Megaloblastosis Produced by a Cytosine Antagonist: 1-beta-D-arabinofuranosylcytosine

1. Cytosine arabinoside induced objective, but temporary, decrease of tumormasses in three patients with lymphosarcoma and slight decrease in some lesions in two out of ten treated patients with disseminated carcinomatosis.

2. In doses of 3 to 50 mg./Kg. given at varying intervals, cytosine arabinosideinduced definite megaloblastic changes in the marrow of all patients studied.Mitotic abnormalities similar to those found in other megaloblastic anemiasalso occurred.

3. Associated with bone marrow changes, depressions of hemoglobin, whiteblood cells and platelets in the peripheral blood were observed.

4. The exact mechanism of action of cytosine arabinoside has not beenelucidated. It is speculated that because of the close structural similarity between cytidylic acid, cytosine arabinoside could interfere with DNA synthesis.

Submitted on August 6, 1962 Accepted on November 7, 1962     

The First Observation of Homozygous Hemoglobin S-Alpha Thalassemia Disease and Two Types of Sickle Cell Thalassemia Disease: (a) Sickle Cell-Alpha Thalassemia Disease, (b) Sickle Cell-Beta Thalassemia Disease

Six patients with sickle cell-thalassemia disease are reported together withhematologic and genetic data. A case of homozygous hemoglobin S-alphathalassemia disease, the son of parents with asymptomatic sickle cell-thalassemia disease and sickle cell trait, is presented, showing the possibilities involved in the presence of two genes for hemoglobin S and one gene forthalassemia.

Submitted on December 7, 1962 Accepted on July 15, 1963     

The Familial Aplastic Crisis in Hereditary Spherocytosis. Urocanic Acid and Formiminoglutamic Acid Excretion Studies in a Case with Megaloblastic Arrest

A case of herditary spherocytosis who presented with an aregenerative crisisis reported. Evidence of megaloblastic hemopoiesis was present and was accompanied by the urinary excretion of large amounts of urocanic acid following oral dose of histidine hydrochloride. The severe illness in this patientwas accompanied by a reticulocytopenia in a younger sister who, however,remained well clinically.

Submitted on November 16, 1961 Accepted on March 8, 1962     

Heterogeneity of Hemin

A method for the separation of the hemin of hemoglobin into three fractionsby ascending paper chromatography is presented. The relative concentrationof each fraction of hemin in normal dog and human hemoglobin is fairly constant. The relative concentration of the three fractions varies in induced anemiain dogs and in various types of human anemia.

Submitted on January 11, 1962 Accepted on May 31, 1962     

Hemoglobin MKankakee, A New Variant of Hemoglobin M

1. A new variant of hemoglobin M (hemoglobin M_Kankakee) has been detected in a family in Illinois.

2. The spectroscopic and electrophoretic features of this new mutant aredescribed.

3. Hybridization with canine hemoglobin indicates the presence of abnormal chains.

Submitted on March 26, 1962 Accepted on June 3, 1962     

Kinetics of the Alkali Denaturation of Hemoglobin in the Single Erythrocyte

A microspectrophotometric method was used to record the alkali denaturation kinetics of the hemoglobin in the single erythrocyte. The results showedthat differently reacting types of hemoglobin were co-existing in the single cellfrom human fetal or adult chicken blood.

Submitted on August 6, 1962     

Hemoglobin S/C disease in a pregnant woman with crisis and fat embolization syndrome

The complications of painful crisis and megaloblastic anemia are hallmarks of the pregnant patient with hemoglobin S/C disease. We describe here the clinical course in a patient with hemoglobin S/C disease in whom painful crisis and the fat embolization syndrome developed postpartum with severe neurologic abnormalities. Response to exchange blood transfusion was dramatic, and the patient recovered without neurologic impairment.     

Urinary methylmalonic acid excretion and clinical features in megaloblastic anemia due to vitamin B12 deficiency

Urinary methylmalonic acid (MMA) excretion in megaloblastic anemia due to vitamin B12 (B12) deficiency was studied using a colorimetric method. Average MMA excretion in 20 patients with untreated B12 deficiency was 164 mg/day, whereas it increased to 518 mg/day following oral administration of 10 g L-valine. Urinary MMA correlated significantly with platelet number, erythroblast percentage and deoxyuridine suppression test, while no correlation was found with hemoglobin, leukocyte number, reticulocyte, serum LDH, serum B12 and folate concentration. Patients with neurological disturbances excreted significantly larger amounts of MMA than those without neurological disorders. The results also indicated that MMA could be a useful adjunct for differentiation of megaloblastic anemia from myelodysplastic syndromes showing marked megaloblastic changes.     

Metabolism of Heterogenic Hemoglobins: Fe59 Incorporation in Sickle Cell Trait

The relative rates of incorporation of Fe⁵⁹ into heterogenic hemoglobinswas studied in four patients with sickle cell trait. Three of the patients werefree of superimposed disease, while one had active pulmonary tuberculosis.In all subjects there was a significantly greater incorporation of radioiron, permilligram of hemoglobin, into hemoglobin S than into hemoglobin A.

The data indicate that in sickle cell trait the rates of synthesis of theheterogenic hemoglobins are not proportional to their circulating concentrations. Two interpretations appear possible. Since the size of the intra-marrowpool of hemoglobin S was not known, it is possible that there exists a smallerpreformed pool of the abnormal hemoglobin, with the isotope making itsappearance first in hemoglobin S. However, it is also possible that hemoglobinS is synthesized at a rate which is greater than that reflected by its circulatingconcentration. This implies that the relative concentrations of hemoglobin Sand hemoglobin A vary from erythrocyte to erythrocyte, and that those cellswith the greatest proportion of hemoglobin S are selectively destroyed.

     

Schwere mikrozyt?re An?mie bei megaloblast?ren Ver?nderungen im Knochenmark

We discuss the case of a 32 year-old male with severe microcytic anemia (hemoglobin 2,9 g/dl) and megaloblastic changes in the bone marrow. The patient reported of substantial dietary weight loss. The family history was positive for β-thalassemia. Previous blood work showed iron deficiency with mild anemia. Further work-up verified β-thalassemia minor and revealed severely decreased vitamin B12 levels with positive anti intrinsic-factor antibodies, pathognomonic for autoimmune pernicious anemia. The paradoxon therefore dissolved as a pernicious anemia with megaloblastic changes with microcytic erythrocytes due to β-thalassemia.     

Hemoglobin Zurich. I. A New Hemoglobin Anomaly Associated with Acute Hemolytic Episodes with Inclusion Bodies after Sulfonamide Therapy

A new abnormal hemoglobin was observed in 15 members over four generations of a large Swiss family and has been termed "Hemoglobin Zürich."The discovery of this hemoglobin was prompted by a severe hemolytic crisisin two members of the family after sulfonamide therapy. During this episode,virtually all erythrocytes and reticulocytes contained a single large inclusionbody which was visible with Giemsa and brilliant cresyl blue stains. Outsidethe hemolytic episode, the erythrocytes revealed no morphologic abnormalities.The results of enzyme studies were all within normal limits. The associationof a hemoglobinopathy with a drug-induced inclusion body anemia withoutany demonstrable enzyme defect is a new entity. The anomalous hemoglobinis inherited as a dominant character and affects both sexes. Thus far, onlythe heterozygous form has been observed.

Submitted on April 9, 1962 Accepted on June 20, 1962     

Hemoglobin H Associated with an Uncommon Variant of Thalassemia Trait

A 26 year old American housewife of Sardinian extraction with chronichypochromic anemia was found to have a hemoglobin component identicalto hemoglobin H. The A₂ hemoglobin fraction was decreased. Relatives werefound to exhibit the hematologic features of thalassemia trait. In this pedigree,in contrast to the usual finding in the "thalassemia trait," the A₂ values werenot increased. The same observation had been made in the only other comparable report.

Submitted on August 15, 1959 Accepted on November 20, 1959     

Influence of hemoglobin E trait on the antimalarial effect of artemisinin derivatives

To determine whether hemoglobin E trait influences the antimalarial effect of artemisinin derivatives, we retrospectively compared 32 case patients with hemoglobin E trait to 32 control patients who did not have hemoglobin E, beta-thalassemia, glucose-6-phosphate dehydrogenase deficiency, or alpha-thalassemia trait on the basis of a mean corpuscular volume > or =78 femtoliters. All patients were admitted to the Hospital for Tropical Diseases in Bangkok, Thailand, with acute falciparum malaria. Control patients were matched to case patients with hemoglobin E trait by treatment with artemisinin derivatives versus other antimalarial drugs, by ethnic group, and by parasite count. Among 38 patients treated with artemisinin derivatives, the presence of hemoglobin E trait was associated with significantly faster parasite clearance (2.9-fold; 95% confidence interval [CI], 1.4-6.3; P=.006). Among 26 patients treated only with other antimalarial drugs, hemoglobin E trait did not significantly enhance parasite clearance (hazards ratio, 1.1; 95% CI, 0.5-2.5; P=. 8). Hemoglobin E trait may potentiate the antimalarial effect of artemisinin derivatives.     

Clearance Kinetics of Haptoglobin-Hemoglobin Complex in the Human

In 15 human Subjects the rate of clearance of haptoglobin-hemoglobin complex was rectilinear with respect to time between plasma levels of 175-20mg. of bound hemoglobin.

Submitted on August 16, 1961 Accepted on March 15, 1962     

Vitamin E Deficiency in the Monkey. IV. Further Studies of the Anemia with Emphasis on Bone Marrow Morphology

Nuclear abnormalities were observed in all the erythroid precursors in thebone marrow of vitamin E-deficient monkeys. Many of these cells were multinucleated. The remainder of the marrow elements appeared normal. Reasonsfor considering the anemia to be primarily due to inadequate erythropoiesisare given.

Serum iron, glutathione stability of the erythrocytes, hemoglobin electrophoresis, osmotic fragilities and platelet counts were all found to be normalin the vitamin E-deficient monkey.

Submitted on March 23, 1962 Accepted on May 12, 1962     

Studies on abnormal hemoglobins. VIII. The gelling phenomenon of sickle cell hemoglobin: its biologic and diagnostic significance

1. When sufficiently concentrated sickle cell hemoglobin containing solutionsare exposed to a constant stream of CO₂ gas, the hemolysates gel. This gellingphenomenon is indicative of the presence of S hemoglobin and cannot be obtainedwith any other type of human hemoglobin in the absence of S pigment. Thelowest S hemoglobin concentration (Gm. per cent) of a hemolysate at which thegelling phenomenon can still be elicited is designated as its lowest gelling point.

2. A simple apparatus was developed to analyze the gelling phenomenon understandardized conditions. It could be shown that the lowest gelling points ofhemolysates prepared from erythrocytes of the sickle cell trait (containing A +S hemoglobins), of the "C variant" (containing C + S hemoglobins), and fromsickle cell anemia cells (containing S + F hemoglobins) differ distinctly. Furtherexperiments suggest that the presence of A hemoglobin decreases the minimalamount of S pigment required for gel formation, and that type C hemoglobinreduces this amount even further. F hemoglobin seems to exert no significantinfluence on the gelling phenomenon. Serum albumin is also capable of decreasingthe amount of S hemoglobin required for gelation.

3. A sickled erythrocyte is visualized as an S hemoglobin tactoid or gel, specifically influenced by the companion pigment which interacts with the S compound.Thus, in the sickle cell trait, a positive sickling test is not only caused by thepresence of S hemoglobin, but also by its interaction with A hemoglobin. Onlyin the sickle cell anemia cells does sickling seem to depend solely upon the interaction of the S hemoglobin molecules.

4. The readily demonstrable differences of the lowest gelling points of hemolysates prepared from the various types of sickling red cells form the basis of thediagnostic gelling test which distinguishes sharply between sickle cell anemia andsickle cell trait erythrocytes. By this procedure atypical cases of sickle cell disease,for example, those whose erythrocytes contain C hemoglobin, may also bedetected.

Submitted on April 21, 1953 Accepted on May 25, 1953     

Combinations of hemoglobin G,hemoglobin S and thalassemia occurring in one family

1. A Caucasian family is described in which, on the basis of clinical, hematologic and biochemical findings, it is postulated that the genes responsible forhemoglobins S and G and for the thalassemia defect are present.

2. On the basis of the study of this family, it is concluded that:

a. The genes responsible for hemoglobins G and S cannot be alleles.

b. The genes responsible for hemoglobin G and thalassemia cannot be alleles.

c. The absence of hemoglobin A in individuals heterozygous for two "hemoglobin genes" does not provide critical evidence concerning the allelic relations ofsuch genes.

d. In this family, heterozygosity for the gene responsible for hemoglobin Gresults in an asymptomatic trait condition, in which some 40% of the hemoglobinis abnormal. When the gene responsible for G is combined with a hemoglobin Sgene or a thalassemia gene, or both, the presence of hemoglobin G does not significantly alter the expression of these genes on their combinations. For example,an individual of the phenotype SG, whose hemoglobin contained no demonstrableA, was clinically a sickle cell trait, in that he showed no evidence of physiologichandicap.

e. Individuals heterozygous for both the G and thalassemia genes may showon electrophoresis only hemoglobin G. This illustrates the unreliability in somecases of diagnosing genotype on the basis of electrophoretic findings.

f. On the basis of these findings, hemoglobin G should probably be regardedas a normal variant of hemoglobin rather than as an abnormal type of hemoglobin.

Submitted on August 4, 1956 Accepted on September 15, 1956     

The Frequency of Heterozygosity for S and C Hemoglobins in Western Pennsylvania

The frequency of AS and AC type hemoglobin was studied by hemoglobin electrophoresis in 26,882 residents of WesternPennsylvania. In the black population, thefrequency of S trait was estimated at7.4% and the frequency of C trait at 1.8%.Reasons for variation in frequency fromone to another subpopulation are discussed. The frequency of S and C trait wasindependent of age, suggesting little or nomortality can be attributed to these traits.Sickle trait was no more common in outpatients than in the general population,suggesting little or no significant trait-associated morbidity.

Submitted on November 2, 1973 Accepted on May 20, 1974     

Differentiation between Vitamin B12--deficient and Folic Acid--deficient Megaloblastic Anemias with C14--Histidine

Intermediary metabolism of the monocarbon pool and histidine in normalsubjects and patients with megaloblastic anemia was studied by continuousmeasurement of pulmonary excretion of C¹⁴O₂ and urinary excretion of C¹⁴after injection of L-histidine-2(ring)-C¹⁴. Cumulative pulmonary and renalexcretion of C¹⁴ for 1 month by two normal subjects approximates 45 percent of the amount injected. Within 4 months after injection of the doseused in this study, the resultant average tissue radiation decreases belowthe average natural terrestrial and cosmic radiation level.

Simultaneous determination of two parameters, (1) cumulative 1-hourpulmonary C¹⁴ excretion and (2) the time of occurrence of maximum C¹⁴O₂specific activity (T_max), may permit rapid and unequivocal differentiation between folic acid deficiency and vitamin B₁₂ deficiency in the pathogenesisof megaloblastic anemia. Folio acid deficiency results in marked diminutionof pulmonary C¹⁴ excretion (approximately 0.1 per cent of injection C¹⁴ in1 hour) and marked prolongation of C¹⁴O₂-specific activity T_max (approximately 3 hours), while both parameters are normal (approximately 1 percent and less than 1 hour, respectively) in patients with vitamin B₁₂ deficiencyand megaloblastic anemia.

Measurement during periods of reticulocyte response to either folio acidor vitamin B₁₂ demonstrate normal C¹⁴O₂-specific activity T_max but decreasedpulmonary C¹⁴ excretion. These observations suggest that prolongation ofC¹⁴O₂-specific activity T_max is a sensitive index of folic acid deficiency orblock and that if T_max is normal, pulmonary C¹⁴ excretion is a sensitiveindex of the relative partition of the active monocarbon pool between pathways for oxidation and pathways for nucleic acid synthesis.

This type of breath analysis seems to provide a quantitative dynamic representation of metabolic function which may be particularly useful in differentiating between the alterations of intermediary metabolism that occur inpatients with folic acid-deficient megaloblastic anemia and in patients withvitamin B₁₂-deficient megaloblastic anemia.

Submitted on August 24, 1962 Accepted on November 28, 1962     

Clinical and molecular correlations in the sickle/beta+-thalassemia syndrome

Sickle/beta thalassemia is a sickling disorder of varying severity which results from compound heterozygosity for sickle cell trait and beta-thalassemia trait. Clinical and genetic studies have shown an inverse correlation between the level of hemoglobin A and the severity of the disease. It has been suggested that the level of hemoglobin A may be a function of the severity of the beta-thalassemia defect. In this study, we use molecular biological techniques to test this hypothesis. We show that the interaction of the mildest of the beta+-thalassemia genes with the sickle gene results in a high level of hemoglobin A. However, the interaction in this case resulted in a severe sickling disorder in the absence of significant anemia. We hypothesize that a mild beta+-thalassemia gene may have two opposite effects on the clinical course of sickle/beta+ thalassemia: (1) A high level of hemoglobin A which probably confers a favorable antisickling effect and (2) decreased hemolysis leading to increased numbers of total circulating red cells, thereby increasing the blood viscosity and the propensity for sickling. The inheritance of heterozygous alpha thalassemia 2 in conjunction with the mild beta+-thalassemia gene and sickle gene in this patient may have further enhanced the latter effect and resulted in a severe sickling disorder.