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Erythropoiesis has been studied in three patients with sideroblastic anaemia and one case of erythraemic myelosis. The marrows showed erythroid hyperplasia, plasma iron turnover was high, red cell iron utilization low, and retention of 59Fe prolonged in the marrow. A combined quantitative cytochemical and autoradiographic analysis showed an accumulation of early polychromatic cells in G2 and the presence of several cells which were apparently arrested after a period in DNA synthesis. DNA synthesis was rarely seen in cells with pronounced siderotic deposits. These results indicate the presence of ineffective erythropoiesis with a disturbance in the progress of early polychromatic cells through interphase, probably leading to intra-marrow cell death. In erythraemic myelosis there was also a reduced red cell production due to faults of cell division; the nature and consequence of the bizarre forms of cell replication are discussed.

SummaryThe clinical course and the haematologic events in a patient suffering from metastatic thyroid cancer after administration of 806 mCi of 131I are described. A serious bone marrow depression developed and was treated successfully. The haematological changes during the early and late phases of the radiation injury were studied in detail and compared with those after external irradiation. The haematological events after internal irradiation with 131I are characterised by initial neutrophilic leukocytosis, protracted lymphopenia, slowly developing anaemia reaching lowest values about 3 months after administration, erythroid hyperplasia in the bone marrow after recovery from bone marrow depression and prominent cytological features of the bone marrow, especially pronounced erythropoietic polyploidy.

During the study of an inbred strain of Wistar rats which spontaneously develop hypertension when they reach a weight of approximately 150 g, it was found that these animals also develop an erythrocytosis. A significant increase in red cell count was observed in spontaneously hypertensive (SH) rats (8-11 x 10(6) RBC/mm(3)) when compared with normotensive rats (6-7 x 10(6) RBC/mm(3)) of the same strain. This increase in red cell count paralleled the increase in body weight and the rise in blood pressure. Since the plasma volume, as measured with labeled albumin was normal, there was an absolute increase in red cells. The hematocrit and hemoglobin content of the blood measured in SH rats were only slightly greater than those found in normotensive rats. However, the mean cell volume (MCV) of the red cells in the SH rats was 45-47 mu(3) as compared with 51-53 mu(3) in normotensive rats.A fourfold increase in 24 hr (59)Fe incorporation into the red cells was found in the SH rats when compared with normotensive controls. The bone marrow of the SH rats showed erythroid hyperplasia. When the SH rats were treated with alpha-methyldopa (Aldomet 200 mg/kg daily, i.p.) the red cell count fell in parallel with the drop in blood pressure. No change in red cell count or blood pressure was observed in normotensive rats treated in the same manner. The erythropoietin titer was high in SH rats, and was undetectable in normotensive rats. These observations suggest a direct relationship between the hypertension and the erythrocytosis mediated by erythropoietin; both are genetically controlled.

Summary. What appears to be a hitherto unreported type of congenital anaemia has been found in six members of an Irish family. It is inherited in an autosomal dominant manner and is characterized by moderate anaemia, lifelong jaundice, cholelithiasis and splenomegaly, marked morphological abnormalities of the red cells (which are, however, well haemoglobinized), erythroid hyperplasia of the bone marrow with increased numbers of multinucleate red cell precursors, and the presence of large inclusion bodies in the normoblasts, both in the marrow, and in the peripheral blood after splenectomy. Potassium flux across the red cell membranes is increased and there is imbalanced globin chain synthesis with α-chain production exceeding that of β-chains by a factor of 2/1. Excess α-chains in the bone marrow form a pool of similar magnitude to that observed in β-thalassaemia heterozygotcs but the latter do not have red cell precursor inclusion bodies or the degree of ineffective erythropoiesis seen in the present cases. The most likely molecular mechanisms for this disorder are either an ‘overproduction abnormality’ of α-chain synthesis, or a defect in cell division leading to increased amounts of genetic material per cell, a mechanism postulated recently as a basis for the unusual distribution of red cell enzyme levels in congenital dyserythropoietic anaemia.

Young male rats (115 g) were maintained on diets containing 4-8 mg of magnesium per 100 g of diet for 12 wk. By 3 wk the characteristic features of magnesium deprivation developed, including decreased plasma and tissue magnesium concentration, growth retardation, ruffled fur, patchy dermatitis, irritability, hyperemia of acral parts, onychymegaly, and in the most severely restricted, premature death. By 7 wk of deprivation, evidence of a hemolytic state existed and thereafter reticulocytosis, spherocytosis, shortened 51Cr red cell survival, erythroid hyperplasia of the bone marrow, and mild anemia were present. Erythrocytes during magnesium deficiency were characterized by decreased intracellular magnesium, glucose utilization, lactate production, ATP and 2,3-DPG concentration. A progressive decrease in red cell deformability as measured by cell elastimetry occurred. The reduction in lactate production and in ATP concentration due to magnesium deficiency may be causal in the development of rigid spherocytes with shortened survival in vivo. In addition, the shape and deformability alteration of the red cell may be due to defective membrane construction in a magnesium-deficient environment.

Two children with congenital dyserythropoietic anemia type II, are described and contrasted. This recently recognized disorder of unknown pathogenesis is characterized by variable degrees of anemia, splenomegaly, and jaundice. Diagnosis was established by the demonstration of erythroid hyperplasia and erythroblastic multinuclearity in the bone marrow, and a positive acidified serum test. Erythrokinetic studies revealed a significant degree of ineffective erythropoiesis. One of the patients demonstrated Gaucher cells in the marrow as a presumed consequence of the increased rate of red blood cell destruction. Means of distinguishing this autosomal recessive disorder from other refractory anemias is discussed.

The pluripotential stem cell (CFU) compartment of marrow and spleen was evaluated in mice subjected to an intense erythroid stimulus associated with phenylhydrazine-induced anemia. Erythroid hyperplasia occurred in both marrow and spleen. CFU in the marrow gradually declined to approximately 50 per cent of control levels (day 5) while their numbers in the spleen increased (fourfold) by day 3 and were maintained at this level for several days. These changes in numbers of marrow and splenic CFU were not associated with CFU proliferation. Thereafter, CFU in the marrow, but not in the spleen, entered active cell cycle. The data suggest that CFU migrate from marrow to spleen during the demands of severe anemia. The induction of marrow CFU into cycle further suggests a negative feedback, which, perhaps through cell-cell interaction, maintains stem cells at a critical compartment size. The failure of splenic CFU to cycle may reflect the converse effect, i.e. an inhibition on stem cell proliferation in the wake of an expanded stem cell pool.

The evolution of erythromonocytic leukemia has been studied in two patients. One (Case 1) presented with DiGuglielmo's syndrome manifested by erythroid hyperplasia, dyserythropoiesis, periodic acid-Schiff-positive erythroblasts, normal heme biosynthesis and ineffective erythropoiesis. In vitro stimulation of the patient's bone marrow with exogenous erythropoietin demonstrated decreased responsiveness. Progressive infiltration of the bone marrow and peripheral blood with primitive monocytic cells was accompanied by an increased number of hypodiploid cells. The second patient (Case 2) presented with a picture of polycythemia vera, progressing to myelofibrosis and terminating as erythromonocytic leukemia in which a paroxysmal nocturnal hemoglobinuria-like defect was demonstrated in the erythroid cells. The leukemic cells were hyperdiploid. It is concluded that erythromonocytic leukemia may result from clonal evolution occurring in any of the myeloproliferative syndromes.

SummaryThe degree of erythropoietic polyploidy (expressed by the index: IEP) of the bone marrow in 8 patients with thyroid cancer and 5 cases with thyrotoxicosis, both treated with radioiodine, has been studied. It was found that:1. the incidence of polyploid erythroblasts after administration of diagnostic doses of I131, compared with a group of healthy persons is slightly but significantly enhanced,2. after the administration of therapeutic doses in patients suffering from thyrotoxicosis or thyroid cancer, a further rise of erythropoietic polyploidy occurred in the early phase of therapy (up to 2 months), as compared with the values found after diagnostic doses only,3. in a later phase after radioiodine administration (3 months — 6 years), an increase of the number of polyploid erythroblasts was established only in those bone marrows which showed erythroid hyperplasia. In marrows with a hypoplastic erythroid series the IEP value was normal.Since the determination of the IEP is neither difficult nor time-consuming, the possibility of the use of this index for the assessment of changes caused by minute radiation doses is considered.

Transient erythroblastopenia of childhood (TEC) is a benign condition, occasionally preceded by an upper respiratory tract infection, affecting infants and children between 1 month and 6 years of age. At presentation, it is characterized by anemia, which may be quite severe, reticulocytopenia, and absent or markedly decreased erythroid precursors in the bone marrow. Spontaneous resolution occurs in two to eight weeks without therapy. With the exception of pallor, there are no abnormal physical findings.1-3 It has recently been demonstrated that serum and IgG specimens obtained at the time of diagnosis in four patients with TEC uniformly suppressed erythroid colony development from CFU-E whereas one patient had a serum inhibitor of erythropoiesis; thus, a transient immune suppression phenomenon is implicated as a possible factor in the development of anemia.4

The course of trypanosomiasis was observed over a period of 68 days in eight red sokoto goats experimentally infected with Trypanosoma vivax strain Y58. The goats developed parasitaemia five days after infection; the intensity of parasitaemia varied within and between individual goats. The course of the disease was acute, subacute or chronic. Anaemia was the principal clinicopathological feature of the disease. The rate of development of anaemia was not related to the degree of parasitaemia. Other clinical signs included emaciation, weakness, rough hair coat, profuse lacrimation and development of corneal opacity. Bone marrow of infected goats showed marked erythroid hyperplasia. Erythrophagocytosis and haemosiderosis in the bone marrow, liver and spleen were the principal histopathogical features in infected goats.

Interleukin-6 (IL-6) administered as a single intravenous (IV) injection caused the following changes in the peripheral circulation of rats: (a) a biphasic neutrophilia with an initial peak at 1.5 hours and a second sustained wave of neutrophilia between four and 12 hours, (b) a mild lymphocytosis at 0.5 hours and a mild lymphopenia between 1.5 and four hours, and (c) a reticulocytosis between 12 and 24 hours. The bone marrow showed no significant changes at 1.5 hours, suggesting that the peripheral neutrophilia at that time is caused by demargination of intravascular neutrophils and not by release of marrow neutrophils. The bone marrow at 12 hours showed a mild left-shifted myeloid hyperplasia of myeloblasts and promyelocytes and a tremendous erythroid hyperplasia of intermediate and late normoblasts. The bone marrow at 24 hours showed a continued mild myeloid hyperplasia and striking erythroid hyperplasia. In conclusion, IL-6 in vivo acts as a stimulus for myelopoiesis and erythropoiesis and causes accompanying peripheral changes in the number of neutrophils, lymphocytes, and RBCs.

At the onset of his disease a man with polycythaemia vera had chromosomally normal cells in the bone marrow and Rh blood group CDe/cDE. Five years later he developed pancytopenia with erythroid hyperplasia of the bone marrow. This was associated with the presence of a major abnormal clone, 45,XY,B-,C-,16+, a minor clone, 45,XY,2+,3-,C-, and a few apparently normal cells. At the same time Rh blood grouping showed two populations of red cells, one CDe/cDE and one giving the reactions of CDe/CDe which can be interpreted as CDe. If monosomic CDe be the correct interpretation the case provides a strong hint that the Rh complex locus is sited either on the long arm of a B-group chromosome or, less probably, on an autosome of the C group.

A 12-year-old patient with thalassemia and severe nasal obstruction secondary to erythroid hyperplasia within the inferior turbinates is presented. Although marrow expansion is almost a constant feature in patients with homozygous thalassemia, little reference has been made to its occurrence within the turbinates accounting for nasal obstructive symptoms.

The bone marrow biopsy specimens of 35 patients with benign and malignant erythroid hyperplasias were examined for the presence of hemoglobin A, hemoglobin F, muramidase (lysozyme), and transferrin, using an indirect immunoperoxidase method (PAP) on Zenker's-fixed paraffin-embedded bone marrow biopsy specimens and particles. Five cases of each of the following entities were studied: erythroleukemia and erythremic myelosis, acute granulocytic leukemia with maturation (FAB M2), polycythemia rubra vera, myeloproliferative syndrome in childhood, megaloblastic anemia (B12 and folate deficiency), erythroid hyperplasia (regenerating bone marrow and hemolytic anemia), and Ph' chromosome positive chronic granulocytic leukemia. Hemoglobin A was present in both the early and late erythroid precursors in all conditions. Hemoglobin F was the predominant hemoglobin in early erythroblasts of pernicious anemia and in both early and late erythroid elements in erythroleukemia and erythremic myelosis. Small quantities of hemoglobin F were present in a few isolated clusters in other conditions. Staining for hemoglobin F may be useful in identifying immature erythroid precursors and in distinguishing some cases of dysplastic erythroid hyperplasia from neoplasia. Additionally, these findings suggest that the maturational switch in hemoglobin synthesis operates with distinct pathways under different conditions.

Quantitative measurements of transferrin receptors, tissue transferrin, tissue iron uptake, and erythroid cellularity have been carried out in rats with altered erythropoiesis and altered iron balance. Erythroid receptors increased with erythroid hyperplasia, with the increase in proportion to the increased number of red cell precursors in phenylhydrazine-treated rats. Receptors increased disproportionately in iron deficiency due to both erythroid hyperplasia and an increase in receptors in the individual cell. There was a ratio of 1:1 between cell-related transferrin and receptors in circulating reticulocytes but a disproportionate amount of cell-related transferrin in fixed erythroid tissues (marrow and spleen), suggesting that there was some other reason for the concentration of transferrin in these tissues. Erythron iron uptake was increased in proportion to the increased receptor number in phenylhydrazine-treated animals but was reduced in iron deficiency because of the limited amount of iron-bearing transferrin. These studies demonstrate the dominant role of erythron cellularity and iron status in vivo in determining total receptor number and the importance of receptor number and iron supply in tissue iron uptake.

The clinical picture of anemia with erythroid hyperplasia of the bone marrow, but without excessive hemolysis, has been a puzzle to hematologists for many years. In 1907, Luzzatto described one of the first cases as “pseudoaplastic anemia” [70]. However, it was only in 1941 that this syndrome became generally accepted with the description of 100 cases by Bomford and Rhodes [18]. Originally, cases with folic acid deficiency were included in this “refractory anemia” group. However, with the discovery of folic acid in the late 1940s a clear separation could be made between folic acid deficient myelodysplastic states and refractory anemia. As early as 1953, Block et al. recognized that patients with refractory anemia may develop leukemia [16]. He coined the term “preleukemia” in his report on 12 patients, 11 of whom showed features of refractory anemia.

We measured steady-state levels of the human globin mRNAs in liver samples from several mid-gestational fetuses. RNA from the epsilon, gamma, beta, zeta, theta, and alpha globin genes were present in fetal liver samples isolated from 10-25-wk embryos. The abundance of all human globin mRNAs declined in older fetuses, presumably because of a gradual reduction in the proportion of erythroid precursors in the liver as development proceeds. The gamma:beta globin mRNA ratio in 10-18-wk fetal erythroblasts was 6-7:1, and in adult erythroid bone marrow the ratio was 0.02:1. In fetal liver samples, the relative abundance of epsilon transcripts was less than 1% that of gamma, and zeta transcripts less than 5% that of alpha. Embryonic transcripts declined in abundance during late fetal development and were not detected in newborn liver or adult erythroid bone marrow. theta globin mRNA also represented a minor species (less than 1% that of alpha) in fetal liver samples, but in contrast to the embryonic mRNAs, was most abundant in adult marrow samples obtained from patients with erythroid hyperplasia. These results support the hypothesis that globin protein levels are regulated by the relative amounts of each globin mRNA at various stages of erythropoietic development.

A. H. Mohamed , A. M. Saleh , S. Ahmed and M. El-Maghraby . Effect of Cerastes vipera snake venom on blood and bone marrow cells. Toxicon 15, 35–40, 1977.— In vivo experiments Lethal doses of Cerastes vipera venom injected intraperitoneally in rabbits produced a significant initial rise of the erythrocyte count 15 min after venom injection, followed by a progressive drop. Total leucocyte and platelet counts gradually dropped. The bone marrow picture showed erythroid hyperplasia 3–4 hr after venom injection. Sublethal doses produced a small insignificant initial rise of red cell count followed by a progressive drop during the first hr. In the second hr the counts rose and gradually reached the pre-injection levels after 24 hr. An initial leucopenia and thrombocytopenia was followed by fluctuations in both counts with significant leucocytosis and increased percentage of neutrophil after 24 hr. The platelet counts reached the pre-injection values in 24 hr. The bone marrow picture revealed erythroid hyperplasia 5–6 hr after venom injection. Reticulocyte counts were above normal levels. In vitro studies Incubation of 1 ml blood with 0·5 mg venom for 1 hr resulted in marked haemolysis as evidenced by reddish coloration of plasma, decreased rouleaux formation, microspherocytosis, disruption of leucocytes and drop of all cell counts.

PREGNANCY is normally a state of erythroid hyperplasia. Increased erythropoiesis during pregnancy is controlled by erythropoietin, which is augmented by the action of placental lactogen and inhibited by high levels of estrogen. 1 We describe a case of a patient with pure red cell hypoplasia during pregnancy that resolved completely in the postpartum period. Report of a Case On Jan 22, 1981, a 23-year-old primigravida came to the obstetric clinic at Naval Regional Medical Center (NRMC), Charleston, SC, for an initial prenatal visit at approximately 24 weeks' gestation. A routine hemoglobin level and hematocrit reading were noted to be 9.0 g/dL and 27.1%, respectively. Administration of ferrous sulfate, 325 mg, one tablet three times a day, was begun. A follow-up visit four weeks later revealed a hemoglobin level of 7.1 g/dL and a hematocrit reading of 24.3%. The patient denied noncompliance with respect to self-administration of the prescribed medication. The

We have developed a method that permits rapid identification of the consequences of mutations that alter beta-globin RNA processing in erythroid cells. S1 nuclease mapping techniques were used to analyze total bone marrow RNA obtained fron 15 patients who are clinically homozygous for beta-thalassemia and from 5 patients with erythroid hyperplasia from other causes. This analysis was facilitated by the use of single-stranded uniformly labeled DNA probes of high specific activity that were prepared by using recombinant phage M13-beta-globin DNA templates. Two abnormalities of RNA processing were found to occur with high frequency in these patients. Nine thalassemic patients were found to have increased levels of an RNA species that retains all sequences transcribed from intervening sequence 1, implying the presence of mutations that decrease the correct splicing of this intron. Seven of 15 thalassemic patients were found to have an abnormally processed RNA species that retains 19 nucleotides transcribed from the 3' end of intron 1; this abnormality is caused by the G leads to A substitution in intron 1 that is known to create an alternative splice acceptor site.

A large presacral myelolipoma associated with increasing constipation is reported in a 70-year-old obese diabetic female. The resected tumor was encapsulated and dark red to yellow. Light and electron microscopy revealed mature and immature hematopoietic tissue, lymphoid aggregates and mature adipocytes. Myelolipomas arising in extra-adrenal sites are rare. Considered in the differential diagnosis are reactive extramedullary hematopoietic tumors that usually occur in patients with severe chronic anemias. Patients with extramedullary hematopoietic tumors are characterized by anemia, frequent hepatosplenomegaly and abnormal peripheral blood smears, and may be any age. The tumors are usually multiple and usually located in the mediastinum or epidural space. In contrast, patients with extra-adrenal myelolipomas are usually older than 40 years, have normal blood studies, absent hepatosplenomegaly, and usually have chronic debilitating diseases or endocrinopathies. Extra-adrenal myelolipomas are single and usually occur within the abdomen. Extramedullary hematopoietic tumors have a predominance of the hematopoietic component, with erythroid hyperplasia of that component. Extra-adrenal myelolipomas may have a predominance of either the hematopoietic or fatty component, chiefly the latter, and generally have a more conspicuous lymphocyte population. Although the components of these tumors are the same, we consider them separable clinically, pathogenetically and, in many cases, pathologically.

The haematological features of 118 cases of primary myelodysplastic syndromes (PMDS) were reviewed to see how these could be related and classified according to the recent FAB proposals. A majority of the cases were elderly who presented with a macrocytic or normocytic anaemia and reticulocytopenia. Cases of acquired idiopathic sideroblastic anaemia (AISA) usually had normal leucocyte and platelet counts, erythroid hyperplasia, marked dyserythropoiesis and more than 20% ringed sideroblasts. Cases of refractory anaemia with excess of blasts (RAEB) had frequent neutropenia and thrombopenia usually with prominent dysgranulopoiesis and dysthrombopoiesis. Refractory anaemia or refractory cytopenia appeared morphologically to be a heterogeneous group. Leukaemic transformation did not occur in any of these 16 cases of AISA whereas six of the 34 cases of RAEB transformed into acute leukaemia. It appears that the cases of PMDS present with well defined haematological features which permit recognition of different groups; these latter groups appear to be morphologically and prognostically distinct.

• Seventeen patients aged 7 to 33 months, including a pair of identical twin girls, came to the Children's Memorial Hospital, Chicago, between January 1975 and December 1979 with transient normocytic anemia and reticulocytopenia. In 16 of the patients, bone marrow aspirates were obtained; 15 showed erythroblastopenia and one showed erythroid hyperplasia indicative of recovery. Except for a cluster of six cases occurring from July to October 1979, no seasonal variation was observed. Unlike patients with congenital hypoplastic anemia, all 17 patients were of normal stature. Other distinguishing features of transient erythroblastopenia of childhood included onset after early infancy, normocytosis, and rapid, spontaneous recovery. (Am J Dis Child1981;135:937-940)

Ferrokinetic studies and external organ measurements of radioiron were performed on five patients with pure red-cell aplasia (PRCA) in remission. One patient with PRCA in relapse was also studied. Of those in remission, one patient had erythroid hyperplasia and ineffective erythropoiesis after the remission occurred. This was indicated by a very short 59Fe clearance rate and reduced red-cell 59Fe incorporation, a marked increase of the erythron iron turnover over the fixed red-cell iron turnover, and a prolonged marrow transit time. These indices were normal three years later. Four patients had normal effective erythropoiesis while in remission. Two patients had an extended marrow distribution. These studies indicate that some cases of PRCA evolve into a state of ineffective erythropoiesis with erythroid hyperplasia. It is possible that in some patients, primary refractory anemia with ineffective erythropoiesis may be related to PRCA because of the evolution from one state into the other. Alternatively, a second pathologic process may have been acquired between the PRCA and normal hematopoiesis.

The thalassemias are a group of hereditary disorders in which there is a decreased production of one or more of the normal polypeptide chains of hemoglobin. In recent years with the advent of modern transfusion regimens the complications associated with chronic anemia and compensatory erythroid hyperplasia are rarely seen. The clinician is now faced with treating the complications related to repetitive transfusion therapy, including transfusional hemosiderosis, transmission of viral illnesses and proper timing of splenectomy. Chelation therapy for iron overload is an integral part of therapy and requires strict compliance if maximal benefits are to be achieved. Future areas of research include development of oral iron chelators, bone marrow transplantation and methodology for stimulating fetal hemoglobin production.

Infection of susceptible strain mice with the oncogenic Friend erythroleukemia virus initially results in fulminant erythroid hyperplasia. Several weeks later a frank erythroid leukemia develops. At the earliest stages of Friend disease there is extensive cell fusion involving erythroid cells but not platelets and granulocytes. Fusion was detected in experiments with allophenic (chimeric) mice whose component strains express electrophoretically distinct forms of the dimeric enzyme glucose phosphate isomerase (GPI). Infection of such animals with the polycythemic strain of Friend virus resulted in the rapid development of Friend disease. Concomitant with the appearance of early disease symptoms was the appearance in the red cells of the heterodimeric form of GPI, an unequivocal consequence of cell fusion. Platelet and granulocyte samples from the same infected animals failed to exhibit the hybrid GPI form. Furthermore, no hybrid dimer was evident in red cells from chimeric mice in which blood formation had been stimulated by phenylhydrazine treatment. These observations suggest that the occurrence of cell fusion early after infection by Friend virus is a significant aspect in the rapid development of neoplastic disease.

SummaryThe kinetics of erythroid proliferation have been studied in the newborn rat of different ages by the method of 3H-Tdr-labeled mitoses. The experimental results have been analyzed by the method of Steel and Hanes (7).A generation time of 10 hr has been obtained in the adult rats for the proerythro-blasts and basophilic erythroblasts, while in the newborn rat the generation time for the same cells was found to be of the order of 7.5 hr. It has been shown that these reductions are mainly due to decrease in the duration of G1 and G2 phases.The possibility is suggested that the shorter cell-cycle of the erythroid cells could, at least in part, account for the erythroid hyperplasia observed in the rat during the first 2 weeks of life.

An acutely ill 6-month-old female infant presented with massive hepatomegaly, accompanied by severe anemia with peripheral normoblastemia and thrombocytopenia. Bone marrow examination revealed erythroid hyperplasia with gross erythroid dysplasia, reduced granulocytic precursors, and virtually absent megakaryocytes. The bone marrow also contained completely necrotic cells occurring in clumps as well as singly. The appearances suggested bone marrow involvement by neuroblastoma. Accordingly, combination chemotherapy was instituted and laparotomy was performed as soon as her clinical condition had improved. Left adrenalectomy was carried out, because a small adrenal nodule of ganglioneuroma was present. Liver biopsy showed expansion of portal tracts by loose fibrous connective tissue containing hemosiderin deposits and some degenerate cellular debris, consistent with areas of involuted metastatic neuroblastoma. Complete recovery followed, and subsequent bone marrow examination was entirely normal. It is thought that the dyserythropoiesis probably resulted from the release of toxic metabolites from regressing neuroblastoma.

The frequency, type, and mechanism of the anemia caused by amphotericin B were studied in 30 patients with systemic fungal disease who received 37 courses of intravenous therapy. A decrease in hematocrit of 11 units or more was seen during 28 of the 37 courses. The anemia was normocytic, normochromic, and was not accompanied by reticulocytosis or erythroid hyperplasia. Red cell survival studies in five patients indicated that the rate of hemolysis was not affected by amphotericin administration. We concluded that the anemia was caused by suppression of red cell production by amphotericin imposed on mild preexisting hemolysis due to the systemic infection. The anemia was self-limited and return of the hematocrit to normal occurred in all but three cases after discontinuation of therapy.

In some 14% of patients with a ruptured spleen, the onset of the hemorrhage is delayed days or weeks after the initial injury. This syndrome is of clinical significance, for the patient may later present with a variety of confusing signs and symptoms. Four patients presented with this syndrome and exhibited a mass in the left upper abdominal quadrant, variable anemia, bone marrow findings of erythroid hyperplasia, and absent iron stores, ahaptoglobinemia, abnormal radioisotope spleen scans, and x-ray films of the abdomen.

A case of congenital dyserythropoietic anaemia with erythroblastic multinuclearity in a 36-year-old woman is described and the literature reviewed. The syndrome is characterized by a protracted clinical course, a relatively mild anaemia, a low reticulocyte count, slight hyperbilirubinaemia, splenomegaly, pronounced erythroid hyperplasia with reversal of the myeloid erythroid ratio, and in particular by the presence of multinucleated erythroblasts in the marrow. The picture of ineffective erythropoiesis is confirmed by erythrokinetic studies. The present case is the forty-first to be described in the literature and is the third from Britain. Thirty-one of these have occurred in seven families but a family history has been lacking in the remaining ten. The onset of anaemia occurred in childhood in 21 of the 41 cases.

THE metabolic fate of erythropoietin is not clearly understood. Stohlman has suggested that utilization of erythropoietin was proportional to the number of normo-blasts in the marrow1. This hypothesis was supported by the fact that the half disappearance time of erythropoietin in rats exposed to simulated altitude was longer in irradiated than in normal animals, after return to normal pressure. Moreover, the erythropoietin titre has often been found higher in the plasma of anaemic patients with bone marrow hypoplasia than in those with haemolytic anaemia.

A 63 year old man was admitted during a haemolytic crisis. A direct Coomb’s test was positive and a non-specific agglutinin detected. Bone marrow biopsy showed erythroid hyperplasia with megaloblastic crythropoiesis. Treatment with blood transfusion, antibiotics, intravenous hydrocortisone and oral prednisolone was followed by a reversion of crythropoiesis to normoblastic and a rise in the haemoglobin to a normal level. Biopsy of a lymph node revealed features of Hodgkin’s disease.

THE term "ineffective erythropoiesis" is used to describe a pathophysiologic state in which a significant fraction of the erythropoietic activity of the bone marrow fails to produce circulating red cells with a measurable life-span.1 , 2 Instead, much of the heme pigment synthesized appears to be destroyed while the maturing erythroid cells are still in the bone marrow or shortly after their release into the circulation.3 This results in a disproportionately low reticulocyte count in the peripheral blood despite marked erythroid hyperplasia in the bone marrow. Studies of plasma iron turnover, radioiron utilization, fecal urobilinogen excretion and myeloid-erythroid ratio in the bone . . .

Red blood cell production is regulated in part by a specific humoral factor, erythropoietin. 1-5 Although the physiologic properties of this substance have been studied extensively, the relationship of erythropoietin to clinical disease remains speculative. 6-12 This paper reports the results of an assessment of plasma and urine erythropoietin levels in 16 patients with acute or chronic bone marrow failure. In 1 patient serial studies were undertaken during the development of a fortuitous remission, while in another, plasma and urinary erythropoietin levels were compared in simultaneously collected samples. Methods and Material Sixteen patients with marrow failure were studied. Twelve were hospitalized at the St. Louis Veterans Administration Hospital, the remainder at the Barnes and Jewish Hospitals. * In 13 patients the disorder was chronic. The diagnosis in 4 patients was chronic bone marrow failure with erythroid hyperplasia; in 5, chronic bone marrow failure with erythroid hypoplasia; in 1, congenital erythroid hypoplasia

A cytochemical study of the enzyme content of megaloblasts compared with normoblasts under comparable conditions of erythroid hyperplasia has shown an increased activity of representative enzymes of the Embden-Meyerhof pathway, pentose phosphate shunt and tricarboxylic acid cycle in individual megaloblasts at all stages of maturation. The finding of a mixed population of cells with regard to enzyme content in late megaloblasts may be related to reported variations in prolongation of the intermitotic period at an earlier stage of maturation in megaloblasts. An increased cell content of soluble, NAD-linked, α-glycero-phosphate dehydrogenase in the megaloblast contrasts with reports of a selective decrease of this enzyme in homogenate studies of human and animal tumours which has been claimed to be a specific metabolic change in neoplastic cells. It is concluded that the increased serum lactate dehydrogenase levels in megaloblastic anaemia are derived from the intramedullary destruction of large numbers of megaloblasts containing an increased amount of this enzyme.

Contrasted with severe anemia followed by compensation by erythroid hyperplasia in neonate chicks infected with Plasmodium gallinaceum , embryonic chickens displayed neither anemia nor significant deviation from normalcy in the blood picture. In view of the fact that no volume changes in erythrocytes were observable it appeared that in these immunoincompetent animals there was destruction of neither uninfected nor infected erythrocytes. A corollary would imply the egress of merozoites from host cells without erythrocyte destruction.

Congenital dyserythropoietic anemias belong to a group of inherited conditions characterized by a maturation arrest during erythropoiesis with a reduced reticulocyte production in contrast with erythroid hyperplasia in bone marrow. The latter shows specific morphological abnormalities that allowed for a morphological classification of these conditions mainly represented by congenital dyserythropoietic anemias types I and II. The identification of their causative genes provided evidence that these conditions have different molecular mechanisms that induce abnormal cell maturation and division. Some altered proteins seem to be involved in the chromatin assembly, such as codanin-1 in congenital dyserythropoietic anemia I. The gene involved in congenital dyserythropoietic anemia II, the most frequent form, is SEC23B. This condition seems to belong to a group of diseases attributable to defects in the transport of newly synthesized proteins from endoplasmic reticulum to the Golgi. This review will analyze recent insights in congenital dyserythropoietic anemias types I and II. It will also attempt to clarify the relationship between mutations in causative genes and the clinical phenotype of these conditions.

Abstract 3009 Poster Board II-985 Congenital dyserythropoietic anemia type II (CDA II) is an autosomal recessive disorder affecting the normal differentiation-proliferation pathway of the erythroid lineage. It comprises an anemia of variable severity, jaundice, and variable splenomegaly. Erythroid hyperplasia with binuclearity or multinuclearity involving late erythroblasts in the bone marrow (BM) is a key feature of the diagnosis (Iolascon, 2001). In addition, on electron microscopy, vesicles of endoplasmic reticulum (ER) appear to be running beneath the plasma membrane (Alloisio, 1996). The principal biochemical feature is the hypoglycosilation of several proteins, such as transferrin and band 3 (Anselstetter, 1977). Recently, we identified SEC23B as the CDA II causative gene (Schwarz, 2009). The SEC23B gene encodes the SEC23B component which is part of the cytoplasmic coat protein (COP)II complex. COPII coated vesicles bud from the endoplasmic reticulum to export newly synthesized proteins to the trans Golgi. In yeast, COPII coated vesicles form by the sequential binding of Sar1-GTP, the inner complex proteins Sec23-Sec24 and the outer complex components Sec13-Sec31 on the endoplasmic reticulum (ER) (Fromme, 2008). Our aim was to characterize the COPII complex in CD34+ progenitor cells during erythroid differentiation by gene expression analysis. Mononuclear cells from the peripheral blood of normal subjects were isolated on a Ficoll-Hypaque gradient and CD34+ progenitors were separated on immuno-affinity columns. For erythroid differentiation, CD34+ cells of three different pools were separately plated on plastic culture dishes in methylcellulose medium containing 3U/mL erythropoietin (EPO) (Pinho, 2008). The cells have been cultured for 7 and 14 days after EPO treatment. Quantitative real time (qRT)-PCR on CD34+ during erythroid differentiation was performed to assess the gene expression level. The relative gene expression was calculated by 2*(-ΔCt) method (Livak, 2001), using GAPDH gene as internal control (figure 1). Mammalian orthologues have been identified for each of the five proteins involved in COPII coat formation. In humans, two isoforms of Sec23, Sar1 and Sec31 and four mammalian isoforms of Sec24 have been reported (Kuge, 1994; Paccaud, 1996; Wendeler, 2007; Mancias, 2008; Shugrue, 1999; Tang, 2000; Stankewich, 2005). We already demonstrated that during normal erythropoiesis a SEC23A down regulation is associated to SEC23B upregulation. These data suggest that SEC23B mutants could disrupt the COPII complex in erythroid lineage, and consequently induce CDA II (Schwarz, 2009). On the contrary, the two isoforms of SAR1 showed the same trend during erythroid differentiation: however, SAR1A isoforms has an higher expression when compared to SAR1B isoform. Among the four SEC24 isoforms, SEC24A, B and C showed the same increased expression after EPO treatment; SEC24D, indeed, showed a decreasing trend during differentiation time. Only one form of mammalian SEC13 has been described (Shaywitz, 1995), and it showed an increased expression after EPO treatment. Between SEC31 mammalian isoforms, SEC31A showed overall an higher gene expression compared to SEC31B gene. The gene expression analysis of SEC12, the transmembrane guanine nucleotide exchange factor that catalyzes the COPII vesicle formation by GDP-GTP exchange on Sar1 (Sato, 2004), revealed an higher mRNA level at 14 days when compared to 7 days after EPO treatment. Here, we have identified the isoforms of COPII complex most expressed during erythroid differentiation. This study could allow us to clarify the role of each COPII gene in erythroid lineage, and to identify other genes potentially involved in CDA II pathogenesis.Figure 1.Gene expression profile during CD34+ erythroid differentiation. Data are presented as mean ± standard deviation. *p value < 0.05 calculated on day 0 by Student t test corrected by Bonferroni method.Figure 1. Gene expression profile during CD34+ erythroid differentiation. Data are presented as mean ± standard deviation. *p value < 0.05 calculated on day 0 by Student t test corrected by Bonferroni method. Disclosures: No relevant conflicts of interest to declare.

FOUR cases of jaundice were previously reported from this laboratory in which the hyperbilirubinaemia was not related to the breakdown of circulating erythrocytes nor to a defect in hepatic function1. The hyperbilirubinaemia was familial, the serum bilirubin predominantly indirect-reacting pigment and the total urobilinogen excretion in urine and stool increased. The bone marrows showed erythroid hyperplasia and the increased marrow activity was reflected in a peripheral reticulocytosis. Erythrocyte destruction, as measured by chromium-51 red cell survival, was not a causative factor. It was suggested that the excess bile pigments were derived from marrow erythrocytes or their precursors—either by their destruction or by a direct synthesis of bilirubin from haem or its precursors. This short cut in bilirubin production was termed ‘shunt hyperbilirubinaemia’ and was thought to represent a marked exaggeration of the normal pathway in which at least 11 per cent of bile pigments (stercobilin) are derived from sources other than the haem of the circulating red cell2. To test this postulate we have since studied four normals and one of the affected patients (A. P., case II)1, using 2-14C-glycine as an index of haem and stercobilin formation.

5 cases of lead poisoning were investigated clinically. Of the 5 patients, 4 were male and 1 was female. The causes of lead poisoning in 3 cases were ingestion of herb drug pills and in 2 cases were occupational poisoning. Chief complain at admission in 4 cases were in defined colicky abdominal pain and constipation. Only 1 case complained of dizziness and palpitation without gastrointestinal symptom. On peripheral blood, normocytic normochromic anemia (mean Hgb 9.2gm/dl), reticulocytosis (mean 4.7%) and basophilic stippling were found in 100% of patients. Bone marrow aspiration was done in 4 cases. Erythroid hyperplasia and basophilic stippling were found in all 4 cases. Mean M : E ratio was 0.7 : 1. The lead concentration in serum was in creased in 4 cases (80%) of patients. Lead concentration, deltaaminolevulinic acid concentration in 24 hours collected urine were in creased in 5 patients (100%). Qualitative test of coproporphyrin of urine was positive in all 5 cases. 3 patients treated with Ca-EDTA, abdominal pain was improved rapidly and hemoglobin level was in creased slowly.

Since birth a 3-year old black girl has had severe refractory hypochromic microcytic anemia. Her usual red blood cell (RBC) values are Hgb 6.0 gm/dl, Hct 20%, Retic. 0.5%, MCV 52 fl, MCH 15 pg. Iron deficiency and clinically significant thalassemia were excluded by: lack of response to oral or parenteral iron, serum Fe/TIBC 231/276 μg/dl and serum ferritin 407 ng/ml; normal hemoglobin electrophoresis, absence of erythroid inclusions in the peripheral blood and bone marrow (BM), α/β globin synthetic ratio of 0.85 in peripheral blood reticulocytes and negative family studies. Intensive erythroid hyperplasia and numerous ring sideroblasts were present in the BM aspirate, and electron microscopy confirmed intramitochondrial deposits of iron. Free RBC protoporphyrin, urine porphyrins and porphyrin precursors, and BM ferrochelatase activity were normal. RBC ALA dehydrase, uroporphyrinogen synthetase and pyridoxal kinase activities were increased. Activity of BM ALA synthetase was markedly reduced to 5.5 pmoles ALA/106 erythroblasts/30 min (normal 127±29) but was enhanced 5-fold by pyridoxal phosphate (normal 0-25% increase). Therapy with oral pyridoxine has thus are not noticeably increased effective RBC production. The sideroblastic anemia in this patient appears to be related to an inherited defect in the initial step of heme biosynthesis.

Pure RBC aplasia developed in two renal transplant recipients who were receiving long-term azathioprine therapy. With substitution of cyclophosphamide therapy for azathioprine, erythroid hyperplasia and reticulocytosis developed at three weeks in one patient and at three months in the other. Selective erythroid toxic reaction is a potential problem that must be considered when anemia develops in patients receiving long-term azathioprine therapy. ( JAMA 240:552-554, 1978)

Erythroid colony (EC) formation and heme biosynthesis were studied in marrow cultures of a 2 year old girl with severe CSA and neutropenia. Bone marrow showed micronormoblastic erythroid hyperplasia, ringed sideroblasts and decreased granulopoeisis. The patient had not responded to hematinics. and prednisone. EC formation was determined in plasma clot (pc) and methyl cellulose (mc) culture systems after 7 days incubation by benzidine staining and expressed as CFUE/8×105 marrow cells. In pc cultures, EC(140) were fewer than normal adult controls (1100).However, cultures in me resulted in exuberant EC growth (1400). Good EC formation (900) also occurred without added erythropoeitin (ep), in contrast to no growth in controls. Addition of hemin stimulated EC formation (2000) and reversed pyridoxal PO4 inhibition. δ-aminolevulinic acid (ALA) synthetase activity of marrow itself was substantially decreased and heme oxygenase was increased. However, in me culture ALA synthetase, ALA dehydratase, C- 14ALA incorporation into heme and H-3 leucine incorporation into protein were normal and increased by addition of hemin. This patient's excellent capacity to synthesize hemoglobin and form EC in me culture, even in the absence of added ep, suggests that CSA may result from an unfavorable marrow microenvironment.

To the Editor. —The association between hyperthyroidism and hematologic abnormalities including thrombocytopenia and hemolytic anemia is well described.1-3We herein report an association between pancytopenia and hyperthyroidism both primary and secondary to excessive exogenous thyroid replacement. Report of a Case. —A 48-year-old woman was admitted to the hospital in 1974 with anemia and generalized weakness. Her medical history included a left ovarian papillary cystadenocarcinoma treated in 1971 with transabdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic irradiation. On physical examination, she had ecchymoses on both lower extremities and enlargement of the right lobe of the thyroid. Laboratory data indicated the following: hemoglobin level, 9.0 g/dL; hematocrit reading, 28%; WBC count, 3,100/cu mm; platelet count, 105,000/cu mm, reticulocyte count, 1.5%; serum iron level, 45 mg/dL; and total iron-binding capacity, 210. Coombs' test was negative. Bone marrow aspiration showed normocellularity with a slightly decreased megakaryocyte level and erythroid hyperplasia. Thyroid function tests

The existence of hemolysis in sickle cell disease has been documented by both indirect and direct methods. The existence of bone-marrow erythroid hyperplasia, reticulocytosis, indirect hyperbilirubinemia, and elevations of plasma hemoglobin and serum lactic acid dehydrogenase values show hemolytic disease. Direct studies of erythrocyte survival, including the Ashby differential agglutination technique as well as isotopic methods have all shown a markedly decreased red blood cell survival in the range of 10 to 30 days mean cell life-span. Data obtained by means of endogenous production of carbon monoxide have shown that the mean rate of heme catabolism is approximately six times normal but varies from 3 to 14 times normal in individual patients. These data document, by a relatively new technique, the consistent presence of a severe hemolytic process in sickle cell anemia.

The concept of malignancy of the erythron was reexamined by characterization of erythropoiesis in a 6-year-old boy with erythroleukemia. Erythroblastic and myeloblastic activities were monitored with bone marrow and peripheral blood examinations at three-to four-week intervals for 21 months. Fluctuations in myeloblastic proliferation bore no relationship to the profile of erythroid proliferation. In contrast, a direct relationship between severity of anemia and magnitude of erythroid hyperplasia was demonstrated, and a physiologic relationship between serum erythropoietin and the hemoglobin concentration was observed. Though qualitatively abnormal, erythropoiesis in erythroleukemia is regulated by physiologic control mechanisms.