Successful treatment of postinfectious bronchiolitis obliterans with gamma globulin in a tertiary center: 10 years of experience

INTRODUCTION

Bronchiolitis obliterans is characterized by partial or total occlusion of the bronchioles due to inflammation and fibrosis, and the most common form is postinfectious bronchiolitis obliterans (PIBO). This study aimed to retrospectively present our intravenous immunoglobulin (IVIG) treatment experience in PIBO patients with a clinically severe course despite receiving commonly used treatment protocols.

MATERIALS AND METHODS

The study included patients aged 0-18 with subtle immunological abnormalities who were followed up in our center for PIBO between 2010 and 2021. Clinical evaluation, body mass index (BMI), computerized tomography (CT) image scoring, and immunological parameters were recorded before and after IVIG treatment.

RESULTS

Of the 11 patients included in the study, 90% were male, the mean age at diagnosis was 27.1 months (range: 5-68 months) and the mean current age was 81.4 months (range: 15-188 months). The number of hospital visits due to infection and the frequency of hospitalizations decreased markedly in the patients who underwent IVIG therapy. Oxygen therapy was discontinued in all patients, and improvements in radiological severity scores were observed. BMI z-scores improved over the baseline values after IVIG therapy.

CONCLUSION

Corticosteroids are considered the best first-line treatment to control inflammation in PIBO. In our study group, PIBO patients showed favorable clinical and radiological responses to regular IVIG treatment, possibly due to minor immune deficiency secondary to steroids or as a result of undetected adaptive and innate immune defects involved in the etiology of severe PIBO.

Unintended findings: Therapeutic effects of hormones or gamma globulins on Lentiform Fork sign in 3 diabetic uremic patients: Case report/case series

INTRODUCTION

The lentiform fork sign (LFS) is a unique magnetic resonance imaging (MRI) finding characterized by a bright hyperintense rim delineating the lentiform nucleus as a fork associated with metabolic acidosis in end-stage renal disease.

PATIENT CONCERNS

We report 3 cases of LFS in diabetic uremic patients. In one case of uremia, intensive hemodialysis treatment was not effective. Given our poor understanding of LFS, it was regarded as bilateral basal ganglia pathology, and pulse hormone and gamma globulins therapy was initiated. The patient neurological symptoms improved, and the pathological signs on imaging subsided. Based on our experience with the first LFS case, 2 diabetic uremic cases presenting with LFS were successfully treated with hormone or gamma globulin pulse therapy in addition to intensive hemodialysis.

DIAGNOSIS

Based on the clinical manifestations, past medical history and MRI imaging changes of the 3 cases reported here, the diagnosis of LFS was established.

INTERVENTIONS

Our experience from these 3 cases suggests that hormone supplementation and gamma globulin therapy may be indicated for treating LFS.

LESSONS

Our findings highlight that in diabetic uremic dialysis patients with neurological symptoms, LFS should be suspected. The clinical manifestations, past medical history and MRI imaging findings are essential for diagnosing LFS. Hormone supplementation and gamma globulin therapy may be the effective treatment for LFS.

Prediction of venous thromboembolism in patients with multiple myeloma treated with lenalidomide, bortezomib, dexamethasone, and transplantation: Lessons from the substudy of IFM/DFCI 2009 cohort

BACKGROUND

Venous thromboembolism (VTE) is a concern for patients with newly diagnosed multiple myeloma.

OBJECTIVES

We aimed to evaluate VTE incidence, risk factors, and risk score.

PATIENTS/METHODS

We performed a substudy of the "Intergroupe Francophone du Myelome 2009" randomized controlled trial.

RESULTS

We assessed 700 patients receiving lenalidomide/bortezomib/dexamethasone, followed or not by autologous hematopoietic stem cell transplantation. VTE incidence at 6 months was 4.8% (95% confidence interval [CI]: 3.3-6.9%) and 1.5% (95% CI: 0.8-2.9%) from 6 to 12 months. Using multivariate analysis we confirmed history of VTE (odds ratio 5.1 [1.6-16.7], P = .007) as a strong VTE-related risk factor, invalidated erythropoietin exposure (0.6 [0.2-1.7], P = .3) as risk factor, and added two new risk factors: fracture at diagnosis (2.6 [1.3-5.5], P = .01), and serum gamma globulin level > 27 g/L (2.8 [1.2-6.8,] P = .02). Moreover, we noticed that VTE occurred earlier in patients with gamma globulin levels >27 g/L, suggesting a need to revisit the thromboprophylaxis timeframe. Heparin administration was associated with a decreased risk (0.3 [0.1-0.7], P = .005) but failed to erase the risk regardless of dose. The area under the receiver operating characteristic curve of the IMPEDE VTE score was 0.67, as previously reported, confirming our cohort was well representative.

CONCLUSIONS

Prospective studies are warranted in light of these results to improve VTE risk stratification and to design adapted thromboprophylaxis in terms of timing and dose.

Gamma-Delta T-Cell Phenotype and Function in DAA-Treated HIV-HCV Co-Infected and HCV-Mono-Infected Subjects

HIV-HCV co-infected subjects are at risk of liver fibrosis which may be linked to immune imbalances. Direct-acting antivirals (DAAs) represent the mainstay of HCV treatment in co-infected individuals, yet their effects on immune cell populations playing a role in fibrogenesis is unknown. We assessed γδ T-cell phenotype and function, Treg and Th17 frequencies, as well as γ-globulins and B-cell activation in 47 HIV-HCV co-infected and 35 HCV mono-infected individuals prior to and following DAA treatment (SVR12). Γδ T-cell activation decreased in both groups yet persisted at higher levels in the HIV-HCV co-infected subjects. No differences were registered in terms of γδT-cell function. Of note, the Vδ2/Th17 ratio, inversely linked to liver damage, increased significantly in the two groups upon treatment, yet a negative correlation between the Vδ2/Th17 ratio and liver function enzymes was found in the co-infected subjects alone. B-cell activation and γ-globulin levels decreased in both settings, yet B-cell activation remained higher in the HIV-HCV co-infected individuals. In HIV-HCV co-infected and HCV mono-infected participants, the effect of DAA was limited to γδ T- and B-cell activation as well as γ-globulin concentrations and the Vδ2/Th17 ratio, with no changes in γδ T-cell function and Treg frequencies. Importantly, γδ T- and B-cell activation remained at higher levels in the co-infected individuals than in those with HCV mono-infection alone. The persistence of such alterations within these cell subsets may be associated with the risk of hepatic and extrahepatic complications.

Effectiveness of gamma globulin combined with methylprednisolone sodium succinate in severe hand foot mouth disease - Baoding Children's Hospital, China

OBJECTIVE

To determine the curative effect of gamma globulin combined with methylprednisolone sodium succinate on paediatric patients with severe hand-foot-mouth disease and analyse its influence on cardio-pulmonary functions.

METHODOLOGY

Eighty paediatric patients with severe hand-foot-mouth diseases (HFMD) treated in Baoding Children's Hospital, Key Laboratory of Clinical Research on Respiratory Digestive Disease from January 2015 to January 2017 were selected. This study was designed as a case control study with equally dividing patients into test and control groups through random digital method. Patients in the control group accepted methylprednisolone sodium succinate treatment based on conventional therapy. Those in the test group accepted gamma globulin combined with methylprednisolone sodium succinate. The efficacy of the two groups were observed and compared and the improvement of cardiac function index was detected after 3 days of treatment.

RESULTS

The time for symptom remission and hospitalisation of children in the test group were significantly shorter than those in the control group (P<0.05). The differences between the two groups had no statistical significance in terms of PaO2, PaCO2, OI, HR, EF% and CO before treatment. After the treatment, patients in the test group had significant improvement compared with the control group (P<0.05).

CONCLUSIONS

Curative effect of gamma globulin combined with methylprednisolone sodium succinate on paediatric patients showed significance and this treatment could be effectively improve clinical symptoms and cardio-pulmonary functions of paediatric patients.

Novel coronavirus infection and acute kidney injury in two renal transplant recipients: a case report

BACKGROUND

The causative virus of coronavirus disease 2019 (COVID-19) may cause severe fatal pneumonia. The clinical presentation includes asymptomatic infection, severe pneumonia, and acute respiratory failure. Data pertaining to acute renal injury due to COVID-19 in patients who have undergone renal transplantation are scarce. We herein report two cases of COVID-19 along with acute kidney injury following kidney transplantation.Case presentation: Two patients with COVID-19 underwent renal transplantation and were subsequently diagnosed with acute kidney injury. The first patient presented with progressive respiratory symptoms and acute renal injury. He was treated with diuretics and suspension of immunosuppressive therapy; however, the patient died. The second patient presented with respiratory tract symptoms, hypoxemia, and progressive deterioration of renal function followed by improvement. Her mycophenolate mofetil was stopped after admission, and tacrolimus was discontinued 10 days later. Moxifloxacin and methylprednisolone were continued in combination with albumin and gamma globulin infusion. A diuretic was administered, and prednisone was gradually reduced along with tacrolimus. The patient exhibited a satisfactory clinical recovery.

CONCLUSION

Patients who develop COVID-19 after kidney transplantation are at risk of acute kidney injury, and their prednisone, immunosuppressant, and gamma globulin treatment must be adjusted according to their condition.

Efficacy of cefotaxime combined with gamma globulins on C-reactive protein and procalcitonin in neonatal sepsis

C-reactive protein (CRP) is encoded by CRP or PTX1 gene and procalcitonin (PCT) is produced by the CALC-1 gene induction. Both PCT and CRP are known as valued biomarkers markers in prediction of Serious Bacterial Infections (SBI) in children. This experiment carried out to analyze the efficacy of cefotaxime combined with gamma globulins on neonatal sepsis and the effect on CRP and PCT. For this purpose, a total of 120 sepsis children were selected and randomly divided into observation and control groups. Children in the control group were treated with cefotaxime, while children in the observation group were treated with cefotaxime combined with gamma globulins. The two groups were compared in terms of the relative measures of efficacy, the total effective rate of treatment, the incidence of complications and serum CRP and PCT levels before and after treatment. The clinical measures of the observation group were all lower than those of the control group, and the total effective rate of the treatment was higher than that of the control group, while the incidence of complications was lower than that of the control group. In addition, before treatment, there was no difference in CRP and PCT between the two groups; after treatment, the above measures in the observation group were lower than those in the control group. It is concluded that Cefotaxime combined with gamma globulins in the treatment of neonatal sepsis has significant efficacy and is clinically more effective than cefotaxime monotherapy. This combination can shorten clinical symptom remission time and hospital stay, improve serum CRP and PCT levels and promote the recovery of children, worthy of promotion.

Impact of HCV eradication with direct-acting antiviral agents on serum gamma globulin levels in HCV and HCV/HIV coinfected patients

BACKGROUND

chronic viral infections by both HCV and HIV may lead to polyclonal activation of B cells resulting in hypergammaglobulinemia. This study retrospectively analyzed the effect of HCV eradication with interferon-free direct-acting antiviral agents (DAAs) on the gamma globulin levels in HCV-infected patients with or without HIV coinfection to identify factors potentially associated with gamma globulins decrease.

METHODS

The charts of patients treated with DAAs for HCV chronic infection between January 2015-June 2019 were retrospectively reviewed. Gamma globulin levels before treatment and 12 weeks after the end of anti-HCV therapy were evaluated along with liver tests, liver fibrosis stage by elastography, SVR achievement, HIV-coinfection. Multivariate analyses were carried out to assess the factors and the potential confounders related to the changes in gamma globulin levels.

RESULTS

A significant decrease of gamma globulin concentration was found in both cirrhotic and non-cirrhotic HCV-infected patients after treatment (from mean ± SD of 1.5 ± 0.44 g/dL to 1.31 ± 0.37 g/dL; p = 0.0001). Adjusted linear regression analyses of serum gamma globulin changes from baseline to SVR12 showed a positive significant association with pre-treatment gamma-globulin levels (β-coefficient -0.23; p = 0.0001), Metavir fibrosis score (β-coefficient -0.74; p = 0.008), ALT values and baseline HCV-RNA levels > 800,000. No difference was found between HIV-infected and HIV-uninfected patients.

CONCLUSIONS

Our study confirms previous preliminary observation of the decrease of serum gamma globulins after HCV eradication either achieved with interferon-based therapy or with DAAs, suggesting a leading role of the virus on the activation of B cell compartment and gamma globulins production.

Borders and Blood Fractions: Gamma Globulin and Canada's Fight against Polio, 1950-55

During the early 1950s, Canada's efforts to prevent polio became heavily influenced by developments in the United States. America's foremost polio charity, the National Foundation for Infantile Paralysis, sponsored University of Pittsburgh researcher Dr. William McD. Hammon to evaluate the efficacy of a human blood fraction, gamma globulin (GG), to prevent paralytic polio. When the resulting clinical trial data appeared to show that the blood fraction offered some protection against the disease, Canadians embraced the concept for reasons of historical trust, parental demand, and public health pragmatism. They established Canada's first national immunization program to fight polio before the vaccine, as well as developed a plan to produce, evaluate, and distribute GG to epidemic areas. Despite being an expensive enterprise for a geographically vast and sparsely populated nation, Canada's GG program was extended to citizens and it became an important response to polio before a safe and effective vaccine was licensed. Although the blood fraction was not as effective at preventing polio paralysis as researchers had anticipated, its systematic use reveals how Canadian health leaders drew on transnational relationships to reduce the incidence of disease.

Analysis of curative effects of human gamma globulin on bacterial pneumonia in pediatric patients

The main aim of this study was to investigate the effects of human gamma globulin (HGG) on inflammation targets in children. A total of 80 children were randomly divided into observation and control group with 40 cases in each group. The control group was given comprehensive treatment while the observation group was treated with HGG. The time of disappearance of clinical signs and symptoms, time of improvement of pulmonary iconography, inflammatory indices, time and degree of improvement of lung function and adverse reactions were observed. The total effective rate in the observation group was 97.5% and significantly higher than control group (77.5%). The time of fever clearance, imaging improvement as well as cough and pulmonary rales disappearance in the observation group was shorter than control group. After treatment, the levels of inflammatory indicators such as erythrocyte sedimentation rate (ESR) and C-reaction protein (CRP) in the observation group were lower than control group. No obvious abnormalities of urea nitrogen, creatinine, serum alanine amino transferase (ALT) and aspartate amino transferase (AST) were found in the two groups. Overall, HGG effectively shortened the course of RMPP, improved the cure rate, reduced the inflammatory reaction and promoted the recovery of lung function without obvious adverse reaction.

Rescue case of low birth weight infant with acute hepatic failure

We report a case involving a rescued low birth weight infant (LBWI) with acute liver failure. Case: The patient was 1594 g and 32^3/7 gestational wk at birth. At the age of 11 d, she developed acute liver failure due to gestational alloimmune liver disease. Exchange transfusion and high-dose gamma globulin therapy were initiated, and body weight increased with enteral nutrition. Exchange transfusion was performed a total of 33 times prior to living donor liver transplantation (LDLT). Her liver dysfunction could not be treated by medications alone. At 55 d old and a body weight of 2946 g, she underwent LDLT using an S2 monosegment graft from her mother. Three years have passed with no reports of intellectual disability or liver dysfunction. LBWIs with acute liver failure may be rescued by LDLT after body weight has increased to over 2500 g.

Effect of glucocorticoid combined with gamma globulin in treatment of children with myasthenia gravis and its effects on immune globulin and complement of children

OBJECTIVE

To discuss the effects glucocorticoid combined with gamma globulins in the treatment of children with myasthenia gravis and its effects on immune globulin and complement of children.

PATIENTS AND METHODS

Clinical data of 70 cases of childhood myasthenia gravis in this hospital were retrospectively analyzed. These cases were randomly divided into observation group and control group. For observation group, there were methylprednisolone and gamma globulins while the only methylprednisolone in the control group. The clinical effects and changes in immune globulin and complement of two groups were observed.

RESULTS

The total effective rate for observation group was 94.3% and 74.3% for the control group, and this difference was statistically significant (p < 0.05) The time for relief of symptoms (6.55 ± 1.35 days) and total hospital stay (17.15 ± 3.65 days) in observation group was apparently shorter than the control group, with statistical significance (p < 0.05).

CONCLUSIONS

Glucocorticoid and gamma globulin can improve the symptoms and achieve satisfying clinical effects for the treatment of myasthenia gravis in children. Thus, it is valuable for further popularization and application.

The clinical diagnosis and treatment about 22 cases of limbic encephalitis were retrospectively analyzed

To summarize and analyze the clinical characteristics and treatment of limbic encephalitis, in order to provide the basis for clinical work. We retrospectively analyzed the clinical characteristics, magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) and self immune antibody results of 22 patients with limbic encephalitis in Zheng zhou people's Hospital from March 2013 to May 2014. 22 cases of patients with psychiatric disturbance, such as hallucinations being typical clinical manifestations: Memory decline in 18 cases: Seizures in 13 patients: Altered level of consciousness in 10 cases; Movement disorders in 7 cases and 9 cases with febrile.14 cases have relieved after treating with antiviral and immunosuppressive therapy, 5 cases left memory decline, 2 patients left overwhelmingly excited, 1 cases of seizures. The clinical symptoms of patients with limbic encephalitis are complicated changeable and unspecific. so earlier diagnosis and treatment are very important for the prognosis of patients.

Giant right coronary artery aneurysm secondary to Kawasaki disease in child: a case report

Coronary artery aneurysm or ectasia was reported in approximately 15% to 25% of the affected children, particularly in the proximal end of the main blood vessel and the left anterior descending part. Rare patients have been reported with aneurysm in the distal end of the right coronary artery. In this case report, we present a rare case with aneurysm in the distal end of the right coronary artery. Multi-slice computed tomography was performed for the coronary angiography. Aspirin (10 mg/kg body weight per day) and gamma globulin (2 kg/kg body weight) was administrated via intravenous injection. The patient is currently in a healthy status with a 12-month follow up.

Use of Gammaglobulin to Lower Elevated Natural Killer Cells in Patients with Recurrent Miscarriage

OBJECTIVE

To evaluate the effectiveness of intravenous immunoglobulin (IVIG) in patients presenting with recurrent miscarriage and abnormally elevated natural killer (NK) cells.

STUDY DESIGN

This retrospective patient controlled evidence level II-2 pilot study was conducted at Cohen Center, P.A., Medical City Dallas Hospital. Ninety women with a history of recurrent miscarriage (average, 5) and elevated NK cells were retrospectively evaluated to document the outcome of their treatment with IVIG.

RESULTS

Of 90 women with elevated NK cells who received IVIG treatment, 78 (86.7%) became pregnant. Sixty-four (82.0%) of those pregnancies had a successful viable outcome. Fourteen (18.0%) gestations ended as first trimester miscarriages.

CONCLUSION

We conclude at evidence level II-2 that, with adequate precautions, low-dose IVIG therapy is safe and effective for women with immunologic abortion and documented abnormally elevated NK cells.

[Ovarian teratoma associated with anti-N-methyl-D-aspartate receptor encephalitis: a report of 5 cases and review of the literature]

OBJECTIVE

To report the clinical features of ovarian teratoma in patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis.

METHODS

The clinical information of five female patients with ovarian teratoma and anti-NMDAR encephalitis in Peking Union Medical College Hospital and Beijing Tiantan Hospital affiliated to Capital Medical University from June 2011 to May 2013 were obtained. Relevant literatures were reviewed.

RESULTS

The initial symptoms varied from respiratory prodromes or emotional incentives before the onset of psychiatric symptoms. Patients always presented with psychosis, bizarre dyskinesia and seizures. Antibodies to NMDAR in serum and cerebrospinal fluid (CSF) were positive; The psychiatric symptoms were dramatically relieved by tumor reception and immunotherapy which occurred in inverse order of symptom development. No evidence of tumor recurrence was observed during a short-time follow-up after the surgery.

CONCLUSIONS

Ovarian teratoma with anti-NMDAR encephalitis always presents with psychiatric symptoms which could be misdiagnosed as psychiatric diseases. Patients respond to tumor resection and immunotherapy.

Occurrence of Guillain-Barré syndrome as an immune mediated complication after thrombolysis with streptokinase for acute anterior wall myocardial infarction: a caution to be vigilant

Guillain-Barré syndrome (GBS) constitutes a heterogeneous group of immune-mediated peripheral neuropathic disorders that can be triggered by a variety of antecedent events. Clinical symptoms are thought to result from streptokinase antibody-mediated damage to the local blood-nerve barrier. We report the case of a 50-year-old man with acute anterior wall myocardial infarction who developed GBS as a manifestation of autoimmune hypersensitivity reaction to the drug 17 days after thrombolytic therapy with streptokinase. The patient was treated with a 5-day course of intravenous γ globulin and his symptoms improved and there was no residual deficit. The case forms a reminder of the autoimmune complications of non-fibrin specific agents that can sometimes be catastrophic and require persistent and vigilant in-hospital and immediate postdischarge follow-up and immediate management.

Severe thrombocytopenia complicating transcatheter occlusion of a patent ductus arteriosus

Transcatheter closure of a patent ductus arteriosus (PDA) is a well-established technique that may occasionally be complicated by severe thrombocytopenia. We report herein 6 cases of PDA in which circulating platelet counts were notably reduced within 18-48 hours following the procedure. A number of interventions, including blood-pressure control, protection against hemorrhage, and eradication of residual flow, were performed. Platelet counts in all patients were restored to preprocedural levels through intravenous infusion of dexamethasone and human gamma globulin.

[Effects of shugan jianpi gusui recipe on multiple sclerosis recurrence: a primary report]

OBJECTIVE

To observe the effects of Shugan Jianpi Gusui Recipe (SJGR) on multiple sclerosis (MS).

METHODS

A case cohort study was used. The MS patients were assigned to the test group (14 cases) and the control group (21 cases) according to whether they would combine with Chinese herbs. Corticosteroids or gamma globulin was administered to all patients in the acute phase. SJGR was administered to patients in the test group in the remission phase, while those in the control group were not treated or treated by azathioprine alone. They were followed-up for a long time after their first visits. The observation time ranged 10-131 successive months. The recurrence intervals and the yearly average recurrence times were calculated in the two groups.

RESULTS

When compared with before treatment, the recurrence interval was obviously prolonged, and the yearly average recurrence times decreased in the test group after treatment with statistical difference (P < 0.05). There was statistical difference in the recurrence interval and the yearly average recurrence times between the test group and the control group (P < 0.05).

CONCLUSIONS

SJGR showed better effects in prolonging the recurrence interval and reducing the yearly average recurrence times of MS patients. It is worth further researches.

[The comparison of neuroprotective action of antibodies to glutamate and drug preparation semax in the focal ischemic damage of the brain prefrontal cortex of rats]

It was stated, that with bilateral photochemically induced thrombosis of the prefrontal cortex peptide semax and the AB-Glu by intranasal injection provoke pronounced neuroprotective and antiamnestic action. Intranasal injection semax (250 mkg/kg/daily during six postoperative days) and AB-Glu (250 mkg/kg in 1 hour after phototrombosis) demonstrate diminishing of cortex damage volume and relieve preservation and reproduction rat passive avoidance reflex, acquired before bilateral photochemically induced thrombosis of prefrontal cortex.

[Anti-D isoimmunization severe in a twin pregnancy. Case report]

Perinatal hemolytic disease occurs secondary to a hemolytic phenomenon of immune origin resulting in fetal or neonatal anemia. A 38-year-old pregnant woman was referred to the Department of high risk Obstetrics, Hospital Universitario La Paz Madrid because of presenting a dichorionic diamniotic twin pregnancy spontaneously, pre-pregnancy diabetes poorly controlled and severe alloinmunization anti-D. Her first pregnancy ended in a normal delivery at term; in the period of 4 years, she has three newborn with 36, 34 and 40 weeks respectively, who die with a week of life. After that, two intrauterine fetal death occur at 26 weeks of gestation. The patient who is RhD negative, suffers anti-D inmunization with a antibody titration of 1/1024 with 14 weeks of gestation. Twelve plasmapheresis, eight doses of anti-D inmunoglobulins and intrauterine transfusions has been the treatment received. A severe anemia is found during the ultrasound control of the middLe cerebral artery peak systolic velocity in both twins since the 16th week. It remains stable thanks to the treatment. Finally at the 28th week of gestation, pregnancy is terminated with a cesarean section. The twins are born alive and premature, but with good general state. The measurement of the middle cerebral artery peak systolic velocity predicts moderate-severe fetal anemia cases, which are the most important in the clinical management because of the need of active treatment or finish the pregnancy.

[Toxic epidermal necrolysis treated with human gamma globulin]

Toxic epidermal necrolysis and Stevens Johnson syndrome are severe adverse cutaneous drug reactions that predominantly involve the skin and mucous membranes. We report a case of 43 year old female with 75 % body surface area affected, treated with intravenous immunoglobulin who presented favorable outcomes.

[Etiology and clinical characteristics of pregnancy-emerged thrombocytopenia]

OBJECTIVE

To investigate the etiology and clinical characteristics of pregnancy-emerged thrombocytopenia.

METHODS

A retrospective analysis was conducted on clinical data of 159 pregnancies with thrombocytopenia, who were admitted to Peking University People's Hospital from January 2000 to January 2010. All the patients recruited in this study had no history of blood or immune system disease before pregnancy, and thrombocytopenia was the predominate clinical manifestation during pregnancy, with platelet counts less than 100 × 10(9)/L at least twice during pregnancy. The thrombocytopenia should not be induced by drugs, viral infections, preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP). All cases were followed up. The general condition, the onset time of thrombocytopenia, platelet changes, accompany symptoms, maternal and perinatal outcomes as well as follow-up conditions were compared based on the etiology.

RESULTS

(1) ETIOLOGY: among the 159 cases, 101 (63.5%) were diagnosed gestational thrombocytopenia (GT); 43 (27.0%) were idiopathic thrombocytopenic purpura (ITP); 9 (5.7%) were blood system diseases, including 4 cases of megaloblastic anemia (MA), 2 cases of aplastic anaemia (AA), and 3 cases of myelodysplastic syndrome (MDS). Six cases (3.8%) were diagnosed immune system diseases, including 3 cases of systemic lupus erythematosus (SLE), 2 cases of antiphospholipid syndrome (APS), and 1 case of Evans syndrome. (2) Maternal and perinatal outcomes:pregnancy induced hypertension was diagnosed in 21 cases (13.2%), abnormal glucose metabolism in 13 cases (8.2%), anemia in 44 cases (27.7%) and preterm delivery in 18 cases (11.3%). Twenty-nine cases (18.2%) were treated with corticosteroids or gamma globulin during pregnancy. The average gestational week was 38 weeks. Fifty-five cases (34.6%) underwent vaginal delivery, 104 cases (65.4%) received cesarean section. Postpartum hemorrhage was observed in 34 cases (21.4%), and puerperal infection happened in 2 cases (1.3%). No maternal death was found. In a total of 160 fetuses (including twins), there were 157 live births. Three cases of fetal death and 2 cases of early neonatal deaths were observed. Fetal growth restriction was observed in 4 cases, and neonatal thrombocytopenia was seen in 6 cases. No intracranial hemorrhage was detected. (3) The onset time of thrombocytopenia: among the 159 cases, 29 cases (18.2%), 67 cases (42.1%), 63 cases (43.6%) of thrombocytopenia were detected in the first, second and third trimester, respectively. There was a significant difference of the onset time of thrombocytopenia between GT and ITP groups (P < 0.05). Patients with GT tended to have a later onset of thrombocytopenia, which mainly happened in the second and third trimester, while patients with ITP tended to happen in the first and second trimester. (4) The degree of thrombocytopenia: the cases with the minimum platelets level of (51 - 100) × 10(9)/L, (31 - 50) × 10(9)/L, (10 - 30) × 10(9)/L, < 10 × 10(9)/L during pregnancy were 75 (47.2%), 39 (24.5%), 31 (19.5%), 14 (8.8%) respectively. There was a significant difference between GT and ITP groups in the lowest platelets level (P < 0.01). (5) Thrombocytopenia accompany with anemia: among the 159 cases, there were 44 cases (27.7%) accompanied with anemia. The proportion was 9.9% (10/101) in GT group, 58.1% (25/43) in ITP group, with significant difference (P < 0.01). Anemia was also found in 5 cases in blood system disease group (5/9), and 1 case in immune system disease group (Evans syndrome, 1/6). Pancytopenia was observed in 2 cases with ITP (4.7%, 2/43) and 3 cases with blood system disease (AA: 1 cases, MA: 2 cases, 3/9). (6) The recovery of the platelets counts postpartum: the postpartum follow-up periods were 7 months to 10 years. Patients recovered within 1 week, 6 weeks, 6 months postpartum were 66 cases (41.5%), 43 cases (27.0%), 17 cases (10.7%) respectively. The platelets counts did not recover within 6 months postpartum in 33 cases (45.7%).

CONCLUSIONS

GT is the leading cause of pregnancy-emerged thrombocytopenia followed by ITP. There are significant differences between GT and ITP in the onset time of thrombocytopenia, the lowest platelets level, the proportion of anemia accompanied and the postpartum recovery. Other etiologies including immune and blood system diseases are rare. The relevant examinations should be taken for etiology and differential diagnosis.

[Antibody deficiencies. A survey from three Clinical Immunology Centers for adults in Buenos Aires city]

Antibody deficiency (AD) comprises a group of diseases characterized by the inability to develop an effective antibody mediated immune response. These patients suffer mainly of encapsulated extracellular bacterial infections of the respiratory tract. The aim of our study was to describe the clinical characteristics of 128 patients with suspected or confirmed AD who were referred to 3 immunodeficiency centers for adults, from June 2004 to December 2009. Three of these patients (2.3%) consulted for recurrent infections only once, without sufficient data for a proper classification, and were excluded. Of the remaining 125 patients, in 21 (16.8%) AD was excluded, 8 cases (6.4%) were diagnosed with secondary antibody immunodeficiency (SAD) and 96 (76.8%) with primary antibody immunodeficiency (PAD). SAD causes were: one renal failure, one phenytoin use, two monoclonal gammopathy and four B cell lymphoma. The causes of these 96 PAD were: 57 common variable immunodeficiency, 12 X-linked agammaglobulinaemia, 10 selective IgA deficiency, seven IgG1 deficiency, three hyper-IgM syndrome, three IgM deficiency, two X-linked proliferative syndrome, one Good syndrome and one antibody functional deficiency. Sixty-seven patients were in follow up at the time of completion of the study, 25 of them were on follow up at the beginning of the study. Among the 58 patients with indication of gamma globulin replacement therapy, 54 were in treatment at the end of the study. In four patients the initial diagnosis of PAD was not confirmed.

[Clinical analysis of pregnancy complicated with severe thrombocytopenia]

OBJECTIVE

To investigate the etiology and perinatal outcome of pregnancies complicated with extremely severe thrombocytopenia [at least two times of platelets count (PLT) < 10 × 10(9)/L during pregnancy].

METHODS

Clinical data, including basic information, etiology, management and outcomes of pregnant women with extremely severe thrombocytopenia, admitted to Peking University People's Hospital from January 2004 to March 2009, were retrospectively collected. The management of these cases varied according to different etiology and the symptoms: (1) PLT were maintained > 20 × 10(9)/L and hemoglobulin > 70 g/L in those women without spontaneous bleeding; (2) PLT transfusion would be required when PLT < 10 × 10(9)/L or bleeding occur and RBC would be supplied when hematocrit < 25% and hemoglobulin < 70 g/L; (3) Hemoglobulin should be > 70 g/L and PLT > 30 × 10(9)/L before cesarean section or delivery; (4) Predinisone and/or intravenous immunoglobulin G (IVIG) would be given in women complicated with idiopathic thrombocytopenic purpura (ITP) when PLT < (20 - 30) × 10(9)/L or bleeding. PLT would be given if all the above management were failed, or PLT < 10 × 10(9)/L, or bleeding. Women without bleeding would be closely monitored and delivery would be planned.

RESULTS

(1) Twenty-six cases were identified among 9302 deliveries during the study period (0.28%), with an average of maternal age of 29. Seventeen were diagnosed before conception and 9 during pregnancy. Among the 26 women, half received regular prenatal check in our hospital and the average gestations at diagnosis was 24 weeks and the other half without regular prenatal visits and the average gestations at diagnosis was 32 weeks. Etiology was identified in 24 out of the 26 women, including 14 (54%) ITP, 5 myelodysplastic syndrome (MDS), 4 chronic aplastic anaemia (CAA) and 1 systemic lupus erythematosus (SLE). (2) MANAGEMENT: All of the 26 women received blood products. Among the 14 ITP cases, 6 received predinisone and IVIG and 8 only took predinisone. Nine of the 26 patients (35%) had pregnant complications, among which 6 (6/9) were preeclampsia. The overall average gestation at delivery was 36 weeks. Only 2 delivered vaginally with the average blood loss of 83 ml and 23 cesarean sections were performed with the average blood loss of 410 ml. (3) Perinatal outcomes: There were 26 perinatal babies, among which 1 died intrauterine and 25 were born alive (12 preterm infants). The average birth weight was 2877 g. Neonatal severe thrombocytopenia presented in 2 newborns whose mother complicated with ITP.

CONCLUSIONS

The main cause of extremely severe thrombocytopenia during pregnancy is ITP, managed mainly by predinisone and IVIG, followed by CAA and MDS, which may require supportive treatment. Pregnancy complicated with extremely severe thrombocytopenia is not an indication of termination. Better maternal and fetal outcomes can be achieved through proper treatment based on the etiology, intensive care in prevention and management of complications and cesarean section.

Diagnosis and management of immunodeficiencies in adults by allergologists

Primary immunodeficiencies (PIDs) are genetic diseases that cause alterations in the immune response and occur with an increased rate of infection, allergy, autoimmune disorders, and cancer. They affect adults and children, and the diagnostic delay, morbidity, effect on quality of life, and socioeconomic impact are important. Therapy (gamma-globulin substitution in most cases) is highly effective. We examine adult PIDs and their clinical presentation and provide a sequential and directed framework for their diagnosis. Finally, we present a brief review of the most important adult PIDs, common variable immunodeficiency, including diagnosis, pathogenesis, clinical signs, and disease management.

[Evaluation of unresponsiveness to standard high-dose gamma globulin therapy in Kawasaki disease]

OBJECTIVES

We investigated the incidence of unresponsiveness to intravenous gamma globulin (IVIG) treatment in Kawasaki disease (KD) and evaluated its relation with coronary artery involvement.

STUDY DESIGN

The study included 20 children (13 boys, 7 girls; mean age 4.2+/-3.4 years; range 9 months to 12 years) with KD. The mean disease duration on admission was 7.3+/-2.4 days (range 5 to 14 days). Initial treatment consisted of a single dose of IVIG and high-dose of aspirin. Unresponsiveness was defined as the persistence of fever and other symptoms within the first 48 hours of treatment. All the patients were evaluated by two-dimensional echocardiography before and after treatment. The mean follow-up period was 16.5+/-2.8 months (range 9 to 24 months).

RESULTS

Unresponsiveness was seen in five patients (25%), who received a subsequent dose of IVIG, which improved fever in two patients. The remaining three patients received high-dose methylprednisolone. One patient who showed no response to either IVIG or methylprednisolone was treated with low-dose oral methotrexate. Six patients (30%) had coronary artery involvement (4 dilatations, 2 aneurysms), five patients on admission echocardiography, and one patient on control echocardiography seven days after treatment. Of five unresponsive patients, four (80%) had coronary artery involvement on admission. Patients with coronary involvement underwent coronary angiography after a mean of one year. Five patients had normal coronary arteries, whereas no angiographic regression was observed in one patient who had a giant coronary artery aneurysm on admission and was treated with oral methotrexate.

CONCLUSION

The incidence of unresponsiveness to treatment was markedly high in KD patients who had coronary artery involvement on admission.

[Follow-up study of patients with chronic motor axonal neuropathy]

OBJECTIVE

To study the characteristic of chronic motor axonal neuropathy and the prognosis of it.

METHODS

16 chronic motor axonal neuropathy (CMAN) patients were diagnosed by clinical manifestation and neurophysiologic manifestation. Follow-up study was done including living state, medicine they taken, change of physical sign and motor unit number estimation. 60 patients with amyotrophic lateral sclerosis were studies at the same time. The prognosis of these patients was compared.

RESULTS

After being treated with intravenous immunoglobulin therapy, the patients with CMAN showed a good clinical recovery except 6 patients who had the characteristic of ALS in the 18 months follow-up study, and the MUNE changed from 68 +/- 17 to 154 +/- 25. On the contrary, the patients with ALS had worse clinical manifestation, and the MUNE changed from 64 +/- 6 to 55 +/- 9.

CONCLUSIONS

Immunological factor may be involved in the mechanism of chronic motor axonal neuropathy which has a better prognosis and is difficult to differentiate from amyotrophic lateral sclerosis in the earlier stage.

Radial nerve palsy in Guillain-Barré syndrome

The risk of focal compression neuropathy in the setting of an underlying inflammatory polyneuropathy is unknown. A man developed ascending weakness and severe sensory ataxia and could not walk. Electromyography was diagnostic of Guillain-Barré syndrome. He improved with gammaglobulin and was released home 1 month later. Shortly after discharge, he developed severe left arm pain followed by wrist and finger drop. He was readmitted for another round of gamma-globulin without improvement. Subsequent electromyography showed severe radial neuropathy. Only then did he disclose that he usually slept with his wife's head on his arm at home. Two years later, he had recovered from Guillain-Barré syndrome with minimal gait imbalance, but wrist and finger extension remained weak. Reduced awareness of warning paresthesias coupled with the underlying polyneuropathy may account for this case of severe radial nerve compression. Potential mechanisms underlying increased nerve susceptibility to compression in the setting of polyneuropathy are reviewed.

[Comparison of efficacy among early, conventional and late intravenous gamma globulin treatment of Kawasaki disease]

OBJECTIVE

To compare the rates of intravenous gamma globulin (IVIG) non-responder and coronary complication among early, conventional and late IVIG treatment in children with Kawasaki disease (KD).

METHODS

All children with KD and IVIG treatment were retrospectively analyzed at 45 hospitals in Beijing during the 5-year period from 2000 through 2004. The time of IVIG treatment was classified as early (Day 1 - 4), conventional (Day 5 - 9) and late treatment group (Day 10 or later). The efficacy of IVIG was judged by the rate of IVIG non-responder. Echocardiography was used to assess the coronary complication at acute (1 - 2 weeks after onset) and sub-acute (3 - 6 weeks after onset) stage.

RESULTS

A total of 1052 patients (680 boys, 372 girls) aged 2 months to 13.8 years were included. They were grouped as early, conventional and late treatment in 108, 763 and 181 children respectively. The rate of IVIG non-responders was higher in early (28.7%, 31/108) as compared with conventional (11.9%, 91/763) and late treatment group (7.2%, 13/181, both P < 0.01). The incidences of coronary complications were similar in early (17.6%, 19/108 and 5.9%, 4/68) and conventional treatment group (18.3%, 140/ 763 and 5.5%, 25/452), while significantly higher in late treatment group (33.7%, 61/181 and 12.8%, 15/117) in acute and sub-acute stages (both P < 0.01).

CONCLUSIONS

IVIG treatment in children with KD for a disease duration of 1 - 4 days appeared to increase the rate of IVIG non-responders. Children with IVIG given at Day 10 or later had a higher incidence of acute and sub-acute coronary complications. IVIG given at Day 5 - 9 seems to be the best time for IVIG therapy in KD.

Immunoglobulins for preventing hepatitis A

BACKGROUND

Hepatitis A (infectious hepatitis) is a common epidemic disease. Immunoglobulins for passive immunisation are used as prevention.

OBJECTIVES

To assess the beneficial and harmful effects of the pre- and post-exposure prophylaxis with immunoglobulins for preventing hepatitis A.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, The Chinese Biomedical Database, and Science Citation Index Expanded for trials until October 2008. In addition, we read through reference lists of the identified publications and handsearched three journals.

SELECTION CRITERIA

Randomised clinical trials on immunoglobulin prophylaxis for preventing hepatitis A, irrespective of blinding, publication status, or language.

DATA COLLECTION AND ANALYSIS

Data were extracted by two authors and verified by a third author. Results were presented as relative risks (RR) with 95% confidence intervals (CI). The primary outcome was occurrence of hepatitis A (infectious hepatitis).

MAIN RESULTS

We included 13 trials with 567,476 participants randomised to pre- or post-exposure prophylaxis. The trials had high risk of bias. The trials were heterogeneous in terms of study setting, participants, interventions, and outcome measures. Our meta-analysis with six randomised trials showed that immunoglobulins, when used for pre-exposure prophylaxis, significantly reduced the number of adult patients with hepatitis A at 6 to 12 months (1020/286503 versus 761/134529; RR 0.53; 95% CI 0.40 to 0.70; random-effects model) in comparison with no intervention or inactive control. Four trials showed a similar effect in children aged 3 to 17 at 6 to 12 months follow-up (917/210822 versus 677/78960; RR 0.45; 95% CI 0.34 to 0.59). Comparing different doses of immunoglobulins, higher dosage was generally more effective than lower dosage (1.5 ml better than 0.75 ml and 0.75 ml better than 0.1 ml) in preventing hepatitis A. No significant systemic adverse events were reported. One trial showed that immunoglobulin was more effective than placebo for post-exposure prophylaxis. It appeared that there was no significant difference between immunoglobulins and inactivated hepatitis A vaccine in seroconversion to hepatitis A vaccine antibodies at four weeks (RR 1.16; 95% CI 0.98 to 1.38), but immunoglobulins were significantly less effective than vaccine regarding antibody levels at 8, 12, or 24 weeks.

AUTHORS' CONCLUSIONS

Immunoglobulins seem to be effective for pre-exposure and post-exposure prophylaxis of hepatitis A. However, caution is warranted for the positive findings due to the limited number of trials, year of conductance, and risk of bias. Conductance of rigorous trials will be justifiable.

Hyponatraemic encephalopathy as the initial presentation of Guillain-Barre syndrome

This report deals with an elderly lady with Guillain-Barre Syndrome (GBS), who presented with features of unusually severe hyponatraemia. The hyponatraemia was probably due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The hyponatraemia resolved with water restriction and infusion of hypertonic saline; GBS was treated with human immunoglobulin (IVIG). This patient's experience stresses the importance of monitoring serum sodium levels as hyponatraemia has been identified to be a marker of poor prognosis in GBS.

[Effects of cholinergic drugs and blood plasma proteins on the development of Arthus reaction]

Delayed-type hypersensitivity (DTH) reaction was induced in (CBA x C57BL/6) F1 mice by subcutaneous injection of complete Freund adjuvant (0.02 ml) at the base of the tail. The effects of methacine (2 mg/kg), ipratropium bromide (0.01 mg/kg), their combinations with neostigmine (0.02 mg/kg), hexamethonium (10 mg/kg), acetylcholine (2 microg/kg), nicotine (0.5 mg/kg), gamma globulin and CRP (both 1 mg/kg), and albumin (500 mg/kg) on DTH reaction development, B cell functions and Arthus reaction were investigated. It was established that ipratropium bromide and CRP prevented Arthus reaction development. The administration of acetylcholine, nicotine, and combinations of muscarinic antagonists with neostigmine, as well as gamma globulin and albumin resulted in the later onset of Arthus reaction. The administration of hexamethonium increased DTH reaction and led to early appearance of the Arthus reaction and its maintenance during 21 days. These results demonstrate the role of cholinergic system and plasma proteins in the organism sensitization development.

Successful treatment of neonatal herpes simplex-type 1 infection complicated by hemophagocytic lymphohistiocytosis and acute liver failure

Neonatal disseminated herpes simplex virus (HSV) infection with acute liver failure (ALF) and neonatal hemophagocytic lymphohistiocytosis (HLH) are severe diseases. We recently experienced a male infant with HLH and ALF induced by HSV type 1 (HSV-1). The infant, born at 39 weeks of gestation by normal delivery, developed a fever on day 4. On day 9, laboratory investigations showed progressive liver dysfunction and coagulopathy, and the serum ferritin was excessively elevated. Furthermore, the blood levels of interleukin (IL)-6, IL-10, and interferon-gamma were also elevated. HSV-1 DNA was detected in the serum and cerebrospinal fluid by the real-time PCR method. A diagnosis of HLH was established based upon the following criteria: fever, splenomegaly, cytopenia (two cell lines), serum ferritin (> 500 mug/l) and hypofibrinogenemia (< 150 mg/dl). High-dose acyclovir therapy, steroid pulse therapy using methylprednisolone, high-dose gamma globulin therapy and a blood transfusion were given. The patient recovered without neurological deficit. Neonatal disseminated HSV infections may be complicated by the development of HLH and hypercyokinemia. If HLH is suspected, not only high-dose acyclovir therapy but also anti-cytokine therapy should be considered.

[Effects of three intravenous gamma globulin regimens on Kawasaki disease and relevant coronary complication rates in pediatric patients: a comparative study]

OBJECTIVES

To compare the effects on Kawasaki disease (KD) of 3 different intravenous gamma globulin (IVIG) regimens and coronary complication rates in children with Kawasaki disease (KD).

METHODS

The clinical data of 1052 children with KD treated in 45 hospitals in Beijing from 2000 through 2004, 680 male and 372 female, aged 2 months-13.8 years, 656 (60.1%) undergoing IVIG 2 g/kg for one dose (single dose group), 292 (26.7%) undergoing 1 g.kg(-1).d(-1) for 2 days (2 d group), and 104 (9.5%) undergoing 400 - 600 mg.kg(-1).d(-1) for 4 - 5 d (4 - 5 d group) in addition of oral administration of aspirin, were analyzed retrospectively. Echocardiography was used to assess the occurrence of coronary complications 1 - 2 weeks after onset (acute stage) and 3 - 6 weeks after onset (sub-acute stage).

RESULTS

The rate of IVIG non-responder of the 2 d group was 20.9%, significantly higher than those of the single dose group and 4 - 5 d group (9.9% and 8.7% respectively, both P < 0.01). There were no significant differences in rates of coronary complication, pericardial effusion, and mitral regurgitation at the acute stage among the 3 groups (all P > 0.05). However, the rates of coronary complication and of coronary aneurysm at the sub-acute stage of the single dose group were 5.1% and 1.6%, significantly lower than those of the 4 - 5 d group (11.6% and 4.7%) and 2 d group (9.8% and 5.4%, P = 0.035 - 0.047) were significantly lower in single dose group (5.1% and 1.6%) as compared to those in 4 - 5 d group and (11.6% and 4.7%) and 2 d group (9.8% and 5.4%) (P = 0.035 - 0.047).

CONCLUSION

IVIG 2 g/kg in a single dose has lower rates of coronary complications and IVIG non-responders in children with KD, and is recommended for initial KD therapy.