THE EFFECT OF VITAMIN B12 ON THE ANEMIA AND COMBINED SYSTEM DISEASE OF ADDISONIAN PERNICIOUS ANEMIA

The effect of the parenteral administration of vitamin B₁₂ has been observed in eight patients with Addisonian pernicious anemia.Vitamin B₁₂ in initial doses of 50 micrograms or 25 micrograms induced satisfactory reticulocyte response and a return of erythrocyte count to within normal range in 60 days.In only two of the patients were secondary reticulocyte responses induced on a second injection of vitamin B₁₂.Concurrently with the hemopoietic response, the bone marrow changed from megaloblastic hyperplasia to normoblastic distribution.The paresthesias associated with combined system disease as well as disturbances in position sense and locomotor function may be entirely relieved or greatly diminished following injections of vitamin B₁₂.Maintenance injections of vitamin B₁₂ may be from 30 to 50 micrograms at intervals of one month, the amount depending upon the individual case.Vitamin B₁₂ may be used without untoward symptoms in patients previously sensitive to liver extract.     

Defective DNA synthesis in megaloblastic anaemia. Studies employing velocity sedimentation in alkaline sucrose gradients.

1. Autoradiographic experiments revealed that the average size of the replicating unit (replicon) in human phytohaemagglutunin-stimulated lymphocytes is 45 (+/- 1.3) micron. 2. A 5 min pulse of [3H]thymidine labelled DNA chains of approximately 40 S (15 micron) in control lymphocytes as revealed by velocity sedimentation in alkaline sucrose density gradients. Upon chasing in the absence of [3H]-thymidine the labelled DNA increased in size. By 6 h the bulk of the label co-sedimented with full-sized chromosomal DNA. 3. In untreated lymphocytes from patients with megaloblastic anaemia due to vitamin B-12 or folate deficiency or lymphocytes treated with methotrexate (10(-5) M) or hydroxyurea (5 . 10(-4) M) the increase in size of pulse-labelled DNA was slower than in control cells. 4. The block in maturation of pulse-labelled DNA to bulk DNA was not permanent. At 24 h of chase 75-80% of the pulse-label in both control and megaloblastic lymphocytes co-sedimented with bulk DNA. 5. We conclude that the lesions seen in DNA synthesis in megaloblastic anaemia due to folate or vitamin B-12 deficiencies occur through impaired biosynthesis of nucleotide precursors of DNA. Possible explanations of why the defects in DNA synthesis cause altered morphology of proliferating cells in megaloblastic anaemia are suggested.     

Anaemia of pregnancy: the changing postwar pattern.

A popluation survey covering over a quarter of a century has shown clearly the improvement in haemoglobin levels in women attending antenatal clinics at the Glasgow Royal Maternity Hospital. Various influences have helped to bring this about, foremost among these being routine early prophylaxis with combined iron and folate supplements. Indeed, a time-space relationship between changes in prophylactic therapy, rates of improvement, and the incidence of megaloblastic anaemia can be shown. The women at risk are still essentially the same except for a new group of young, unmarried girls, who must be watched. In our view the withdrawal of routine prophylactic therapy in pregnancy would be retrograde step.     

Vitamin B12 Malabsorption after Cobalt Teletherapy for Carcinoma of the Bladder

After cobalt teletherapy for carcinoma of the bladder, eight out of 14 consecutively admitted patients were shown to have malabsorption of vitamin B₁₂, though none had developed a megaloblastic anaemia. Despite lack of symptoms this group of patients is at risk after radiotherapy.     

Reticulocytopenia and "absence" of red cell autoantibodies in immune haemolytic anaemia.

A raised reticulocyte count is common in patients with immune or autoimmune haemolytic anaemia, and the result of the direct antiglobulin test (DAGT) is usually positive because of IgG or IgG and complement components on the red cells. We report on three patients who had low reticulocyte counts when they were most anaemic, and in whom no red cell autoantibodies could be detected by the DAGT. We postulate that reticulocytes may be selectively destroyed if antibodies are directed against antigenic sites on these young red cells, thus giving rise to a population of cells whose antigenic sites are poorly expressed. This theory might explain the low reticulocyte counts and the "absence" of antibodies (as tested by the DAGT) in such patients. Radioisotopic studies with 51Cr and 59Fe may provide useful information on the rate and sites of red cell destruction.     

Base Composition of Normal and Megaloblastic Bone Marrow DNA

PARRY has speculated that in megaloblastic anaemia, deficiency of folate or vitamin B₁₂ may mean that a population of cells is formed in the marrow containing DNA with subnormal amounts of thymidine, so accounting for some of the abnormalities of megaloblastic erythropoiesis¹. We have therefore determined the base composition of DNA from normal and megaloblastic cells and have also measured the amounts of 5-methylcytosine^2,3 present in these DNA preparations, as vitamin B₁₂ and folate are known to be concerned in many methylation reactions in man⁴ and could be directly or indirectly concerned in the formation of 5-methylcytosine.     

Sulphasalazine in rheumatoid arthritis.

Seventy-four patients with rheumatoid arthritis were treated with sulphasalazine. There was a significant improvement in clinical score, with substantial falls in serum C-reactive protein concentrations and erythrocyte sedimentation rate four weeks after starting the drug. Improvement was maintained in the 38 patients who remained on the durg for one year. The mean Rose-Waaler titre did not change. There was little difference between the results in seropositive and seronegative patients. The commonest adverse effect was dyspepsia, but five patients developed a megaloblastic anaemia and one patient neutropenia; all made a complete recovery. The results suggest that the drug has a disease-modifying action not attributable to its "salicylate" content. The mode of action might be by an antibacterial effect on gut flora.     

Primary Acquired Sideroblastic Anaemia: Response to Treatment with Pyridoxal-5-Phosphate

A 72-year-old woman with primary sideroblastic anaemia showed no response to treatment with pyridoxine. When she was given pyridoxal-5-phosphate there was a prompt reticulocyte response and sustained symptomatic improvement with satisfactory control of the anaemia.     

Alternative metabolic fates of thymine nucleotides in human cells.

Three types of experiments have been used to study the metabolism of thymine nucleotides by human cells. (1) Cells were labelled continuously with [3H]thymidine and the incorporation of label into DNA compared with the specific radioactivities of pools of individual thymine nucleotides separated by chromatography on polyethylene-imine-cellulose. (2) Cellular thymine nucleotides were labelled with [3H]thymidine at 13 degrees C, followed by incubation at 37 degrees C in unlabelled medium. Incorporation of label into DNA and loss of label from the nucleotide pools were monitored during the 'chase' period at 37 degrees C. (3) The experiments described in (2) above were repeated in the presence of the DNA-synthesis inhibitor cytosine arabinoside, in order to demonstrate more clearly and to quantify degradative pathways for thymine nucleotides. In phytohaemagglutinin-stimulated lymphocytes and in bone-marrow cells, only a proportion (25-60%) of labelled thymine nucleotide was incorporated into DNA, the rest being rapidly degraded and lost from the cell. In contrast, an established cell line (HPB-ALL) from a patient with acute lymphoblastic leukaemia of thymic origin incorporated 100% of its exogenously labelled thymine nucleotides into DNA. These results indicated that alternative metabolic routes are open to thymine nucleotides in human cells. In lymphocytes from patients with megaloblastic anaemia and in normal lymphocytes treated with methotrexate, the utilization of labelled thymine nucleotides for DNA synthesis was more efficient than in controls. These results offer an explanation for the observation of a normal pool of thymidine triphosphate in the cells of patients with untreated megaloblastic anaemia even though the amount of this compound available for DNA synthesis appears to be decreased.     

Plasma transcobalamins in haematological disorders

Plasma UBBC-B12 and transcobalamins were measured in 112 patients suffering from different haematological disorders. The data showed different patterns of changes in plasma transcobalamin profile in different haematological disorders. Plasma UBBC-B12 and transcobalamins were significantly higher than normal in untreated chronic myeloid leukaemia, acute promyelocytic leukaemia, nutritional megaloblastic anaemia and in refractory anaemias with hypercellular marrow. Normal levels of these proteins were noted in chronic lymphatic leukaemias, in primary and secondary hypereosinophilic states and in multiple myeloma. Subnormal levels of these proteins were observed in hypoplastic anaemia and acute lymphoblastic leukaemia. Chronic myeloid leukaemia patients during blast crisis and acute myeloid leukaemia patients except those suffering from acute promyelocytic leukaemia showed varying pattern of plasma transcobalamins depending on type of blast crisis or FAB subtype of AML. The significance of these changes in plasma transcobalamins have been discussed along with the experience of other workers in this field.     

Preferential invasion of reticulocytes during late-stage Plasmodium berghei infection accounts for reduced circulating reticulocyte levels

Insufficient circulating reticulocytes have been observed during severe malarial anaemia in both human and murine infection, and are often attributed to reduced production of red cell precursors. However, a number of Plasmodium species display a preference for invading reticulocytes rather than erythrocytes. Thus, the reduction in circulating reticulocyte numbers may arise as a result both of increased parasitization and lysis of reticulocytes, as well as decreased production. We have analysed both circulating reticulocyte numbers and the percentage of infected reticulocytes during murine Plasmodium berghei infection. We found a large reduction in circulating numbers when compared with an equivalent chemically induced anaemia. However, mathematical analysis of parasite and red cell numbers revealed the preference of P. berghei for reticulocytes to be approximately 150-fold over that for erythrocytes, leading to increased destruction of reticulocytes. Although erythropoietic suppression is evident during the first week of P. berghei infection, this preferential infection and destruction of reticulocytes is sufficient to mediate ongoing reduced levels of circulating reticulocytes during the latter stages of infection, following compensatory erythropoiesis in response to haemolytic anaemia.     

Prognosis in acquired aplastic anemia. An approach in the selection of patients for allogeneic bone marrow transplantation.

In a retrospective study, factors influencing the eventual course and outcome of patients suffering from aplastic anaemia were analysed. Of the 62 patients with pancytopenia concomitant with an aplastic or hypoplastic bone marrow, 36 have died during the first 24 months following diagnosis, 27 of these 36 cases within the first six months. 26 patients survived more than two years after presentation, but a further six of these cases succumbed during the following months. Of the 62 cases, 46 had neutrophil counts under 1 X 10(9)/l and platelet counts under 20 X 10(9)/l. These cases were subdivided according to their reticulocyte levels. In the age group of patients between 10 and 35 years, all those patients having more than 10,000/mul reticulocytes survived more than two years with only one exception, whereas only one of the 11 patients having reticulocyte counts below 10,000/mul has survived. In our series, the initial neutrophil and platelet counts were not of predictive value in identifying poor prognosis patients. The initial reticulocyte counts, however, appear to be a valid parameter for selecting patients in two groups, one with a favorable, and the other with an extremely unfavorable prognosis on conservative treatment. Young individuals with a poor predicted prognosis could thus be defined as possible candidates for bone marrow transplantation.     

CELL CLASSIFICATION AND KINETIC ASPECTS OF NORMOBLASTIC AND MEGALOBLASTIC ERYTHROPOIESIS

Mitotic indices and ³H-thymidine flash labelling indices have been determined in a total of 6000 erythroid cells from patients with megaloblastic anaemia (vitamin B₁₂ deficiency) and 4000 erythroid cells from patients with increased, normoblastic erythropoiesis. In the anaemic states there is a lack of mitoses in the more mature erythroid compartments relative to the number of mitoses in the early erythroid precursors; this must reflect skipped division and/or cell death in the later precursors. In order to further locate the deficit of mitoses, erythropoietic cells were subdivided in a way which aimed at stratifying them according to cell generations. It appears that there are four consecutive generations of recognizable proliferating red cell precursors. Balance considerations of mitotic figures suggest that in stressed normopoiesis all cells which enter generation III divide, whereas only about one-half of cells leaving generation III divide again in generation IV. In megaloblastic erythropoiesis it appears that only about one of three cells which leave generation III divide in generation IV. The data suggest that in megaloblastic anaemia, skipped division and/or cell death to a large extent take place in generation IV or at the transition from III to IV. In normoblastic erythropoiesis, the ratio labelled cells/mitotic cells is rather independent of cell maturation. In contrast, this ratio varies considerably in megaloblastic erythropoiesis, from 25:1 in early forms to 4-5:1 in late forms. As an explanation of the lack of mitoses, relative to cells in DNA-synthesis, in the early stages and the relative surplus of mitoses in the late stages it is proposed that cell cycle and cytological boundaries do not coincide in all cells. The present observations can be accounted for if a significant fraction of cells change their morphology (from basophilia to polychromasia) between their DNA-synthesis phase and the subsequent mitosis. It cannot be decided whether in addition there is a death function between DNA-synthesis and mitosis in the large basophilic megaloblasts, megaloblastic system could absorb a direct entry from the large basophilic cells amounting to perhaps about one-half of the flux through the S-pool of the large basophilic cells without being more dominated by very large cells than is actually the case; still, in large measure this will depend on the time from entry into the polychromatic pool until the subsequent mitosis or possible cell death. The alternative is a significant death function between S-phase and mitosis at the level of the large basophilic E1-E2 cells (generation I + II).     

THE EFFECTS OF CYTOSINE ARABINOSIDE ON THE CELL CYCLE OF CULTURED HUMAN LEUCOCYTES: A MICRODENSITOMETRIC AND AUTORADIOGRAPHIC STUDY

PHA-stimulated leucocytes treated with cytosine arabinoside showed a changed uptake of [³H]thymidine, a lowered mitotic index and chromosome damage. Combined autoradiography and Feulgen microdensitometry demonstrated inhibition of DNA synthesis. Cells in the S period of the cell cycle were arrested in their progress, and cells newly entering S accumulated at the beginning of this period. At stronger concentrations these effects on the cell cycle were complicated by the cytotoxic effect of cytosine arabinoside. The inhibition of DNA synthesis is considered in the light of the chromosomal damage and megaloblastic changes caused by cytosine arabinoside, and is compared to the different pattern of DNA arrest found in megaloblastic anaemia.     

The neuropsychiatry of megaloblastic anaemia.

The neuropsychiatric states of 50 patients with vitamin B12 deficiency and 34 patients with folate deficiency presenting with megaloblastosis in a general hospital were examined and compared. Abnormalities of the nervous system were found in two-thirds of both groups. Peripheral neuropathy was the most common condition associated with vitamin B12 deficiency and affective disorder with folate deficiency. The proportions of patients with organic mental change were similar in the two groups. Subacute combined degeneration of the cord was an uncommon complication and occurred only in the patients with vitamin B12 deficiency. There was no relation between haematological and neuropsychiatric abnormalities. The neuropsychiatry of megaloblastic anaemia seen in this study of patients presenting to haematologists or general physicians contrasts with that reported previously, before haematological techniques for separating the two deficiencies were introduced.     

Pigmentation in Megaloblastic Anaemia Associated with Pregnancy and Lactation

Generalized skin pigmentation in five African women with megaloblastic anaemia in the postnatal period was associated with low serum folate levels, as distinct from vitamin B₁₂ deficiency. It is suggested that the occurrence of pigmentation in both folate and vitamin B₁₂ deficiency may reflect a common abnormality of metabolism.     

Risk factors associated with malaria infection identified through reactive case detection in Zanzibar, 2012–2019

Kra monkeys (Macaca fascicularis), a natural host of Plasmodium knowlesi, control parasitaemia caused by this parasite species and escape death without treatment. Knowledge of the disease progression and resilience in kra monkeys will aid the effective use of this species to study mechanisms of resilience to malaria. This longitudinal study aimed to define clinical, physiological and pathological changes in kra monkeys infected with P. knowlesi, which could explain their resilient phenotype. Kra monkeys (n = 15, male, young adults) were infected intravenously with cryopreserved P. knowlesi sporozoites and the resulting parasitaemias were monitored daily. Complete blood counts, reticulocyte counts, blood chemistry and physiological telemetry data (n = 7) were acquired as described prior to infection to establish baseline values and then daily after inoculation for up to 50 days. Bone marrow aspirates, plasma samples, and 22 tissue samples were collected at specific time points to evaluate longitudinal clinical, physiological and pathological effects of P. knowlesi infections during acute and chronic infections. As expected, the kra monkeys controlled acute infections and remained with low-level, persistent parasitaemias without anti-malarial intervention. Unexpectedly, early in the infection, fevers developed, which ultimately returned to baseline, as well as mild to moderate thrombocytopenia, and moderate to severe anaemia. Mathematical modelling and the reticulocyte production index indicated that the anaemia was largely due to the removal of uninfected erythrocytes and not impaired production of erythrocytes. Mild tissue damage was observed, and tissue parasite load was associated with tissue damage even though parasite accumulation in the tissues was generally low. Kra monkeys experimentally infected with P. knowlesi sporozoites presented with multiple clinical signs of malaria that varied in severity among individuals. Overall, the animals shared common mechanisms of resilience characterized by controlling parasitaemia 3–5 days after patency, and controlling fever, coupled with physiological and bone marrow responses to compensate for anaemia. Together, these responses likely minimized tissue damage while supporting the establishment of chronic infections, which may be important for transmission in natural endemic settings. These results provide new foundational insights into malaria pathogenesis and resilience in kra monkeys, which may improve understanding of human infections.     

The effects of iron deficiency on neutrophil/monocyte apoptosis in children

OBJECTIVES: Iron is essential for DNA synthesis; its deficiency may lead to impaired DNA synthesis and subsequent alterations in levels of apoptosis. Here, we have aimed to investigate effects of iron deficiency anaemia (IDA) on apoptotic response of phagocytic cells and to understand whether the effect is reversible after iron supplementation. MATERIALS AND METHODS: Forty-nine IDA patients and 26 healthy controls, aged between 6 months and 12 years with similar demographic status, were considered. Neutrophil- and monocyte-apoptotic responses of IDA patients and the control group were compared by flow cytometry. Then, IDA patients were provided with oral iron supplementation. On day 15 of iron therapy, neutrophil- and monocyte-apoptotic responses of IDA patients were rechecked and were compared to those of control group. RESULTS: Neutrophil- and monocyte-apoptotic responses in terms of early and late percentages of apoptosis, and percentages of necrotic cells, were significantly less in IDA patients compared to the control group. The significantly low apoptotic responses of IDA patients rose to levels of the control group by day 15 of iron therapy. Besides, the effect of IDA on apoptotic responses was found to be more enhanced in severe IDA patients that those of mild IDA patients. CONCLUSION: Correction of differences after iron supplementation therapy implies that IDA might be a cause for changes in neutophil- and monocyte-apoptotic responses. The impact of this diminution of apoptotic cellular function in IDA should be further investigated, with longitudinal studies, in order to document the impact of any severe and/or long-lasting IDA on autoimmunity and malignancy.     

Severe thrombocytopenia associated with acute folic acid deficiency and severe hemorrhage in two patients.

Severe thrombocytopenia associated with acute folic acid deficiency in two inpatients is described. Both patients had severe hemorrhagic manifestations. A similar syndrome has previously been described in patients who have undergone extensive surgery or dialysis or both. The present cases show that acute folic acid deficiency can occur in other circumstances and may go unrecognized because other signs in the peripheral blood of a megaloblastic process may be minimal. A good response was obtained with folic acid therapy.