PubMed · 7675064
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M J Telen. 1995-10-19. Clinical problem-solving: costly errors.. https://pubmed.ncbi.nlm.nih.gov/7675064/
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OBJECTIVE: To evaluate the efficacy and safety of intravenous administration of human immune globulin in the treatment of dogs with immune-mediated hemolytic anemia (IMHA). DESIGN: Prospective clinical trial. ANIMALS: 10 dogs with confirmed primary IMHA that had failed to respond to conventional immunosuppressive treatment (administration of prednisone and cyclophosphamide or azathioprine). PROCEDURE: Diagnosis of IMHA was confirmed by detecting spherocytosis or autoagglutination in blood smears and by excluding secondary causes of IMHA. Dogs were treated with human immune globulin (1 g/kg [0.45 g/lb] of body weight, i.v.) during a 6- to 12-hour period. Prednisone treatment was continued in all dogs, and cyclophosphamide treatment was continued in 4. RESULTS: Median duration of prior immunosuppressive treatment was 12.5 days. Short-term response could not be evaluated in 2 dogs, because they were given blood transfusions within 7 days after immune globulin treatment. However, there was a significant increase in mean Hct and hemoglobin concentration in 8 other dogs from day 0 to 28 after treatment. Five dogs had clinically meaningful responses to treatment. Three dogs were alive 12 months after treatment. There were not any adverse effects that could be definitively attributed to immune globulin treatment; however, thrombocytopenia was observed in 6 dogs after treatment, and evidence of thromboembolism was detected at necropsy in 5 of the 7 dogs that died. CLINICAL IMPLICATIONS: Human immune globulin may be useful for short-term stabilization of some dogs with IMHA; however, it did not appear to improve long-term survival.
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Programmed cell death (apoptosis) of activated lymphocytes is critical to immune homeostasis. The cell surface protein Fas (CD95) and its ligand play a pivotal role in regulating lymphocyte apoptosis, and defective expression of either Fas or Fas ligand results in marked over accumulation of mature lymphocytes and autoimmune disease in mice. The results of recent studies suggest that defective lymphocyte apoptosis caused by mutations of the Fas gene can result in a severe autoimmune lymphoproliferative syndrome (ALPS) in humans. To define the clinical, genetic, and immunologic spectrum of ALPS, 9 patients and their families were extensively evaluated with routine clinical studies, lymphocyte phenotyping, genotyping, and in vitro assays for lymphocyte apoptosis. Individual patients were followed up for 3 months to 6 years. ALPS was identified in 9 unrelated children as manifested by moderate to massive splenomegaly and lymphadenopathy, hypergammaglobulinemia, autoimmunity, B-cell lymphocytosis, and the expansion of an unusual population of CD4- CD8- T cells that express the alpha/beta T-cell receptor (TCR). All patients showed defective lymphocyte apoptosis in vitro. Heterozygous mutations of the Fas gene were detected in 8 patients. One ALPS patient lacked a Fas gene mutation. Healthy relatives with Fas mutations were identified in 7 of 8 ALPS kindreds. These relatives also showed in vitro abnormalities of Fas-mediated lymphocyte apoptosis, but clinical features of ALPS were not present in the vast majority of these individuals. ALPS is a unique clinical syndrome in which in vitro abnormalities of lymphocyte apoptosis are associated with abnormal lymphoproliferation and autoimmunity. These findings provide evidence that apoptosis of activated lymphocytes is an important mechanism for maintaining immunologic homeostasis and self-tolerance in humans. Fas gene mutations account for impaired lymphocyte apoptosis in only a subset of patients with ALPS.