[Megaloblastic maturation disorder of erythropoiesis in plasmacytoma and chronic lymphatic leukemia]

Quantitative and qualitative investigations of the erythropoiesis in the sternal marrow of untreated 52 patients with a plasmacytoma and 46 patients with a chronic lymphatic leukaemia resulted in about half the cases in an indicated or more distinct megaloblastic disturbance of maturation in a part of the erythroblasts. These changes of the erythroblastic cells might be the expression of a neoplastic transformation and of a disturbance of the differentiation of the pluripotent stem cells in these diseases.

Abnormal deoxyuridine suppression test in congenital methylmalonic aciduria-homocystinuria without megaloblastic anemia: divergent biochemical and morphological bone marrow manifestations of disordered cobalamin metabolism in man

We studied two brothers (J.R. and M.R.) with the cobalamin D variant of congenital methylmalonic aciduria-homocystinuria, whose previously reported lack of megaloblastic anemia conflicted with current concepts of cobalamin's role in DNA synthesis and the "methyltetrahydrofolate (MTHF) trap" hypothesis. Both subjects were indeed hematologically normal, although J.R. had a mean corpuscular volume of 96 fl. However, both demonstrated abnormalities in the deoxyuridine suppression test. J.R. had an abnormal suppression value of 21.0% (normal less than 10%) that was correctable by adding hydroxocobalamin or folic acid in vitro but not MTHF. M.R. had normal suppression (8.9%), but demonstrated worsening (18.6%) when MTHF was added. J.R.'s classical deoxyuridine suppression pattern of cobalamin deficiency thus supports the trap hypothesis. However, his lack of comparable morphological changes suggests that impaired de novo thymidylate synthesis and the trap hypothesis, though valid, may not fully account for the megaloblastic maturation accompanying cobalamin deficiency. Equally noteworthy was the deleterious effect of MTHF on M.R.'s marrow, suggesting its potential usefulness as an in vitro "stress test" for latent cobalamin abnormality.

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.

Humoral and cellular immunity to intrinsic factor in myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease often associated with other autoimmune disorders. A case history of MG with a coexisting atypical megaloblastic anaemia with vitamin B12 deficiency and anti Intrinsic Factor (IF) antibodies, led to a study of humoral and cellular immunity to IF in 81 MG patients. Within this series, 3 other patients had a disturbed humoral and cellular immunity to IF. These 3 patients presented no other features of pernicious anaemia. The possible origins and significance of the anti IF antibodies in MG patients are discussed.

Fever in megaloblastic anemia

Charts of 122 patients with megaloblastic anemia due to either B12 or folic acid deficiency were reviewed for the presence of fever. Fever, defined as a temperature of 100 F (37.8 C) or more, was present in approximately 40% of the patients with both. The elevation was usually minimal but was sometimes over 104 F (40 C), usually in those with more severe anemia and thrombocytopenia, and greater elevations of SGOT and bilirubin concentration. In uncomplicated cases, the temperature returned rapidly to normal after adequate vitamin therapy. Failure of the fever to disappear rapidly with treatment should suggest the probability of some cause other than megaloblastic anemia.

Leukocyte hexose monophosphate shunt activity during phagocytosis in vitamin B12 and folic acid deficiencies

Little information exists about leukocytic function in megaloblastic anemia. A report of abnormal hexose monophosphate shunt and phagocytic activity only in vitamin B12 deficiency and not in folate deficiency prompted us to examine latex-stimulated hexose monophosphate shunt activity in the two conditions. Only two of our five patients with pernicious anemia demonstrated defective activation, while one of the two folate-deficient patients also had this defect. These findings clearly indicate that hexose monophosphate shunt activity is neither consistently impaired in vitamin B12 deficiency nor consistently unaffected in folate deficiency.

Brain damage in infancy and dietary vitamin B12 deficiency

A case of the exclusively breast-fed infant of a vegetarian mother is reported. Neurological deterioration commenced between three and six months of age, and progressed to a comatose premoribund state by the age of nine months. Investigations revealed a mild nutritional vitamin B12 deficiency in the mother, and a very severe nutritional B12 deficiency in the infant, with severe megaloblastic anaemia. Treatment of the infant with vitamin B12 resulted in a rapid clinical and haematological improvement, but neurological recovery was incomplete. Evidence is presented that dietary B12 deficiency was the sole cause of the infant's deterioration, and the literature relating to the condition is reviewed. It is recommended that all strict vegetarians (vegans), especially women in the child-bearing age group, take vitamin B12 supplements.

The pattern of severe protein-calorie malnutrition in Sudanese children attending a large hospital in The Sudan

One hundred fifty patients suffering from severe protein-calorie malnutrition, admitted in 1 month to the Pediatric wards of Wad Medani Hospital, Sudan, were classified according to the Wellcome classification. Marasmus was the prevailing type. It was common in the 2nd year of life, while kwashiorkor occurred mainly under the age of 12 months. Anthropometric measurements showed that kwashiorkor was an acute disease while marasmus and marasmic kwashiorkor were more chronic. The triceps skinfold was unexpectedly low in kwashiorkor. Of the simple measurements and ratios used for assessing the nutritional status, the head/chest ratio applied ot children over 1 year was not found to be reliable and the weight for head circumference correlated poorly with deficits in other variables. Non of the major clinical features was found to be pathognomonic of any type of severe protein-calorie malnutrition. Megaloblastic anemia was common.

Acute pancytopenia due to megaloblastic arrest in association with co-trimoxazole

Three patients who were taking co-trimoxazole developed acute pancytopenia due to megaloblastic arrest, and two of the three died while pancytopenic. One patient had a pre-existing megaloblastic anaemia. In the other two patients, there was no macrocytosis or neutrophil hypersegmentation despite the severe megaloblastosis. Because specific treatment is needed urgently, it is important to distinguish megaloblastic arrest from drug-induced hypoplasia.

[Significance of diabetes mellitus in the activation of the varicella zoster virus (author's transl)]

Eruptive herpes zoster infection (VZV) and its primary and secondary diseases are reported in 28 patients aged between 25 and 85 years. In 2 cases, malignant primary diseases were found. In 16 patients, a disorder of glucose utilization was diagnosed, 8 of them accompanied by a disorder of fat metabolism and 5 by a hyperuricemia. In one case a severe encephalomyelitis was observed. In 2 patients the activation of the VZV infection was related to the cytostatic or immunosuppressive therapy of a generalized Hodgkin's disease and a multiple sclerosis. Once a liver abscess as a sequel to amebic dysentery was diagnosed and once a megaloplastic anemia with symptoms of a funicular myelopathy following a vitamin B12 deficiency syndrome. In VZV infection the search for basal metabolic disorders is of particular importance.

Deaths from severe megaloblastic anaemia in hospitalised patients

In a series of 128 consecutive patients dying from severe megaloblastic anaemia, over half the deaths occurred within one week of hospitalisation and one third were sudden and unexpected. Congestive cardiac failure was extremely common in these patients and was often associated with pleural effusions. Just over half the patients were examined at autopsy and of these 42% had pleural effusions and 15% had pericardial effusions. The cause of the latter is unclear as is their clinical significance, nevertheless this condition has not previously been reported in the megaloblastic anaemias and may well play a part in the fatal outcome in such patients. Blood transfusion was administered to over half the patients, usually in the form of whole blood. It is recommended that transfusions be used sparingly, and consist of cells or preferably exchange transfusion, the latter being of particular value in the elderly or in those with pre-existing cardiac failure.

Patients at high risk for low-birth-weight delivery

A retrospective analysis of 8,839 singleton deliveries was undertaken to determine the relationships of maternal age, maternal hemoglobin concentrations, and past obstetric performance to the incidence of low-birth-weight (LBC) delivery. Patients under 19 years of age and patients with hemoglobin values less than 9.0 Gm. per 100 ml. were found to have significantly higher incidences of LBW deliveries. In addition, the incidence of LBW delivery was found to vary in proportion to the number of previous LBW deliveries and inversely with the number of previous term deliveries.

Significance of subnormal red-cell folate in thalassaemia

Subnormal red-cell folate values were encountered in 20 of 63 thalassaemic subjects in a population with a low incidence of megaloblastosis. The abnormality was not associated with haematological changes of megaloblastosis and could not be explained on the basis of incomplete liberation of intra-erythrocytic folates, serum conjugase deficiency of vitamin B12 deficiency. Evidence is presented to indicate that it is unlikely to represent a state of subclinical folate deficiency. The exact cause of the abnormality is unknown.

Unusual megaloblastic anaemia wiht multinucleate erythroblasts: two cases with septicaemia and acute renal failure

The case histories and blood pictures of two patients who had cardiac lesions, septicaemia, and renal failure and terminally developed a leucoerythroblastic anaemia with megloblastic features associated with multinucleate erythroblasts, are described. Though folate deficiency may have made a minor contribution to the blood abnormalities, it is considered that some other disturbance in erythropoiesis was responsible for the bizarre blood and bone marrow changes in these patients. Similar cases reported in the earlier literature are reviewed.