Characterization of high-risk HIV-1 seronegative hemophiliacs

Mechanisms that protect most high-risk HIV-1 seronegative (HRSN) persons are not well understood. Among hemophiliacs from the Multicenter Hemophilia Cohort Study who remained HIV-1 seronegative despite a high (94%) risk for acquisition of HIV-1 infection, only 7/43 were homozygous for the protective CCR5 Delta32 polymorphism. Among the remainder, neither CCR5 density nor beta-chemokine production, nor in vitro susceptibility to infection with the HIV-1 isolate JR-FL could distinguish HRSN hemophiliacs from healthy controls. When compared to lymphocytes of healthy controls not at risk for HIV-1 infection, diminished spontaneous lymphocyte proliferation was seen in lymphocytes of HRSN hemophiliacs as well as in lymphocytes of hemophiliacs not at risk for HIV-1 infection. Surprisingly sera/plasmas obtained from high-risk HIV-1 seropositve hemophiliacs prior to seroconversion more often contained alloreactive antibodies than date-matched sera/plasmas obtained from HRSN hemophiliacs. Thus alloreactivity may predispose to acquisition of HIV-1 infection after parenteral exposure.

Safety of lumbar puncture in patients with hemophilia

STUDY OBJECTIVE

To determine the safety of lumbar puncture in patients with hemophilia who are pretreated with clotting factor.

DESIGN

Retrospective analysis of medical records between 1980 and 1990.

SETTING

Three hospitals, each serving as a regional hemophilia center.

PARTICIPANTS

Thirty-three patients with hemophilia A or B who received one or more lumbar puncture.

INTERVENTION

All patients received replacement of deficient factor before the lumbar puncture. Serious post-lumbar puncture complications were defined as motor or sensory deficits, incontinence, or documented intraspinal hemorrhage.

RESULTS

Thirty-three patients with hemophilia A or B received a total of 52 lumbar punctures during the study period. Thirty of 33 patients (91%) had severe baseline factor deficiency, two (6%) had moderate deficiency, and one (3%) had mild deficiency. There were no serious complications reported as a result of the lumbar puncture. The 95% confidence interval for the risk of a serious complication was 0% to 5.8%.

CONCLUSION

With adequate factor replacement, a lumbar puncture can be done safely in patients with hemophilia.

Frequency of inhibitor development in haemophiliacs treated with low-purity factor VIII

Clinical studies evaluating highly purified monoclonal-antibody-derived and recombinant-DNA-derived clotting factor concentrates in previously untreated (PUPS) severe factor VIII (FVIII) deficient haemophilia patients, have documented an increased frequency of inhibitors compared with that seen in patients who have received less pure products. However, a valid comparison of inhibitor frequency in patients treated with pure and less pure products has not been possible because appropriate studies have not been done in PUPS treated with the less pure products. To determine the frequency of inhibitor development in PUPS treated solely with less pure plasma-derived products (specific activities < 5 FVIII U/mg protein), we reviewed the records of all haemophilia patients born between 1975 and 1985 and treated with such products at any of seven centres. 89 patients with severe FVIII deficiency (< 1%) were observed and tested for inhibitors from birth to 5 years old or until 30 bleeding episodes had been treated. 25 of the 89 patients developed inhibitors (28%), and 21 of these 25 were high-titre responders (> 5 Bethesda units). This frequency of inhibitor development is greater than that reported in patients treated with monoclonal FVIII products, but the latter patients may not have been followed as long as the patients in our report. Our data may make possible a meaningful comparison with the frequency of inhibitor development in PUPS treated solely with recombinant-DNA-derived FVIII.

A human monoclonal antibody against the CD4-binding site of HIV1 gp120 exhibits potent, broadly neutralizing activity

A human monoclonal antibody (HuMAb) against HIV1, 1125H, was isolated from an asymptomatic, seropositive haemophiliac. This antibody was specific for gp120, and its binding to gp120 was inhibited by soluble CD4, indicating that its epitope was in or near the CD4-binding site. 1125H antibody recognized a variety of divergent HIV1 strains, including most laboratory strains tested as well as some early passage isolates. Commensurate with its specificity and high apparent affinity, 1125H exhibited potent neutralizing activity against IIIB, MN, RF and SF-2 strains. The epitope recognized by 1125H was destroyed by reduction of disulphide bonds, but not by removal of N-linked sugars. Thus, the epitope was conformationally determined and did not involve carbohydrate. Data from radioimmunoprecipitation/SDS-PAGE analysis of proteolytically cleaved viral lysate further indicated that the epitope of 1125H was not affected by cleavage at the V3 loop of gp120, provided that gp120 disulphide bonds remained intact. The potential use of HuMAb 1125H in passive immunotherapy against HIV is discussed as well as the importance of including its epitope in an AIDS vaccine.

AIDS in the transfusion recipient

In summary, the HIV virus was transmitted to approximately 90% of recipients by infectious blood and blood products transfused prior to donor and product testing begun in March 1985. Self-elimination of at-risk donors several years prior to testing donor blood helped to reduce the number of infected donations. Virtually all contaminated donors are now eliminated. The multiply transfused patient developed a stimulated dysregulated immune system due to the numerous antigens and the iron in red cells and plasma. This dysregulated immune system has resulted in a variable response to the added exposure of the HIV virus. The incubation period and progression to disease have been prolonged and variable. Although a small number of patients have progressed as rapidly as other at-risk groups, many continue to do well without therapeutic intervention. Natural history of the disease needs continual monitoring to determine the ultimate outcome of these transfusion recipients.

Efficacy and safety of vapor-heated anti-inhibitor coagulant complex in hemophilia patients. FEIBA Study Group

The study reported here was designed to measure the efficacy and safety of a vapor-heated anti-inhibitor coagulant complex (FEIBA-VH) for the treatment of bleeding episodes in patients with hemophilia A who have inhibitors to factor VIII (FVIII). FEIBA-VH, a second-generation complex, is vapor-heated for 10 hours at a temperature of 60 degrees C and a pressure of 1190 millibar (mbar) and for 1 additional hour at 80 degrees C and 1375 mbar. The current study was performed because of concern that this vapor-heating process would reduce the efficacy of FEIBA-VH as compared with non-heat-treated FEIBA (FEIBA). Forty-one patients received FEIBA-VH for 106 evaluable bleeding episodes. Ninety-three (88%) episodes were controlled, and 13 (12%) were not. Eighty-three (79%) episodes were controlled within 36 hours of the first infusion. No significant toxicity was seen. These results were compared with those of an earlier study with FEIBA. FEIBA-VH was at least as effective as FEIBA in controlling bleeding episodes and can be compared favorably to any reported treatment of bleeding episodes in hemophiliacs with inhibitors to FVIII.

Acute obstructive pancreatitis secondary to a duodenal hematoma

An 18-year-old male with hemophilia presented with symptoms and signs of upper intestinal obstruction. Evaluation was consistent with an intramural duodenal hematoma and obstructive pancreatitis. As it is not possible to distinguish between these two disorders on a clinical basis, it is important to realize that pancreatitis may occur in such patients more often than is recognized.

A consortium for purchase of blood products directed by physicians

Clotting-factor therapy is a costly part of comprehensive hemophilia treatment. Physicians treating patients with hemophilia in New York formed a consortium for the purchasing and regional distribution of clotting-factor concentrates. Concentrates are centrally purchased based on a bidding formula aimed at obtaining the lowest price for quality product while guaranteeing all suppliers continued involvement in a large market area. The consortium has successfully maintained, and, in instances, lowered prices each year. Estimated regional savings this year are more than $750,000 for an anticipated purchase of approximately 60,00,000 units of clotting-factors VIII and IX. Central distribution has additionally lowered costs to participating hospitals. The consortium is able to provide patients and third-party payers with some of the lowest prices for clotting-factor concentrates in the United States. A physician-directed regional approach to purchasing costly medical products might be applied to other areas of clinical medicine.

Assessment for evidence of non A-non B hepatitis in patients given n-heptane-suspended heat-treated clotting factor concentrates

Nineteen patients, (2 adults, 17 children) with inherited bleeding disorders were infused with n-heptane-suspended-heated clotting factor concentrates. Twelve of the nineteen were previously untreated. Six patients were infused with Profilnine Heat-Treated and 13 with Profilate Heat-Treated. Five separate centers participated and were given various lots of concentrates for use. Blood from the seventeen children was sampled prior to entry, at infusion, 2 weeks, 6 weeks, 12 weeks and 6 months after the first infusion. The two adults were sampled every 2 weeks. Twelve of the 19 patients were followed beyond six months. Three patients demonstrated a rise in ALT during the first six months of observation with levels above 2.5 times the upper limit of normal. One of these patients showed a parallel increment in a-CMV IgM titer and a second patient, an adult, had previously received many units of single donor blood components. During the second 6 month observation interval, two patients showed a rise in ALT. One of these patients had been exposed to only one lot of concentrate with no other viral cause being determined. Two additional patients had a moderate increase in ALT up to 98 U/L (normal less than 50). No patients were clinically ill or showed jaundice during these episodes. The hepatitis episode at 11 months in the patient using one lot of concentrate, might suggest a non-viral mechanism in this instance. This study indicates that these concentrates may be associated with episodes of ALT above 2.5 times the upper limit of normal in approximately 20% of the patients treated, but the etiology of the raised ALT may not always be Non A-Non B hepatitis.

HTLV-III/LAV antibody and immune status of household contacts and sexual partners of persons with hemophilia

We evaluated the human T-cell lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) antibody and immune status of 88 persons living with and/or sexual partners of 43 hemophiliacs, 12 of whom had AIDS, five of whom had AIDS-related complex (ARC), 17 of whom were clinically well but HTLV-III/LAV antibody positive, and nine of whom were well and HTLV-III/LAV antibody negative. No nonhemophilic household contacts (0/50) of healthy hemophiliacs were HTLV-III/LAV antibody positive; two of 33 nonhemophilic AIDS/ARC contacts were positive. One was a spouse and one a sexual partner of a hemophiliac. One of these antibody-positive contacts herself had AIDS, and one had ARC. Antibody-negative, nonhemophilic contacts of AIDS/ARC and of antibody-positive hemophiliacs had significantly lower numbers of lymphocytes, T helper lymphocytes, and T suppressor lymphocytes than did contacts of antibody-negative hemophiliacs. We conclude that risk of HTLV-III/LAV transmission may exist for spouses and/or sexual contacts of hemophiliacs with AIDS/ARC, but we cannot now determine the risk for contacts of asymptomatic hemophiliacs.

Elevation of platelet associated antibody levels in patients with chronic idiopathic thrombocytopenic purpura expressing the B8 and/or DR3 allotypes

The HLA type DR3 was present in 11 of 26 patients with Chronic Idiopathic Thrombocytopenic Purpura (ITP), a significantly increased frequency (p less than 0.05). Levels of platelet associated immunoglobulin M(PAIgM) were significantly higher in the B8 and/or DR3 positive group of chronic ITP patients than in the B8 DR3 negative patients despite similar clinical outcomes. Other immunologic parameters assessed, including serum immunoglobulin levels, rate of catabolism of transfused IgG, and antibody coated autologous red cell clearances were similar for both groups. These results suggest that there is an immunobiologic abnormality associated with the B8 DR3 allotypes which may result in a predisposition not only to chronic ITP, but also to a significant increase in PAIgM. These results are in accord with studies linking autoantibody with B8 DR3.

A study of liver biopsies and liver disease among hemophiliacs

Hepatic histologic materials (biopsy or autopsy) and associated clinical data from 155 hemophiliacs were collected by an ad hoc hemophilia study group and analyzed retrospectively in an effort to determine the spectrum of liver disease in this population and to examine the relationship between the severity of liver disease and treatment history. Clinical information on the frequency of complications from 126 biopsies in 115 hemophilic patients provided a unique opportunity to assess the safety of liver biopsy in such patients. The incidence of cirrhosis (15%) and chronic active hepatitis (7%) was lower than previously reported. The frequency of severe liver disease (chronic active hepatitis or cirrhosis) in patients receiving large pooled concentrates was no greater than in patients treated principally with cryoprecipitate or plasma. The risks of liver biopsy in this setting are relatively high: clinically significant hemorrhage followed 12.5% of the procedures.

Immune status of blood product recipients

Persons with hemophilia are at risk of the acquired immunodeficiency syndrome (AIDS), and clinically asymptomatic hemophiliacs have shown a high incidence of AIDS-like immune abnormalities, facts leading to speculation that many hemophiliacs have been exposed to the AIDS agent through their blood products. We therefore evaluated the immune status of three groups of blood product recipients without AIDS in New York City, including 47 persons with hemophilia A receiving factor VIII concentrate, 50 persons with homozygous beta-thalassemia, and 27 persons with sickle cell anemia receiving frozen-packed RBCs and 20 healthy persons who had not received a transfusion. Hemophiliac participants had significantly lower lymphocyte counts (median, 1,826/cu mm) than did the thalassemic (6,110/cu mm) or anemic (4,443/cu mm) participants, had lower numbers of T-helper lymphocytes (median, 533 cells/cu mm v 1,733 cells/cu mm and 1,554 cells/cu mm), and had a lower T-helper/suppressor ratio (median, 0.8 v 1.8 and 2.1). These differences remained after adjustment for age and sex. Thus, AIDS-like immune abnormalities were found in patients receiving factor concentrate, but not in those receiving RBCs. These defects could be due to both an immunosuppressive effect of the lyophilized factor itself and to contact with the AIDS agent.

Reversal of neutropenia with intravenous gammaglobulin in autoimmune neutropenia of infancy

Intravenous gammaglobulin (IVIgG) was used to treat autoimmune neutropenia of infancy in two males with repeated infections. The neutrophil count increased significantly in both patients with the initial IVIgG therapy; 1 patient went into remission. The neutrophil count in the other remained above baseline for 3 wk, and a subsequent booster infusion also caused the neutrophil count to increase. The patients have remained clinically well since their treatment began. Serial studies of antineutrophil antibody and serum lysozyme, performed to elucidate the mechanism of action, suggested decreased neutrophil destruction, perhaps by Fc receptor blockade, as well as decreased synthesis of antineutrophil antibody. Neutrophil function was not impaired after the neutrophil count increased. Many patients with immune neutropenia have a benign course, but those who have significant infections could be treated, acutely or prophylactically, with intravenous gammaglobulin.

Chelation therapy in beta-thalassemia major. III. The role of splenectomy in achieving iron balance

Transfusion requirements for 1978 were compiled for 79 patients with thalassemia major (ages 1 to 29 years) who were maintained at hemoglobin concentrations of greater than 10 gm/dl. In 46 patients with intact spleens, the mean transfusion requirement was 258 ml/kg/year, and there was a clear increase with age. The transfusion history prior to 1978 had no influence on the increase of transfusion requirement with age. In contrast, in 33 splenectomized patients, the mean transfusion requirement was 203 ml/kg/year and it did not increase with age. Urinary iron excretion in response to deferoxamine increased with age, with no obvious difference between splenectomized and nonsplenectomized patients. The ability to achieve iron balance with a daily dose of 20 mg/kg of deferoxamine was a function of the transfusion requirement splenectomized patients with lower blood requirements generally achieved negative iron balance, whereas nonsplenectomized patients did not. We conclude that the spleen should be removed when the transfusion requirement exceeds 250 ml/kg/year, which usually occurs between 6 and 8 years of age. In young patients with intact spleens, a higher dose of deferoxamine may be use in order to prevent hemosiderosis.