Natural history of acquired immunodeficiency syndrome in hemophilic patients

During the 5-year period from 1981 to 1985, we have observed 8 cases of acquired immunodeficiency syndrome (AIDS) among our 85 patients with hemophilia A. Thus, the prevalence of AIDS with hemophilia A is 9.4% in our patient population. By utilizing stored serum or plasma samples dating back to 1978, antibody against HTLV-III was detected in all 8 cases with AIDS. Based on the time interval from the appearance of antibody to HTLV-III to the diagnosis of AIDS in these patients, the incubation period ranged from 27 months to 60 months, with a median of 36 months. Before the diagnosis of full-blown AIDS, all patients exhibited a variety of prodromal manifestations of non-specific nature, including weight loss, oral candidiasis, unexplained non-productive chronic cough, generalized lymphadenopathy, and thrombocytopenia lasting several months to several years. Serial T-lymphocyte subset studies were available in some patients during the HTLV-III seropositive period and showed progressive lymphopenia, depletion of T4 cells with an average absolute count of 94 +/- 128 per mm3 (mean +/- 1 S.D.), and a markedly reversed T4/T8 ratio of 0.26 +/- 0.19 (mean +/- 1 S.D.). These findings suggest that the incubation period of AIDS is considerably long and that prospective study of serial immunologic markers and HTLV-III markers may be warranted in hemophilic patients at risk.

Long term follow-up of arthroscopic synovectomy for chronic hemophilic synovitis

Recurrent hemarthrosis of the knee in hemophiliac patients leads to chronic synovitis, predisposing the joint to further hemarthroses and degeneration. Open synovectomy controls bleeding, however, significant loss of motion frequently results. We are reporting on seven patients who underwent arthroscopic synovectomy and had decreased bleeding episodes while maintaining range of motion. The seven patients had frequent recurrent hemarthroses despite medical management. All had had signs of degenerative arthritis preoperatively. Five of the seven had loss of motion. Length of follow-up averaged 4 years. Six of the seven had reduced bleeding episodes with an average of 0.22 hemarthroses per week. The seventh patient required significantly less Factor to control bleeding. No patient lost more than 10 degrees of motion. Three patients had increases in motion; two were unchanged. Radiographic progression of degenerative changes was noted in five patients, the other two were unchanged. We recommend early arthroscopic synovectomy in the treatment of recurrent hemarthrosis in hemophiliac patients.

Paraproteinemia in patients with scleredema. Clinical findings and serum effects on skin fibroblasts in vitro

Four patients with paraproteinemia and scleredema were studied. Histologic features included marked thickening and fibrosis of the dermis and subcutis. Variable amounts of mucin deposits were detected in the interfibrillar spaces. Serum from one patient significantly stimulated collagen production in normal skin fibroblast cultures, whereas serum from another patient stimulated collagen production in autologous cell cultures. Moreover, serum from one patient stimulated the [35S]sulfate incorporation into the fibroblasts. Circulating serum factors, possibly related to the paraprotein, may enhance the synthesis of extracellular macromolecules by dermal fibroblasts in these patients, thus providing a mechanism for dermal fibrosis.

Effect of danazol on clotting factor levels, bleeding incidence, factor infusion requirements, and immune parameters in hemophilia

Several recent studies have reported conflicting results on the effectiveness of danazol, an attenuated androgen, in raising plasma levels of clotting factors VIII and IX in patients with hemophilia. We undertook a randomized, double-blind cross-over trial using 8 weeks' administration of danazol (D), 600 mg/d, and 8 weeks' administration of placebo (P) separated by 2 weeks of rest in 12 patients with hemophilia A and four patients with hemophilia B. Plasma factor VIII and IX levels, frequency and type of bleeding episodes, amount of factor concentrate infused, fibrinogen, fibrinolysis assays, antithrombin III, liver function, and immune parameters were followed. During the danazol phase a minimal increase was noted in the average clotting factor levels, an increase that, although statistically significant, was of hemostatically marginal magnitude. Significant increases in protein C and plasminogen levels, however, were observed during the danazol period, suggestive of danazol-mediated enhanced fibrinolysis. Clinically, bleeding frequency was significantly increased, and more clotting factor was consumed during the danazol period. Furthermore, eight episodes of hematuria and oral mucosal bleeding was reported during the danazol phase in contrast to only one episode of hematuria during the placebo phase, consistent with an enhancement of fibrinolytic activity with danazol. We conclude that danazol does not have a hemostatically significant effect on plasma levels of factor VIII and IX but may be associated with enhancement of fibrinolytic activity, resulting in increased bleeding frequency and requiring more clotting factor infusions. Therefore, danazol is not a viable alternative in the treatment of hemophilia.

Clinical trial of a new disposable bleeding-time device

A new disposable bleeding time device (Hemalet) was tested in 20 normal individuals and 11 patients with various bleeding disorders. The results were compared with those of Simplate II. The mean bleeding time for normal individuals was 5.4 +/- 1.5 (mean +/- 1 SD) minutes by Hemalet and 5.8 +/- 1.4 (mean +/- 1 SD) minutes by Simplate II, with good correlation between the results by the two devices (r = 0.81). The bleeding time in patients with various bleeding disorders were also comparably prolonged between the two devices. The new disposable bleeding time device with a disposable blade has quick release (penetration) into skin and retraction, and offers an alternative means of a bleeding time test.

Hypersensitivity reaction to a metabolite of cyclophosphamide

Generalized urticaria and fever were noted in a patient with IgA (kappa) myeloma after intravenous cyclophosphamide. Intradermal skin testing revealed no reaction to cyclophosphamide and its analog, isophosphamide. However, phosphoramide mustard, a principle metabolite of cyclophosphamide, evoked an immediate wheal-and-flare response. Subsequent therapy with isophosphamide was well tolerated. These findings suggest that acute hypersensitivity reactions to cyclophosphamide are due to its metabolites and can be delineated with skin testing.

Cystic degeneration of thymic Hodgkin's disease following radiation therapy

A case of thymic Hodgkin's disease presenting with an anterior mediastinal mass is reported. The mass progressively expanded in size on plain chest radiography during and following a mantle radiation therapy. A repeat computed tomographic (CT) scan of the chest in this patient revealed a cystic component to the mass, and thin-needle aspiration of the cyst led to a shrinkage of the mass. An experience in this case and review of literature suggest Hodgkin's disease involving the thymus gland frequently predisposes to cystic degeneration especially following radiotherapy, leaving a stable or progressively enlarging residual mass. A precise diagnosis of such a progressively expanding mass despite the adequate radiation therapy is crucial. CT scan of the chest in such cases and a thin-needle aspiration of the cystic mass offer precise diagnosis and may obviate the need for an open thoracotomy procedure.

Life-threatening complications in a child with hemoglobin SD-Los Angeles disease

Hemoglobin SD-Los Angeles is an uncommon sickle hemoglobinopathy. We describe a boy with documented Hb SD-Los Angeles who had experienced acute splenic sequestration, pneumococcal sepsis, aplastic crisis and functional asplenia during his first two years of life. We suggest that children with Hb SD-Los Angeles are at similar risks for the life-threatening complications which characterize sickle cell anemia and should receive the same comprehensive medical care currently recommended for children with Hb SS disease.

Serotonin induced platelet aggregation in systemic sclerosis

We studied in vitro platelet aggregation response to serotonin in 19 patients with systemic sclerosis and 18 matched controls. Individuals with early systemic sclerosis had increased % platelet aggregation at 3 minutes over a wide range of serotonin concentrations when compared to individuals with late systemic sclerosis. Patients with generalized disease did not differ from those with limited disease. No significant differences in initial slope of platelet aggregation were detected in any patient subgroup. These data support previous studies suggesting platelet activation in systemic sclerosis and further suggest that future studies of platelet abnormalities in systemic sclerosis should consider the effects of disease duration.

Smoking, hemoglobin levels, and birth weights in normal pregnancies

Of 811 otherwise healthy, nonanemic, pregnant Norwegian women, 43% smoked during the third trimester. No significant association existed between smoking habits and hemoglobin levels during the third trimester, but the fairly small number of heavy smokers (greater than 10 cigarettes per day) may have precluded the discovery of subtle true differences. Birth weights were transferred to a weight-for-dates percentile scale, based on the distribution of the total Norwegian birth population over an 11-year period. With a grouping in quartiles according to this scale, a strong correlation between smoking habits and low birth weights emerged, with 47% of newborn infants of heavy smokers falling in the lowest quartile. Levels of hemoglobin were inversely correlated to birth weight quartiles, equally in mothers who smoked and those who did not smoke. However, when birth weights were grouped according to maternal hemoglobin at term, the tobacco-related effect on birth weight appeared only with levels of hemoglobin above 12 gm/dl, being particularly strong for levels above 13 gm/dl. Hemoglobin levels of 9.0 to 11.9 gm/dl appeared to protect from growth retardation the fetuses of nonanemic mothers who smoked. Studying ponderal, or weight-by-length, indices, we found that growth-retarded babies of mothers who smoked tended to be thin, thus indicating that they had been deprived of nutrients.

Effect of transfusion therapy on arteriographic abnormalities and on recurrence of stroke in sickle cell disease

Stroke is a relatively frequent and severe complication of sickle cell disease. We performed cerebral arteriograms in 30 patients with sickle cell disease to evaluate the cause of acute neurologic deficits and to assess the effects of transfusion therapy given for a year or more after the acute episode. Twenty-three patients with motor and speech deficits had multiple abnormalities of major cerebral arteries. The internal carotid and anterior and middle cerebral arteries showed stenosis and/or occlusion at their common junction. Irregular luminal surfaces suggested that endothelial damage and intimal hyperplasia were the basis of stroke. Prolonged transfusion therapy nearly stopped progression of stenosis and markedly decreased the irregularity of the luminal surfaces; in 4 untransfused patients, the degree of stenosis doubled and the luminal abnormalities persisted. Prior to transfusion, 90% of patients had recurrence of stroke. With transfusion therapy, only 10% of patients had recurrence despite persistent arterial abnormalities. Clinical recurrences per patient-month decreased 75-fold. The patients tolerated prolonged transfusion therapy well, despite progressive iron accumulation. Seven patients with smooth abnormalities of a single artery, nonocclusive changes, or with normal arteriograms did not receive transfusions. Only one of this group had recurrence of symptoms.

Maternal hemoglobin concentration is closely related to birth weight in normal pregnancies

Maternal Hb levels during the third trimester were studied in relation to certain maternal and fetal parameters in 877 apparently normal pregnancies. Low Hb levels at term were closely associated with increased frequency of newborns in the heavy weight-for-date group. Conversely, high maternal Hb levels were closely associated with an increased frequency of newborns in the light weight-for-date group. The maternal Hb levels both in the early third trimester and at term were significantly higher in mothers of small-for-date newborns than in those with newborns of normal weight. In both groups the maternal Hb levels increased significantly during the third trimester of pregnancy. High maternal Hb levels both early and late in the third trimester of pregnancy should be a matter of concern rather than of reassurance.

The predictive value of total estriol; HPL and Hb on perinatal outcome in severe pre-eclampsia

The prognostic value of total maternal plasma estriol, human placental lactogen (HPL) and hemoglobin (Hb) with regard to perinatal outcome was compared in 74 cases of severe pre-eclampsia. No combination of the tests predicted all cases of fetal and newborn pathology. HPL was the most reliable single test in cases of intra-uterine growth retardation, while Hb was the best predictor of severe fetal pathology and perinatal distress. In cases of severe fetal and neonatal pathology, the prognostic value of the combination of HPL and Hb was more reliable than the combination of all the three tests.

RBC destruction caused by a micropore blood filter

Two infants who received whole blood filtered through commercially available woven stainless steel micropore filters experienced a sudden onset of hemoglobinuria. The plasma hemoglobin level in one child was 200 mg/dL. To investigate whether filters might lead to RBC destruction, we experimentally quantitated filter-induced hemolysis using standard conditions. Our studies in vitro show that hemolysis decreases with increased speed to transfusion. Hemolysis is particularly extensive with blood stored more than 14 days, but measurable hemolysis occurs with blood stored for as little as one day.

"Pseudo-hemolytic" transfusion reaction caused by intravenous iron-dextran therapy

Intravenous iron-dextran therapy can cause a red-brown discoloration of the plasma, simulating a hemolytic transfusion reaction. A rapid and simple test to differentiate between true hemolysis and plasma discoloration due to circulating iron-dextran complexes is described.

Nonsteroidal anti-inflammatory drugs in the treatment of hemophilic arthropathy

This study was undertaken to investigate the safety and efficacy of nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) in controlling the pain and stiffness of hemophilic arthropathy. Data were collected from eight adult hemophilic patients in successive double-blind controlled studies using choline magnesium trisalicylate (CMT) and ibuprofen (IPF). In seven patients, neither drug consistently affected bleeding times, platelet aggregation studies, frequency of joint hemorrhages, or frequency of factor infusions. In one patient, platelet aggregation appeared to be affected by CMT and bleeding time became markedly prolonged after IPF therapy. Three patients taking CMT and four patients taking IPF reported greater relief of pain and stiffness with the drugs than with placebos. Our results suggest that IPF and CMT can benefit the hemophiliac and that they can be used safely in most hemophilic patients under closely supervised conditions.

Three-dimensional digital subtraction angiography

A dye-edge tracking algorithm was used to determine the corresponding points in the two images (anterior-posterior and lateral) of the digital subtraction biplane angiography. This correspondence was used to reconstruct three-dimensional images of cerebral arteries in a dog experiment and a clinical observation. The method was tested by comparing the measured image of oblique view to the computed reconstructed image. For the present study, we have developed three new algorithms. The first algorithm is to determine the corresponding dye-edge points using the fact that the density of contrast media at the moving edge shows the same changing pattern in the two projection views. This moving pattern of dye-edge density is computed using a matching method of cross correlation for the two sequential frames' dye density. The second algorithm is for simplified perspective transformation, and the third is to identify the corresponding points using a complementary method for locating the approximate points on the small vessels. The present method can be applied to compute the velocity of blood flow using the dye-edge displacement and the three-dimensional distance data.