BririchJoirrnal of Huematology, 1972,a3,

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DYSERYTHROPOIESIS AND DYSERYTHROPOIETIC ANAEMIA When, for one or other reason, haemopoiesis is disturbed it may at times be difficult to know how to describe the phenomenon which has occurred, especially if the disturbance is both quantitative and qualitative. The random use of such terms as aplasia, hypoplasia, dyshaemopoiesis, dyserythropoiesis and dyserythropoietic anaemia may give rise to confusion. It would seem rational to use the terms aplasia and hypoplasia to describe conditions in which there is a quantitatively decreased haemopoiesis, so that the bone marrow produces and releases an insufficientnumber of blood cells into the circulation. Dysplasia, on the other hand, would describe the situation where there is a qualitative abnormality of the bone marrow. This may result in inefficient or ineffective haemopoiesis or, if limited to the erythroid cells (i.e. dyserythropoiesis), in ineffective erythropoiesis. It implies either a defect primarily of a stem cell with consequent abnormality of development of the cell line or lines, or an abnormal environmental state within the bone marrow which inhibits normal cell proliferation, or a combination of both factors. In practice hypoplasia alone is the exception rather than the rule and aplastic anaemia is usually accompanied by dysplasia. Dysplasia may occur in a wide range of diseases which primarily affect either the nucleus or the cytoplasm of the erythroblast. It is present in megaloblastic anaemias, thalassaemia and erythroleukaemia. A dyserythropoietic component of greater or lesser severity occurs in aplastic anaemia, myelosclerosis, iron deficiency and iron utilization defects, including acquired sideroblastic anaemias, and in infections (Lewis, 1969; Dreyfus et a!, 1969a). It also occurs as a congenital disorder (Crookston et al, 1969; Verwilghen et al, 1969), and (? rarely) as a primary acquired defect (Lewis, 1969, 1972). The term dyserythropoietic anaemia should be confined to these congenital and acquired primary cases in order to distinguish them from the dysplasia which is associated with identifiable diseases. Congenital sideroblastic anaemias might be included in this group. It is important to correlate morphological and functional aspects of dysplasia and to establish diagnostic criteria for making the diagnosis of dyserythropoietic anaemia.

Morphological Features o Dyserythropoiesis f Morphological appearances of the erythroblasts in dyserythropoiesis have been extensively illustrated in recent reviews (Lewis, 1969,1972). Signs of an asynchrony of nuclear cytoplasmic maturation are common. There is evidence of nlitotic abnormalities with nuclear lobulation and fragmentation, associated with karyorrhexis and pyknosis, binuclearity and multinuclearity with internuclear bridging and budding and, in some cases, megaloblastic changes. These features are seen especially in congenital dyserythropoietic anaemias but may be found to a greater or lesser extent in any dysplastic condition. Cytoplasmic abnormalities which occur includecytoplasmicvacuolation and basophilic stipplingand excessiveamounts of iron in lysosomes or mitochondria; in some cases, electron microscopy demonstrates the absence of polyribosomes in reticulocytes.

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Functional Evaluation of Dyserythropoiesis A number of interrelated parameters may be used to assess the state of erythropoietic productivity. (a) Inefficiency may be implied when there is a relatively low reticulocyte count associated with a relatively hypercellular marrow which contains morphologically abnormal erythroblasts. This qualitative assessment does, however, require confirmation by quantitative tests. (b) Although haemoglobin synthesis does not necessarily run parallel to erythropoiesis, as a rule measurement of the former provides a measure of the latter. Efficiency of haemoglobin synthesis can be measured readily by ferrokinetic studies with 59Fe;rapid plasma clearance of an administered dose r 9 F e T,, less than 40 min as a rule) with decreased erythrocyte incorporation (zs-so%) occurs in dyserythropoiesis. Surface counts indicate an accumulation of the iron in the bone marrow. By frequent measurement over sacrum, liver and spleen during a period of several days it should be possible to distinguish cases where there is failure of the iron to be taken up by normoblasts (as in aplastic anaemia) from ineffective erythropoiesis occurring after an initial period of intramedullary iron utilization. Increased unconjugated bilirubin (in the absence of conjugation defects such as Gilberts disease) and high carbon monoxide production are evidence for increased haemoglobin catabolism which in the absence of peripheral blood haemolysis is a pointer to ineffective erythropoiesis. Impaired haemoglobin synthesis can result in hypochromia, as, for example, in lead poisoning, sideroblastic anaemias, thalassaemia. Conversely,inefficienterythropoiesis occursas a secondary event in iron deficiency and is associated with decreased erythrocyte survival and Robinson & at least some of the morphological features of dyserythropoiesis (Robinson, 1969; Tsong, 1970). (c) Inefficient DNA synthesis and metabolism can result in folic acid deficiency and hyperuricaemia, as is frequently observed in thalassaemia and in myelosclerosis. Nucleic acid metabolism can be investigated in vitro by means of tritiated thymidine; this has been used in the investigation of megaloblastic anaemia (Messner et al, 1969)and congenital dyserythropoietic anaemia (Queisser et a f , 1971). (d) Intramedullary destruction of cytoplasm results in the liberation of various enzymes; of these the lactic dehydrogenase fractions and aldolase have been used as parameters for ineffectiveness of erythropoiesis (Hansen & Andersen, 1968;Griffiths & Lothian, 1969). Mechanism o f Dyserythropoiesis To understand the concept of functional efficiency, as applied to erythropoiesis, a parallel might be considered in the field of economics. In an industrial manufacturing process productivity is the ratio of output to input. Efficiency is characterized by high productivity; this depends upon high output of finished products of satisfactory quality with maximum utilization of raw materials, whilst keeping expenses during the production at a low level. Thus, as is the case in a well-run assembly chain in a factory, efficient erythropoiesis will require a low input of stem cells and metabolites to achieve a good output of erythrocytes of good quality. On the other hand, inefficiency will result in an increased input (i.e. higher demands of stem cells and metabolites) but a low output of erythrocytes, possibly of poor quality, from a relatively overpopulated bone marrow.

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Several mechanisms can result in a decreased erythropoietic productivity within the bone marrow. The main factors are: (a) Skipping of one or more cell divisions, resulting in a lowering of the number of erythrocytes proceeding from one stem cell. (b) Increase in the duration of the mitotic cycle of erythroblastsresulting in overpopulation of the bone marrow. (c) Failure of erythroblasts to mature; this is associated with intraniedullary destruction of normoblasts and is referred to as ineffective erythropoiesis. (d) Destruction of reticulocytes as soon as they reach the blood circulation, and the production of defective erythrocytes which fail to survive. The morphological abnormalities reflect a disturbed DNA or RNA metabolism and an abnormal protein synthesis during maturation of the erythroblast. They can be mimicked by the action of a number of agents acting in vitro on normal tissue cultures or in vivo. These agents include folic acid antagonists and other antimetabolites, irradiation, spindle inhibitors such as colchicine or vincristine which disrupt microtubules and cytochalasine B which inhibits cell motility and cytoplasmic cleavage (Carter, 1967) possibly by disrupting the microfilament system (Wessells et a!, 1971). It is, however, not clear whether these experimental observations offer an explanation for the pathogenesis of dyserythropoietic anaemias.

Red-Cell Abnormalities in Dyserythropoietic States As a result of dyserythropoiesis the red cells may have membrane abnormalities. Most frequently there is an increased sensitivity to lysis by anti-I serum (i.e. a positive cold-antibody lysis test) (Lewis et al, 1970) and an increased agglutinability by anti-i serum (Hillman & Giblett, 1965; Cooper et al, 1968). A positive cold-antibody lysis test occurs in all types of dyserythropoiesis, irrespective of cause. In one form of congenital dyserythropoietic anaemia (CDA type 11, HEMPAS) the red-cell membranehas, in addition, antigen against an antibody present in the serum of about one-third of normal people. This results uniquely in a positive acidified-serum lysis test with some normal sera but not with others nor with the patients own serum (Crookston et al, 1969). It is thus distinguished from PNH in which lysis occurs with the patients own serum, and also from other forms of congenital dyserythropoietic anaemia (e.g. CDA Type I) in which the acidified-serum lysis test is negative. Modifications of other blood-group antigens have been observed in rare cases of dyserythropoiesis (Dreyfus et al, 1969b). Aberrant levels of red-cell enzymes have been observed, especially decreased glutathione reductase (Dreyfus et ul, 1969a; Verwilghen et al, 1972). Reappearance of haemoglobin F and an elevated level of Hb A2 has been noted. Neither the in-vitro lysis tests nor the morphological features are specific markers of a single defect. They do, however, draw attention to a state of dysplasia which warrants further investigation in order to assess the extent of inefficient and ineffective erythropoiesis, and to determine whether the dyserythropoiesis is secondary to some other identifiable disease or due to a primary dyserythropoietic anaemia. Royal Postgraduate Medical School, S. M. LEWIS London, w.12, U.K. Akademisch Zie kenhuis St Rap hael, Leuven, Belgiuni R. L. VERWILGHEN

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REFERENCES

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