alternate use of deferiprone and desferrioxamine in primary school children with thalassaemia major

Correspondence

ALTERNATE USE OF DEFERIPRONE AND DESFERRIOXAMINE IN PRIMARY SCHOOL CHILDREN

WITH THALASSAEMIA MAJOR

A recent report from Wonke et al (1998) on the combinedtherapy with deferiprone and desferrioxamine (DFO) showedthe effectiveness of this regimen with a substantial fall inserum ferritin in all ®ve patients after 6±12 months. Oraldeferiprone therapy was given at a dose of 75±110 mg/kg/d,and subcutaneous infusions of DFO were added on 2±6 deach week.

Since the low compliance to DFO treatment remains themajor problem in the management of our transfusion-dependent thalassaemic children, we have been using aprotocol of alternate deferiprone and DFO. We describe ourexperience of treating seven transfusion-dependent thalas-saemic children (four girls and three boys), aged between 6and 13 years (mean 9´4 6 3´1 years) and previouslychelated by DFO alone. Deferiprone (Vitra Pharmaceuticals,U.K.) at a dose of 75 mg/kg/d was given for 4 schooldays perweek. The group used DFO at a dose 40±50 mg/kg s.c. overan 8±12 h infusion with battery-operated pump for 2 d atthe weekend. Intravenous DFO infusions (40±50 mg/kg)were continued to cover regular transfusions of packed redcells every 3±4 weeks. In addition to the safety variables, thepatients were monitored for serum ferritin levels and hepaticiron concentrations in liver tissues were determined at thebeginning and sixth month of the therapy (Robbins, 1988).The severity of hepatic damage was graded according to theKnodell hepatic activity index and the ®brosis was quanti®ed(Knodell et al, 1991).

It is particularly of interest that initial serum ferritinlevels and hepatic iron concentrations of all patients exceptone were considerably above the threshold associatedwith cardiac disease and early death in thalassaemiamajor (Olivieri et al, 1994; Brittenham et al, 1994).Although none of the patients had hepatitis C virus(serum HCV Ab, HCV RNA, liver tissue HCV Ag) and allhad seroconversion against hepatitis B virus at the time ofthe initial biopsy, the severity of hepatic ®brosis was grade 3in 4/7 patients and one patient (9 years old) was alreadycirrhotic (Table I). These ®gures remarkably indicated theinevitable result of the compliance problem with DFO in ourthalassaemics.

Compliance with alternate therapy was excellent in everypatient. The patients refusing DFO administration for 5±6 dweekly, readily accepted use of DFO on 2 d a week on analternate therapy protocol. In this way the patients used theoral iron chelator allowing a more acceptable iron chelationmethod and yet also had the bene®t of a well-known andeffective chelator, DFO.

At the sixth month of the therapy a non-signi®cant declinein serum ferritin was observed (P�0´08), a signi®cantreduction in hepatic iron concentration was also determined(P�0´03). Hepatic activity index in liver tissues of thepatients at the sixth month of the alternate therapysigni®cantly decreased (P�0´03), whereas ®brosis scoresdid not differ signi®cantly (P�0´25) (Table I).

British Journal of Haematology, 1999, 106, 252±262

252 q 1999 Blackwell Science Ltd

Table I. Changes in effectivity variables in the patients treated with the alternate therapy.

Initial Final

Age Tx* Ferritin Hep.Fe² Tx Ferritin Hep.FePatient (yr) (U) (mg/l) (mg/g) HAI³ Fibrosis (U) (mg/l) (mg/g) HAI Fibrosis

1 13 206 3950 19´2 8 1 223 2510 16´1 3 1

2 6 62 2190 15´0 3 1 72 2210 15´0 1 0

3 10 114 4710 28´5 18 3 131 3690 25´9 12 34 9 89 3030 35´1 17 4 99 2340 23´6 10 4

5 7 107 4290 26´6 14 3 119 4490 20´9 6 1

6 11 172 17220 42´4 4 3 189 8890 31´8 6 3

7 6 64 3360 18´5 12 3 74 2320 14´0 4 1Mean 9´4 116´3 5536 26´5 10´8 2´5 129´6 3778 21´0 6´0 1´8

6SD 3´1 54´3 5220 9´8 6´0 1´1 57´3 2412 6´5 3´8 1´4

* Represents the overall number of packed RBC units which had been transfused.² Hepatic iron (mg Fe/g of liver dry weight).

³ Knodell hepatic activity index.

In conclusion, deferiprone and DFO therapy on alternatedays may improve compliance with chelation therapy. Anegative iron balance can be achieved with this regimen andit may well be cost-effective. A larger prospective randomizedstudy evaluating this model over a longer period of timeseems necessary.

Department of Paediatric Haematology Y. AY D I N O K

Ege University Hospital, G. N I S L I

Bornova, Izmir, Turkey K. K AVA K L I

REFERENCES

Brittenham, G.M., Grif®th, P.M. & Nienhuis, A.W. (1994) Ef®cacy of

desferrioxamine in preventing complications of iron overload in

patients with thalassemia major. New England Journal of Medicine,331, 567±573.

Knodell, R.G., Ishak, K.G., Black, W.C., Chen, T.S., Craig, R.,

Kaplowitz, N., Kiernan, T.W. & Wollman, J. (1991) Formulation

and application of a numerical scoring system for assessing

histological activity in asymptomatic chronic active hepatitis.Hepatology, 13, 431±435.

Olivieri, N.F., Nathan, D.G., MacMillan, J.H., Wayne, A.S., Liu, P.P.,

McGee, A., Martin, M., Koren, G. & Cohen, A.R. (1994) Survival

in medically treated patients with homozygous beta-thalassemia.New England Journal of Medicine, 331, 574±578.

Robbins, D.A. (1988) Metals in Blood or Tissue. In: Methods for

Biological Monitoring. (ed. by T. J. Kreip and J. V. Crable), chapter118, pp. 223±227. American Public Health Association.

Wonke, B., Wright, C. & Hoffbrand, A.V. (1998) Combined therapy

with deferiprone and desferrioxamine. British Journal Haematology,

103, 361±364.

Keywords: deferiprone, desferrioxamine, hepatic ®brosis,hepatic iron, thalassaemia.

INFECTIOUS PURPURA FULMINANS: CAUTION NEEDED IN THE USE OF PROTEIN C

We disagree with the assertion by Smith & White (1999)that a randomized placebo-controlled trial of protein C inmeningococcal septicaemia would be impossible to perform.A large randomized study of the anti-lipopolysaccharideantibody HA1A was carried out between 1991 and 1995and recruitment to a large multicentre study of rBPI insevere meningococcaemia is currently nearing completion.

There is no question that such studies pose great logisticand ethical challenges. However, it would be unethical toembark upon general use of a new adjunctive treatmentbased on anecdotal experience alone, however compelling.Untested treatments may have unforeseen and signi®cantadverse effects (for example another recent study showedunexpected untoward effects of two anticoagulants usedtogether (The MAST-I Group, 1995)), can be very expensive,and may simply not work. Furthermore, as other treatmentsare developed, the safety and effectiveness of differentcombinations cannot be undertaken without a secureknowledge base.

We currently have very little understanding of whetherthe endothelial mechanisms required to activate protein Care intact in meningococcal disease. Without some informa-tion about this it is impossible to make a choice as to whetherwe should be assessing native protein C or the activated formfor therapy. Furthermore, a trial cannot be designed until wehave more data on the kinetics of protein C.

We agree with the ®nal assertion of Smith & White (1999)that the coordination of studies should be improved. It isonly by large-scale collaboration that we can progress. Anetwork which will aim to include all the units providingintensive care to children and young people in the UnitedKingdom is now being planned, and, as the Republic ofIreland is af¯icted with a similarly high incidence, centresthere may wish to participate as well. Its aims will be tofacilitate all multicentre clinical studies of the epidemiol-ogy, pathophysiology, treatment and prevention of thisinfection.

Shef®eld Institute for Vaccine Studies, A DA M F I N N

Division of Child Health,University of Shef®eld,Shef®eld Childrens Hospital,Shef®eld S10 2TH

Department of Paediatric Epidemiology RO B E RT B O OY

and Public Health,Institute of Child Health,London WC1N 1EH

Imperial College School of Medicine, M I C H A E L L E V I N

London W2 1PG S I M O N NA D E L

S AU L FAU S T

REFERENCES

Smith, O.P. & White, B. (1999) Infectious purpura fulminans:

diagnosis and treatment. British Journal of Haematology, 104,

202±207.The MAST-I (Multicentre Acute Stroke Trial±Italy) Group (1995)

Randomised controlled trial of streptokinase, aspirin, and

combination of both in treatment of acute ischaemic stroke.

Lancet, 346, 1509±1514.

We welcome the comments of Dr Finn and colleagues andbelieve they have raised a number of interesting points.Firstly, the assertion that a placebo-controlled randomizedtrial is required prior to the introduction of novel therapieshas its merits and supporters in the context of protein C (PC)replacement in severe purpura fulminans associated withmeningococcaemia. The major concern we have withthis argument is that it presupposes that the rapidsevere depletion of PC that is seen in patients withpurpura fulminans secondary to meningococcaemia isnot playing a pivotal role in the pathophysiology ofthe widespread microvascular thromboses that is the hall-mark of this disease. Also, we know that PC de®ciency is a

253Correspondence

q 1999 Blackwell Science Ltd, British Journal of Haematology 106: 252±262

well-recognized cause of purpura fulminans and that PCreplacement therapy has been shown to reverse thiscondition in other situations (Dreyfus et al, 1991).

Secondly, the reference by Finn et al to be potential hazardsassociated with the use of aspirin and heparin in ischaemicstroke may not be entirely appropriate. We believe that theconceptual difference between heparin and protein Creplacement in purpura fulminans and anti-platelet therapyplus heparin in ischaemic stroke, together with thedifferences in the pathophysiology of these two conditions,invalidates any meaningful comparison. However, althoughthe potential risks of haemorrhagic complications with theuse of heparin and protein C are low, we do advocateaggressive coagulation support with particular reference toplatelet count and ®brinogen level, as outlined in theAnnotation (Smith & White, 1999).

Thirdly, Finn et al state that there is insuf®cient data on PCkinetics to design a study on PC replacement therapy inmeningococcaemia. This is not correct. We have con-siderable data on the kinetics of PC replacement in thiscondition. A loading dose of 100 iu/kg followed by 10 iu/kg/h,with subsequent dose adjustments according to the levelof circulating protein C as measured by a clotting and orchromogenic assay, is a highly reliable regimen formaintaining protein C in the normal range.

Finally, the use of activated protein C (APC) may be morecomplicated than PC replacement. At present there isinsuf®cient data on the failure of mechanisms responsiblefor PC activation in meningococcaemia to justify the use ofAPC in meningococcaemia, given the increased potential forhaemorrhagic complications with this therapy. We knowthat PC is severely reduced in meningococcaemia associated

with purpura fulminans and is predictive of morbidity andmortality in this condition. We also know that PC de®ciencycauses purpura fulminans. Therefore, given our currentstate of knowledge, we believe that the primary aim shouldbe to normalize circulating PC levels with PC replacementtherapy.

We thank Finn et al for their comments. We do accept thatsome physicians will require a randomized trial prior to theuse of PC replacement therapy and this is clearly stated in theAnnotation. We welcome the development of a UnitedKingdom `network' to coordinate trials in meningococcae-mia and we would certainly make our data available to thisgroup.

National Centre for Inherited O W E N P. S M I T H

Coagulation Disorders, B A R RY W H I T E

National Childrens Hospital andSt James's Hospital,Dublin 8,Ireland

REFERENCES

Dreyfus, M., Magny, J.F., Bridey, F., Schwarz, H.P., Planche, C.,Dehan, M. & Tchernia, G. (1991) Treatment of homozygous

protein C de®ciency and neonatal purpura fulminans with a

puri®ed protein C concentrate. New England Journal of Medicine,

325, 1565±1568.Smith, O.P. & White, B. (1999) Infectious purpura fulminans:

diagnosis and treatment. British Journal of Haematology, 104,

202±207.

Keywords: infectious purpura fulminans, protein C, septi-caemia, wagnlapathy.

SUCCESSFUL USE OF RECOMBINANT FVIIa (NOVOSEVENÒ) IN THE MANAGEMENT OF PULMONARY

HAEMORRHAGE SECONDARY TO ASPERGILLUS INFECTION IN A PATIENT WITH LEUKAEMIA

AND ACQUIRED FVII DEFICIENCY

Haemorrhage is a well-described and frequently fatalcomplication of invasive pulmonary Aspergillus infection(Pagano et al, 1995). Standard treatment includes trans-fusion support, localization of the site of bleeding, andemergency surgical resection (Wex et al, 1993). A successfuloutcome, however, may be compromised by dif®culty inidentifying the site of bleeding and time delay to surgery. Wereport the successful use of recombinant FVIIa (NovosevenÒ)in the treatment of pulmonary haemorrhage secondary toAspergillus in a patient with acquired FVII de®ciencyundergoing treatment for acute myeloid leukaemia.

The patient initially presented with myelodysplasticsyndrome (French±American±British classi®cation (FAB):refractory anaemia). He failed to respond to two courses ofchemotherapy, which included daunorubicin, cytarabineand thioguanine, and remained pancytopenic. Two yearslater he developed acute myeloid leukaemia (FAB M2) andwas commenced on a chemotherapeutic regimen, whichincluded idarubicin (10 mg/m2 days 1±3), cytarabine (2 g/m2

days 1±5), ¯udarabine (25 mg/m2 days 1±5) and g-CSF400 mg/m2 (IDA-FLAG). At this stage a coagulation screenwas normal with a prothrombin time of 15 s (range 12±16 s). Three weeks after receiving chemotherapy he becamepersistently febrile and chest X-ray revealed multiplepulmonary in®ltrates. CT demonstrated multiple pulmonarylesions consistent with invasive Aspergillus infection. Hewas treated with 4 mg/kg of liposomal amphotericin(AmbisomeÒ). The following day he suffered from persistenthaemoptysis. The prothrombin time was prolonged at 19 s(reference 12±16 s) and activated partial thromboplastintime of 34 s (reference 23±36 s). Factor assay analysisrevealed an isolated low FVII of 35 iu/dl (normal range 70±120 iu/dl). The remaining vitamin K dependent coagulationfactors were normal: factor II was 56 iu/dl (range 0´5±1´5 iu/dl), factor V was 65 iu/dl (0´6±1´4 iu/dl) and factor Xwas 56 iu/dl (0´5±1´5 iu/dl). No inhibitor to FVII was detectedby serial dilutions or correction studies. The patient received2 ´ 90 mg/kg doses of Novoseven (recombinant VIIa) 2 h apart,

254 Correspondence


with immediate resolution of haemoptysis. The same dose ofNovoseven was repeated the following day and there was nofurther pulmonary haemorrhage. Infusion of Novoseven wasassociated with a reduction in prothrombin time at 30 minpost infusion, from 19 s to a mean value 6 standard deviationof 8´9 6 0´14 s. After 8 weeks of anti-fungal therapy thelesions had almost completely resolved, the repeat coagulationscreen was normal, and FVII level was 89 iu/dl. The patient'smarrow had reverted to the appearances of myelodysplasticsyndrome.

A transient isolated de®ciency of FVII is uncommon buthas been described in association with infection (Biron et al,1997), malignancy (Slease & Schumacher, 1977; deRaucourt et al, 1994) and aplastic anaemia (Weisdorf et al,1989). Although it is possible that the acquired FVIIde®ciency detected in the above patient was related to thedevelopment of acute leukaemia or myelodysplasia, webelieve that it is unlikely given the fact that the prothrombintime was normal after the onset of both these conditions.Moreover the normal levels of other vitamin K dependentfactors and the absence of liver dysfunction suggest that thereduction in FVII was not due to vitamin K de®ciency orliver disease respectively. The development of FVII de®ciencymay, however, relate to Aspergillus infection as it wasdetected at the onset of clinical symptoms and correctedwith resolution of infection. The pathophysiologicalmechanism by which fungal infection could result in FVIIde®ciency is unclear. Aspergillus spp. are known to produceproteolytic enzymes and one such enzyme has been shownto result in the proteolytic cleavage of ®brinogen (McClellanet al, 1985). The release of similar proteolytic enzymes fromthe Aspergillus organism may have been responsible for thedevelopment of FVII de®ciency in this case.

Novoseven was used to treat the patient because itcorrected the factor de®ciency with a recombinant productand provided site speci®c thrombin generation by enhan-cing tissue factor (TF):FVIIa assembly at the site of bleeding.As far as we can ascertain, this is the ®rst reported case ofthe use of FVIIa in pulmonary haemorrhage secondary toAspergillus infection. We believe that Novoseven may have arole in either treating pulmonary haemorrhage associatedwith Aspergillus infection or alternatively as an adjunctive

therapy to control bleeding pending emergency surgicalintervention. Further clinical data, however, are required tojustify the widespread use of Novoseven in this situation.

Department of Haematology, B. W H I T E

St James's Hospital, Dublin, M. M A RT I N

and Trinity College Dublin, S. K E L L E H E R

Ireland P. B RO W N E

S. R. M C C A N N

O. P. S M I T H

REFERENCES

Biron, C., Bengler, C., Gris, J.C. & Schved, J.F. (1997) Acquired isolated

factor VII de®ciency during sepsis. Haemostasis, 27, 51±56.

de Raucourt, E., Dumont, M.D., Tourani, J.M., Hubsch, J.P., Riquet,

M. & Fischer, A.M. (1994) Acquired factor VII de®ciencyassociated with pleural liposarcoma. Blood Coagulation and

Fibrinolysis, 5, 833±836.

McClellan, S.L., Komorowski, R.A., Farmer, S.G., Hussey, C.V.,Kauffman, H.M.J. & Adams, M.B. (1985) Severe bleeding diathesis

associated with invasive aspergillosis in transplant patients.

Transplantation, 39, 406±410.

Pagano, L., Ricci, P., Nosari, A., Tonso, A., Buelli, M., Montillo, M.,Cudillo, L., Cenacchi, A., Savignana, C. & Melillo, L. (1995) Fatal

haemoptysis in pulmonary ®lamentous mycosis: an undereval-

uated cause of death in patients with acute leukaemia in

haematological complete remission: a retrospective study andreview of the literature. Gimema Infection Program (Gruppo

Italiano Malattie Ematologiche dell'Adulto). British Journal of

Haematology, 89, 500±505.Slease, R.B. & Schumacher, H.R. (1977) De®ciency of coagulation

factors VII and XII in a patient with Hodgkin's disease. Archives of

Internal Medicine, 137, 1633±1635.

Weisdorf, D., Hasegawa, D. & Fair, D.S. (1989) Acquired factor VIIde®ciency associated with aplastic anaemia: correction with bone

marrow transplantation. British Journal of Haematology, 71, 409±

413.

Wex, P., Utta, E. & Drozdz, W. (1993) Surgical treatment ofpulmonary and pleuro-pulmonary Aspergillus disease. Thoracic

and Cardiovascular Surgery, 41, 64±70.

Keywords: recombinant FVIIa, haemorrhage, Aspergillus,leukaemia.

PREVENTION OF VITAMIN K DEFICIENCY IN NEWBORNS

In his review of the neonatal use of vitamin K, Zipursky(1999) argues for clinicians in Europe to return to the samepolicy of comprehensive intramuscular prophylaxis that isstill in use in North America, but I fear the analysis is ¯awed.Professor Zipursky is right to say `that there is no proven riskof cancer/leukaemia associated with the [intramuscular]administration of vitamin K at birth,' but saying thereis no proof of a link is not the same thing as showing thatno link exists. Five case±control studies were undertaken inan attempt to replicate the ®rst study suggesting thatintramuscular prophylaxis might be associated with a

higher incidence of cancer. None found a statisticallyraised odds ratio, but all found 20±50% more cases ofacute lymphoblastic leukaemia in children given 1 mg i.m.vitamin K at birth (Passmore et al, 1998). The result ofthe meta-analysis of these studies commissioned by theDepartment of Health in the U.K. more than 18 months agois still awaited but, given that childhood cancer isrelatively common whereas dangerous late vitamin Kde®ciency bleeding is now very uncommon, even a 10%increase in the incidence of childhood cancer, were itgenuine, might easily result in a policy of universal

255Correspondence


intramuscular prophylasix doing more harm than good(Passmore et al, 1998).

Parents have a right to know that later childhood cancer iscommoner in babies given a large pharmacological dose ofvitamin K at birth, and that we do not know why. It is ofcourse true that the 20±30% of babies given vitamin K inthese studies differed from those not so treated (the mainground for selective prophylaxis in all these studies beingpreterm, operative or `traumatic' delivery) and that theobserved association may not be causal. However, it isextremely unlikely that the controlled trial that should havebeen done before routine prophylaxis ®rst became common-place will be carried out. Uncertainty will therefore persist(Tripp & McNinch, 1998).

How should we respond to this dilemma? The concept of`early' haemorrhagic disease is a dogma that has never beencritically examined (Hey, 1999), but is probably only an issuein mothers taking some of the more rarely used anti-epilepticdrugs, while `classic' disease at 2±5 d is easily recognized,rarely dangerous and extremely uncommon in the arti®ciallyfed baby. The main hazard is the risk of potentially disablingor lethal bleeding due to `late' vitamin K de®ciency 2±12weeks after birth. This is only seen in the exclusively breast-fed baby, and made more likely by the presence of occult liverdisease. Contrary to what Professor Zipursky writes, there isevidence that this risk can be abolished by a policy of oralprophylaxis that replicates what is achieved by using asupplemented arti®cial formula milk. No case of late bleedinghas been seen among the 300 000 births in Denmark sincea policy of repeat high dose, parent-administered, oralprophylaxis was ®rst launched in 1993 (Nùrgaard Hansen& Ebbesen, 1996, and personal communication). Oralprophylaxis is at risk of being discredited merely becausethe dose and, more importantly, the dose frequency used inthe early studies was inappropriate.

There can be no justi®cation for continuing to recommendroutine intramuscular prophylaxis to all otherwise healthyarti®cially fed babies at birth when we still have noexplanation for the excess of cancer or leukaemia seen inevery one of the six carefully conducted case-controlledstudies, and no good reason for not allowing mothers whoare breast feeding a choice between intramuscular andregular oral prophylaxis.

51 Alwinton Terrace, E D M U N D H E Y

Newcastle upon Tyne NE3 1UD

REFERENCES

Hey, E. (1999) The effect of maternal anticonvulsant treatment on

neonatal blood coagulation status. Archives of Disease in Childhood,

80, (in press).

Nùrgaard Hansen, K. & Ebbesen, R. (1996) Neonatal vitamin Kprophylaxis in Denmark: three years' experience with oral

administration during the ®rst three months of life compared with

one oral administration at birth. Acta Paediatrica, 85, 1137±1139.

Passmore, S.J., Draper, G., Brownbill, P. & Kroll, M. (1998) Case±

control studies of relation between childhood cancer and neonatal

vitamin K administration. British Medical Journal, 316, 178±184.

Zipursky, A. (1999) Prevention of vitamin K de®ciency bleeding innewborns. British Journal of Haematology, 104, 430±437.

In his letter Dr Hey raises a very important issue, namely theneed to evaluate the risks and bene®ts of therapy. He believesthat intramuscular vitamin K prophylaxis in newborns islikely to cause harm by predisposing to the development ofcancer/leukaemia, a risk which he considers greater thanthe bene®t of preventing haemorrhagic disease of thenewborn (HDN).

In my review I carefully examined the studies of vitamin Ktherapy and the development of cancer/leukaemia andreached a conclusion that `there is no proven risk ofcancer/leukaemia associated with the intramuscular admin-istration of vitamin K at birth.' In his letter Dr Hey states thathe agrees with that conclusion; however, he feels that a riskmay still exist!

No proven evidence that vitamin K is harmful must beweighed against concrete proof that HDN will occur ifvitamin K is not given, or if oral vitamin K is substituted forintramuscular vitamin K at birth. Dr Hey does not agreewith that conclusion, citing one study of 300 000 childrengiven weekly doses of vitamin K during the ®rst 3 months oflife. No cases of HDN occurred, and he concludes that oraltherapy could substitute for a single intramuscular injectionat birth. There are two fallacies in that reasoning. The ®rst isthat a programme relying on oral therapy does not preventall cases of HDN. In my review I discussed the results of ®vestudies which included more than 2 000 000 children givenrepeated oral doses of vitamin K, which showed that none ofthe regimens failed to prevent all cases of HDN. The seconderror of reasoning is the belief that repeated doses of vitaminK given orally are safer than a single dose given intramus-cularly at birth. There is no evidence for that dangerousassumption. Indeed, it is very likely that the levels of vitaminK achieved by repeated oral doses of vitamin K will besubstantially higher during the ®rst 3 months of life thanthose following neonatal i.m. injection. Is repeated dosage ofvitamin K for 3 months really safe?

A major criticism of routine injections is that they areinvasive, painful and unnatural. I share that concern;however, routine injections have prevented and evenerased diseases such as measles, polio and smallpox.Haemorrhagic disease of the newborn deserves to beprevented as well.

Professor Emeritus, A LV I N Z I P U R S K Y

University of Toronto

Keywords: vitamin K, haemorrhagic disease of the newborn.

256 Correspondence


AUTOMATED MALARIA DETECTION

The interesting article by Mendelow et al (1999) describes ablood-cell-analyser, Cell-Dyn 3500 (CD3500), that detectsbirefringent malaria pigment as a means for malariadiagnosis. Unfortunately the reference methods are poorlyde®ned: the number of microscopic ®elds examined wasnot given (standard should be >200 in a thick blood®lm) and the important limitations of the immuno-cromatographic Parasight-FÒ test were not mentioned. Thetest detects Histidine-Rich-Protein 2, which is only present inP. falciparum infections. It can remain in the circulation ofcured patients for up to 2±3 weeks, causing persistent false-positive results (Mharakurwa & Shiff, 1997). Rheumatoidfactor might also cause false positives. Regarding pigment-containing white blood cells (WBC), they have been shownto persist for up to several weeks in the circulation (Metzgeret al, 1995; Day et al, 1996). We have seen some cases ofCD3500 positives, in clinically and parasitologically curedpatients, who had had malaria 2±3 weeks before. Theauthors counted nine microscopically negative but CD3500and Parasight-F positive cases (cured?) as `true' positives.This has implications for the calculated sensitivity/speci®cityand raises questions about the authors' de®nition of malariadiagnosis. Foremost, any test has to detect the clinicallyacute malaria case. Usually after a few days of treatment thepatients are clinically and parasitologically cured. So what isthe clinical importance of a test that remains positive at sucha stage? If the Parasight-F (and it seems the CD3500) remainpositive after cure, they are of little use in immediate follow-up (Mharakurwa & Shiff, 1997). The clinical value of suchpersistent `false' positivity lies only in the retrospectivecon®rmation of a previous malaria case. Contrary to this, theauthors gave no explanation for the other ®ve (`genuine')false positives. Could they have been undiagnosed but treatedmalaria cases? Or what other reasons could there be for suchchanges in the CD3500 plots?

It seems unlikely that the CD3500 detects gametocytes orschizonts. We have observed cases of treated patients with only(but many) gametocytes. The CD3500 showed only minorabnormalities. Similarly, a case with cerebral malaria hadmany schizonts, but showed few changes in the instrumentalplot. We ®nd that the CD3500 plots seem to correlate well withthe amount of pigment-containing WBC seen upon micro-scopy. The markedly different size and structure of gametocytesand schizonts as opposed to WBC makes it unlikely that theinstrument's algorithm allows their detection.

The low sensitivity in the white population (43%) could beexplained, arguing that this group was less immune anddeveloped symptoms earlier during infection. Obviously theywould then have less parasites and consequently lesspigment, which could be ingested by WBC.

We are sceptical about the authors' claim that `automatedfull blood count (FBC) technology is available in many partsof Africa'. In most (holo- and hyper-) endemic countrieshealth-budgets of a few US$ per capita are a sad reality andeven simple microscopy is often not available (Foster &Phillips, 1998), let alone automated FBC.

Further studies in various endemic and non-endemicareas have to con®rm the usefulness of this new approach,especially in the light of the kinetics of pigment-containingWBC. Further consideration to the other non-P. falciparumspecies has to be given.

Laboratory of Haematology, Piso 7, T H O M A S H AÈ N S C H E I D

University Hospital Santa Maria,Av. Prof. Egas Moniz,1699 Lisboa Codex,Portugal

Infectious and Tropical Diseases, E M I L I A VA L A DA S

London School of Hygiene andTropical Medicine,

Keppel Street,London WC1E 7HT, U.K.

REFERENCES

Day, N.P.J., Diep, P.T., Ly, P.T., Sinh, D.X., Loc, P.P., Chuong, L.V.,

Chau, T.T.H., Main, N.T.H., Bethell, D.B., Phu, N.H., Hien, T.T. &White, N.J. (1996) Clearance kinetics of parasites and pigment-

containing leukocytes in severe malaria. Blood, 88, 4694±4700.

Foster, S. & Phillips, M. (1998) Economics and its contribution to the

®ght against malaria. Annals of Tropical Medicine and Parasitology,92, 391±398.

Mendelow, B.V., Lyons, C., Nhlangothi, P., Tana, M., Munster, M.,

Wypkema, E., Liebowitz, L., Marshall, L., Scott, S. & Coetzer, T.L.

(1999) Automated malaria detection by depolarization of laserlight. British Journal of Haematology, 104, 499±503.

Metzger, W.G., MordmuÈ ller, B.G. & Kremsner, P.G. (1995) Malaria

pigment in leukocytes. Transactions of the Royal Society of TropicalMedicine and Hygiene, 89, 637±638.

Mharakurwa, S. & Shiff, C.J. (1997) Post treatment sensitivity

studies with the Parasight-F test for malaria diagnosis in

Zimbabwe. Acta Tropica, 66, 61±67.

We agree with most of the points raised by Drs HaÈnscheidand Valadas.

Regarding the reference methods, details of standardprocedures were omitted in the interest of brevity, as themain substance of the paper dealt with the white cellpigment method (Mendelow et al, 1999). To answer thequestion, thick ®lms were examined in their entirety beforebeing designated negative. The ability of Para-sight F todetect convalescent malaria is, of course, well known.

We ®nd the comments on gametocytes and schizontsuseful as we were unable on our data to exclude these aspossible contributors towards abnormal white cell distribu-tion pro®les encountered in malaria.

On the low sensitivity in white patients, we stated in thepaper that `previous exposure or varied patterns ofpresentation could account for some of the differencesfound'. We are thus in agreement with Drs HaÈnscheid andValadas on this point as well.

With regard to the distribution of automated FBC countersin Africa we agree that in most holo- and hyper-endemic

257Correspondence


areas such technology is scarce. In these areas, however,malaria is not likely to be overlooked as a possible cause ofsymptoms. In contrast, in other areas, where the index ofsuspicion is lower, the availability of automated counters ismuch higher. In South Africa, for example, there arehundreds of laboratories equipped with automated counters.

Finally, we of course agree that the instrument detectsconvalescent as well as active malaria. Both the Materialsand Methods and the Results sections of our paper spelt thisout explicitly. It may well also be that some or all of the ®vecases assigned to the false positive category could have beenundiagnosed or convalescent malaria patients, but we wereunable to document this.

With regard to the speci®city and sensitivity ®gures,whether the truth is de®ned as acute malaria or combinedacute and convalescent malaria, it is clear that the methodcannot be regarded as an alternative to existing methods ofmalaria diagnosis or monitoring, and once again this pointwas explicitly stressed, this time in the Discussion. It was andremains our conclusion that the main utility of our studywas that it drew attention to the potential to make anunexpected diagnosis of active malaria as part of a screeningFBC, in some cases. We are of the opinion that in such cases

the exercise could well be life-saving, especially as white cellpigment has been associated with adverse prognosis. If theprice to be paid for this unexpected bonus is that somepractitioners are alerted by the laboratory to a convalescentstate of which they are already aware, we do not believe thisprice to be excessive.

Department of Haematology, B A R RY V. M E N D E L O W

School of Pathology, T H E R E S A L. C O E T Z E R

Medical School,York Road,Parktown 2193,South Africa

REFERENCE

Mendelow, B.V., Lyons, C., Nhlangothi, P., Tana, M., Munster, M.,Wypkema, E., Liebowitz, L., Marshall, L., Scott, S. & Coetzer, T.L.

(1999) Automated malaria detection by depolarization of laser

light. British Journal of Haematology, 104, 499±503.

Keywords: malaria, pigment-containing white cells, laserlight depolarization, full blood count.

FATAL FRESH FROZEN PLASMA INFUSION CONTAINING HPA-1a ALLOANTIBODIES

Fetal/neonatal alloimmune thrombocytopenia (NAIT) andpost-transfusion purpura are well-known manifestations ofplatelet alloantibodies, most often directed against humanplatelet antigen 1a (HPA-1a) (for review see Nugent, 1992).In case of post-transfusion purpura, alloantibodies cross-react with HPA-1a-negative platelets of a transfusionrecipient who has become sensitized either by pregnancyor blood products containing HPA-1a-positive platelets.Another (rare) type of transfusion-associated alloimmunethrombocytopenia results from passive transfer of plateletalloantibodies.

We report a 73-year-old woman with fatal intracranialbleeding following neurosurgery due to acute thrombocyto-penia after infusion of single-donor fresh frozen plasmacontaining HPA-1a-alloantibodies. The patient, with a 2-year-history of progressive cognitive deterioration and left-sided hemiparesis, was admitted to our hospital when acranial computed tomography (CT) had revealed a largeright-sided frontal, heavily vascularized tumour (maximumdiameter 8 cm) suggesting a meningioma. The tumour wassuccessfully removed but marked intraoperative bleedingnecessitated transfusion of packed red blood cells (RBC).Immediately after the operation the patient was extubated.Haemoglobin was 8´9 g/dl, platelet count 96 ´ 109/l andprothrombin time 19´8 s (normal range 10±14´6 s; normalvalues before intervention). Two units of fresh frozenplasma (FFP) from whole blood donations were adminis-tered. Half an hour after the second unit was started thepatient began to shiver and hypertension (blood pressure205/70 mmHg), tachycardia (pulse rate 118/min) and ageneralized exanthema developed. Transfusion of FFP was

stopped (after 200 ml) and antihistaminic drugs weregiven. Petechial haemorrhages and macrohaematuriaappeared and the patient became comatose. Laboratoryreevaluation indicated severe thrombocytopenia (plt7 ´ 109/l; 1 h later 2 ´ 109/l) without evidence of dissemi-nated intravascular coagulation (PT 16´8 s, aPTT 38´6 s[normal range 25±36 s], thrombin time 12´2 s [normalrange 11´5±15 s], ®brinogen 2´0 g/l [normal range 1´5±3´0 g/l] ). Cranial CT scan showed a massive haemorrhageinto the cavity of the tumour resection with secondarycentral herniation and subdural, epidural and subgalealbleedings. Emergency craniotomy was performed and thehaematoma was evacuated. Perioperatively, 30 unitsplatelet concentrates (0´5 ´ 1011 plt/U), 6 units FFP and5 units RBC were transfused. Postoperatively, plateletsremained between 70 and 100 ´ 109/l and normalizedlater. However, the patient remained deeply comatose anddied 6 d later.

Analysis of the remaining FFP by monoclonal antibody-speci®c immobilization of platelet antigens assay (MAIPA)(Kiefel et al, 1987) revealed a platelet alloantibody directedagainst glycoprotein IIb/IIIa with speci®city for HPA-1a(�PLA1). No HLA antibodies or platelet alloantibodies ofother speci®city were found. In the blood drawn from thepatient the day after the transfusions neither circulating norbound platelet antibodies were detectable; platelets weretyped as HPA-1a-positive and showed reactivity whenincubated with the FFP.

The donor of the FFP was a 59-year-old woman who haddonated blood about 65 times. She had given birth to threehealthy children but had experienced one miscarriage in the

258 Correspondence


second trimester. She had never received blood products. Herplatetets were typed as HPA-1b/1b (�PLA2) and HPA-5a/5a(�Brb), whereas her husband was HPA-1a/1a and HPA-5a/5a (con®rmed by PCR). Her serum reacted with platelets ofher husband but not with platelets of her own nor withHPA-1a-negative control platelets. Testing serum dilutionsyielded an HPA-1a-antibody titre as assessed by MAIPA of1:8. Since 1995, 3 units FFP from this donor had beentransfused to three patients in our hospital. Bleedingcomplications along with thrombocytopenia were docu-mented in two of them: postoperative blood loss of 3 litresafter aortic valve replacement and development of twolarge haematomas after plastic surgery, respectively. Theminimal platelet counts in the two patients were 16 ´ 109/lat about 6 h and 6 ´ 109/l at about 4 h after transfusion ofthe incriminated FFP, respectively. Surprisingly, the treatingphysicians judged the thrombocytopenia in each case asa consequence rather than the cause of excessivebleeding.

To our knowledge, this is the ®rst report of a fatalcomplication due to transfusion of FFP containing HPA-1a-antibodies into an HPA-1a-positive patient (98% of thepopulation). The recipient died despite immediate transfu-sion of random donor platelets which is the most effectivetherapeutic measure leading to rapid absorption of free HPA-1a-alloantibodies (Brunner-Bolliger et al, 1997) unless HPA-1b/1b-platelets are available. Three of the nine patientsdescribed in the literature so far (Table I) were observed inour hospital, suggesting considerable under-reporting.This may be related to the fact that in the operativesetting, where FFP is used most often, thrombocytopenia isusually attributed to other causes, such as blood loss,dilution and/or consumption. Furthermore, consecutivetransfusions of random donor platelets may partly offsetsevere adverse events in the majority of the cases. However,to prevent morbidity and mortality of plasma-containingblood products from single donors, screening for plateletalloantibodies in female donors at risk (past history of NAIT,miscarriage in the second or third trimester or stillbirth

as possible consequences of fetal alloimmune thrombo-cytopenia) should be considered.

ACKNOWLEDGMENT

The authors thank Dr CeÂcile Kaplan, Paris, for performingplatelet typing by PCR.1Department of Haematology, M. S O L E N T H A L E R

1

2Department of Neurosurgery, J. K. K R AU S S2

3Department of Anaesthesiology F. B O E H L E N4

and Intensive Care, R. KO L L E R3

University Hospital Bern, and M. H U G3

4Department of Haematology, B. L AÈ M M L E1

University Hospital Geneva,Switzerland

REFERENCES

Ballem, P.J., Buskard, N.A., Decary, F. & Doubroff, P. (1987) Post-transfusion purpura secondary to passive transfer of anti-PlA1 by

blood transfusion. British Journal of Haematology, 66, 113±114.

Brunner-Bolliger, S., Kiefel, V., Horber, F.F., Nydegger, U.E. &

Berchtold, P. (1997) Antibody studies in a patient with acutethrombocytopenia following infusion of plasma containing anti-

PlA1. American Journal of Hematology, 56, 119±121.

Kiefel, V., Santoso, S., Weisheit, M. & Mueller-Eckhardt, C. (1987)

Monoclonal antibody-speci®c immobilization of platelet antigens(MAIPA): a new tool for the identi®cation of platelet-reactive

antibodies. Blood, 70, 1722±1726

Nijjar, T.S., Bonacosa, I.A. & Israels, L.G. (1987) Severe acute

thrombocytopenia following infusion of plasma containing antiPlA1. American Journal of Hematology, 25, 219±221.

Nugent, D.J. (1992) Alloimmunization to platelet antigens. Seminars

in Hematology, 29, 83±88.Scott, E.P., Moilan-Bergeland, J. & Dalmasso, A.P. (1988) Posttrans-

fusion thrombocytopenia associated with passive transfusion of a

platelet-speci®c antibody. Transfusion, 28, 73±76.

Keywords: alloimmune thrombocytopenia, fresh frozenplasma, PlA1, HPA-1a.

259Correspondence


Table I. Summary of reported transfusion-induced alloimmune thrombocytopenias resulting from anti-HPA-1a alloantibodies.

Patient Plt before/after (nadir) Time to reaction Blood Donor(age/sex) transfusion (bleeding/plt decrease) product (all females)

73 years/f 96 ´ 109/l ! 2 ´ 109/l 1 h* FFP One miscarriage (this case)

79 years/m 135 ´ 109/l ! 5 ´ 109/l 12 h RBC Three miscarriages (Ballem et al 1987)

18 years/f 216 ´ 109/l ! 5 ´ 109/l 5 h FFP Three miscarriages (Nijjar et al, 1987)76 years/m 193 ´ 109/l ! 11 ´ 109/l Immediately* WB One stillbirth (Scott et al, 1988)

70 years/f 237 ´ 109/l ! 20 ´ 109/l 1´5 h RBC One stillbirth (Scott et al, 1988)

17 months/n.r. 630 ´ 109/l ! 11 ´ 109/l First postoperative day WB One stillbirth (Scott et al, 1988)

25 years/f n.r. ! 8 ´ 109/l Immediately* WB One stillbirth (Scott et al, 1988)55 years/m 241 ´ 109/l ! 1 ´ 109/l 2 h FFP Four miscarriages (Brunner-Bolliger et al, 1997)

n.r./f 284 ´ 109/l ! 6 ´ 109/l 4 h FFP Four miscarriages (Brunner-Bolliger et al, 1997)

Plt, platelet count; FFP, fresh frozen plasma; WB, whole blood; RBC, packed red blood cells; n.r., not reported.

* Acute transfusion reaction.

MONITORING ERYTHROPOIETIN ABUSE IN ATHLETES

Recombinant human erythropoietin (rEpo) is used by someathletes to increase oxygen transport and as an arti®cialperformance enhancer. Although rEpo is on the list ofbanned substances issued by the medical commission of theInternational Olympic Committee, the analytical techniquescurrently available are inadequate to detect its use as anergogenic agent. In fact, although the plasma half-life of rEpovaries between 4 and 12 h (Fried et al, 1970), a signi®cantincrease in blood haematocrit occurs several days aftertreatment. In other words, the erythropoietic effect becomesevident when rEpo is no longer detectable in circulation. Inan attempt to overcome these limitations, Gareau et al(1996) have suggested the use of the ratio between theconcentration of the soluble transferrin receptor (sTfr, amarker for erythroid activity) and the concentration ofserum ferritin (fr, a measure of the stores of iron in the body).This approach is particularly interesting because in principleit does not depend on body hydration (as does thehaematocrit) and could reveal rEpo abuse as well as othermanoeuvres that accelerate erythropoiesis. In a subsequentpaper, Bressolle et al (1997) used population pharmacody-namic studies to identify threshold values for the sTfr andsTfr/fr ratio indicative of rEpo doping, with a probability oferror <1%. Since several anti-doping commissions aroundthe world are considering the introduction of these analysesto detect rEpo misuse, we repeated the experiments ofGareau et al (1996) in ®ve athletes (group A: 200 U/kg ofrEpo) and compared the results with those obtained in asecond group (group B: 200 U/kg of rEpo, ®ve athletes) alsoreceiving iron, folic acid and vitamin B12 supplementation.A third group (group C, eight athletes) received 30 U/kg of

rEpo three times per week for a total of 12 administrationsinstead of the ®ve high doses used for groups A and B. Therationale for comparing the results of group A with dataobtained from groups B and C was based on the observationthat functional iron de®ciency commonly occurs in patientsreceiving rEpo and that low doses of this hormone threetimes per week are preferable for a signi®cant rEpo response(Spivak, 1994). In our studies all three treatments provideda similar haematocrit increase (mean value 3´29 6 0´74%)without signi®cant differences (by ANOVA test) among thethree groups at any of the time points considered. Incontrast, when the sTfr/fr ratio was investigated (Fig 1) thesame behaviour reported by Gareau et al (1996) wasobserved for group A but was signi®cantly different ingroups B and C. Statistical treatment of the data revealedthat in group A the sTfr/fr ratio was signi®cantly differentfrom the value obtained before rEpo administration at everytime from day 2 to day 31 (P <0´01). In group B the datawere signi®cantly different from those observed at time zeroonly between days 4 and 24 (P <0´01); in group C, only thevalues measured at days 18 and 24 were signi®cantlydifferent from the value at time zero (P <0´01). Further-more, in group C the sTfr/fr ratio was always lower thanthe threshold value of 403 established by Bressolle et al(1997) as signi®cant for the intake of rEpo. Thus, ourresults con®rmed the conclusions of Gareau et al (1996)only when rEpo is administered at repeated high doses andwithout iron supplementation. In contrast, when rEpo isadministered at low doses and/or associated with an ironsupplement as clinical practice suggests (Spivak, 1994), thesTfr and sTfr/fr ratio cannot be considered predictive of rEpomisuse. It is worth noting that during these studies wefound that although the concentration of immunoreactivesTfr in the plasma increased to a maximum value 5 timesgreater than the basal values, Tfr mRNA expression(detected by RT-PCR) increased up to 40 times. Thesedata suggest that it will be possible in the near future toextend the observations of Gareau et al (1996) by analysingexpression of selected erythroid gene markers to detect rEpoabuse in athletes.

Institute of Biological Chemistry M AU RO M A G N A N I

`G. Fornaini', DA R I O C O R S I

University of Urbino, M A R Z I A B I A N C H I

61029 Urbino, Italy M I R KO PA I A R D I N I

L U C A G A L L U Z Z I

University Institute for Motor Sciences, AT T I L I O PA R I S I

00194 Rome, Italy FA B I O P I G O Z Z I

REFERENCES

Bressolle, F., Audran, M., Guidicelli, C., Gareau, R., Baynes, R.D.

& Gomeni, R. (1997) Population pharmacodynamics for

monitoring epoetin abuse in athletes. Clinical Drug Investigation,14, 233±242.

260 Correspondence


Fig 1. Soluble transferrin receptor/ferritin ratio in the blood of

healthy trained adult males receiving ®ve subcutaneous injections

(200 U/kg) at days 0, 2, 4, 8 and 10 (group A, B; group B, X) or 12

injections (30 U/kg) at days 0, 2, 4, 8, 10, 12, 14, 16, 18, 21, 24 and28 (group C, O) of recombinant human erythropoietin. Groups B

and C also received intravenous injections of folic acid (25 mg;

Lederfolin 25), iron (25 mg; Ferlixit) and vitamin B12 (2500 mg;

Epargriseovit) at days 0, 4, 8, 12, 16, 21, 24 and 28. Values aremeans 6 SE.

Fried, W., Johnson, C. & Heller, P. (1970) Observations on regulation

of erythropoiesis during prolonged periods of hypoxia. Blood, 36,

607±616.

Gareau, R., Audran, M., Baynes, R.D., Flowers, C.H., Duvallet, A.,Senecal, L. & Brisson, G.R. (1996) Erythropoietin abuse in

athletes. Nature, 380, 113.

Spivak, J.L. (1994) Recombinant human erythropoietin and the

anemia of cancer. Blood, 84, 997±1004.

Keywords: erythropoietin abuse, athletes.

AUTOIMMUNE THROMBOCYTOPENIA AFTER TREATMENT WITH CAMPATH 1H

IN A PATIENT WITH CHRONIC LYMPHOCYTIC LEUKAEMIA

Campath 1H is a humanized monoclonal antibody (class G1)directed against CD52, an antigen present on the vastmajority of all human lymphocytes but not expressed onneutrophils or platelets. The role of Campath 1H in thetreatment of (chronic lymphocytic leukaemia (CLL) has beenevaluated in patients who have had multiple previoustherapies, and it has also proved to be very active in the®rst-line treatment of the disease. We describe a patient whoachieved a good partial response to Campath 1H butsubsequently developed severe refractory thrombocytopenia.

A 49-year-old man was diagnosed as suffering from B-cellCLL in July 1996. The white cell count at presentationwas 49 ´ 109/l, haemoglobin 15´2 g/dl and platelets,239 ´ 109/l. In addition he had previously been diagnosedas having rheumatoid arthritis (RA) for which he hadreceived non-steroidal anti-in¯ammatory agents.

Treatment for CLL was initiated in July 1997 followingevidence of disease progression with a rapid doubling time.First-line therapy was chlorambucil 10 mg/d for 28 d. Therewas little response in either the lymphadenopathy or whitecell count and the treatment was changed to single-agent¯udarabine, given as a 5 d course of 25 mg/m2/d intra-venously, every 28 d. Due to an exacerbation of symptomsrelated to his RA and in the face of disappointing results from¯udarabine therapy, which produced no reduction in hisdisease, treatment was stopped after two cycles. Disease-modifying agents for the RA were indicated and a regime ofweekly oral methotrexate, oral sulphasalazine and pulsedintravenous methylprednisolone was started.

By June 1998 his RA was relatively quiescent but thewhite cell count had risen to 181 ´ 109/l with fallinghaemoglobin and platelet counts. Further treatment forCLL was required. Campath 1H was given on a dose-escalating regime of 3 mg intravenously on day 1, 10 mg onday 2, and 30 mg on day 3. Treatment continued thriceweekly at a dost of 30 mg intravenously, for a total of sevendoses. He suffered major morbidity from serum sicknessdespite premedications with chlorpheniramine and para-cetamol, and subsequently the subcutaneous route wasused; this was better tolerated and treatment continuedthrice weekly for a total of 22 doses. A break from therapywas necessitated by an episode of line-associated sepsis,which required admission for antibiotics and line removal.

Coincident with the end of treatment an abrupt fall in theplatelet count was noted. Bone marrow aspirate andtrephine biopsies were performed and showed only nodularresidual CLL and plentiful megakaryocytes, suggestive ofperipheral platelet destruction. Sulphasalazine was

discontinued and due to the development of troublesomebleeding, platelet support was given. Screening for IgM andIgG antiplatelet antibodies con®rmed the presence of bothclasses of antibody reactive to GpIIb/IIIa, GpIb, GpIa/IIb,HLA class 1 activity independent of HPA 1, 2, 3 and 5con®rming an autoimmune rather than alloimmune process.

Unfortunately the severe thrombocytopenia persisteddespite further platelet transfusions and was unresponsiveto intravenous immunoglobulin given daily for 5 d at a doseof 0´4 g/kg/d. The patient developed frank haematuria, andwas found to be direct Coombs test positive. He becameanaemic secondary to a gastrointestinal bleed and alsosuffered a retinal haemorrhage. Daily platelets were admi-nistered together with red cells as required, but still theplatelet count remained <10 ´ 109/l. It was decided to performa splenectomy after plasmapheresis and intensive plateletsupport. The immediate post-operative period was satisfactoryalthough no improvement in the platelet count was seen; anisotope scan failed to reveal active residual splenic tissue.Further treatment consisted of vincristine and cyclophos-phamide but these salvage measures were also unsuccessfuland intra-abdominal bleeding could not be controlled and thepatient died 6 d after removal of the spleen.

CLL has long been known to be associated withautoimmune phenomena. Autoimmune haemolytic anae-mia (AIHA) occurs in 10±20% of patients with CLL at somestage in their disease. It is postulated that a disturbance inthe function of immunoregulatory T cells may be funda-mental to the development of the autoimmune phenomena(Hamblin et al, 1986).

It is now recognized that purine analogues can triggersevere AIHA and that commonly further courses of ¯udar-abine or even alternative chemotherapeutic agents may lead toexacerbations of haemolysis (Orchard et al, 1998). All purineanalogues produce a profound and long-lasting depletion in Tlymphocytes as does Campath 1H, and this may be themechanism of the autoimmune phenomenon.

The incidence of clinically signi®cant antiplatelet auto-antibodies in CLL is lower than those directed against redcells, but they are still reported as a cause of thrombocyto-penia in 2% of patients. Although antiplatelet antibodies arereported in association with RA they seldom cause severethrombocytopenia, and the production of clinically signi®-cant problems by sulphasalazine is a very rare event indeed.Montillo et al (1994) reported the development of auto-immune thrombocytopenia in a patient with CLL duringtreatment with ¯udarabine therapy. To date, Campath 1Htherapy has not been associated with an increased incidence

261Correspondence


of either AIHA or ITP. Indeed, there are reports of thesuccessful treatment of autoimmune neutropenia withCampath 1H (Killick et al, 1997).

Corticosteroids represent the conventional ®rst-line ther-apy for autoimmune thrombocytopenic purpura, but a long-term complete response (platelet count >100 ´ 109/l) isachieved by only 20% of patients. Splenectomy is advocatedas the treatment of choice for non-responders as it cures 60±80% of patients. Refractory patients are a challenge, since allsubsequent therapies offer unpredictable response rates andoften their side-effects are severe. Our patient failed torespond to all salvage measures as is often the case in severerefractory ITP.

ACKNOWLEDGMENTS

Campath 1H was supplied by PFK Ilex (Edinburgh). Plateletantibody studies were undertaken by Dr G. Lucas, IBGRL,Bristol.

Department of Haematology, S. H. O T T O N

Taunton and Somerset Hospital, D. L. T U R N E R

Taunton R. F R E W I N

S. V. DAV I E S

S. A. J O H N S O N

REFERENCES

Hamblin, T.J., Oscier, D.G. & Young, B.J. (1996) Autoimmunity inchronic lymphocytic leukaemia. Journal of Clinical Pathology, 39,

713±716.

Killick, S.B., Marsh, J.C., Hale, G., Waldmann, H., Kelly, S.J. &

Gordon-Smith, E.C. (1997) Sustained remission of severe resistantautoimmune neutropenia with Campath 1H. British Journal of

Haematology, 97, 306±308.

Montillo, M., Tedeschi, A. & Leoni, P. (1994) Recurrent of

autoimmune thrombocytopenia after treatment with ¯udarabinein a patient with chronic lymphocytic leukaemia. Leukaemia and

Lymphoma, 15, 187±188.

Orchard, J., Bolam, S., Myint, H., Oscier, D.G. & Hamblin, T.J. (1998)In patients with lymphoid tumours recovering from the auto-

immune complications of ¯udarabine, relapse may be triggered by

conventional chemotherapy. British Journal of Haematology, 102,

1112±1113.

Keywords: Campath 1H, autoimmune thrombocytopenia,CLL.

262 Correspondence


alternate use of deferiprone and desferrioxamine in primary school children with thalassaemia major

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