Ultrastructural characterization of the erythroid cells in a novel case of congenital anemia

Congenital dyserythropoietic anemia type I (CDA-I) is a rare genetic disease that affects erythropoiesis. On the other hand, hemoglobin H (HbH) disease is a severe form of alpha-thalassemia. We herein present ultrastructural and immunocytochemical data concerning the first reported case of congenital anemia with clinical and molecular diagnosis of HbH disease complicated by CDA-I-specific dysplasies of the erythroid cells. Fine structure and transmission electron microscope immunolabeling analysis of the bone marrow and peripheral blood samples were consistent with a potential co-existence of the two defects in the same patient, producing a novel and diagnostically important dyserythropoietic profile. In the patient under investigation both nuclear and plasma membrane of the erythroid cells are almost equally defective. The unknown defect causes the concomitant precipitation of beta- and alpha-globin chains (or hemoglobin), along with an unidentified protein(s). The unusual inclusions gain access to the euchromatin area and exhibit higher affinity for the plasma membrane than the classic inclusions of precipitated alpha- or beta-globin chains seen in thalassemia. The affected erythroid precursors are presented with severe nuclear distortions, endonuclear globin loads, morphological evidence of apoptosis and increased erythrophagocytosis. Plasma membrane distortions and the rate of protein precipitation were aggravated with differentiation. Our findings provide additional evidence for a specific activation of a beta-thalassemic-like mechanism in CDA-I, containing not only the hemoglobin biosynthesis as previously suggested, and interpret the prototypal hematological portrait, which is an HbH disease, modified and partially counterbalanced by the effect of CDA-I or an unidentified CDA-I-like disease. The reported data describe the complexity of the interactions between the CDA-I and the HbH disease, revealing essential pathogenic events of the novel anemia and, indirectly, of the CDA-I.     

Defective organization of the erythroid cell membrane in a novel case of congenital anemia

In the present paper, we demonstrate the erythroid cell membrane unique properties in a previously characterized case of hemoglobin-H disease, associated with congenital dyserythropoietic anemia type-I features. In order to explain the patient's cell membrane distortions and the high affinity for the various intracellular inclusions, we studied its composition and structure in comparison to other anemic and non-anemic cases. Red cells from peripheral blood were fractionated into cellular, membrane and protein extracts. Membrane attached immunocomplexes were separated and collected by immunoprecipitation. The subcellular fractions were analyzed by SDS-PAGE electrophoresis and immunoblotted against a variety of erythroid-specific antibodies. The protein composition of the membrane was characterized by immunogold electron microscopy. In the membrane of the CDA-associated case, we identified sialic acid and protein deficiencies, formation of protein crosslinkings, excesses of bound globin and immunoglobulins and aberrant peptides. In contrast to the typical hemoglobin-H disease, the ghost-bound globin exhibited preferential attachment to the skeletal proteins than the band 3 and the skeleton-bound globin consisted not only of beta- but also of alpha-globin chains. Another hallmark, probably associated with the CDA defect, was the participation of glycophorins in the membrane-bound immunocomplexes and the pathological clustering of the latter in the membrane. This study strongly suggests that the result of the combinatorial effects on the diseased membrane created a unique profile, quite distinct from the one observed in several typical hemoglobinopathies. Our observations shed light into critical membrane alterations leading to hemolysis in the novel CDA-associated disease and probably into the CDA-I or CDA-I-like diseases.     

Intravenous iron therapy restores functional iron deficiency induced by infliximab

Background and aimsInfliximab (IFX) and iron sucrose (FeS) are of high value in inflammatory bowel disease (IBD). We aimed to assess the relative role of both therapies in IBD related anaemia and their safety when used in combination.MethodsIBD patients with anaemia receiving a first series of FeS infusions in addition to IFX were prospectively followed. We investigated serum kinetics of erythropoietin (EPO), soluble transferrin receptors (sTFRs) and vascular endothelial growth factor (VEGF).ResultsData analysis included 87 patients of whom 49.4% achieved the target Hb level of 12.0 g/dL. IFX resulted in a significant increase of EPO and sTFR compared to baseline pre-IFX levels (p = 0.029 and p = 0.005 respectively) and after a 12-week combined FeS and IFX treatment, EPO and sTFR levels dropped significantly compared to pre-FeS levels (p < 0.001 for both). Infusion related adverse events were recorded in 2 IFX treated patients (2.3%, 0.7% of the infusions) and were mild. Disease activity and quality of life were not affected.ConclusionsIn anaemic IBD patients treated with IFX, combined administration of FeS is safe. Infliximab significantly increases serum EPO and sTFR levels resulting in an increased functional iron deficiency, which is restored after combined treatment with I.V. iron sucrose.     

Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents

Digestive Diseases and Sciences - Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known...     

Avascular necrosis of the femoral head among children and adolescents with sickle cell disease in Greece

Hemoglobinopathies are very common in Greece, the incidence of beta-thalassemia trait being 8% and that of sickle cell trait ranging from 1 to 32% in various districts. In Greek populations, sickle cell disease (SCD) is mainly represented by S-beta thalassemia.     

Haemarthrosis after superwarfarin poisoning

INTRODUCTION: Superwarfarins are widely used as rodenticides. They are similar to warfarin, but they are more potent and act longer. In case of poisoning, they cause severe bleeding, usually from multiple sites. CASE REPORT: A 67-yr-old man was admitted with melaena, epistaxis and haemarthrosis in his left knee. PT, INR and aPTT were markedly increased. Initially, the patient was treated with blood and fresh frozen plasma (FFP) transfusions. However at the second day, PT, INR and aPTT were even worse. The combination of persistent coagulopathy, normal mixing studies, normal liver function tests and absence of hepatic failure or malabsorption syndromes lead to the suspicion of vitK dependent clotting factors deficiency due to superwarfarin poisoning. Indeed, the patient admitted a suicide attempt with rodenticide, although he had previously denied it. Psychiatric evaluation revealed a disturbed personality. Melaena stopped after 7 d. Then, the patient was administered 30 mg of vitK daily for a total period of 4 months. CONCLUSIONS: Superwarfarin poisoning leads to severe bleeding, usually from multiple sites. Prolonged treatment with high doses of vitK is necessary. Haemarthrosis, as a complication of superwarfarin poisoning, is presented here for the first time in literature.