Sea-blue histiocytes and Gaucher cells in bone marrow of patients with chronic myeloid leukaemia.

A retrospective study of 211 bone marrow aspirates from patients with chronic myeloid leukaemia (CML) was undertaken to assess the incidence of Gaucher cells and sea-blue histiocytes. A significant correlation between the presence of these cells and prolonged survival was seen. Such storage histiocytes occurred most often during periods of relapsed chronic phase. This study shows that Gaucher cells and sea blue histiocytes are a common feature of CML and that their accumulation seems to be associated with a prolonged increase in leucocyte turnover.

Giant lymph node hyperplasia of the mediastinum and refractory anaemia.

An example is described of the syndrome of refractory anaemia in association with the plasma cell variant of giant lymph node hyperplasia of the mediastinum; the anaemia responded to removal of the lymphoid mass. The entity of giant lymph node hyperplasia is discussed and its relationship to the haematological syndrome is considered.

Red cell hypoplasia, thrombocytosis, and leucocytosis: myelodysplastic and proliferative syndrome.

Three patients with chronic red cell aplasia also showed thrombocytosis or granulocytosis, or both. All had morphological evidence of myelodysplasia on examination of bone marrow aspirate but none had a detectable chromosomal abnormality. These patients seem to provide evidence of a separate entity within the spectrum of myelodysplastic and myeloproliferative disease.

Detection of erythroid hypoplasia in myelofibrosis using erythrokinetic studies.

The iron kinetic model described by Ricketts et al was used to study haemopoiesis in chronic myelofibrosis. The clearance of 59Fe-labelled transferrin from the plasma was analysed to quantify total, effective, and ineffective erythropoiesis, denoted by the terms marrow iron turnover (MIT), red cell iron turnover (RCIT), and per cent ineffective iron turnover (IIT%), respectively, in 12 cases of this disease. The patterns obtained were variable: values for MIT ranged from 24.4 to 510 mumol/l blood/day; those for RCIT from 0.4 to 119 mumol/l blood/day; and those for IIT% from 67 to 98%. One noteworthy feature was the presence in two cases of functional erythroid hypoplasia; these were characterised by severely reduced values for MIT (24.4 and 28 mumol/l blood/day) and RCIT (0.4 and 8 mumol/l blood/day.) A systematic study of the erythrokinetic features of myelofibrosis may indicate that erythroid hypoplasia is a more common cause of anaemia in this disease than has been previously recognised.

Benign familial polycythaemia.

An English family suffering from thalassaemia minor is described. Three generations are affected, and all the affected members had a considerably raised red cell count in the presence of slight or moderate anaemia, obviously abnormal peripheral films, and only slightly reduced M.C.H.C. values; and each had a moderately raised haemoglobin A(2) level, though foetal haemoglobin levels were normal. The presentation of a family with erythrocytosis recalls the condition described in the older literature as benign familial polycythaemia which was, in some cases at least, thalassaemia minor. It is suggested that the presence of a raised red cell count is a more reliable distinguishing feature than the presence of target cells, or the serum iron level, in thalassaemia minor.

Systemic mastocytosis, myelofibrosis and portal hypertension.

A case of systemic mastocytosis is described in which the finding on initial presentation was hepatosplenomegaly. No dermatological abnormality was present, and the bone marrow histology originally caused some confusion with primary myelofibrosis. The clinical course and the importance of distinguishing between these two diseases is discussed. The dermatological manifestation of systemic mastocytosis, in the form of urticaria pigmentosa, is well recognised, and alerts the physician to the underlying disease. In the absence of cutaneous signs, however, the diagnosis is less obvious. The case reported had predominantly marrow and splenic involvement by the disease process, giving rise to portal hypertension, and illustrates the problems of diagnosis which can arise.

A case of IgD myeloma presenting as diffuse osteosclerosis.

A case of IgD myeloma accompanied by diffuse osteosclerosis is reported. A trephine biopsy specimen showed only reticulin fibrosis, but histomorphometric analysis of a full thickness transiliac bone biopsy specimen showed increased trabecular bone mass, with no local deposit of tumour. An excess of bone surfaces were covered by osteoid seams, all of which showed active mineralisation, indicating a relative increase in osteoblastic activity; osteoclasis seemed to be unaffected. It is suggested that the cause of the generalised osteosclerosis might be production of an osteoblast stimulating factor by the myeloma cells.

Two-colour immunoenzymatic technique using sequential staining by APAAP to evaluate two cell antigens.

AIMS: To extend the alkaline phosphatase-antialkaline phosphatase (APAAP) immunoenzyme single stain method to a more generally applicable double stain technique. This will allow two primary antibodies of the same isotype of IgG and specifically the nuclear antigen bromodeoxyuridine (BRdU) to be evaluated with a cell surface antigen identifier. METHOD: Sequential applications of the APAAP method showed two antigen sites by different dye couplings to a common alkaline phosphatase substrate, producing blue and red reaction products on the same slide. Antigens on different cell populations as well as those in different compartments of the same cell were analysed. The method allowed a surface antigen monoclonal to be revealed first, using an optimal fixative, before alcohol/gluteraldehyde fixation was used to start the second (BRdU) staining sequence. RESULTS: An analysis of double staining of T lymphocyte subsets (CD4 and CD8) showed no significant difference in the order of application of the primaries (n = 10) and no significant difference from their corresponding single stain results (n = 50), confirming the validity of the technique where antigens are exclusively distributed. Other examples, including antigens distributed in different compartments of the same cell, displayed discrete staining which implied validity. CONCLUSION: Double staining by APAAP with this technique seems to be applicable to those cases where antigens are exclusively distributed and includes cases where different compartments of the same cell are stained. It is especially useful in revealing antigens that require different fixation and preparation--that is DNA incorporated BRdU with a surface antigen. But it does seem to have a limited ability to produce a dual colour at a common site.

Comparative ferrokinetic study with initial and extended iron clearance models.

Erythrokinetic studies were performed on 10 patients with chronic myelofibrosis and 11 patients with myelodysplasia (MDS). Values for plasma iron turnover, marrow iron turnover, and erythron transferrin uptake were derived using two ferrokinetic models. One entailed analysis of the extended plasma iron clearance over a number of days, the other comprised analysis of the initial plasma iron clearance during the first few hours of the study. A close correlation was found between the variables quantifying total erythropoiesis (marrow iron turnover and erythron transferrin uptake) in the two methodologies. Functional classifications produced by both models and based on the values for plasma iron turnover, marrow iron turnover, and erythron transferrin uptake were compared. Both models identified functional heterogeneity in the group with myelofibrosis and functional homogeneity within the MDS group. Each method produced comparable data on erythropoiesis. The main reason for analysing the extended plasma iron clearance is to differentiate levels of effective and ineffective erythropoiesis. The short analysis presents the practical advantages associated with a one-day study. This could be further enhanced if the level of effective erythropoiesis could be clearly defined.

High incidence of type II autoantibodies in pernicious anaemia.

AIMS: To investigate the incidence of type II autoantibodies to intrinsic factor in pernicious anaemia. METHODS: Three hundred and forty four serum samples submitted for intrinsic factor antibody (IFAB) analysis on clinical or laboratory grounds were tested by an established radioassay and a new enzyme linked immunosorbent assay (ELISA) method for type I and total IFAB, respectively. Sixty of these were found to be positive by ELISA; this method was used to test further, 40 samples of adequate volume for types I and II antibodies. RESULTS: Type II antibodies were detected in 39 of the 40 sera tested. A comparative analysis indicated that seven samples contained pure type II antibody, being positive for total and type II by ELISA, but negative for type I by both the ELISA and radioassay technique. CONCLUSIONS: The occurrence of type II antibody, both alone and in combination with type I, seems to be more common than has previously been recognised, and emphasises the advantage of using a technique which will detect both types of antibody.

Simple method for granulocyte-macrophage cell culture and staining in soft agar: comparison with a standard research technique.

A modified, small volume, two phase, disc culture system for CFU-GM (seven and 14 days of incubation) was compared with a standard single layer system. The 1 ml single layer cultures were counted unstained in situ before both sets of cultures were transferred to glass slides for staining. Bone marrows were cultured from forty eight subjects, including normal controls and patients with acute non-lymphoblastic leukaemia, acute lymphoblastic leukaemia, and myelodysplastic syndrome. Observer error was least with the disc cultures, whereas variation between replicate cultures was similar for both methods. A high degree of correlation was found between the two methods for both day 7 (r = 0.90) and day 14 (r = 0.91) cultures. The number of colonies and clusters was higher with the disc system, indicating better cloning efficiency. Analysis of subsets of clinical groups showed similar patterns of abnormality with both systems. The simplicity of the method makes the use of this technology possible in most laboratories, and the superior morphological resolution may increase the clinical usefulness of such studies.

Continuous assessment of performance in External Quality Assessment Schemes.

A simple, standardised procedure was used for processing data from External Quality Assessment Schemes and for producing performance charts. A graphic presentation of cumulative performance is generated for each test, using an integrated software package to display results in a standardised format. This permits interpretation of satisfactory and poor performances and facilitates identification of "outlying" results. Although most results are recorded as Deviation Indices, the system is flexible and can be used to present other performance variables, such as Percentage Deviations and relevant textual information relating to interpretative assessments. It is therefore readily adaptable for use by other pathology disciplines.

Effects of azathioprine on response of renal anaemia to subcutaneous recombinant human erythropoietin.

AIMS: To determine the effect of concomitant azathioprine treatment on the response of patients with renal failure to treatment with subcutaneous recombinant human erythropoietin (r-HuEPO). METHODS: Two groups of patients with renal failure not receiving haemodialysis were studied. One comprised seven patients receiving erythropoietin alone, the second consisted of nine patients who were also treated with azathioprine. The haematological changes were monitored, and the functional erythropoietic response was studied by two different ferrokinetic models. One analysed the initial, the other the extended plasma iron clearance. Studies were performed before r-HuEPO treatment on all 16 patients, and repeated on 11 of these when the target haemoglobin (10-11 g/dl) was achieved and stabilised. Total erythropoiesis was determined using both techniques. Analysis of the extended plasma iron clearance also permitted calculation of both effective and ineffective erythroid activity. RESULTS: The haematological response to r-HuEPO was the same for both patient groups. Measurement of total erythropoiesis by both ferrokinetic methods showed good correlation. For those receiving long term azathioprine, the percentage ineffective erythropoiesis was high compared with that of the other patients, and remained so for as long as they continued with azathioprine. For those uncomplicated by azathioprine treatment, r-HuEPO increased levels of both effective and ineffective erythropoiesis by the same degree. A substantial reduction in ineffective erythropoiesis was shown only by those patients who either discontinued or reduced their azathioprine once they started r-HuEPO treatment. CONCLUSIONS: Azathioprine increases ineffective erythropoiesis. In this study, the r-HuEPO dose was sufficient to overcome this effect and promoted effective erythropoiesis so that the anaemia lessened. Measurement of total erythropoiesis provided limited information on the functional changes involved, differentiation of effective from ineffective erythropoiesis being necessary to define the changes after azathioprine reduction or withdrawal.

Aplastic anaemia, acute myeloblastic leukaemia, and oxymetholone.

Four patients developed acute myeloblastic leukaemia after treatment of aplastic anaemia with oxymetholone. Two had previously shown an excellent clinical response to the drug and a third some improvement. Though no definite causal relationship between therapy and the onset of leukaemia has been established, the number of cases is greater than might have been expected by chance. The association of the two diseases is discussed.

Lymphopenia in histiocytic medullary reticulosis.

A survey of the Western literature of histiocytic medullary reticulosis (malignant histiocytosis) provided 104 case reports with sufficient data from which the presence or absence of an absolute lymphopenia could be ascertained. Of these, 46 (44%) were lymphopenic at presentation or within the subsequent 10 days. A survey of a series of publications containing detailed peripheral leucocyte counts recorded in patients with diseases that, like HMR, may present with, or develop, pancytopenia showed that the incidence of lymphopenia ranged from 14% (Hodgkin's: stages I & II) to 46% (acute myelofibrosis; systemic lupus erythematosus; angio-immunoblastic lymphadenopathy). It was concluded a that HMR should be added to the list of accepted causes of lymphopenia, b that lymphopenia, as an aid to the diagnosis of HMR, will be of limited value, c that when the peripheral leucocyte count of a patient is recorded in a case report, it should be accompanied by a full differential count.