Hemolytic reactions produced in dogs by transfusion of incompatible dog blood and plasma; serologic and hematologic aspects

1. Dogs injected intravenously with dog erythrocytes containing one or moreantigenic factors lacking in their own red cells developed iso-hemagglutinins andhemolysins exhibiting characteristics of immune antibodies.

2. Transfusions of incompatible whole dog blood and plasma were carried outunder controlled conditions. Pretransfusion observations were made and followedby closely spaced post-transfusion measurements of serologic and hematologicalterations.

3. The rate of destruction of incompatible donated corpuscles was determinedby tagging the cells with radioactive iron and also by employing the technique ofdifferential agglutination of erythrocytes. It was thereby shown that all of theincompatible donated cells disappeared from the recipient’s circulation withinthe first thirty to ninety minutes following transfusion. The probable mechanismsand relative importance of intra- and extravascular destruction of erythrocytes arebriefly discussed.

4. Destruction of recipient dogs’ corpuscles by donated immune plasma wasrelatively slow, and spherocytosis and increased osmotic fragility of the recipients’ cells were evident for periods as long as twenty days. These observationsare compared with those made in human beings after transfusions of plasma and ofblood from dangerous universal donors.

5. The titer of complement in the sera of recipient dogs was sharply reducedfor at least five hours after all transfusions of incompatible whole blood, but isoagglutinin titers were less regularly reduced after such transfusions.

6. Other notations of interest included estimates of the concentrations of serumbilirubin, sodium and potassium, determinations of clotting time, prothrombinconcentration, and observations on red cell morphology, intravascular erythrophagocytosis, and shifts in distribution of leukocytes and in the electrophoreticpatterns of plasma.

Note: ACKNOWLEDGMENTSIt is a pleasure to acknowledge the technical assistance of Mrs. Jane Peters, Miss Mary Jane Izzo andMiss Shirley Deshon.

     

Chediak''s anomaly of leukocytes in malignant lymphoma associated with leukemic manifestations: case report with necropsy

A case of Chediak’s anomaly of leukocytes was described, the fourth reported in the literature.

The patient was an 11-month-old boy who, in addition to Chediak’s anomalyof the leukocytes, presented a leukemic blood picture.

He died five days after admission to the hospital, and necropsy revealeda malignant lymphoma.

We consider it possible that in all the reported cases there were generalizedpathologic changes in the reticulohistiocytic system.

Submitted on December 3, 1957 Accepted on May 15, 1958     

Studies on the histamine content of blood,with special reference to leukemia,leukemoid reactions and leukocytoses

The literature concerning blood histamine has been reviewed, including theevidence that the incorporation of histamine within the myeloid leukocytes maybe one of the metabolic functions of myelopoiesis. Data are presented on the histamine content of blood in normal subjects and in subjects with acute leukemia,chronic myelocytic leukemia, erythremia, and with leukocytoses or leukemoidreactions of other etiologies. The changing relationships of total blood histamineto unit myeloid cell histamine in subjects receiving irradiation therapy for chronicmyelocytic leukemia are also presented.

The data indicate that total blood histamine in chronic myelocytic leukemiais usually very high in comparison to normal, that the values in erythremia showa definite but less marked tendency in the same direction, while the values inleukocytoses of other etiology are, with few exceptions, normal or low. The bloodhistamine per million myeloid cells is, on the average, about twice normal in subjects with chronic myelocytic leukemia, within the normal range or a little lowin erythremia, and very low on the average in the group of leukocytoses studied.The suggestion is tentatively made that an aberration in this metabolic process(histamine incorporation within myeloid leukocytes) may be an inherent component of chronic myelocytic leukemia, whereas in physiologic leukocytoses andleukemoid reactions this is not the case.

Note: ACKNOWLEDGMENTSThe authors wish to express their grateful appreciation to Mr. John Fuschetti for valuable technicalassistance in performing the histamine determinations. The cooperation and aid of Dr. Gurth E. Carpenter, Dr. Henry H. Henstell, Dr. Myron Prinzmetal and of many members of the staff of WadsworthGeneral Hospital, Veterans Administration, Los Angeles were invaluable in obtaining blood specimensfrom suitable clinical material, and to them the authors wish to express their sincere thanks.

     

THE EXCRETION OF UROBILINOGEN IN THE STOOLS AND URINE DURING MALARIAL INFECTION

In 10 cases of malaria (6 benign tertian, 4 malignant tertian), the excretion ofurobilinogen in the stools and in the urine was studied. In all 10 cases the amountof urobilinogen excreted in the stools was found to be increased. After defervescence and disappearance of parasites from the blood the excretion gradually declined. The increased excretion of urobilinogen in the stools was the constant andsometimes the only evidence of increased blood destruction occurring at times in the complete absence of jaundice and reticulocytosis. Increased excretion of urobilinogenin the urine was not a constant feature.

It is suggested that the development of jaundice and of urobiligenuria is duenot only to the liberation of pigments by the hemolysis, but to a disturbance in theliver function.

This study lends further confirmation to the concept that the only unequivocalevidence of increased blood destruction is shown in an increased output of urobilinogen in the feces.

Note: The author is indebted to Dr. M. Rachmilewitz for his suggestions and criticisms.

     

Eosinophilic leukemia; report of a case with autopsy confirmation; review of the literature

1. The data in a case of fatal leukemia with predominant eosinophilia in theperipheral blood and bone marrow are presented; we believe that this case was oneof eosinophilic leukemia.

2. During the period of observation, these eosinophils showed progesssiveimmaturity as the symptoms became more severe. Eventually this "left shift"became so marked that a large proportion of the cells were terminally myeloblastsin both the blood and the bone marrow.

3. Autopsy revealed invasion of many of the tissues and organs with thesemature and immature eosinophil granulocytes and with myeloblasts.

Note: ACKNOWLEDGMENTOur thanks for helpful criticism are particularly extended to Dr. Charles Doan and to Dr. WilliamDameshek.

     

Prophylaxis of hookworm anemia-deficiency disease

1. In individuals severely infested with Ancylostoma or Necator, it is possible tomaintain the normality of blood value by the administration of a sufficient dose ofan iron salt.

2. The minimum dose necessary to maintain normality of the blood in an individual weighing 45 kilograms, with 1051 helminths, was 0.2. Gm. daily of ferrous sulfate, administered in mixture with manioc flour.

3. The patient observed became clinically normal two weeks after the beginningof blood regeneration up to the end of the trial period one year later. In this period,with the various doses of iron tried, hemoglobin varied from 8.0 to 11.0 per 100ml. of blood.

Note: ACKNOWLEDGMENTWe owe thanks to the kindness of our colleague, Dr. Genard Nobrega, for the case report and electrocardiographic study of the patient.

     

Refractory megaloblastic anemia

1. Fifty-nine cases of megaloblastic anemia refractory partially or completelyto potent liver extracts given parenterally have been investigated in Edinburghduring the past six years. Thirty-four of these cases were associated with pregnancy, the puerperium or the sprue syndrome. No explanation of the cause of themegaloblastic anemia was discovered in the remaining 25 cases.

2. The etiology, clinical features and treatment of 25 cases of idiopathic refractory megaloblastic anemia are described. Attention is directed to the excellenttherapeutic effects produced by proteolysed liver or folic acid.

3. The mechanisms involved in refractoriness to potent parenteral liver extractsare discussed.

4. In certain cases of refractory megaloblastic anemia it is suggested that an unknown hematinic principle, in addition to the liberating factor in purified parenteral liver extract and folic acid, is required for the complete restoration of normoblastic blood formation.

Note: ACKNOWLEDGMENTSMy thanks are due to many members of my staff who have helped in theseinvestigations, particularly to Professor L. J. Davis formerly lecturer in Medicinein the University of Edinburgh, and to Dr. Girdwood. Grateful acknowledgmentmust also be made to Doctor Riding, Medical Director of Evans Medical SuppliesLtd. and his research chemists who were responsible for the preparation of proteolysed liver and the other fractions of liver mentioned above.

     

A SIMPLE APPARATUS AND PROCEDURE FOR PREPARING AND ELECTROPLATING RADIOACTIVE IRON

A simple, easily constructed apparatus for electroplating radioactive iron hasbeen described by which certain disadvantages of other forms of apparatus havebeen eliminated. Sixteen samples can be plated each day without difficulty.

The technic employed for preparing the radioactive iron for electroplating hasbeen given.

Note: The writers are indebted to Dr. P. F. Hahn and his staff who permitted one of them (M. L.) to spendseveral weeks in the Biochemical Laboratory at the Vanderbilt University School of Medicine and generously gave invaluable instruction and advice.

     

The relationship between carbonic anhydrase activity and zinc content of erythrocytes in normal,in anemic and other pathologic conditions

A good correlation exists between zinc content and carbonic anhydrase activityof the red blood cells under all conditions studied, including anemia and polycythemia. In almost all patients with anemias other than pernicious anemia, bothzinc and carbonic anhydrase levels were lowered in parallel fashion. These changeswere proportional to decreases in hematocrit and hemoglobin levels and erythrocyte counts so that both zinc and carbonic anhydrase values per unit of RBC werein the normal range. In a few instances of anemia associated with leukemia andin one of sickle cell anemia, neither zinc content nor carbonic anhydrase activitywas decreased in proportion to the anemia; in these cases the zinc and carbonicanhydrase levels per unit of blood were both elevated to the same degree.

Patients with pernicious anemia showed no decrease in absolute values for zincand carbonic anhydrase activity in spite of marked lowering of hematocrit andhemoglobin levels and of erythrocyte count. Accordingly, both zinc concentrationand carbonic anhydrase activity per unit of blood were elevated, often to a markeddegree. These increases were parallel, varying inversely with the degree of anemia;when they regressed under treatment, both did so at the same rate.

There are no methods available for estimating carbonic anhydrase concentration;all methods now in use measure only the activity of the enzyme. It is suggestedthat zinc concentration could be used as an indicator of carbonic anhydrase contentof the red blood cells.

Note: ACKNOWLEDGMENTSDrs. Joseph C. Aub and Ira T. Nathanson were kind enough to refer several patients for study. Dr.Byrl J. Kennedy was most helpful in regard to obtaining samples of blood. The technical work wasperformed by Miss Mary Lou Roney, Betty Hickey and Marion Taylor.

     

Blood exchange in replacement transfusions; studies with erythrocytes tagged with radioactive phosphorus

Red cells labeled with radioactive phosphorus have been used by us to measurethe extent and the rate of the replacement of blood in exchange transfusions. Theexperimental results confirmed the theoretic formulations developed in the preceding paper. On the basis of the above data, it seems reasonable to introduce thesecurves and formulae whenever exchange transfusions are to be performed.

Note: ACKNOWLEDGMENTSWe are indebted to Miss G. Ohno and Miss S. Rezek for technical assistance rendered during thisstudy.

     

The effect of administration of epinephrine on the leukocyte counts of normal subjects

1. Thirty-seven normal subjects were given subcutaneous injections of epinephrine, ranging from 0.25 to 0.5 mg., and the effects on the leukocytes were noted.

2. The neutrophils rose steadily for the three and one-half hours during whichblood counts were made. The small lymphocytes rose in the first half hour, thenfell below normal and finally returned towards normal. The eosinophils rose atfirst and then fell below normal for the remainder of the period.

3. The three doses of epinephrine used produced effects which differed quantitatively but not qualitatively. The most readily identified effect of the smallest dosewas the one-half hour rise in lymphocytes or the one-half hour rise in total count.A dose of 0.5 mg. is satisfactory for work of this kind.

4. Subjects with a history of allergy showed a greater tendency than the remainder to exhibit a one-half hour rise in the eosinophil count.

5. The changes in the leukocyte count produced by epinephrine are similar to,but not identical with, those produced by adrenocortical hormone or adrenocorticotropic hormone.

Note: ACKNOWLEDGMENTSWe are indebted to the Faculty Research Committee of the University of Pennsylvania for a grant toone of us (C. W.) towards the expenses of this investigation.

     

EXPERIMENTAL LEUKOCYTOSIS. THE INEFFICACY OF P-CHLOROXYLENOL AND METHYL ACETAMIDE AS BONE MARROW STIMULANTS

1. Single and multiple injections of CXM (methyl acetamide and p-chloroxylenol) have a similar action in increasing the total number of polymorphonuclearleukocytes in the peripheral blood of a group of 32 rats. No "shift to the left"takes place.

2. There is no stimulation of the myeloid elements of the bone marrow to suggest that this leukocytosis is due to hyperplasia.

3. The evidence suggests that the mechanism for the leukocytosis produced bythe CXM consists of releasing blood cells from depots in the body. This action isselective for the granulocytes as the red cells and platelets are not affected.

4. There is progressive degeneration of the parenchymal cells of the liver aftersingle and multiple injections of these substances.

5. If less toxic combinations of methyl acetamide and para-chloro-xylenol couldbe obtained, they might be of value in the treatment of certain patients withleukopenia or agranulocytosis more particularly when the bone marrow is hyperplastic but the granulocytes are not released.

Note: The author expresses his appreciation to Dr. Oscar Riddle for the generous provision of animal andlaboratory facilities.

     

Hematological changes following the administration of large doses of quinacrine hydrochloride

The administration of quinacrine to rats, mice, rabbits, hamsters, guinea-pigs,dogs, monkeys, chickens, and ducks results in definite hematological changes.Peculiar basophilic inclusions, usually associated with vacuoles, appear in thecytoplasm of lymphocytes of all nine species following drug therapy. Inclusions ofa similar nature are seen in erythrocytes of the rat, mouse, and hamster and rarelyin monocytes of the rat.

The rat shows an anemia, polynucleosis, lymphopenia, and monocytosis afterquinacrine dosing. None of the other species develop a leukocytosis or monocytosis,but they sometimes show a polynucleosis and lymphopenia after quinacrine therapy. Leukopenia occurs in the monkey and occasionally in the dog following theuse of this drug.

Note: ACKNOWLEDGMENT: Grateful acknowledgment is due to Drs. H. Molitor andH. A. Charipper, who so willingly gave of their time in discussing this problemand in offering suggestions and criticisms.

     

STUDIES ON THE PHYSIOLOGY OF THE WHITE BLOOD CELL: THE GLYCOGEN CONTENT OF LEUKOCYTES IN LEUKEMIA AND POLYCYTHEMIA

The technic of determining glycogen in isolated white blood cells was appliedto the study of the different types of leukemia and of polycythemia, in order toobtain information on the physiology of the white blood cell. From this study itis concluded that the granulated leukocyte is the only carrier of glycogen in wholeblood. The "reducing substances" in lymphocytes and blast cells are not consideredas true glycogen.

The glycogen content of wet white blood cells in the rabbit amounts to about1 per cent. In the human being a range of from 0.17 to 0.67 per cent was calculated.In disease higher percentages occur, in polycythemia up to 1.64 per cent and inglycogen storage disease up to 3.05 per cent.

The glycogen concentration of normal white blood cells is within the same rangeas that of the striated muscle.

Note: I acknowledge with gratitude my indebtedness to Dr. William Dameshek for giving me the opportunity of analyzing the blood of some of the patients studied. Miss M. H. Campbell, Miss H. A. Clark,and Miss L. M. Garofalo have aided in carrying out many of the blood counts.

     

Thrombotic thrombocytopenic purpura; hemorrhagic diathesis with generalized platelet thromboses

1. "Thrombotic thrombocytopenic purpura" is the name which we propose fora rare but well-defined disorder which manifests itself clinically as an acute febrileillness and which is characterized by (a) petechiae and ecchymoses, thrombocytopenia, prolonged bleeding time and poor clot retraction, (b) by a severe anemia outof proportion to any observed blood loss, (c) by mild acholuric jaundice, hepato-splenomegaly, (d) by bizarre and intermittent mental and neurologic symptomsand signs, and (e) by a transient leukemoid reaction in the peripheral blood.

2. This clinical picture must be correlated with a remarkable histologic pattern,namely the presence of myriads of platelet thrombi in the small arterioles andcapillaries of almost all organs of the body.

3. Eleven such cases have been described in the literature. One case of our ownis added.

4. The clinical features of this disease are detailed and the differential diagnosisis discussed. It is emphasized that if the physician is familiar with this syndromea correct clinical diagnosis may become readily possible.

Note: Acknowledgment for the support of this work is made to the Hulda B. and Maurice L. RothschildFoundation for Scientific Research.

     

RENAL FUNCTION DURING CHRONIC ANEMIA IN MAN

1. Renal function has been studied quantitatively in 15 patients with chronicanemia, 8 of whom were proved to have pernicious anemia. In 7 the anemia wassecondary to chronic blood loss, iron deficiency, paroxysmal nocturnal hemoglobinuria, and leukemia. The effective renal plasma flow and glomerular filtrationrate were measured by clearance technics; and tubular function, by saturationmethods (diodrast Tm and glucose Tm).

2. The effective renal plasma flow, the glomerular filtration rate, and the filtration fraction (percentage of plasma filtered at the glomerulus) were reduced slightlybelow the normal values in most subjects. The effective renal whole blood flowwas always greatly reduced, by 46 per cent on the average in males and by 31.8per cent in females.

3. Since arterial pressure was not significantly depressed it was concluded thatrenal vasoconstriction occurs in chronic anemia, possibly as a homeostatic devicefor the diversion of blood to tissues more sensitive to oxygen lack. The relativelysmall reduction of filtration fraction implies afferent and efferent arteriolar vasoconstriction with dominance by the afferent arterioles. These changes were shownto be reversible, a return to normal values paralleling the return of the blood pictureto normal.

4. Diodrast Tm was reduced significantly in 9 of 10 patients while the values ofglucose Tm were normal in 6 of 7 patients. The normal values for glucose Tm indicated continued operation of all glomeruli and implied the absence of shuntingor of cessation of blood flow in any significant portion of the kidney. The fall indiodrast Tm, which appeared to be reversible in 2 of 4 individuals, was interpretedas evidence of intracellular dysfunction rather than destruction or inactivation ofnephrons.

Note: We wish to express our gratitude to the Misses Elizabeth Nolan and Constance Qua for technicalassistance.

     

Autohemagglutinins and hemolysins with hemoglobinuria and acute hemolytic anemia,in an illness resembling infectious mononucleosis

A case is reported of a young man with acute hemolytic anemia and hemoglobinuria who presented: an initial blood picture consistent with infectious mononucleosis, associated with a heterophile agglutination test positive in high dilution;auto-hemagglutinins, active in the cold, at room temperature and at 37 Centigrade;a hemolysin active at 37 C. after chilling, requiring the presence of a thermolabilecomponent of serum for hemolysis; a positive Donath-Landsteiner test but no evidence of syphilis. In addition there was clubbing of the digits with certain otherroentgenologic changes in the bones; absence of any other etiologic factors knownto be concerned with such anemia; uneventful improvement under massive transfusion therapy, with apparent recovery from his hematologic disorder whenstudied two years later.

Note: ACKNOWLEDGMENTOur thanks are due to Dr. Maxwell Finland and Dr. Philip F. Wagley for suggestions in preparingthis report. We are especially indebted to Dr. T. Hale Ham for his patient and critical advice and encouragement.

     

THE EFFECT OF DIET ON THE HEMOGLOBIN, ERYTHROCYTE, AND LEUKOCYTE CONTENT OF THE BLOOD OF THE RHESUS MONKEY (MACACA MULATTA)

1. Rhesus monkeys fed purified rations supplemented with adequate amountsof the B vitamins, ascorbic acid, and whole liver substance maintained the following average blood picture:

See PDF for Table

2. Natural diets or purified rations supplemented with liver extract do not support the above blood picture. The hemoglobin is lower and there is an increase inthe range of the total leukocyte count and in the neutrophil-lymphocyte ratioto 2.0 ([unknown]). These figures are similar to the values in the literature and generallyaccepted as the normal.

3. Previous reports have shown the characteristic blood dyscrasias which develop when monkeys are fed certain B vitamin-deficient diets. These changes aresummarized graphically in this paper.

4. The importance of determining the concentration of hemoglobin and theformed elements of the blood as a diagnostic test in nutritional studies has beenshown.

Note: We wish to acknowledge our indebtedness to Merck and Co., Rahway, N. J., for some of the crystalline vitamins; to Wilson Laboratories, Chicago, Ill., for the various liver preparations; and to LederleLaboratories, Inc., Pearl River, N. Y., for synthetic folic acid.The authors are grateful to Miss Ethel Thewlis for aid in determining cellular elements and to Drs.Harry A. Waisman and James H. Shaw for assisting in early parts of the work.

     

Specificity of lytic factors for erythrocytes,leukocytes and platelets in a case of pancytopenia

A case of chronic idiopathic pancytopenia in a young girl is presented, in whichthe pancytopenia was shown to be due to increased destructions of all 3 blood celltypes. Antileukocyte and antiplatelet antibodies were demonstrated by transfusion methods as well as by in vitro agglutination, while differential agglutination provided evidence of a plasma factor causing increased red cell destruction.

Cross absorption experiments demonstrated the presence in the patient’sserum of at least 2 separate and distinct antibodies, specific for leukocytes andplatelets respectively.

Observations on the phagocytic behavior of leukocytes and on the electrophoretic mobility of leukocytes and platelets exposed to the patient’s serum arereported.

Submitted on October 21, 1955 Accepted on March 24, 1956     

Studies on Agranulocytosis. II. The Effect of Chlorpromazine upon the Influx of S35 L-Cystine and L-Methionine into Human Leukocytes

1. When whole blood was incubated in vitro with S-35 L-cystine and L-methionine, the blood cells became radioactive.

2. Preincubation of whole blood from normals and from patients susceptibleto agranulocytosis with chlorpromazine showed no effect upon uptake of S-35L-cystine and L-methionine by leukocytes.

3. The in vivo administration of S-35 L-cystine was followed by the appearance of radioactive leukocytes. Peak radioactivity occurred in leukocytes in 5to 12 days.

4. Pretreatment of test subjects with large doses of chlorpromazine did notblock the uptake of S-35 L-cystine by leukocytes in vivo. Leukocytes of womenshowed an increase in the incorporation of S-35 L-cystine, in vivo. Studiesperformed in vivo on two persons during recovery from agranulocytosisshowed enhanced uptake of L-cystine in one and a normal uptake in the other.

Submitted on March 24, 1960 Accepted on July 13, 1960