocytopenic patients refractory to random-donor platelet support can usually be substituted by platelets obtained from donors identical with respect to HLA-A and -B antigens [1]. Since such "full-house" identity is rarely available, reliable cross-match tests (CM) are needed in order to pick out donors compatible in spite of HLA non-identity. By use of the thrombocyte migration test (TMT), DUQUESNOY et al. have shown that antiplatelet antibodies may exert an inhibitory effect on platelet migration. Therefore, we have explored this test system for its efficiency as CM compared with the "long-time" lymphocyte cytotoxicity test (LLT). Of 8 sera from polysensitized patients, serial dilutions were performed and simultaneously tested by TMT and LLT with cells obtained from the same control individuals. The sensitivity of TMT exceeded LLT by 2-4 dilution steps in all sera tested. Moreover, 9 patients with incompatible transfusion responses to single-donor platelets in spite of negative LLT had the following results in TMT with pre-transfusion sera: 5 positive (i.e. migration inhibition), 1 negative: enhanced migration was observed 3 times. This phenomenon of enhancement remains to be clarified, since low titers of anti-HLA-antibodies do not cause enhanced platelet migration. Repeated transfusion of platelets obtained from the same donor may cause antibody production against leukocytic antigen not shared by platelets, leading to "false-positive" LLT. 2 patients were successfully substituted with platelets from HLA/MLC-identical siblings in spite of positive LLT, but with negative TMT; in 2 cases with unrelated HLA-A and -B identical donors, TMT results were inconsistent.