results. Perhaps increased awareness of these reactions will lead to clarification of their mechanism. Report of a Case.\p=m-\A 56-year-old woman was admitted to the hospital for acute lower abdominal pain and tenderness. She required surgery for intestinal obstruction secondary to acute diverticulitis. Three units of packed RBCs were uneventfully transfused during the immediate postoperative period.Because of subsequent self-induced wound dehiscence with fecal contamination of the peritoneum, the patient became septic, could not take food by mouth, and became hypoalbuminemic. Within ten minutes after the infusion of 50 g of normal serum albumin, she experienced respiratory distress, a flushed face, and dramatically decreased responsiveness. She was successfully resuscitated with drugs, intubation, and mechanical ventilation. Wheals developed over her trunk within four hours of infusion, even though diphenhydramine hydrochloride had been used during resuscitation.Since she was receiving combined anti¬ biotic therapy, a drug reaction was sus¬ pected, and her antibiotic treatment was changed. An additional 25 g of albumin was infused two days after the first dose. A reaction clinically similar to the first ensued, except for greater respiratory dis¬ tress requiring more medication and more prolonged mechanical support for control.Several tests provided negative results from the patient's serum. Studies were performed for RBCs, WBCs, IgA, and HLA antibodies, and the albumin agglutinating phenomenon. No antibodies to the albumin were detected by Ouchterlony double-dif¬ fusion technique or by passive hemagglutination using albumin-coated RBCs.Studies of the same lot number of serum albumin gave negative results for pyrogens and showed only 4.5% prekallikrein activator (PKA) present (lots of plasma protein fraction previously implicated in acute hypotension usually contained 20% or more of PKA5).Comment.-The following are pos¬ sible explanations for these results: neutralization of antibodies by the product; antibodies to albumin aggre¬ gates, not detectable by routine meth¬ ods; or an idiosyncratic response.Fortunately reactions to normal serum albumin are rare, but this case demonstrates that they can be severe, even in the absence of demonstrable offending antibodies. al: Hypotension associated with prekallikrein activator in plasma protein fraction. N Engl J Med 1978;299:66-70. Hypocholesterolemia in MyelofibrosisTo the Editor.\p=m-\Gilbertet al (Blood 54(suppl):84, 1979) reported low serum cholesterol levels in 24 patients with polycythemia vera or myeloid metaplasia. We examined the records of 20 patients who had agnogenic myelofibrosis and myeloid metaplasia.There were 12 men and eight women aged 42 to 94 years (\l=x_\ = 7 0 . 5 \ m = + -\ 1 4 . 5 SD), all without diseases known to alter plasma cholesterol levels. Seventeen patients (11 men and six women) had total plasma cholesterol values significantly lower than those reported in the Framingham study for age-matched men and women.Cholesterol levels for the ...