BLOOD-CELL CYCLES IN POLYCYTHÆMIA VERA

Two patients with polycythæmia vera were studied in order to determine whether blood-cell cycles were present. Neutrophil and platelet cycles were found in one and a reticulocyte cycle in the other. The findings suggest that control of cell production by the marrow is partly retained in polycythæmia vera. In contrast to the findings in chronic granulocytic leukæmia, no evidence was found for slowed cellular maturation.     

STUDIES CONCERNING A COMPUTER ANALYSIS OF PATIENTS WITH PRIMARY,SECONDARY OR STRESS POLYCYTHÆMIA

Previously published hæmatological data concerning patients with primary, secondary or stress polycythæmia have been analysed by digital computer. The mathematical model utilized is presented, and the results of the analysis have been related to the clinical and laboratory findings. It is emphasized that different mathematical methods of treating the data may produce variable results. Accordingly, the results of computer analysis should be regarded critically and with an awareness of the limitations of the mathematical methods involved. Complex data are often assembled under less than ideal conditions for subsequent computer analysis. However, the present study concerning previously published hæmatological data indicates that such material may be amenable to certain statistical techniques provided that the subsequent computer results are interpreted carefully. It is further emphasized that computer analysis of any medical data must involve close cooperation between clinician and mathematician if the resultant information is to be regarded as accurate.     

AN EVALUATION OF NUCLEAR ARYL SULPHATASE ACTIVITY AS AN AID TO THE CYTOLOGICAL DIAGNOSIS OF ACUTE LEUKÆMIA

A cytochemical method for the detection of aryl sulphatase in the nuclei of cells was applied to bone marrow smears of 16 children and two adults with leukæmia. Four children with an acute undifferentiated leukæmia were found to have nuclear aryl sulphatase, as seen in acute lymphatic leukæmia. The clinical course of these patients has been similar to that seen in acute lymphatic leukæmia. It is suggested that this test will facilitate a cytological diagnosis in acute leukæmia, particularly in those cases found to be undifferentiated by other criteria.     

HEPATIC FUNCTION IN PATIENTS WITH HYPOXÆMIA DUE TO CHRONIC PULMONARY DISEASE

The effects of chronic hypoxæmia on hepatic function were appraised by routine liver function tests and by a prolonged BSP infusion procedure in patients with chronic pulmonary disease unaccompanied by heart failure. Despite the presence of hypoxæmia sufficient to severely limit exercise, hepatic function was unimpaired. Abnormalities in hepatic function described previously in patients with chronic pulmonary disease by others may have been due to accompanying heart failure.     

HYPOFIBRINOGENÆMIA IN ACUTE LEUKÆMIA WITH EXTENSIVE FIBRINOUS PERICARDITIS

A case of acute myeloid leukæmia and hypofibrinogenæmia is described. The hypofibrinogenæmia was associated with decreased levels of factor V and factor VIII, but there was no increase in fibrinolytic activity. The clinical course was marked by a severe hæmorrhagic diathesis and evidence of cardiac tamponade. At autopsy there was extensive fibrinous pericarditis. It is suggested that the extensive pericardial fibrin deposition might have contributed to the coagulation abnormality observed.     

AN ANALYSIS OF HYPOPLASTIC ANÆMIA WITH SPECIAL REFERENCE TO THE USE OF OXYMETHOLONE (”ADROYD“) IN ITS THERAPY

Eight of II patients with refractory anæmia, who required regular blood transfusions to maintain their hæmoglobin level, gave a dramatic clinical and hæmatological response to oxymetholone. Analysis of bone marrow aspirates revealed an overall increase in erythropoietic tissue and mitotic indices following successful treatment with oxymetholone. A significant increase in the incidence of karyomeres was noted in the red-cell precursors in some patients with hypoplastic anæmia. This was interpreted as reflecting abnormalities in mitosis similar to the effects seen after irradiation. Possible factors in the ætiology of aplastic anæmia are discussed.     

CYTOGENETIC STUDIES IN FAMILIAL LEUKÆMIAS

Familial aggregation of chronic granulocytic leukæmia is rare and even the occurrence of chronic granulocytic leukæmia in onto member of a family and another type of leukæmia in a close relative is very uncommon. When such instances occur they provide an opportunity for ascertaining if the Philadelphia chromosome (Ph¹), characteristic of chronic granulocytic leukæmia, is ever an inherited rather than an acquired anomaly. The possible existence of a special liability to other chromosomal aberrations can be investigated in such families. In a man with chronic granulocytic leukæmia whose mother had died of the same disease, the Ph¹ was identified in bone marrow cells and in 50% of the dividing cells of peripheral blood cultured during a period of relapse. No Ph¹-positive cells were identified in a culture of subcutaneous fibroblasts, and so it may be assumed that in this patient the Ph¹ was an acquired and not an inherited chromosomal abnormality. The Ph¹ was not present in cultures of peripheral blood leucocytes or of subcutaneous fibroblasts from a girl with acute leukemia whose father died of chronic granulocytic leukæmia. These studies provide further evidence of the status of the Philadelphia chromosome as an acquired cytogenetic anomaly.     

THROMBO-EMBOLISM AND INCREASED PLATELET ADHESIVENESS IN POST-SPLENECTOMY THROMBOCYTOSIS

Platelet count data have been obtained from patients suffering from various types of hereditary hæmolytic anæmia, sideroblastic anæmia and thalassæmia, and from hæmatologically normal controls. One-third of the patients studied had been subjected to splenectomy. Patients with persistent anæmia after splenectomy developed post-splenectomy thrombocytosis. The percentage of platelets which were adhesive was increased after splenectomy irrespective of whether anæmia and thrombocytosis persisted. Six of the 25 patients with persistent post-splenectomy thrombocytosis developed thrombo-embolic complications. On the other hand, signs or symptoms of thrombo-embolism were not observed in any of 21 patients who had normal platelet counts after splenectomy, or in 72 patients suffering from similar disorders who had not been subjected to splenectomy. The cause of the high incidence of thrombo-embolic complications in patients with continuing anæmia after splenectomy is not completely understood, but it seems likely that thrombocytosis and increased platelet adhesiveness may play a part.     

AN ASSESSMENT OF RED CELL SURVIVAL IN IDIOPATHIC UNCONJUGATED HYPERBILIRUBINÆMIA (GILBERT'S SYNDROME) BY THE USE OF RADIOACTIVE DIISOPROPYLFLUOROPHOSPHATE AND CHROMIUM

Red cell survival was determined in 20 patients with idiopathic unconjugated hyperbilirubinæmia without overt signs of hæmolysis (Gilbert's syndrome) by means of a double isotope technique with the use of diisopropylfluorophosphate (DF³²P) and chromium (⁵¹Cr) simultaneously. Red cell life span was significantly reduced in 42% of patients. However, the degree of hæmolysis was not sufficient to produce hyperbilirubinæmia in persons with normal hepatic function. The incidence of familial involvement in patients with reduced red cell survival was not significantly different from that in patients with normal red cell survival. Similarly, there was no difference between the groups with respect to symptomatology, age of onset of jaundice, or results of laboratory investigations. It is concluded that the hyperbilirubinæmia in this syndrome is more likely to be due to a defect in hepatic handling of bilirubin than to compensated hæmolysis. This defect appears to occur whether or not there is a reduced red cell survival. It remains to be shown why some patients with this syndrome have a reduced red cell survival while others do not.     

CYTOGENETIC STUDIES IN CHRONIC GRANULOCYTIC LEUKÆMIA

A review of the literature shows that the Philadelphia (Ph¹) chromosome is present in cells from a majority of patients with chronic granulocytic leukæmia, including 19 presented here. An adequate explanation has been found for the failure to demonstrate the Ph¹ chromosome in all but four cases in the literature. The Ph¹ chromosome has only rarely been reported in other myeloproliferative disorders, and never in other conditions. The positivity in the myeloproliferative disorders is discussed and the probability that the few reported cases are atypical examples of chronic granulocytic leukæmia is considered. The diagnostic value of cytogenetic studies in prognosis and therapy is considered. The conclusion is reached that such studies are of definite but limited value. Theoretical implications of the Ph¹ chromosome are discussed with particular reference to the stem cell, leucopoiesis and chromosome 21, the inter-relationship of the myeloproliferative disorders and the pathogenesis of chronic granulocytic leukæmia.     

SOME CLINICAL AND CHEMICAL MANIFESTATIONS OF ALCOHOL-INDUCED HYPERLIPÆMIA

Some of the clinical features and the values of the plasma lipids of 10 subjects with alcohol-induced hyperlipæmia are presented. The finding of lactescence in samples of fasting plasma from subjects who had been drinking heavily led to the establishment of the diagnosis. The presenting symptoms were abdominal pain in seven cases, coronary heart disease in two and recurrent xanthomatosis in one cases. Pancreatitis was found in three cases, marked hepatomegaly subsiding rapidly after admission of the subjects to hospital in seven, and transient hyperglycæmia in four. The very high concentrations of plasma triglyceride and cholesterol fell rapidly when alcohol intake was stopped. The frequency of finding and the pathogenesis of this disorder are discussed.     

HYPONATRÆMIA AND RENOVASCULAR HYPERTENSION

A case of traumatic renal artery thrombosis in which the patient developed the hyponatnemic hypertensive syndrome is described. Decreased vascular sensitivity to angiotensin, grossly elevated plasma renin levels, hypertension and hyponatræmia returned to normal after unilateral nephrectomy. Sequential renin and electrolyte studies indicated that this syndrome was caused by the pressor and natriuretic actions of high circulating levels of renin and angiotensin. No evidence could be found to support the suggestion that the high renin levels were secondary to sodium depletion. A positive result to a phentolamine test was recorded, leading to initial problems in diagnosis. The patient is normotensive and well three years after this episode.     

LEUCOCYTES CONTAINING BACTERIA IN PLAIN BLOOD FILMS FROM PATIENTS WITH SEPTICÆMIA

A search for infected cells was made with the low power (× 10 or × 20) objective in plain blood films from patients known to have, or suspected of having, septicæmia. It was found that scanning of a film in this way for a short time will detect even small concentrations of infected cells. Infected leucocytes occurred in highest concentration in the first drop of blood issuing from the previously unmanipulated ear lobe. They occurred most frequently in films in which there was also an increase in mononuclear cells containing inclusions of corpuscular origin, and were found whether or not the patient had recently been given apparently effective antibiotic treatment. Consideration is given to the requirements for a diagnosis of septicæmia from the presence of infected cells in blood films and the distinction of bacteria from other structures in leucocytes which may resemble them. A search for infected leucocytes in a plain blood film of the first drop of blood from the ear lobe appears to be a useful procedure in routine investigation of patients who may have septicæmia.     

THALASSÆMIA MINOR IN AUSTRALIANS OF NORTHERN EUROPEAN EXTRACTION: A REPORT OF FIVE FAMILIES

Five families of heterozygous beta (type 1) thalassæmia minor with elevated hæmoglobin A₂ values and no “known” Mediterranean ancestry are presented. Four families are of Anglo-Saxon origin, and one family is of German descent. All five propositi and an isolated sixth patient with an elevated hæmoglobin A₂ value were referred with hypochromic microcytic anæmia unresponsive to iron therapy. The purpose of this paper is to draw attention to the incidence of thalassæmia minor in Northern Europeans resident in Australia, and to emphasize the importance of full investigation of all cases of iron refractory hypochromic microcytic anæmia, to avoid the over-treatment with iron of persons with thalassæmia minor.     

Rapid regression of bone marrow fibrosis after dose-reduced allogeneic stem cell transplantation in patients with primary myelofibrosis

OBJECTIVE: To investigate the effect of a busulfan/fludarabine-based reduced intensity conditioning followed by allogeneic stem cell transplantation on regression of bone marrow fibrosis in patients with myelofibrosis. METHODS: Twenty-four patients (male, n = 16; female, n = 8) with a median age of 52 years (range, 32-63 years) were included. Six patients were transplanted from human leukocyte antigen-identical siblings and 18 patients from matched unrelated donors. Diagnosis was primary myelofibrosis in 18 patients and secondary myelofibrosis in 6 patients; in 4 of them, primary myelofibrosis evolved from polycythemia vera, and in 2 of them from essential thrombocythemia. Using the European Consensus on grading bone marrow fibrosis, all patients had advanced marrow fibrosis MF-2 (n = 13) or MF-3 (n = 11) before allografting According to the Lille Risk Factor Scoring System, patients were classified as low risk (n = 5), intermediate risk (n = 16), or high risk (n = 3). RESULTS: After stem cell transplantation, a complete (MF-0) or nearly complete (MF-1) regression of bone marrow fibrosis was seen in 59% at day +100, in 90% at day +180, and in 100% at day +360. No correlation between occurrence of acute graft-vs-host disease and fibrosis regression on day +180 was observed. CONCLUSION: This study shows that allogeneic stem cell transplantation after reduced-intensity conditioning resulted in rapid regression of bone-marrow fibrosis.     

TREATMENT OF "PRIMARY" RENAL AMYLOIDOSIS WITH MELPHALAN

Eight patients with " primary " amyloidosis presenting as renal disease are described. This diagnosis was made in 4% of 169 adults having renal biopsy for heavy proteinuria. Careful examination of the renal biopsy specimens, preferably including electron microscopy, is essential to detect this disease, which is not confined to the older-age groups. Selective proteinuria does not exclude amyloid. In view of increasing evidence that primary amyloid has an immunoglobulin origin, these patients were carefully screened for abnormal proteins and evidence of reticuloendothelial-system disease. Paraproteinæmia was found in a 64-year-old man and Bence Jones proteinuria in a 34-year-old woman whose marrow contained an excess of plasma cells. In the face of rapidly deteriorating renal function the latter patient was treated with melphalan and showed improved renal function over the next four years. Immunosuppressive therapy has an uncertain value in primary amyloid, but should be considered, especially when there is associated paraproteinæmia or para-proteinuria.     

Immunohistochemical assessment of ferritin in bone marrow trephine biopsies: correlation with marrow hemosiderin

In 340 bone marrow biopsies we compared ferritin, stained with an immunoperoxidase method, with hemosiderin, stained with Perls' reaction. Ferritin and hemosiderin showed the same distribution in reticuloendothelial cells. All the Perls-positive cases (n = 177) were ferritin-positive too. None of the ferritin-negative cases (n = 13) were Perls-positive. Of 163 cases with negative Perls' reaction in bone marrow, 13 (12.5%) were also ferritin-negative: these patients were mainly affected by polycythemia vera or by untreated iron deficiency anemia. Thus, immunohistochemical assessment of bone marrow ferritin can be a more sensitive tool for the evaluation of body iron stores in iron deficiency than Perls' reaction.     

The Gain-of-Function JAK2 V617F Mutation Shifts the Phenotype of Essential Thrombocythemia and Chronic Idiopathic Myelofibrosis to More “Erythremic” and Less “Thrombocythemic”: A Molecular,Histologic, and Clinical Study

We investigated the prevalence of the JAK2 V617F gain-of-function mutation in patients with Philadelphia chromosome-negative chronic myeloproliferative disorders (Ph- MPD) and explored the links between JAK2 mutational status and the clinicopathologic picture of essential thrombocythemia (ET), chronic idiopathic myelofibrosis (CIMF), and polycythemia vera (PV). Allele-specific polymerase chain reaction results for 59 ET, 18 CIMF, and 9 PV cases were compared with values for clinical variables at presentation and last follow-up and with the diagnostic trephine bone marrow biopsy pictures. JAK2 V617F was found in 38 (64%) of ET cases, 7 (39%) of CIMF cases, and 9 (100%) of PV cases. The ET patients with the mutant JAK2 showed significantly higher (although not overtly polycythemic) red blood cell parameter values, lower platelet counts, and higher white blood cell counts. Similar trends were found in CIMF. Megakaryocyte clustering was much less pronounced in the CIMF cases with mutant JAK2, with an analogous trend occurring in the ET cases. Bone marrow cellularity values and the numbers of CD34+ and CD117+ blasts in the ET and CIMF groups did not differ. Fibrosis was slightly less marked in the ET cases with mutant JAK2. The mutation did not significantly influence the clinical course during the follow-up in either disease in the short term (median follow-up, 22 months). The JAK2 V617F mutation is prevalent in all Ph- MPD and may skew their presenting phenotype, including bone marrow histology, toward a more "erythremic" and less "thrombocythemic" phenotype.     

PHILADELPHIA-CHROMOSOME-POSITIVE PRELEUKÆMIC STATE

Serial chromosomal analyses were performed in an untreated patient who demonstrated little or no hæmatological disease for over 5 years before the development of overt blastic leukæmia. The Philadelphia chromosome (Ph') was present in a small percentage of marrow cells during the preleukæmic period. Hæmatological remission of the blastic leukæmia was achieved with hæmopoiesis derived from a Ph' positive cell line. The Ph' chromosome was an indicator of the preleukæmic state in the absence of other abnormalities.     

Qualitative platelet defects in chronic myeloproliferative disorders: evidence for reduced ATP secretion

19 consecutive untreated patients with chronic myeloproliferative disorders and thrombocytosis were subjected to comprehensive platelet function tests including platelet aggregometry. 12 patients had essential thrombocythaemia (ET) and 7 patients had polycythaemia vera (PV). Bleeding time was normal. Arachidonic acid, collagen and ristocetin aggregation were abnormal only in a minority of patients, whereas ADP aggregation was impaired in 16 out of 19 patients. The most conspicuous findings were abolished second-wave adrenalin aggregation, increased ADP aggregation threshold, and markedly reduced ATP secretion during collagen-induced aggregation. This triad of qualitative platelet defects seems to be a good diagnostic marker of chronic myeloproliferative disease with thrombocytosis.