Scott N. Swisher

Erythrocyte lipid loss in hereditary spherocytosis.

Probable manifestations of the intrinsic corpuscular defect leading to shortened red blood cell (RBC) survival in hereditary spherocytosis (HS) have been induced by in vitro incubation of these erythrocytes (2-4). The classical in vitro changes that have been described are a marked increase in autohemolysis in the absence of metabolized substrate and an increase in osmotic fragility. Young, Izzo, Altman, and Swisher (4) showed that a number of substrates utilized by RBC to produce ATP could substitute for glucose in preventing the exaggerated in vitro hemolysis in HS erythrocytes. The exact role of cellular ATP in preventing these changes has, however, been debated. Selwyn and Dacie (3) suggested that, particularly in the absence of metabolized substrate, a premature degeneration of the membrane occurred in HS erythrocytes during in vitro incubations. In a preliminary report (1), we described an in vitro loss of lipid in HS erythrocytes not found in normal cells that was minimized, but not prevented completely, by the presence of glucuose. These findings appeared to be a specific manifestation of the membrane degeneration postulated by Selwyn and Dacie (3) and to represent an example of the mechanism, originally proposed by London and Schwartz (5), whereby RBCcellular energy is utilized in preventing changes in membrane lipids; in HS erythrocytes, it appeared that utilization of energy through this pathway was inefficient.

A review of Rh serology and presentation of a new terminology.

The extensive accumulated literature pertaining to Rh blood group serology reveals a complexity that is to be expected in the absence of critical immunochemical data. Unfortunately the language that has been employed in scientific reports, as well as the choice of descriptive notations, has obstructed critical immunological interpretations and the opportunity to employ modern methods of dealing with large volumes of complex data. A new coding notation for Rh data has been devised to overcome these deficiencies.

Hemodynamic studies of the portal circulation in myeloid metaplasia

P ORTAL hypertension occasionally has been described in association with several hematologic diseases [P-70]. In some cases an extrahepatic venous obstruction has been demonstrated [7,9], in other instances intrahepatic obstruction of the portal system has been the apparent etiology [ 7,3]. In a few reported cases, despite clear evidence of portal hypertension, no evidence of either intraor extrahepatic anatomic obstruction to portal blood flow was apparent [4-61. Several investigators have directed attention to indications of portal hypertension in patients with myeloid metaplasia. Hunt [IO] studied a patient with this disorder and documented significant portal hypertension, which was corrected by splenectomy. Another such patient with myeloid metaplasia and hemorrhage from bleeding esophageal varices was studied by Shaldon and Sherlock [7], and found to have presinusoidal obstruction of the portal venous system. In a recently reported series of cases, esophageal varices were found in two of eighteen autopsy patients and one of these had no obvious block [5]. In addition, reference has been made to “unexplained” ascites and edema in patients with myeloid metaplasia 161. Among the twentynine patients described by Nakai, Craddock and Figueroa [6], seven had edema and three ascites. Two of the three patients with ascites were studied at autopsy, and no obvious portal block was identified. A patient with myeloid metaplasia, portal hypertension and bleeding esophageal varices was studied in this clinic in 1960 [4]. Neither intrahepatic nor extrahepatic obstruction could be demonstrated. This patient underwent a successful end-to-side portacaval shunt and survived for an additional two years, although her course was complicated by the development of mild recurrent hepatic encephalopathy. These workers postulated that the portal hypertension in this instance was of a hyperdynamic type, caused by augmented blood flow through the massively enlarged spleen and into the portal system. The results of studies of portal and systemic hemodynamics in five patients with myeloid metaplasia, several of whom exhibited esophageal varices, and/or edema and ascites, are reported herein. One case is described in detail, with autopsy findings; the others are presented briefly.

Studies of the Effects of Administration of ACTH and Adrenal Corticosteroids on Erythrophagocytosis

Phagocytosis of effete erythrocytes or red cell fragments by reticuloendothelial cells appears to play some role in normal red cell destruction, although the details of the process are poorly understood. The marked increase in erythrophagocytosis occurring in several types of hemolytic anemia, especially in acquired hemolytic disease and in some examples of transfusion reactions and erythroblastosis fetalis, indicates the possible importance of this process as a mechanism of red cell destruction. The rapid, often dramatic, suppression of erythrocyte destruction in patients with acquired hemolytic disease frequently produced by therapeutic adrenal corticosteroids suggests that these compounds may exert a specific effect on phagocytosis of these abnormal erythrocytes, apart from possible suppression of production of antibody-like proteins. The present study extends preliminary observations (1) on the suppression of the in vitro erythrophagocytic capabilities of peripheral blood leukocytes obtained from patients receiving ACTH or adrenal corticosteroids.

ELECTRONIC PARTICLE COUNTING APPLIED TO THE QUANTITATIVE STUDY OF RED CELL AGGLUTINATION.

Quantitation of red cell agglutination can be made by counting the residual free cells remaining after agglutination and comparing the count with the pre‐agglutination red cell count. Most previous studies have used visual hemocytometry for this purpose. The use of the Coulter Model B electronic particle counter has been investigated and is shown to be a practical alternative.

Serum sickness and plasmacytosis: A clinical, immunologic and hematologic analysis

Abstract A mild case of serum sickness following an injection of equine tetanus antitoxin is reported. During the illness there was a plasmacytosis amounting to 30 per cent of the white cells in the peripheral blood. Three months after the illness, a skin test with equine serum produced an intense local reaction and the reappearance of plasmacytosis. Precipitating antibody was demonstrated against three types of equine globulins, two of which are known to carry antibodies. The patients precipitins were γ 2 -globulins, while her hemagglutinins were both γ 2 - and γ 1 -globulins. Skin sensitizing antibody was also found and it sedimented with the 7S globulins. In four cases of serum sickness with 1 to 3 per cent plasmacytosis and in four cases without plasmacytosis, antibodies were found to have developed to the same horse serum antigens, and no distinction could be made between the two groups in respect to the classes of antibodies developed. All patients had 7S antibody, whereas 19S antibody was found only in two. No single immunologic factor could be correlated closely with plasmacytosis.

CLINICAL CORRELATIONS OF THE DIRECT ANTIGLOBULIN REACTION

The cardinal role of the antiglobulin reaction in the diagnosis of autoimmune hemolytic disease (AH D) is generally recognized. Recent literature on this topic makes clear how closely our concepts of the pathogenesis of these disorders are related to the mechanisms of this reaction and to ways in which antiglobulin reactivity can be conferred experimentally upon red cells. Two patterns of direct red cell antiglobulin reactions, the anti-y and anti-non-y reactions, have been known since 1951.’ These two patterns of the antiglobulin reaction are also encountered when the erythrocytes of patients with AHD are examined with appropriate antiglobulin reagents. There is still a paucity of data which permits correlation of these two serological reactions with the clinical aspects of the associated hemolytic process or underlying disease. This paper will first review briefly several recent contributions, particularly work by John P. Leddy, to understanding of the mechanisms by which red cells become antiglobulin reactive in uitro. Secondly, studies from our laboratories of the nature of the proteins which are found on the erythrocytes of patients with AHD will be summarized. On this background, a summary of the findings of a five year clinical and serological survey of a large group of patients seen in our clinics will be presented; antiglobulin reagents which permit distinction of the anti-y and anti-non-y reactions have been employed in the Coombs’ tests carried out on these patients. It is generally agreed that the anti-non-y antiglobulin reaction detects primarily the early reacting portion of complement (C’) component 3 on the red cells, specifically component C’3,, the plC-plA protein of MullerEberhard. The anti-non-7 sera used in these studies had primarily this specificity although certain sera may have had specificity for other C’ components in addition to this primary specificity. The anti-y sera employed reacted specifically with y2 globulin. In early 1963, C. A. was seen in our clinic with classical quinine hypersensitivity thrombocytopenia. Her red cells were found to be directly reactive with an anti-C‘ antiglobulin reagent, although there was no clinical evidence of hemolysis. Leddy subsequently demonstrated that normal red cells, and later the patient’s own red cells when they had become Coombs’ negative, could be rendered reactive to an anti-C’ antiglobulin serum, and presumably

Quantitative Aspects of Red Cell Agglutination: The Analysis of a Pattern of Agglutination Produced by Human Group B Cells and Anti‐B Serum

The methods of quantitating the agglutination of red cells have been extended to provide information on the pattern of aggregates formed During the process. A B‐anti‐B system has been studied to illustrate the determination of the size spectrum, the mean cell content and the percentage of two‐cell forms of aggregates. Such data have been used to provide a more complete description of the second stage of red cell agglutination and have been applied to the investigation of the stable state of agglutination resulting from both the aggregation and disaggregation methods of preparation.

Effect of Early Small Exchange Transfusion on the X-Irradiated Dog.

Summary 1. Immediate removal of 250 cc of blood and replacement with an equal volume of normal compatible whole blood in 20 lb dogs given 550 r whole body irradiation (expected LD 80) results in a marked delay in onset of radiation syndrome and mortality. There is a suggestive decrease in ultimate mortality as well. 2. No differences in average leucocyte count, platelet count, or hematocrit were observed in the two groups, nor were there differences in clinical or postmortem anatomical findings. 3. The implications of these results are discussed.

Quantitative Studies of a Two‐stage Hemagglutination System Employing the Antiglobulin Reaction

The quantitative analysis of hemagglutination employing an electronic particle counter has been extended to the development of a two‐stage system for the study of agglutination of red cells sensitized by incomplete antibodies treated with antiglobulin serum. The agglutination of red cells in an anti‐Rho (D) system has been studied to demonstrate the relationship between such parameters as per cent agglutination, per cent two‐cell aggregates, and mean cell number per aggregate. Demonstrations of applications of this technic to such problems as the measurement of comparative potency and characterization of anti‐Rho sera, dosage effects, disaggregation patterns with antisera of different specificities, use of chain‐specific antiglobulin sera, and antiglobulin consumption studies are given.