Gerald A. Hoeltge

Allergic transfusion reactions: An evaluation of 273 consecutive reactions

CONTEXT Allergic reaction to transfusion is common. However, the review of a large series of allergic transfusion reactions has not been performed. OBJECTIVE To review a large series of allergic transfusion reactions. DESIGN A retrospective review of all reported and evaluated transfusion reactions during a 9-year period at 1 institution was performed. Associated clinical signs and symptoms were evaluated. SETTING Large, tertiary-care teaching hospital. RESULTS A total of 1613 adverse reactions to transfusion were evaluated. Allergic transfusion reactions accounted for 17% (273 of 1613) of the transfusion reactions. Severe allergic reactions (anaphylaxis, anaphylactoid signs and symptoms, and/or hypotension) were observed in 21 patients (7.7% of allergic reactions, or 1.3% of all transfusion reactions). Serum tryptase, a marker for anaphylaxis, was measured in 1 patient and determined to be borderline elevated. Five patients experienced allergic transfusion reactions to autologous red cell transfusions. One patient experienced hives during the transfusion of a major ABO mismatched red blood cell. A wide variety of skin manifestations were observed, but 26 (9.5%) patients did not have skin manifestations. Allergic transfusion reactions were estimated to occur in approximately 1 in 4124 blood components transfused, or 1 in 2338 transfusion episodes. Severe allergic reactions occurred in approximately 1 in 30,281 transfusions. No deaths directly attributable to transfusion were observed in this patient group. CONCLUSIONS The clinical presentation of allergic transfusion reactions was quite variable, and the pathophysiology remains unclear. Recommendations for clinical evaluation and therapy remain problematic and often empirical.

The common SCN5A mutation R1193Q causes LQTS-type electrophysiological alterations of the cardiac sodium channel

Long QT syndrome (LQTS) is a prototypic arrhythmic disorder that is characterised by prolonged QT interval (or QTc) on electrocardiograms (ECGs), syncope, and sudden death from episodic ventricular tachyarrhythmias, specifically torsade de pointes.1–4 LQTS causes sudden deaths in young, otherwise healthy, individuals, and in many cases the first symptom is sudden death. Both genetic and acquired factors contribute to the pathogenesis of LQTS. Predisposing genetic mutations have been identified in six genes. These include the cardiac potassium channel genes KvLQT1 or KCNQ1 (chromosome 11p15.5, LQT1),5–7 HERG or KCNH2 (7q35–36, LQT2),8 KCNE1 (21q22, LQT5),9,10 and KCNE2 (21q22, LQT6),11 the cardiac sodium channel gene SCN5A (3p21–24, LQT3),12,13 and the non-ion channel ankyrin-B gene encoding a protein that links ion channels to the cytoskeleton (4q25–27, LQT4).14 Acquired long QT syndrome (aLQTS) is LQTS caused by factors such as bradycardia, cardiac ischaemia, metabolic abnormalities (including hypocalaemia and hypomagnesaemia), starvation (anorexia nervosa), and various medical manipulations and medications including general anaesthetics, antibiotics, antihistamines, and ironically anti-arrhythmic agents.15,16 Acquired LQTS is common, with a population prevalence rate of up to 8%.17 Because almost all cases of acquired LQTS are sporadic, genetic analysis of acquired LQTS has been lagging behind inherited LQTS. However, there has recently been increased interest in determining the genetic basis of acquired LQTS by studying genes causing inherited LQTS.18–21 We carried out a similar analysis in this study. Voltage gated sodium channels are transmembrane proteins responsible for generating cardiac action potentials, and for rapid conduction of electrical signals through cardiac tissues. The cardiac sodium channel is a large protein of 2016 amino acids encoded by the SCN5A gene.22 The cardiac sodium channel consists of a pore forming α-subunit composed of four homologous domains (I–IV), each containing …

A multicenter investigation with interphase fluorescence in situ hybridization using X- and Y-chromosome probes

Twenty-six laboratories used X and Y chromosome probes and the same procedures to process and examine 15,600 metaphases and 49,400 interphases from Phaseolus vulgaris-leucoagglutinin (PHA)-stimulated lymphocytes. In Part I, each laboratory scored 50 metaphases and 200 interphases from a normal male and a normal female from its own practice. In Part II, each laboratory scored 50 metaphases and 200 interphases on slides prepared by a central laboratory from a normal male and a normal female and three mixtures of cells from the male and female. In Part III, each laboratory scored 50 metaphases (in samples of 5, 10, 15, and 20) and 100 interphases (in samples of 5, 10, 15, 20, and 50) on new, coded slides of the same specimens used in Part II. Metaphases from male specimens were scored as 98-99% XY with no XX cells, and 97-98% of interphases were scored as XY with 0.04% XX cells. Metaphases from female specimens were scored as 96-97% XX with 0.03% XY cells, and 94-96% of interphases were scored as XX with 0.05% XY cells. Considering the data as a model for any probe used with fluorescence in situ hybridization (FISH), a statistical approach assessing the impact of analytical sensitivity on the numbers of observations required to assay for potential mosaicisms and chimerisms is discussed. The workload associated with processing slides and scoring 50 metaphases and 200 interphases using FISH averaged 27.1 and 28.6 minutes, respectively. This study indicates that multiple laboratories can test/develop guidelines for the rapid, efficacious, and cost-effective integration of FISH into clinical service.

A multicenter investigation with D-FISH BCR/ABL1 probes

Twenty-eight laboratories evaluated a new fluorescence in situ hybridization (FISH) strategy for chronic myeloid leukemia. In a three-part study, bcr/abl1 D-FISH probes were used to study bone marrow specimens. First, laboratories familiarized themselves with the strategy by applying it to known normal and abnormal specimens. Then, collectively the laboratories studied 20 normal and 20 abnormal specimens blindly and measured workload. Finally, each laboratory and two experts studied six serial dilutions with 98-0% abnormal nuclei. Using the reported normal cutoff of < 1% abnormal nuclei, participants reported no false-negative cases and 15 false-positive cases (1-6.6% abnormal nuclei). Results provided by participants for serial dilutions approximated the expected percentages of abnormal nuclei, but those from the experts exhibited greater precision. The clinical sensitivity, precision, nomenclature, workload, recommendations for training, and quality assurance in methods using D-FISH in clinical practice are discussed.

Biclonal Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is well characterized clinically and immunophenotypically. Demonstration of a monotypic CD19+, CD5+ B-cell population is central to the diagnosis. We report 2 cases of biclonal CLL. Two elderly men were encountered with an absolute lymphocytosis consisting of the typical CD5+, CD19+, CD23+ B-cell population seen in CLL; however, immunoglobulin light chain restriction by flow cytometry was not apparent as B cells expressed kappa or lambda light chains without a clear monotypic population. Molecular genetic analysis of flow cytometry-sorted cells (kappa and lambda populations) revealed in both cases 2 monoclonal B-cell populations. The characterization of these cases and a review of the issues surrounding biclonal CLL are presented.

Acquisition of doxorubicin resistance in human leukemia HL-60 cells is reproducibly associated with 7q21 chromosomal anomalies

Tumor cell resistance to doxorubicin (DOX) is usually associated with the overexpression of P-glycoprotein (PGP) in model systems. We have characterized the karyotypic changes in two sublines of HL-60 cells which differ in the induction of differentiation by retinoic acid. The parental sublines, designated HL-60A/S and HL-60Y/S, were selected in increasing concentrations of 0.025-0.1 micrograms/mL DOX. Monosomy 8 in HL-60Y/S was the only karyotypic difference prior to DOX exposure. Both sublines acquired 7q+ markers upon exposure to DOX. In HL-60Y/S, and add(7)(q21) replaced one homologue at 0.025 micrograms/mL DOX, and an add(7)(q32) appeared which replaced the other normal 7 at 0.05 micrograms/mL DOX. The HL-60A/S cells acquired an add(7)(q21) at 0.025 micrograms/mL DOX. The 7q+ abnormalities involved breakpoints in the midregion of 7q. The overexpression of phosphorylated PGP in immunoprecipitates with C-219 antibody was identified in both sublines of DOX-resistant HL-60 cells with 7q+ abnormalities, and this is consistent with the location of mdr-1 sequences to 7q21-21.1. Also, analysis of RNA from parental-sensitive and DOX-resistant sublines by reverse transcriptase-polymerase chain reaction revealed: a) comparable expression of multidrug resistance related protein (MPR) in sensitive and resistant sublines; and b) overexpression of mdr-1 only in the DOX-resistant sublines. Thus, the selection of DOX resistance in two sublines of HL-60 cells which differ in their response to retinoic acid-induced myeloid differentiation is reproducibly associated with overexpression of mdr-1 versus MRP.

Expression of blood group antigen A by stage I non-small cell lung carcinomas

To clarify the significance of blood group antigen A (BAA) expression by neoplastic cells, we studied patients who had curative resections of stage I non-small cell lung carcinomas. Immunohistochemical staining using monoclonal antibodies was used to detect BAA expression by paraffin-embedded carcinoma cells. One hundred three patients were studied; mean age was 62.6 years, and 70 (68%) were male. Histologic types were as follows: adenocarcinoma, 52 (50.5%); squamous cell, 25 (24.3%); large cell, 24 (23.3%); and adenosquamous, 2 (1.9%). Histologic grades were as follows: I, 13 (12.6%); II, 26 (25.3%); and III, 64 (62.1%). All patients had American Joint Committee on Cancer stage I tumors: 65 patients (63.1%) had T1 tumors, and 38 (36.9%) had T2 tumors. Recurrences developed in 25 (24.3%) and metachronous malignancies in 4 (3.9%). Survival was 75% +/- 4.8% at 3 years and 66.6% +/- 7.5% at 5 years. Eighty-nine patients (86.4%) were blood group A and 14 (13.6%) were AB. Ninety-five (92.2%) were secretors of BAA and 8 (7.8%) were not. The expression of BAA by neoplastic cells was not detectable in 34 (33%), trace (1% to 5% of neoplastic cells) in 10 (9.7%), 1+ (6% to 25%) in 8 (7.8%), 2+ (26% to 50%) in 12 (11.7%), 3+ (51% to 75%) in 12 (11.7%), and 4+ (76% to 100%) in 27 (26.2%). The pattern of neoplastic cell staining was homogeneous in 14 patients (20.3%) and heterogeneous in 55 (79.7%). Carcinoma recurrence, overall survival, and event-free survival were not related to secretor status, BAA expression, or pattern of staining.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of the breakpoints in a t(8;13)(p11;q12) translocation from a patient with myeloproliferative disease using fluorescence in situ hybridization

We used fluorescence in situ hybridization to characterize the molecular position of the breakpoints in a t(8;13)(p11;q12) reciprocal translocation from a patient with an atypical myeloproliferative disorder. This structural chromosome abnormality is characteristic of this specific disease and occurs often as the only chromosome abnormality in the malignant cells. Yeast artificial chromosome (YAC) analysis has demonstrated that the 8p11 breakpoint lies within a region defined by YAC 959A4 and that the 13q12 breakpoint is spanned by YAC 769F9. Identifying the position of the breakpoints in this rearrangement provides the means to search for candidate genes rearranged by this highly specific structural chromosome abnormality. Genes Chromosomes Cancer 21:160–165, 1998.

A case of fatal West Nile virus meningoencephalitis associated with receipt of blood transfusions after open heart surgery

First identified in the United States in 1999, West Nile virus caused approximately 3,500 infections in the late summer and fall of 2002. The virus is predominantly transmitted by mosquitoes, and the risk of infection through blood product transfusion is believed to be low. We present a case of West Nile virus encephalitis transmitted by red blood cell transfusion at the time of coronary artery bypass grafting that resulted in the patients death. Individuals undergoing procedures with high blood product transfusion requirements, such as cardiac surgery or organ transplantation, may be at higher risk of this nosocomial infection during epidemics.

A pulmonary syndrome in patients with acute myelomonocytic leukemia and inversion of chromosome 16.

Different subtypes of acute myelogenous leukemia have distinct clinical presentations and courses. The specific clinical and molecular aspects of these leukemias have helped modify and create specific strategies for their management. We observed an increased incidence of pulmonary complications in patients with acute myelomonocytic leukemias (AMML) with inversion of chromosome 16 [inv(16)] irrespective of the presence of hyperleukocytosis. We reviewed patient records available over a period of 12 years at The Cleveland Clinic Foundation of patients with AMML with inv(16) and compared the incidence of pulmonary complications to a matched control group of patients with AMML but without inv(16). We found an increased incidence of pulmonary complications in the AMML with inv(16) group when compared to the control group. Two of these patients demonstrated brochiolitis obliterans with organizing pneumonia (BOOP) on lung biopsy. No specific etiology for the pulmonary complications was identified. These findings represent the first observation of an association between WHO-AMML with inv(16) [FAB-AML M4 with inv(16)] with a pulmonary syndrome at presentation. BOOP should be suspected in these cases. A larger prospective study to evaluate this association is warranted.