[ ISSN : 2573-3680 ]
This is a classical case involving a woman with a history of giving birth to a child with Hemolytic Disease of the Newborn (HDN). The client was in her eleventh week of her third pregnancy when she reported to our facility for antibody detection, identification and titration. Consequently, we detected two alloimmune antibodies capable of crossing the placenta barrier; IgG B and Rh “D” antibodies. The Rh “D” antibodies were in alarming and increasing states from week 11 to week 25 when the woman traveled out of jurisdiction. The IgG anti-B was in a relative stable quantity throughout the monitoring period. She was delivered on the 38th week of gestation and the baby was typed to be A Rh “D” Negative and was not carrying any of the antigens to the antibodies detected. We found this worth reporting because there was no fetal stimulus causing the rising levels of the Rh “D” antibody; we thus propose fetal microchimerism as the potential cause since the woman had a history of bearing children with the antigens to the antibodies detected. This is a phenomenon that has been postulated to be involved in the etiology of hemolytic disease of the newborn.
Hemolytic Disease of the Newborn (HDN) or erythroblastosis fetalis is a grave hemolytic anemia in neonates that results from the development of anti-Rh or blood group antibody in an Rh-Negative or any clinically significant blood group antigen Negative mother, in response to the Rh antigen or that blood group antigen in the fetal blood. HDN could be as a result of hyperimmune ABO antibodies, Rh (D, C, c, E, e) antibodies and other minor blood group antibodies. These antibodies are IgG in nature and have the capacity to bypass the placenta barrier causing lysis of the fetal cells.
HDN is characterized by many erythroblasts in the circulation, and often generalized edema of the fetus with enlargement of the liver and spleen. Hemolysis due to alloimmune antibodies is seen with acute and delayed RBC transfusion reactions, following stem cell transplantation where there is an antigenic blood type difference between the donor and stem cell recipient, and during the neonatal period as a result of differences in maternal and fetal RBC antigens [1]. The quantum of clinical problems in hemolysis occurring in the fetus ranges from minimal hyperbilirubinemia to severe anemia with hydrops fetalis and/or kernicterus. HDN is further characterized by hemolysis as a consequence of maternal sensitization to fetal RBC antigens inherited from the father resulting in the presence of IgG antibodies in maternal circulation, which causes hemolysis in the fetus by crossing the placenta.
Early detection and treatment of neonatal hyperbilirubinemia is important in prevention of bilirubin-induced encephalopathy. Rh “D” incompatibility remains the commonest cause of HDN, although other RBC incompatibilities are increasing in incidence [2,3]. The mechanism through which blood cells from the fetus cross the placenta barrier to sensitize the mother is well understood. It is established that a lot of sensitization of Rh “D” Negative mothers occurs during delivery or through transfusion. The fetal cells in the mother may persist longer than 40 years through a mechanism called fetal microchimerism [4]. Cells of fetus that persist in the mother may trigger an immune response in later years. Though fairly understood, microchimerism is one phenomenon that could be implicated in causing HDN as observed in cases of autoimmune diseases and multiple sclerosis [5].
in her eleventh week of gestation with the third pregnancy. The husband is reportedly blood group B Rh “D” Positive whilst she is A Rh “D” Negative. Her sample was taken for antibody screening and identification as well as the levels of the antibodies detected until she left to give birth at a hospital in Lebanon. She returned to Ghana later with successful delivery of a child with blood group A Rh “D” Negative.
This is a clinical follow up study of a woman with Rh “D” Negative blood group (A Rh “D” Negative) and a husband of Rh “D” Positive antigen (B Rh “D” Positive). She has a history of two previous successive births with the latter baby having a complication of hemolytic anemia and jaundiced; placed under phototherapy upon delivery. The first born who has a rhesus D antigen was successfully delivered with minimal or no complications. However, the mother was not taken through the anti-IgG (RHOGRAM) recipe recommended for cases of this nature.
The client reported to the 37Military Hospital during her 11th week of gestation. She is a Lebanese aging 42 years with a body weight of 64 kg on her first visit. She was scared of delivering a stillborn child for her third pregnancy.
10 ml of venous blood sample was taken into a BD plain tube and she was asked to return a fortnight. Seven samples were taken within the period, at weeks 11, 13, 15, 17, 20, 22 and 25 of gestation. Various tests were run on the sample including blood group, antibody detection, identification and titration.
The standard tube grouping technique was used to determine the blood group. Both the forward and reverse grouping techniques were carried out. The serum was separated from the cells and a 5-10% cell suspension was made after the cells had been washed three times in warm saline (Saline at 37° C); this was used for the forward grouping using antisera from Rapid Diagnostics Ltd. Reverse grouping was done using a drop of 5-10% known A, B, O cells against two drops of the woman’s serum.
With the antibody detection, identification and titration, the Ortho BioVue Gel Technique was used in the analysis of the sample. This technique makes use of a gel matrix impregnated with antihuman globulin/anti-C3d. The gel system is based on the principle that the matrix acts as a filter through which sensitized erythrocytes get entrapped.
A Negative reaction is indicated by a clear pellet of red cells settling at the bottom of the microtube. In the antibody detection, the indirect Coomb’s test was performed. A drop each of 0.1% cell suspensions of known O Rh “D” Positive and O Rh “D” Negative (so as to prevent the interference of ABO antibodies) was used against two drops of the serum of the client. This was incubated at 37° C for 10 minutes according to the manufacturer’s instruction. It was then allowed to stand at room temperature for 5 minutes and span to observe for agglutination. Commercially prepared monoclonal anti-D was used as the control. An auto-control was also set using the woman’s serum and her washed cells. The antibody identification made use of commercially prepared eleven panel cells from Ortho Clinical Diagnostic Panel C. The results were matched against the Panel C from Ortho Clinical Diagnostic, a John & Johnson company product. A control was set using the anti-D monoclonal antibody and an auto-control.
In the antibody titration, a double serial dilution of twelve labeled tubes was made using the fresh serum. Again, the serum was pretreated with Dithiotretiol (DTT) to immobilize any IgM present by incubating equal volumes of 1M of DTT and the serum at 37° C for 2 hours. A double serial dilution of the DTT pretreated serum was also made. 0.1% of Known cell suspension of rhesus D antigen was used to titrate the serially diluted fresh serum for the anti-D antibodies whilst same percentage of B Rh “D” Negative was used to titrate both the serially diluted fresh serum and the DDT pretreated serially diluted serum for the total anti-B and IgG anti-B respectively.
The standard anti-IgG/C3d test tube technique was used in parallel to confirm the results of the gel technique described. However, in the tube technique, 5-10% cell suspension in all cases was used. A fresh sample was also always run parallel with the immediate previous sample (sample stored at 4° C-8° C) to compare the outcome.
Two different alloimmune antibodies were detected. They include anti-D and IgG anti-B. The client’s blood group was also confirmed to be A Rh “D” Negative as indicated in Table 1.
Table 1: Detection of ABO blood antigens and antibodies in the serum of the mother.
The level of anti-D fluctuated in increasing quantities. The highest of 8142 was recorded in week 25 with the lowest titer of 512 occurring in weeks 11, 13 and 15 of gestation. The alloimmune anti-B was in relatively stable levels with the highest titer of 32 recorded in weeks 11, 12 and 17 whilst the titer of 16 was recorded in the rest of the weeks as shown in Table 2.
Table 2: The titer levels of the antibodies detected at various weeks of gestation.
There were steady and sharp rises in the level of anti-D detected from week 11 through to week 25. The alloimmune anti-B was however, relatively stable as shown in Figure 1.
Figure 1: The levels of Anti-D, IgM+IgG Anti-B and IgG Anti-B detected at various gestation weeks.
There was not much difference in the titers of the antibodies after two weeks of storing sample at 4-8° C. When the titer levels were compared, there was no significant level variation shown in Table 3.
Table 3: A comparison of the level of freshly run antibody titers with titer levels repeated after several weeks.
There were significant fluctuations in the anti-D antibodies until she travelled to Lebanon for delivery. The IgG anti-B antibody was however relatively stable. Before she travelled the anti-D level was 8142 IU/L with the IgG anti-B level at 16 IU/L.
The titer level of alloimmune antibodies at which an immediate attention is needed is 16 IU/L [6]. The test results indicated that the anti-D level exceeded this value by a factor of 29 whilst the IgG anti-B was exactly at that level at week 25. This suggested a higher chance of a still birth and the life of the mother at risk. The results were reported periodically to the obstetrician in charge. We recommended a clinical psychologist be employed so as to aid in calming the nervousness of the woman which grew by the day. The anti-D levels rose steadily from 512 to 1024 in the final week of our testing whilst the IgG anti-B remained relatively stable.
For a classical situation of an Rh “D” Negative pregnant woman, continual production of the anti-D would only be as result of the presence or continual exposure of the woman to the antigen (Rh “D” antigen. However, our case revealed that the woman was carrying a baby with rhesus “D” Negative (A Rh “D” Negative). The woman had no history of transfusion and the only possible way she could have been sensitized was from her two previous births (both of whom were carrying the rhesus “D” antigen). For the sensitization from those previous pregnancies to persist and cause continual production of the antibody, it is postulated that “fetal microchimerism” is the most likely mechanism.
Generally, microchimerism is the persistent presence of a few genetically distinct cells in an organism. Though the mechanism is fairly understood various processes leads to the presence of genetically distinct cells in an organism. Most commonly, fetal microchimerism results from the exchange of cells across the placenta during pregnancy. Another increasing evidence of microchimerism indicates that cells may be transferred from mother to infant during nursing [7,8]. In addition to exchange between mother and fetus, there may be exchange of cells between twins in utero, and there is also the possibility that cells residing in the mother, obtained from an older sibling may find their way back across the placenta to a younger sibling during the latter’s gestation. Women may have microchimeric cells both from their mother as well as from their own pregnancies, and there is even evidence for competition between cells from grandmother and infant within the mother.
Even though the immunogenic consequences are not well understood [9] there is evidence of the implication of microchimerism in multiple sclerosis, an autoimmune disease [5].
We hypothesized that the change in antibody levels was as a result of fetal microchimerism which might have occurred due to the previous pregnancies. However, we were unable to establish this hypothesis as we were limited in resources and material availability. We projected that since pregnancy is accompanied by low hemoglobin level due to increased utilization of iron, there is an increase hematopoiesis (erythropoiesis) in the bone marrow so as to compensate for the low hemoglobin. Therefore, during pregnancy, there is an increase synthesis of normal cells and fetal microchimeric cells causing the stimulus for anti-D production to increase if these microchimeric cells are in the erythropoietic tissues; hence the rising anti-D levels. The fetal antigen for anti-B production may also have increased, but the woman’s naturally occurring IgM anti-B antibodies bind this antigen making it less available for more IgG anti-B production.
This postulate, if established, would mean that fetal microchimerism may be implicated in HDN and can aggravate the problem. In this case, there was successful delivery and the fetus was unharmed due to the lack of the Rh “D” antigen and B antigen on its red blood cell surface. It may not be so if in subsequent pregnancy, fetus carries the D or B-antigen from the father. There is a high risk of fetal death as chimeric cells can cause the production of potent antibodies (IgG).
Our sincere thanks go to the staff and supporting-staff of the blood bank and serology department of the 37 military hospitals for the support over the years.
Akonde M, Narter-Olaga EG, Boaheng K and Antuamwine BB. Rh Disease and Potential Implication of Fetal Microchimerism: A Case of Rising Rhesus “D” Antibodies Levels in a Woman with Rh “D” Negative Fetus. SM J Clin Med. 2017; 3(1): 1023
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH