Atypical familial hemolytic anemia

1. The genetic, clinical and hematologic features of an atypical chronic hemolytic anemia in two siblings of a French Canadian family have been described.

2. The anemia is normocytic, normochromic and not associated with anycharacteristic morphologic abnormality of the red cells.

3. Slight increases in osmotic and incubated mechanical fragility, as well asa more definite increase in aumtohemolysis were found which could not be demonstrated after splenectomy.

4. The survival time of normal red cells was shortened before splenectomy inone patient. Normal red cell survival was demonstrated in both patients aftersplenectomy.

5. The features which differentiate this hemolytic anemia from hereditaryspherocytosis are discussed.

6. French or French Canadian ancestry has been noted in some of the reportedpatients most similar to our own.

7. The association of this type of hemolytic anemia with blood group A hasbeen confirmed in our patients.

8. Splenectomy decreased the severity of the hemolytic process in both patients. This benefit may have resulted from removal of an extracorpuscuarhemolytic mechanism.

Submitted on September 15, 1955 Accepted on October 27, 1955     

Erythrokinetics: quantitative measurements of red cell production and destruction in normal subjects and patients with anemia

Red cell turnover of 19 normal subjects and 25 anemic patients was measuredwith the following technique: erythroid-myeloid ratio of the marrow, reticulocytecounts, plasma iron turnover, red cell utilization of radioiron, and urobilinogendeterminations. Measurements of blood production and destruction were so expressed as to allow comparison between normal and anemic individuals of different size and different red cell mass. The usefulness and disadvantages of eachprocedure in the study of anemia are discussed.

From studies of various types of anemia, it has become apparent that erythropoiesis must be defined in terms of total quantity of red cells produced and interms of the portion of red cells produced in the marrow which are delivered tothe circulating blood (effective versus ineffective erythropoiesis). A quantitativedefect alone exists when a normal ratio is maintained between effective andtotal erythropoiesis. Here, there are changes of similar magnitude of all erythrokinetic indices, although reticulocyte and urobilinogen values are occasionallydisproportionately high. The normal marrow appears to be able to increase itseffective red cell production to three times normal in acute anemia and six timesnormal in chronic anemia. In many disease states this maximal quantitativeresponse is impaired.

Dyspoiesis of the marrow is characterized by a dissociation of erythrokineticindices. Values which reflect total erythropoiesis (i.e., plasma iron turnover,fecal urobilinogen and erythroid-myeloid ratio of the marrow) are considerablygreater than the reticulocyte level and red cell utilization of radioiron whichrepresent effective erythropoiesis. Such defects may result in the pattern of ahemolytic process or aregenerative anemia, depending on their severity.

Submitted on October 26, 1955 Accepted on December 7, 1955     

Observations on the anemia of cryptogenetic splenomegaly. II. Expansion of the plasma volume

In cryptogenetic splenomegaly, although there is consistently a significantreduction in hemoglobin concentration and in the red cell count, the totalred cell volume may be reduced, normal or increased.

Following splenectomy the total red cell volume is either within normallimits or is increased, yet significant anemia persists.

Before splenectomy a significant increase in plasma volume is consistentlypresent. Following splenectomy the plasma volume falls, but it remains significantly greater than normal. It would appear that the greater the plasmavolume before splenectomy the greater is the fall following splenectomy.This fall in plasma volume is not a prompt response to splenectomy, for thefall which occurs one month after splenectomy is equalled or exceeded bythat occurring in the succeeding four months.

It is concluded that an expanded plasma volume before splenectomy contributes with the hemolysis previously reported to the development of theanemia encountered in cryptogenetic splenomegaly. Expansion of the plasmavolume at least contributes to the anemia which persists following splenectomy.

Submitted on February 12, 1957 Accepted on December 25, 1957     

Anemia following nerve resection

1. Unilateral sciatic and femoral nerve resection is followed by a markedand lasting fall in the red cell count and hemoglobin value in the albino rat.

2. There are different types in the course of the anemia.

3. A definite parallelism has been observed between the course andseverity of anemia and of trophic disturbances developing in the limb almostdeprived of its nerve supply.

4. The resection of different peripheral nerves equally results in anemia inthe albino rat. The grade of anemia depends on the size of the area suppliedby the resected nerve.

5. It is essential in the development of nerve resection anemia that thearea with impaired nerve supply and trophic disturbances remain in theorganism. Humoral or neurohumoral effects emitted from this area with impaired metabolism are the factors eliciting the anemia observed.

6. Anemia following nerve resection is not due to a change in the distribution of blood cells, nor is it a sequel to loss of blood.

7. Secondary infections, or manifestations of some latent infection (firstof all, bartonellosis) are not involved in the development of nerve resectionanemia.

8. Chronic tissue destruction induced in areas with intact innervationcauses no anemia.

9. Anemia following nerve resection is not due to a deficiency in nutrition.

10. Nerve resections are followed by changes in the entire blood cell system,especially in the formation, maturation and destruction of erythrocytes.

11. Hematologic studies carried out after nerve resections indicate an increased reticuloendothelial activity and the impairment of iron and nucleicacid metabolism.

Submitted on January 30, 1958 Accepted on July 17, 1958     

Autoerythrocyte sensitization; a form of purpura producing painful bruising following autosensitization to red blood cells in certain women

Four patients with purpura who manifested an unusual response to bruisingwere studied. This response was characterized by the development of an areaof painful ecchymosis at the site of trauma followed by progressive erythemaand edema. This unusual tissue response was seen only in women. The variousfeatures of the cases suggested an autosensitization by the patients to theirown blood.

Special studies utilizing skin testing procedures indicated an abnormal tissueresponse of sensitivity to red blood cells. The factor responsible was presentin the red cell stroma and was not associated with the hemoglobin.

The clinical manifestations and possible therapy are discussed.

This syndrome may represent another example of autosensitization such ashas been speculated for lupus erythematosus, some forms of acquired hemolyticanemia and of thrombocytopenic purpura, and for an increasing number of disease states.

Submitted on October 5, 1954 Accepted on February 7, 1955     

Red cell stroma in dogs; variations in the stroma protein and lipid fractions related to experimental conditions

Red cell stroma has not been prepared free of iron and/or hemoglobin. It isnot certain whether the iron is a contaminant or an essential constituent of thestroma. Extensive washing does not eliminate iron from the stroma but doescause loss of the stroma constituents, protein and lipid.

Red cell stroma protein is increased in anemia due to blood loss in the dog, onthe average in severe anemia, almost twice the figures recorded in the poolednormal samples of red cell stroma.

Lipid fractions under the same conditions show minor fluctuations: approximately 90 per cent of total lipids in the red cells are recovered in the stroma bythese methods.

The technic for isolation and fractionation of dog erythrocyte stroma is described. Analyses made from the same blood sample by 3 different workers givecomparable results.

Red cell stroma deserves careful study in controlled experimental conditions.

Submitted on October 10, 1952 Accepted on November 26, 1952     

Macrocytosis Resulting from Early Denucleation of Erythroid Precursors

In an attempt to elucidate the mechanism of production of macrocytosis inacute anemia, we studied changes in red cell volume and hemoglobin content, the RNA level of normoblasts and reticulocytes and RNA synthesis inreticulocytes of rabbits made anemic by blood loss or phenylhydrazine administration. The results were as follows:

(1) In severe phenylhydrazine anemia, red cell volume and hemoglobincontent per cell increased to twice the normal values.

(2) The RNA level of normoblasts decreases with the maturation of thecells and reaches a minimum at the orthochromatic stage. The decrease issimilar in the normal and anemic rabbits.

(3) The RNA level of reticulocytes in the bone marrow is higher in anemicthan in normal rabbits. In general, the RNA level of reticulocytes of anemicrabbits is comparable to that of the polychromatic normoblasts, while in normal rabbits this value is comparable to that of orthochromatic normoblasts.

(4) Autoradiographs of reticulocytes incubated with H³-uridine indicatethat the increased level of reticulocyte RNA of anemic rabbits is not due tonewly synthesized RNA.

From these results, we conclude that in an "emergency" situation of erythropoietic stimulation denucleation of normoblasts occurs at the polychromaticstage of red cell maturation, with skipping of the terminal cell division toorthochromatic cells and formation of macrocytic reticulocytes and red cells.

Submitted on August 28, 1963 Accepted on April 30, 1964     

Studies on abnormal hemoglobins. V. The distribution of type S,sickle cell,hemoglobin and type F,alkali resistant,hemoglobin within the red cell population in sickle cell anemia

1. By transfusing sickle cell anemia erythrocytes with a relatively high concentration of F hemoglobin into normal recipients, it was demonstrated that thedisappearance rates of the transfused cells and of their alkali resistant pigmentconsistently showed great discrepancies. These observations suggest an unequaldistribution of the F pigment within the erythrocyte population. A nonuniformdistribution of F hemoglobin could also be detected in vitro by exposing sicklecell anemia bloods to mechanical trauma for a longer period of time. The cellsmost resistant to trauma contained a higher percentage of F hemoglobin thanthe original blood specimen.

2. The red cell population of patients with sickle cell anemia seems to be composed of three main fractions: (1) cells containing S hemoglobin and no or littleF hemoglobin, (2) cells containing both pigments and (3) cells containing Fpigment with no or little S hemoglobin.

3. The erythrocytes carrying mostly S hemoglobin have the shortest life span,whereas the red cells containing mostly F hemoglobin have the longest survivaltime.

4. The significance of these findings in regard to clinical and genetic aspectsof sickle cell anemia is discussed. No direct correlation is demonstrable in anindividual patient between the absolute amounts of either type S or type Fhemoglobin and the severity of the anemia. The latter depends on the variablesize of the portion of red cells containing mostly S hemoglobin, and also on theability of the marrow to replace this particular fraction.

Submitted on August 5, 1952 Accepted on September 10, 1952     

Erythrokinetics in pernicious anemia

Quantitative measurements of the erythropoietic activity of the marrow, ofcirculating red cell production and destruction have been made in patients withpernicious anemia in relapse and during response to vitamin B₁₂ therapy.

Total erythropoietic marrow activity as reflected by turnover of heme components proceeds at a rate of approximately 3 times normal. The delivery ofviable red cells to the circulating blood, however, does not increase above normal. This would indicate that the greater portion of marrow activity is ineffective in terms of blood production. This marrow dysfunction coupled with anincreased rate of cell destruction of approximately 3 times normal is responsiblefor the anemia. Total erythropoiesis is somewhat less, and effective erythropoiesisconsiderably less, than that which may be expected of the normal marrow underthe sustained stimulus of anemia.

The reticulocyte count is shown to be an unreliable index of blood productionin untreated pernicious anemia due to loss of reticulum from cytoplasma ofmany red cells before their delivery into circulation.

During the response to vitamin B₁₂ the ineffective erythropoiesis is convertedto effective erythropoiesis, whereas total erythropoiesis remains unchanged.The rate of blood production during recovery is 3 to 4 times normal.

Submitted on January 23, 1956 Accepted on May 3, 1956     

Erythrokinetics in the Megaloblastic Anemia of Tropical Sprue

Blood production and destruction were measured in 10 patients with themegaloblastic anemia of tropical sprue. Methods employed included the determination of the erythroid/myeloid ratio of the marrow, plasma iron turnover, red cell utilization of Fe⁵⁹ and Cr⁵¹ red blood cell survival. Rates ofproduction and destruction were compared to normal.

Patients with the megaloblastic anemia of sprue were usually not irondeficient. Total bone marrow erythroid activity did not approach the maximal response seen in other hemolytic anemias, and there was a marked decreasein the delivery of erythrocytes to the peripheral blood. The rate of red bloodcell destruction was increased, but as the red cell volume decreased, the totalmass of erythrocytes destroyed per day varied from less than normal totwice normal. Bilirubinemia was not marked, because the amount of hemoglobin destroyed daily was usually not excessive and excretory function wasnot impaired. The severity of the anemia was largely related to the erythrocyte production defect.

     

The anemia of the Di Guglielmo syndrome

The physiopathology of the anemia of the Di Guglielmo syndrome (erythremic myelosis) was studied in 11 patients with the acute and chronic varieties of the disease. Ferrokinetic studies were performed in three additionalpatients.

1. The anemia was normochromic and macrocytic; in contrast to the meancorpuscular volume, which was elevated, the mean corpuscular hemoglobinwas often normal. In several patients the mean corpuscular hemoglobin concentration was slightly lower than normal, suggesting slight hypochromia.

2. Reticulocytes were often increased but bore no relationship to the degree of the anemia nor to the shortening of the red cell life span. The reticulocyte count is an unreliable index of blood production in this disease.

3. The degree of erythroblastemia was highly variable. No direct correlation existed between the degree of erythroblastemia and the acuteness of thedisease, nor was there any relationship between the degree of erythroblastemiaand either the degree of anemia or the degree of erythrocytic destruction.

4. The bone marrow showed striking erythroblastic hyperplasia. This wasusually of the megaloblastic type. Primitive erythroblasts (erythrogones) wereconspicuous. The erythroblastic hyperplasia was out of proportion to the relatively minor reticulocytosis or the relatively slight diminution in red cellsurvival.

5. The nucleated red cells of the marrow showed variable numbers ofmegaloblasts and megaloblastoid forms, suggesting the presence of a vitaminB₁₂ deficiency (pernicious anemia). However, the vitamin B₁₂ concentrationof the serum was elevated, and there was no response to the administrationof vitamin B₁₂ or folic acid.

6. Varying numbers of erythroblasts in the bone marrow and in the peripheral blood showed periodic acid-Schiff (PAS)-positive granules in the cytoplasm. No chemical abnormalities of hemoglobin could be detected either bythe method of paper electrophoresis or by the alkali denaturation test.

7. Diminished red cell survival was present in most cases, but it was of arelatively slight degree. It was due to an "intracorpuscular" defect of the redcells.

8. The often great increase in fecal urobilinogen output as compared witha relatively minor rate of red cell destruction suggests "heme pigment diversion" or increased destruction of precursor red cells, as in pernicious anemia,where the same phenomenon has been observed.

9. The great increase in the number of erythroid cells in the bone marrowand the increased rate of iron turnover as compared with the relatively minorincrease in red cell destruction and iron utilization point to an "ineffective"type of erythropoiesis. The high degree of "ineffective erythropoiesis" seenin this disease may be characteristic of the neoplastic proliferation of the redcell series.

10. In conclusion, the anemia of the Di Guglielmo syndrome is due to acombined disturbance: (1) an "ineffective" type of erythropoiesis of markeddegree, perhaps due to an acquired (neoplastic) defect in the uptake or utilization of B₁₂ by the erythroblasts and (2) increased hemolysis resulting fromthe increased destruction of defective red cells.

Submitted on June 11, 1958 Accepted on August 13, 1958     

Studies on the anemia of disseminated malignant neoplastic disease. II. Study of the life span of the erythrocyte

1. A study of the life span of the erythrocyte in patients with advanced neoplastic disease was performed by transfusing blood from 23 hospitalized patientsinto 53 healthy volunteers.

2. The Ashby technic for red cell labeling was used alone in 16 instances, Cr⁵¹technic in 52 instances, and a combination of the 2 technics in 8 instances.

3. Normal or nearly normal life spans were suggested by the slopes of curvesin 15 instances where whole blood from patients was transfused into volunteers.

4. Some shortening of the life span of the patient’s red cells was noted whenthese cells, separated from the plasma, were transfused into volunteers or backinto patients, possibly related to the handling during plasma removal.

5. Control studies using either Cr⁵¹ or Ashby labeling technic indicated anormal life span of approximately 120 days in the volunteers employed could beachieved by each method.

6. Values obtained with Cr⁵¹ were so similar to those using Ashby labeling thatthe easier Cr⁵¹ technic is recommended for future studies.

7. The normal erythrocyte transfused into patients with neoplastic diseasemay have a moderate to considerably shortened life span.

8. These studies seem to demonstrate an absence of an intrinsic defect in theerythrocytes of patients with neoplastic disease, and further favor the presenceof a hemolytic plasma factor of considerable importance in the pathogenesis ofthe anemia of cancer.

Submitted on August 27, 1955 Accepted on January 4, 1956     

Studies on the specificity of autoantibodies in acquired hemolytic anemia

A significant proportion of patients with autoimmune hemolytic anemia formautoantibodies of blood group specificity, rather than nonspecific autoantibodies.

Ashby survival studies suggest that in such cases properly selected blood,lacking the antigens against which autoantibody has been formed, can be transfused successfully.

These concepts are important not only for a better understanding of thenature of autoantibodies, but also can be applied to the practical management ofpatients with autoimmune hemolytic anemia.

Submitted on November 21, 1955 Accepted on January 26, 1956     

Congenital hemolytic jaundice; the pathogenesis of the hemolytic crisis

Six cases of congenital hemolytic jaundice with "hemolytic" crises are reported. It is demonstrated that during the development of the anemia an acuteaplastic condition is present in the erythropoietic tissue of the bone marrow withcomplete cessation of the formation of red cells. The reticulocytes disappear fromthe blood; jaundice, serum bilirubin and urobilinuria decrease to normal values;and the serum iron increases. This period is further characterized by leukopeniaand thrombocytopenia.

The spontaneous recovery is caused by a rapid regeneration of the erythropoietictissue resulting in a marked reticulocytosis in the peripheral blood, and there isalso leukocytosis, an increase in thrombocytes and a rapid fall of serum iron.

During the period of severe anemia an increase in the blood urea and uric acidoccurs.

Transfusion experiments revealed an average lifetime of approximately fifteendays for the red cells in congenital hemolytic jaundice, a fact which fully explainsthe development and symptoms of the crisis as a result of cessation in the formation of red cells.

The findings definitely contradict the theory that an acute increase in thehemolytic process is the reason for the crisis.

The crisis should be called aplastic and not hemolytic.

     

Hookworm Anemia: Iron Metabolism and Erythrokinetics

Iron metabolism, balance of red cell production and destruction and ironabsorption from hemoglobin were determined in 11 patients with heavy hookworm infection and severe anemia.

The plasma iron, total iron binding capacity, bone marrow hemosiderinand plasma Fe⁵⁹ clearance are in agreement with the idea that the anemia associated with hookworm infection is of the iron deficiency type.

The rate of red cell production measured by the E/M ratio, absolute reticulocyte count and plasma iron turnover showed an increase to about twicenormal, while the rate of destruction estimated by the T erythrocytesurvival showed a destruction about 5 times normal. This unbalance betweenproduction and destruction could explain the severity of the anemia.

The increase of fecal urobilinogen output to twice normal was interpretedas due to the metabolism of the hemoglobin lost into the intestine rather than toan increase of hemolysis.

The estimation of fecal blood loss in the patients whose red cells weretagged with Cr⁵¹ and Fe⁵⁹, showed that the radioactivity counted with Fe⁵⁹was only about 63 per cent of the radioactivity counted with Cr⁵¹. This difference was interpreted as due to iron absorption from the hemoglobin lostinto the intestine.

The mean daily fecal excretion of iron reaches 4.7 mg. Since the ironmetabolism in these patients is in equilibrium, we have concluded that theiron loss is replaced by the iron from food; this is in addition to the 3 mg.hemoglobin iron which is reabsorbed from the blood lost into the gut.

Submitted on January 9, 1961 Accepted on April 2, 1961     

Irreversible toxic inclusion body anemia; a rarely recognized syndrome; clinical and experimental studies

1. "Inclusion bodies," distinguishable from the Howell-Jolly bodies, were observed in the red blood cells of a patient with a severe refractory fatal anemia, whohad been receiving erythrol tetranitrate over a period of one year.

2. "Bodies" with similar staining characteristics were reproduced in cats withlarge oral doses of erythrol tetranitrate and other nitrates. These were generallyaccompanied by a temporary fall in the red cell count, followed by recovery uponwithdrawal of the drug.

     

Mediterranean anemia in the Negro; a re-evaluation of four patients and their families

1. Four Negro patients and their families previously reported in 1949 asexamples of Mediterranean anemia were re-evaluated with regard to hemoglobin composition. The data have been presented.

2. Mediterranean anemia was confirmed in one entire family and in the indexcase of another family.

3. Two entire families and one member of another family were found topossess hemoglobin C.

4. Differential diagnostic points of Mediterranean anemia and hemoglobin Cdisease are presented.

Submitted on June 20, 1955 Accepted on August 26, 1955     

Sickle-cell anemia in South Turkey; a study of fifteen cases in twelve white families

1. Fifteen cases of sickle-cell anemia in twelve white families in southernTurkey are reported.

2. In all these cases of sickle-cell anemia and their families, there was nosuggestion of anything Negroid in their features or coloring.

3. The hereditary trait of these patients has been investigated. In 53 healthymembers of twelve families 37 persons had sickle-cell traits.

4. With the exception of case 12, both parents of all cases had sickle-cell trait.

5. The possible explanations of the frequent occurrence of sickle-cell anemiaand the fairly high incidence of sickle-cell trait in this white community havealso been considered.

Submitted on May 26, 1955 Accepted on November 30, 1955     

The immunologic specificity of antiserum for trypsin-treated red blood cells and its reactions with normal and hemolytic anemia cells

1. Rabbits were immunized with both normal (Nrbc) and trypsinized (Trbc)human red blood cells and the antisera examined with normal, trypsinized,periodate-treated, and hemolytic anemia cells.

2. Absorption studies showed the presence of a fraction in both anti-Trbc andanti-Nrbc that was specific for trypsinized cells.

3. This T cell specific fraction from anti-Trbc serum (anti-TE) did not agglutinate or sensitize normal red blood cells, but agglutinated periodate-treatedcells. This latter specificity was shown to be a part of the modification producedby trypsinization.

4. Anti-TE also agglutinated the cells of fifteen of nineteen patients with acquired hemolytic anemia and three of thirteen cases of hereditary spherocytosis.

5. Antibody for trypsinized and normal cells was also detected in antiserumto normal cells. Absorption data suggested the presence in this antiserum ofantibody with a dual specificity for both types of cells.

6. The role of the antigenic modifications produced by trypsin in red cellimmunization and in hemolytic anemia is discussed.

Submitted on October 24, 1952 Accepted on April 24, 1953     

Hemolysis In Vitro and the Anemia of Leukemia

Autohemolysis occurs in vitro in the blood of some patients with leukemiaand other disseminated neoplastic diseases. It is known that patients with suchdiseases are frequently anemic and hemolytic disease frequently contributesto the anemia. The present study has demonstrated that the in vitro autohemolytic phenomenon is not necessarily associated with a short red celllife span. This suggests that the abnormality does not damage the red cellswhile they are in the circulation.

Submitted on November 7, 1960 Accepted on June 6, 1961