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Case report: HIV infection after plasma exchanges for bullous pemphigoid
Plasma Ther Transfus Technol 1988; 9:3.51-352 Printed
in Great Britain.
0278-6222188
All rights reserved
Copyright
0
$3.00+0.00
1988 Pergamon
Press plc
Case Report: HIV Infection after Plasma Exchanges for Bullous Pemphigoid B. Guillot J. Reynes D. Donadio
plasma exchanges. The steroid dosage was decreased beginning in March 1983 and the patient received 3 PE each month during 6 months and each 2 months during the next 4 months (24 exchanges). The exchanges removed 1500 mL of plasma at each procedure and the replacement fluid was first colloid substitution and albumin. During the second PE, the patient developed severe adverse reactions consequently FFP was then used. In October 1984, the patient was receiving only 10 mg of prednisolone daily. She developed a zoster virus infection with neurological deficiency of the left arm and in March 1986 an oral candidiasis Nystatine or resistant to topical Amphotericine B. A positive serology test for HIV was found by ELISA test and confirmed by Western blot. Lymphocyte subpopulations were as follows: total lymphocytes 800/mm3, E. rosettes 30%, T4 3%, T8 25%, T4/T8 ratio 0,12. A strong decrease of mitogenic response after stimulation by non-specific mitogens was also observed. The paraclinical investigation found oesophageal candidinsis. In November 1986, acute respiration distress resulted in admission to the intensive care unit. Pneumocystis carinii was detected in bronchoalveolar lavage fluid. Treatment with trimethoprim and sulfamethoxazol associated with ketaconazol was initiated but progressive aggravation of the hypoxemia occurred and the patient died December 8, 1986.
The use of plasma exchange (PE) has been proposed for the treatment of auto-immune diseases and efficiency seems to be proven in bullous pemphigoid.’ Since 1979, we have treated 35 patients suffering from bullous pemphigoid with plasma exchange. The substitution fluid was usually human albumin or colloid substitutes of plasma. However in 5 patients fresh frozen plasma (FFP) was necessary because of severe adverse reactions to albumin such as chills and fever, pruritus or decrease of blood pressure. Among these 5 patients treated before August 1985 with FFP, a retrospective study of HIV seroconversion was undertaken. Only one patient had a positive reaction and developed a severe illness related to HIV infection 3 yr later. CASE REPORT A 73 yr old white woman was first admitted in the dermatological department in December 1982 for an extensive bullous eruption. The diagnosis of bullous pemphigoid was made on classical clinical, histopathological and immunopathological criteria. Since January 1983 the patient received corticosteroid therapy (prednisolone 1 mgfkglday) and 14
From the Service de Dermatologie, H6 ital Saint-Charles, Service des Maladies Infectieuses A) Centre Gui de Chauliac and Service des Maladies &I Sang, HBpital Lapeyronie, 34059 Montpellier Cedex, France. Received 2/88; Accepted 10188. 351
352
Plasma Ther Transfus TecJmoJ
Vol. 9, No. 4
COMMENT The occurrence of HIV infections after use of blood products is well known.2 Whole blood, red cells, frozen plasma, platelets and Factor VIII can specially induce HIV transmission. Because of possible immunological side effects or infections (nonA nonB hepatitis) we usually prefer albumin or colloid substitute during plasma exchange.3 But the poor tolerance of albumin in 5 patients prompted us to avoid albumin and use fresh frozen plasma. The occurrence of HIV infection after plasma exchange is not well documented in the literature although a recent case has been reported associated with thrombotic thrombocytopenic purpura.4 The role of FFP in the occurrence of the HIV infection in our patient is very likely. The patient did not belong to any high risk population and she did not receive any blood transfusions before the onset of the disease. Using the stored serum of the patient a retrospective search to establish the date of the seroconversion was made: the seroconversion occurred between January and October of 1983. The association of HIV infection and bullous pemphigoid is almost certainly casuals but the corticosteroid treatment and the immunological disturbance during pemphigoidb probably played a role in the deficiency of the immune system and
the development of the opportunistic infections in our patient.
REFERENCES 1. Roujeau JC, Guillaume JC, Morel P, Dalle
E, Guillot B, Gorin I, Lorette G, Souteyrand P, Crickx B, Doutre MS, Godart W, Labeille B, Rifle G, Triller R: Plasma exchange in bullous pemphigoid. Luncet 1984; ii:486 489. 2. Peterman TA, Jaffe HW, Feorino PM, Getchell JP, Warfield DT, Haverkos HW, Stonebumer RL, Curran JW: Transfusionassociated acquired immunodeficiency syndrome in the United States. I Am Med Assoc 1985; 254:2913-2917. 3. Guillot B, Donadio D, Guilhou JJ, Courren C, Meynadier J: Pemphigoide bulleuse traitee par Cchanges plasmatiques: etude ouverte chez 10 malades. PresseMed 1983; 12:1855-1858. W, Reviron M: 4. Bussel A, Vainchenker Relapse of thrombotic thrombocytopenic purpura associated with LAV infection transmitted by plasma exchange. Congr Europ Sot for Hemapheresis, Interlaken, 27-30 September, 1986. 5. Levy PM, Balavoine JF, Salomon D, Merot Y, Saurat JH: Ritrodine-responsive bullous pemphigoid in a patient with AIDS-related complex. Br j Dermatol 1986; 114:635636. 6. Guillot, B, Donadio D, Laure H, Andary M, Meynadier J, Guilhou JJ, Clot J: Cellular immunity in bullous pemphigoid before and after plasma exchange. Life Support Systems: 1986; 4 (Suppl. 2):338-340.
in Great Britain.
0278-6222188
All rights reserved
Copyright
0
$3.00+0.00
1988 Pergamon
Press plc
Case Report: HIV Infection after Plasma Exchanges for Bullous Pemphigoid B. Guillot J. Reynes D. Donadio
plasma exchanges. The steroid dosage was decreased beginning in March 1983 and the patient received 3 PE each month during 6 months and each 2 months during the next 4 months (24 exchanges). The exchanges removed 1500 mL of plasma at each procedure and the replacement fluid was first colloid substitution and albumin. During the second PE, the patient developed severe adverse reactions consequently FFP was then used. In October 1984, the patient was receiving only 10 mg of prednisolone daily. She developed a zoster virus infection with neurological deficiency of the left arm and in March 1986 an oral candidiasis Nystatine or resistant to topical Amphotericine B. A positive serology test for HIV was found by ELISA test and confirmed by Western blot. Lymphocyte subpopulations were as follows: total lymphocytes 800/mm3, E. rosettes 30%, T4 3%, T8 25%, T4/T8 ratio 0,12. A strong decrease of mitogenic response after stimulation by non-specific mitogens was also observed. The paraclinical investigation found oesophageal candidinsis. In November 1986, acute respiration distress resulted in admission to the intensive care unit. Pneumocystis carinii was detected in bronchoalveolar lavage fluid. Treatment with trimethoprim and sulfamethoxazol associated with ketaconazol was initiated but progressive aggravation of the hypoxemia occurred and the patient died December 8, 1986.
The use of plasma exchange (PE) has been proposed for the treatment of auto-immune diseases and efficiency seems to be proven in bullous pemphigoid.’ Since 1979, we have treated 35 patients suffering from bullous pemphigoid with plasma exchange. The substitution fluid was usually human albumin or colloid substitutes of plasma. However in 5 patients fresh frozen plasma (FFP) was necessary because of severe adverse reactions to albumin such as chills and fever, pruritus or decrease of blood pressure. Among these 5 patients treated before August 1985 with FFP, a retrospective study of HIV seroconversion was undertaken. Only one patient had a positive reaction and developed a severe illness related to HIV infection 3 yr later. CASE REPORT A 73 yr old white woman was first admitted in the dermatological department in December 1982 for an extensive bullous eruption. The diagnosis of bullous pemphigoid was made on classical clinical, histopathological and immunopathological criteria. Since January 1983 the patient received corticosteroid therapy (prednisolone 1 mgfkglday) and 14
From the Service de Dermatologie, H6 ital Saint-Charles, Service des Maladies Infectieuses A) Centre Gui de Chauliac and Service des Maladies &I Sang, HBpital Lapeyronie, 34059 Montpellier Cedex, France. Received 2/88; Accepted 10188. 351
352
Plasma Ther Transfus TecJmoJ
Vol. 9, No. 4
COMMENT The occurrence of HIV infections after use of blood products is well known.2 Whole blood, red cells, frozen plasma, platelets and Factor VIII can specially induce HIV transmission. Because of possible immunological side effects or infections (nonA nonB hepatitis) we usually prefer albumin or colloid substitute during plasma exchange.3 But the poor tolerance of albumin in 5 patients prompted us to avoid albumin and use fresh frozen plasma. The occurrence of HIV infection after plasma exchange is not well documented in the literature although a recent case has been reported associated with thrombotic thrombocytopenic purpura.4 The role of FFP in the occurrence of the HIV infection in our patient is very likely. The patient did not belong to any high risk population and she did not receive any blood transfusions before the onset of the disease. Using the stored serum of the patient a retrospective search to establish the date of the seroconversion was made: the seroconversion occurred between January and October of 1983. The association of HIV infection and bullous pemphigoid is almost certainly casuals but the corticosteroid treatment and the immunological disturbance during pemphigoidb probably played a role in the deficiency of the immune system and
the development of the opportunistic infections in our patient.
REFERENCES 1. Roujeau JC, Guillaume JC, Morel P, Dalle
E, Guillot B, Gorin I, Lorette G, Souteyrand P, Crickx B, Doutre MS, Godart W, Labeille B, Rifle G, Triller R: Plasma exchange in bullous pemphigoid. Luncet 1984; ii:486 489. 2. Peterman TA, Jaffe HW, Feorino PM, Getchell JP, Warfield DT, Haverkos HW, Stonebumer RL, Curran JW: Transfusionassociated acquired immunodeficiency syndrome in the United States. I Am Med Assoc 1985; 254:2913-2917. 3. Guillot B, Donadio D, Guilhou JJ, Courren C, Meynadier J: Pemphigoide bulleuse traitee par Cchanges plasmatiques: etude ouverte chez 10 malades. PresseMed 1983; 12:1855-1858. W, Reviron M: 4. Bussel A, Vainchenker Relapse of thrombotic thrombocytopenic purpura associated with LAV infection transmitted by plasma exchange. Congr Europ Sot for Hemapheresis, Interlaken, 27-30 September, 1986. 5. Levy PM, Balavoine JF, Salomon D, Merot Y, Saurat JH: Ritrodine-responsive bullous pemphigoid in a patient with AIDS-related complex. Br j Dermatol 1986; 114:635636. 6. Guillot, B, Donadio D, Laure H, Andary M, Meynadier J, Guilhou JJ, Clot J: Cellular immunity in bullous pemphigoid before and after plasma exchange. Life Support Systems: 1986; 4 (Suppl. 2):338-340.