Analysis of idiopathic thrombocytopenic purpura patients with antiglycoprotein IIb/IIIa or Ib autoantibodies

We analyzed the immunological characteristics of patients with idiopathic thrombocytopenic purpura (ITP) and antiglycoprotein (GP) IIb/IIIa or GPIb autoantibodies. Among 101 ITP patients, 32 had anti-GPIIb/IIIa and 19 had anti-GPIb autoantibodies. Thrombocytopenia was more severe in patients with anti-GPIb autoantibodies than in patients without these autoantibodies, whereas ITP patients with anti-GPIIb/IIIa autoantibodies did not develop severe thrombocytopenia. Patients with anti-GPIb autoantibodies showed significant increases of platelet-associated IgM and platelet-associated C3 in comparison with patients without the autoantibodies, despite there being no significant difference in the platelet-associated IgG levels. The lymphocyte subsets and the blastogenic response in patients with anti-GPIb autoantibodies were also significantly different from those in the patients without these autoantibodies. Furthermore, severe purpura and a poor response to prednisolone were far more common in the patients with anti-GPIb autoantibodies. Activation of the complement system and/or functional abnormalities of lymphocytes thus appear to be involved in the development of thrombocytopenia in ITP patients with anti-GPIb autoantibodies, and such antibodies may be associated with a particularly severe form of ITP.

[HIV isolation and clinical markers on the seropositive subjects]

We investigated 18 anti-HIV seropositive subjects with respect to the isolation of HIV from peripheral blood mononuclear cells (PBMC) and cellular and serologic markers for progression to AIDS. The subjects included homosexuals and recipients of blood products. Three had AIDS, an asymptomatic subject developed AIDS during the study and 14 of the remaining have remained asymptomatic. HIV was isolated from all AIDS patients and 7 asymptomatic subjects. Moreover HIV was detected significantly sooner in symptomatic patients than in asymptomatic subjects. The reductions in CD4 lymphocytes number and CD4/CD8 ratio, as well as anti-HIV core (p24, p17) antigens negativity correlated with deterioration of clinical symptoms and successful HIV isolation. The isolates from AIDS patients and from an asymptomatic subject who 9 months later developed AIDS were infective and cytotoxic to MT-4 cells, however isolates from asymptomatic subjects were not infective. These findings indicate that disease progression correlates with the appearance of variant viruses that are more infective and cytopathic.

[Study on effects of cefminox sodium on blood coagulation system]

Effects of cefminox (CMNX) on hemostasis and blood coagulation system were studied. Adult in-patients admitted to 237 centers (310 clinics) nationwide in Japan during the period from April 1988 to March 1989 were followed up using a newly designed uniformed protocol. Case cards recovered were inspected by an evaluation committee and patients to be included in analysis were determined according to the protocol. Presence or absence of abnormalities in the hemostasis and blood coagulation system was examined objectively using criteria for evaluation prepared by the committee. Out of 1,374 patients included in analysis, 10 patients were judged as having abnormalities which were suspected to have causal relationships with CMNX. Prolongation in prothrombin time was observed in 4 cases (0.29%), prolongation in activated partial thromboplastin time in 4 cases (0.29%), and decrease in fibrinogen in 2 cases (0.15%). Decrease in platelet count was not detected in any of the cases. Cross-sectional analysis according to background factors in these 10 cases revealed that abnormalities of the hemostasis and blood coagulation systems were significantly higher (P less than 0.01) for the group positive for underlying disease or complications ("positive" group) than the "negative" group. Five out of 9 patients of the positive group had malignant neoplasm. Other than this factor, no items showed statistically significant differences. From these results it is considered that the administration of CMNX is nearly free of effects on the hemostasis and blood coagulation system and development of laboratory abnormalities is chiefly due to the patients' condition.

[IgG subclasses of warm red cell autoantibodies in autoimmune hemolytic anemia]

IgG subclasses (G-sub) of warm red cell autoantibodies (anti-Rs) were examined by means of antiglobulin test (DAT) using anti-IgG1, 2, 3, and IgG4 sera (Holland Red Cross) on 12 AIHA, and on 5 cases being DAT positive caused by alpha-methyldopa (alpha MD). In 4 of 5 AIHA cases complicating SLE, the anti-Rs comprised not only IgG, but also IgA, IgM and C3; their G-sub were IgG1 + 2 in 2 and IgG1 + 2 + 3 + 4 in the other 2. In all of the 3 cases with idiopathic AIHA, anti-Rs comprised IgG alone (IgG1 alone, IgG1 + 3 or IgG1 + 2 + 3 in each one). All of the 5 alpha MD induced anti-Rs comprised IgG1 alone. Observation of the course of AIHA revealed that, although IgG3 tended to correlate with their anemia, this trend was not universal. Besides, the G-sub were not related to the anti-Rs titers. Furthermore, the immunological aberrations in patients with AIHA + SLE were found to be more complicated.

Hemolysis after intravenous immune globulin therapy: relation to IgG subclasses of red cell antibody

A patient with chronic idiopathic thrombocytopenic purpura (ITP), a 28-year-old group A, Rh-positive woman, also had hemolytic anemia. At that time, her red cells typed as group A, but the serum typed as group O. This typing followed intravenous high-dose immune globulin therapy, (400 mg/kg for 5 successive days) and was attributable to A antibody of the IgG type, composed of IgG1, IgG2, IgG3, and IgG4, in the immune globulin preparation, which had been given for treatment of ITP. All lots of commercial human plasma preparation products (heat-treated human plasma protein, albumin, factor VIII or IX products, and immune globulin) examined were found to contain A and/or B antibodies of the IgM or IgG type, with titers of 1 to 1024. Twelve of the 20 lots of immune globulin contained RBC antibodies of the IgG type. Subclass IgG1 was found in all 12 of these lots, and all four subclasses, including IgG3, were detected in 8 lots. All 8 showed antibody titers higher than 64.

The presence of platelet-activating factor associated with eosinophil and/or neutrophil accumulations in the pleural fluids

Platelet-activating factor (PAF) has been reported to play a role in the inflammatory reaction, but the mechanism of PAF in humans is still unclear. We examined the presence of PAF in pleural fluids from 23 patients with pleural effusion and in all cases detected PAF associated with eosinophil and/or neutrophil infiltrations. The amounts of PAF in pleural fluids were, respectively, 340, 50 to 170, and 1,250 to 2,130 fmol/ml for a patient with eosinophilic pneumonia, those with pneumothorax (n = 9), and empyema (n = 3). In contrast, patients with tuberculous pleuritis (n = 2), lung edema (n = 3), or malignant disease (n = 5) had no detectable amounts of pleural fluid PAF (less than or equal to 10 fmol/ml). The amount of PAF showed a close correlation with the numbers of eosinophils and neutrophils in the pleural fluids. Furthermore, PAF was mostly detected in the cellular fractions, and the molecular species of PAF from the patients with empyema were almost consistent with those of PAF generated by human blood neutrophils. These results indicate that neutrophils and, presumably, eosinophils were the cellular source of PAF in the pleural fluids in the pathologic state of inflammation.

[Clinical study on the inhibitory effect of AA-2414 on platelet function in asthmatic patients]

We studied the effect of AA-2414, a TXA2 receptor antagonist, on platelet function in 12 asthmatic patients, 6 males and 6 females, whose mean age was 43.6 years. AA-2414 was orally administered to each patient at 20 mg/day for two weeks and then at 40 mg/day for the following two weeks. Platelet aggregation, plasma concentration of TXB2, and serum concentrations of AA-2414 and its metabolites were measured before and after the administration of each dose. Platelet aggregation induced by U-46619 (an analogue of PGH2), STA2 (a stable analogue of TXA2) and arachidonic acid with the administration of AA-2414 was significantly inhibited. The degree of this inhibition was proportional to the serum level of the drug. Plasma concentration of TXA2 tended to be lowered by administration of AA-2414, but it was not statistically significant. Eight (75.0%) of the 12 patients showed clinical improvement. In the cases where the drug was ineffective, the inhibition of platelet aggregation after administration of AA-2414 was less than in those cases where it was effective. We conclude that AA-2414 might exert its antiplatelet and antiasthmatic effects through antagonism of the TXA2 receptor. Investigation of the response to AA-2414 may be useful in assessing the clinical effect of this compound.

[Chronic ITP with a remarkable response to vitamin C administration after splenectomy]

This report deals with a case of 23-year-old woman with chronic idiopathic thrombocytopenic purpura (ITP) showing a favorable response to vitamin C (VC) administration. She was treated with glucocorticoids and immunosuppressants, whereas inadequately controlled with its tolerable dosage. Next, she underwent splenectomy. However, there were only transient effects on platelet counts, so the therapy with ascorbate was carried out according to the report by Brox et al. The platelet counts increased to 20 x 10(4)/microliters after 4 months. Side effects of VC therapy did not occur.

[Analysis of adhesive proteins on the surface membrane of platelet in malignant neoplasm]

Flow cytometry was used to detect fibrinogen (platelet associated fibrinogen: PAFbg) and fibronectin (PAFn) on the surface membrane of platelets in leukemia (9 cases), lung cancer (15 cases) and hepatoma (8 cases) patients (by one color analysis method), and simultaneously to investigate the binding of monoclonal anti-glycoprotein (GP) IIb/IIIa and anti-GP Ib antibodies (by two color analysis). All patient groups showed higher Fbg values than the normal control group, but no differences were found between patient groups. The values of Fbg and Fn showed a correlation, but the pattern of binding did not show a regular tendency in any patient group. There also was no significant correlation between Fbg values and the positive percentage of monoclonal anti-GPIIb/IIIa and anti-GPIb antibodies, and the binding of Fbg did not inhibit that of monoclonal antibody. The results suggest the following. 1. There are no differences in platelet activation in leukemia, lung cancer and hepatoma patients, and the degree of platelet activation is decided by the degree and the kind of stimulation. 2. The increase of both PAFbg and PAFn prove to the existence of activated platelet.

Effect of warfarin on plasma and liver vitamin K levels and vitamin K epoxide reductase activity in relation to plasma clotting factor levels in rats

Changes in plasma and liver vitamin K1 and vitamin K1 epoxide levels, liver microsomal vitamin K epoxide reductase activity, and plasma clotting factor II and VII levels were determined in rats after a single injection of warfarin (2.5 mg/kg, s.c.). The plasma and liver vitamin K1 levels gradually decreased after warfarin injection, attaining the lowest values at 2-3 hrs and remaining low for 48 hrs. They then returned to the control levels at 72 hrs. The changes in vitamin K1 epoxide levels were opposite, with an increase being seen soon after the warfarin injection, the highest values at 3 hrs and a gradual decrease to the initial levels occurring subsequently. The combined levels of vitamin K1 plus vitamin K1 epoxide, however, remained almost constant in both plasma and liver after the warfarin injection. The liver vitamin K epoxide reductase activity decreased to its lowest level soon after the injection and then gradually increased after 12 hrs, but the activity at 72 hrs was only about 30% of the initial activity. The plasma clotting factor levels gradually decreased after the injection, bottomed at 24 hrs and then began to increase, recovering almost to the initial levels at 72 hrs. A positive correlation was found between plasma and liver levels for both vitamin K1 and vitamin K1 epoxide, and the slope of the vitamin K1 epoxide curve was steeper than that for vitamin K1 in the warfarin-treated rats. A similar positive correlation was found for both vitamin K1 and vitamin K1 epoxide after vitamin K1 injection in normal untreated rats, but the slope of the vitamin K1 epoxide curve was much shallower. These results suggest that warfarin inhibits vitamin K epoxide reductase and decreases blood clotting factor synthesis, thus increasing plasma and liver vitamin K1 epoxide levels. A vitamin K epoxide reductase activity one third of that in normal rats is sufficient to maintain normal reduction of vitamin K1 epoxide and synthesis of blood clotting factors.

[Autoimmune hemolytic anemia due to anti-e autoantibody of IgM class-report of a case]

A 83-year-old woman, complaining of jaundice and anemia, was diagnosed as autoimmune hemolytic anemia (AIHA) with bilirubin gall stones. Her red blood cell (RBC) group was A, Rh (D) +, but the details were indefinite due to transfusions previously repeated, while anti-C3d serum reacted positively in the direct antiglobulin test. Her serum reacted with RBC other than R2R2 in the albumin (37 degrees C) method and in the bromelin method, the reaction turning out negative after the pretreatment with 2ME. These findings indicated the autoantibody was anti-e of IgM class, which had been so far rarely reported in Japan.

Randomized trial of combination antibiotic therapy in patients with hematological disorders. Hanshin Study Group of Hematopoietic Disorders and Infection

A 3 arm prospective randomized trial was designed to compare the effectiveness of aztreonam (AZT) + clindamycin (CLDM), amikacin (AMK) + AZT and CLDM + AMK as antibiotic therapy for fever in patients with hematological disorders. Between July 1987 and June 1988, one hundred and sixty of the 199 febrile episodes entered in this study were evaluated for response. Underlying diseases were hematological malignancies in 88.8% of the subjects, and there was no statistically significant differences in incidences of the diseases among the 3 groups. Efficacy rates were 64.2% in the AZT + CLDM group, 52.8% in the AMK + AZT group and 35.2% in the CLDM + AMK group. Efficacy rates in those with neutrophil counts was less than 500/microliters before starting the antibiotics were 53.3%, 43.8% and 25.0%, respectively, in the 3 groups. The combination of AZT + CLDM was found to be the most effective even in the treatment of infections associated with febrile neutropenic patients.

Generalized sarcoidlike granulomas with systemic angiitis, crescentic glomerulonephritis, and pulmonary hemorrhage. Report of an autopsy case

A 19-year-old woman showed rapidly progressive renal and respiratory failure and died after a short clinical course. The autopsy revealed that death was due to crescentic glomerulonephritis and pulmonary hemorrhage. The intrathoracic lymph nodes, lungs, kidneys, and other organs contained numerous epithelioid granulomas, some of which had foci of central coagulative necrosis. The aorta, its major branches, and small- to medium-sized vessels of various organs also had multiple areas of granulomatous angiitis. This is, to our knowledge, the first report of such autopsy findings. A discussion of the etiopathogenesis of the disease is presented.

Effect of vitamin K deficiency on urinary gamma-carboxyglutamic acid excretion in rats

Since gamma-carboxyglutamic acid (Gla) in Gla-containing proteins is stoichiometrically excreted into urine as free Gla, urinary Gla excretion is believed to reflect the rate of synthesis and degradation of vitamin K-dependent proteins and the utilization of vitamin K in body. We studied the daily changes in urinary Gla excretion and plasma vitamin K-dependent clotting factor levels in rats fed vitamin K-deficient diets followed by subcutaneous injection of vitamin K1 or after the oral administration of Warfarin. Urinary Gla excretion in normal rats fed a standard diet that contained about 500 ng of vitamin K1 per gram of diet was 2.35 +/- 0.25 mumoles/day, but the level in rats fed a markedly vitamin K-deficient diet (less than 5 ng/g) decreased to 1.40 +/- 0.14 mumoles/day. When rats were fed a moderately vitamin K-deficient diet (20-50 ng/g), plasma vitamin K-dependent clotting factor levels decreased significantly, but urinary Gla excretion did not decrease. Warfarin, a vitamin K antagonist, caused a significant decrease in urinary Gla excretion and plasma clotting factor levels. When vitamin K, (200 micrograms/kg) was injected subcutaneously in rats fed a markedly vitamin K-deficient diet, the plasma vitamin K-dependent clotting factor levels recovered quickly to normal, but urinary Gla excretion showed only a partial recovery to 1.74 +/- 0.15 mumoles/day. These results indicate that urinary Gla excretion decreases in vitamin K deficiency, but changes in urinary Gla excretion do not reflect vitamin K deficiency in rats as sensitively as changes in the prothrombin time and plasma K-dependent clotting factor levels.

Efficacy of sulbactam/cefoperazone for the treatment of infections in patients with hematologic diseases

The efficacy and safety of sulbactam/cefoperazone (SBT/CPZ) was studied in 94 patients with severe infections and concomitant hematologic diseases. All of the study patients were included in the evaluation for safety, and 76 cases were evaluable for efficacy. Clinical efficacy was excellent in 13 cases (17.1%), good in 27 cases (35.5%), fair in seven cases (9.2%), and poor in 29 cases (38.2%). The bacteriologic eradication was 66.7% for Gram-negative bacilli and 50.0% for Gram-positive bacteria. The efficacy rate for neutropenic patients with counts less than 50 mm3 and 100 mm3 were 47.5 and 42.9%, respectively. Efficacy in patients for whom other antibiotic therapy before treatment with SBT/CPZ had been ineffective was 46.2%. Side effects were reported in one case (1.1%), and abnormal serum liver tests in five cases (5.3%); both returned to normal after discontinuation of the study medication. SBT/CPZ was an effective antibiotic for the treatment of severe infections in the presence of concurrent hematologic diseases.

[Ceftriaxone as a single agent in empirical therapy of infection in patients with hematologic disorders. Hanshin Infection Study Group]

For seventy episodes of infection in hematologic disorders mostly during the phase of severe granulocytopenia, a trial was designed to evaluate the efficacy of a new third-generation cephalosporin, ceftriaxone (CTRX). The regimen consisted mainly of drip infusion of CTRX 2 g every 12 hours. The overall response rate achieved was 54.3 percent. Two episodes of an outpatient with malignant lymphoma were effectively treated by CTRX at a dose of 2-4 g once a day, reflecting its long biological half-life. Gastrointestinal symptoms, hypersensitivity reactions and elevation of hepatic enzyme levels occurred rarely (6.4 and 5.1 percent of the patients, respectively), and these abnormalities were mild and reversible. Thus, CTRX may be recommended as an effective monotherapy in the treatment of infections in immunocompromised patients with hematologic disorders.

[Studies of IgG subclasses of anti-erythrocyte antibodies contained in human plasma preparation products]

Anti-A and anti-B antibodies (1: 1-1: 1, 024) of IgM or IgG type of the titers 1: 1-1: 1, 024 were detected in all of the lots of heat-treated human plasma protein (38 Lots), albumin (15 Lots), factor VIII or IX products (9 Lots) and immune globulin preparations for intravenous use (IVIG) (20 Lots) examined. Twelve out of 20 lots of IVIG contained unexpected anti-erythrocyte antibodies of IgG type. Though IgG1 antibody was detected in all of these 12 lots, antibodies composed of all subclasses including IgG3 could be detected in only 8 lots of them, all showing the anti-erythrocyte antibody titer of IgG type over 1:64. Conversely, none of the lots, in which the titer was less than 1:32, contained IgG3 antibodies. A patient of chronic ITP, 28-year-old female of blood type A and Rh-positive, showed contradictive results between the main (A type) and the accessory test (O type) of red blood cell grouping, accompanied with hemolytic anemia, following intravenous high-dose immune globulin therapy (400 mg/kg x successive 5 days), which was attributable to the anti-A antibody of IgG type composed of IgG1,2,3,4 in the IVIG administered. For high dosage administration of human plasma preparation products, those containing only low titer of unexpected anti-erythrocyte antibody should be selected.

[Comparative evaluation of markers with reverse transcriptase inhibiting antibody in human immunodeficiency virus type 1 infection]

To investigate a non-RI test which is equivalent to the reverse transcriptase inhibiting antibody test, a reverse transcriptase inhibiting antibody was compared to the absolute number of CD-4 or CD-8 cells or CD-4/-8 ratio and also to photodensitometric analysis for western blotting. There is no correlation of the reverse transcriptase with any test for cell numbers and their ratio. In photodensitometry, relative units of anti-p65 and anti-p51 were compared with reverse transcriptase inhibiting antibody. The reverse transcriptase inhibiting antibody showed a higher correlation to the relative unit of p65 antibodies than that of p51 antibodies. The photodensitometric analysis of western blotting for a serum test may be a possible method to find a prognostic marker in HIV-1 infection.

Ultrastructural analysis of megakaryoblasts by simultaneous detection of platelet peroxidase and platelet glycoproteins

We studied the phenotype of megakaryoblasts (MKB) in two patients with blastic crisis of chronic myeloid leukemia by simultaneous detection of platelet peroxidase (PPO) activity and platelet glycoproteins (GP) with monoclonal antibodies at the ultrastructural level. When 227A (anti-GPIb) was used, the finding of GP correlated well with the presence of PPO in the majority of MKB, and a few MKB were found to express PPO but lack GP. When 224B (anti-GPIIb/IIIa) was applied, we found a few MKB of a further type, which expressed GP but lacked PPO. These results indicate that the expression of platelet markers is partially aberrant in neoplastic MKB, and that MKB are heterogenous in their phenotypic expressions. Thus, the detection of PPO or GP alone may miss some MKB. For the accurate identification of MKB and the demonstration of aberrant expression of platelet markers, simultaneous detection of the markers seems to useful.

[Analysis of anti-platelet antibody and platelet volume in idiopathic thrombocytopenic purpura]

We investigated platelets and plasma from patients with idiopathic thrombocytopenic purpura (ITP) to elucidate the antigenic determinants at which their autoantibodies are directed, and studied the relationship between anti-platelet antibody and platelet volume. We used flow cytometry to detect platelet-associated IgG (PAIgG), C3 (PAC3), IgM (PAIgM) and platelet volume, and also to determine the binding rate of monoclonal anti-platelet antibodies in patients with ITP. The following results were obtained. 1. Both anti-GPIIb/IIIa autoantibodies (21 of 71 patients) and anti-GPIb autoantibodies (3 of 71 patients) were found in ITP. 2. The decrease in platelet count in patients without anti-GPIIb/IIIa autoantibodies was significant. 3. The increase in platelet volume was found more frequently in patients with a platelet count less than 50,000 and in untreated patients. 4. There was a positive correlation between the platelet volume and PAIgM in patients with a platelet count less than 30,000 and high levels of PAIgM.

Exposure of fibrinogen-binding sites on stored platelets on stimulation by aggregating agents--an electron microscopic study

We studied the function of stored platelets by immunoelectron microscopy. The distribution of glycoprotein (GP) IIb/IIIa complex was demonstrated by the binding of a monoclonal anti-GP IIb/IIIa complex antibody (NNKY1-32) to platelets, and the binding of fibrinogen to platelets by use of an anti-fibrinogen antibody. The binding of NNKY1-32 decreased significantly in unstimulated platelets after storage for 5 days. When platelet aggregation was tested, 5-day-stored platelets did not aggregate in the presence of either ADP or epinephrine alone (40 microM each) or in combination (8 microM each), but did aggregate on stimulation with the combination of collagen and epinephrine (1 micrograms/ml and 1 microM, respectively). The 5-day-stored platelets stimulated with the combination of ADP and epinephrine scarcely bound fibrinogen, but did bind NNKY1-32. On stimulation with collagen and epinephrine, a large amount of fibrinogen bound to the surface membrane of 3- and 5-day-stored platelets, and the binding of NNKY1-32 also increased, reaching the same level seen in stored platelets stimulated with ADP and epinephrine. Our analysis of stored platelets revealed that the binding of NNKY1-32 decreased after storage for 5 days, but the binding increased even with subaggregating stimulation. The binding of fibrinogen correlated well with the rate of maximal platelet aggregation.