HEMOGLOBIN, 7 ( 1 ) , 71-78 (1983)

ERYTHROLEUKEMIA MANIFESTING AB-THALASSEMIA

Raymond E. Markham, Fred Butler, Kong-oo Goh and Pe ter T. Rowley Department of Medicine and Division of Genetics

University of Rochester School of Medicine, Rochester, New York 14642

Abstract

A 27 year old male with aplastic anemia developed a high fetal hemoglobin, a low hemoglobin A2, a decreased B / a synthetic ratio, and an increased G y/A y synthet ic ratio. This acquired hemoglobinopathy resembling 66-thalassemia was recognized at the onset of acute erythro- leukemia. Certain features of this abnormal globin synthetic pat tern resemble those of the normal fe tus and thus appear to provide another example of gene expression by malignant cells resembling tha t of an earlier stage of the organism's development.

This report describes a n adult pat ient with aplastic anemia who

developed an acquired hemoglobinopathy. An ear ly evidence of the onset

of leukemia was the abnormally high hemoglobin F associated with unbal-

anced globin chain synthetic ra tes resembling 6 E -thalassemia.

A 27 yr old male pharmacist with a two-month history of fat igue and a one week history of dyspnea and petechiae was referred for evalua- tion of pancytopenia in March 1977. The only history of exposure to myelo- suppressive agents was contact with benzene in building model cars. Physical examination revealed pallor, petechiae, and ret inal hemorrhages without organomegaly.

Receiiied : O c t o b e h 1 9 , 1982 ; Accep-ted: Uecemba 9 , 1 9 8 2 .

7 1

Copyright 0 1983 by Marcel Dekker, Inc. 0363-0269/83/0701-007 1 $3.50/0

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72 MARKHAM ET AL.

On his initial visit hemoglobin was 4.2 g/dl, MCV 114 fl, MCH 43 pg, and MCHC 36 g/dl. WBC was 1.1 x lOg / l with 73% neutrophils, 21% lymphocytes, and 6% monocytes. Platelet count was 4 x lOg/ l . The reticulocyte count was 2.5% The peripheral blood showed macrocytes without any nucleated

red cells. Serum folate and B12 levels were normal. Bone marrow biopsy revealed marked hypocellularity with a generalized decrease in erythroid and myeloid elements and an absence of megakaryocytes. The erythroid elements had mild megaloblastoid and macrocytic features. Storage iron was increased without ring sideroblasts. Red cells showed no hemolysis when incubated in sucrose or acid media. The diagnosis of aplastic anemia was further confirmed by a diminished lllindium uptake over the trunk without extension into the long bones. Incorporation of 59Fe into circula- ting RBC after 10 days was 24% (normal, 80-90%).

Marrow transplant was not an option because there was no HLA

identical sibling. Corticosteroids, multiple oral and parenteral androgens, folate, and pyridoxine over a two-year period produced no improvement. Despite prophylactic platelet transfusions, he developed in November 1977 a mechanical ileus which was found a t laparotomy to be secondary to a hemorrhage in the terminal ileum. Subsequently he was treated with prophylactic oral E-aminocaproic acid and transfused with platelets for mucosal bleeding. His absolute neutrophil count was consistently greater than 500 and infections were infrequent. To maintain a hematocrit over 25%, he received three units of red cells every two weeks for two years after diagnosis. The transfusion requirement abruptly ceased in March 1979 and the hemoglobin remained constant a t 8 g/dl for about five months.

In August 1979, megaloblastoid nucleated red blood cells appeared in the peripheral blood. The red cell indices remained macrocytic and prominent siderotic granules were noted; however, uniform coarse basophilic stippling was not seen. Hemoglobin F was heterogeneously distributed in 93% of red cells by an immunofluorescent method. Peripheral blood globin chain synthetic measurements showed increased y-globin synthesis and de-

creased 8-globin synthesis (see table).

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TAB

LE I.

H

EMO

GLO

BIN

DA

TA

Dat

e -

Hba

07

-27-

79

8.2

0 8 - 1

0 - 7 9

8.

9

09-1

0-79

4.

2 09

-21-

79

8.4

02-1

3-80

7.

9

03-0

3-80

6.

8

Nor

mal

val

ue

Glo

bin

Synt

hesi

s f

%H

bFb

%H

bF-c

ells

c %

HbA

2d

y /y

+g

e e/a

e B

fy/a

e G

Y/%

-

93

0.40

0.

46

0.77

39

41

0.85

0.

43

0.39

0.

71

12

35

0.43

0.

46

0.81

0.

99

h 40

<

2

2.9

h1.1

3~

<3

.5

0.05

1t

O.1

lt

O.l

0.

4

~~~

~ ~

aThe

onl

y tr

ansf

usio

ns r

ecei

ved

duri

ng t

he p

erio

d co

vere

d in

the

tabl

e w

ere

thre

e un

its

on 0

9-11

-79.

b~

y

isoe

lect

ric

focu

sing

(1)

‘BY

irnm

unof

luor

esce

nce

(2)

dBy

DEA

E-ce

llulo

se m

icro

colu

mn

chro

mat

ogra

phy

(3)

eBy

carb

oxym

ethy

lcel

lulo

se ch

rom

atog

raph

y in

ure

a (4

)

fBy

poly

acry

lam

ide

gel e

lect

roph

ores

is in

Tri

ton

X-1

00 f

ollo

wed

by

fluo

rogr

aphy

and

den

sito

met

ry (5

,6)

gBoy

er a

nd D

over

(7)

hSch

roed

er a

nd H

uism

an (8

)

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74 MARKHAM ET AL.

Hemoglobin A2 was only 0.85%. The increased hemoglobin concentration and t h e circulating nucleated red cells suggested a transformation of his

marrow from a hypoplastic to a proliferative state. A bone marrow biopsy was hypercellular with marked erythroid hyperplasia, megaloblastoid and binucleated basophilic normoblasts, and an increase in

reticulin fibers consistent with erythroleukemia (FAB M6). Culture of blood and bone marrow, which had grown erythroid colonies in erythropoietin-free media but no granulocytic colonies in August 1979,

grew only granulocytic colonies in September 1979.

Persistent fever without evidence of infection, refractory

congestive hear t failure, and hepatosplenomegaly developed in February 1980. The peripheral blood contained periodic acid Schiff-positive

erythroblasts identical t o those in bone marrow. Marrow chromosomal analysis with banding revealed a modal number of 46 with a wide distribution and no morphologically abnormal chromosomes.

Terminally the circulating blasts rose to 112 x lOg/l. Although

hydroxyurea t rea tment decreased the number of circulating blasts, t h e pat ient died in July 1980 in refractory congestive failure. Autopsy showed hemosiderosis and leukemic inf i l t ra tes in multiple organs. The

bone marrow was completely replaced with leukemic blasts.

DISCUSSION

This pat ient initially presented a clinical picture typical of aplast ic anemia with pancytopepia and a hypoplastic marrow with symptoms referable to anemia. After two years, his disease progressed to a c u t e leukemia with circulating megaloblastoid normoblasts and marrow replacement with abnormal erythroid precursors.

Acute leukemia is a r a r e terminal event for pat ients with aplastic anemia surviving two years or more, occurring in only one of 137 pat ients with a median followup of 5.8 years (9). However t h e rapid decline following the onset of t h e leukemic phase is typical of erythroleukemia (10).

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ERYTHROLEUKEMIA 75

Our pat ient had a history of benzene exposure, a well-documented cause of pancytopenia, which may terminate in acute leukemia (11).

Leukemia secondary to hemapoietic stem-cell injury is usually myeloid

(12). Pat ients chronically exposed to benzene and developing pancytopenia who have high hemoglobin F or low hemoglobin A2 have been reported to be more likely t o develop leukemia (13). In our pat ient increased f e t a l

hemoglobin signaled the development of acute leukemia.

Our pat ient had multiple hemoglobin abnormalities, a high concentration of fe ta l hemoglobin (up to 40%), a high percentage of F-cells (up to 93%),

a low hemoglobin Ag (0.85%), a high y /( Y + B ) synthetic ra t io (0.40-0.431, a low E./a synthetic ra t io (0.39-0.46), and a low (B+y)/ a synthetic ra t io (0.71-0.81).

Although elevated fe ta l hemoglobin concentration is seen in a wide

variety of hematologic malignant diseases, levels as high as this patient's a r e seen chiefly in juvenile chronic myelocytic leukemia and erythroleukemia (14). In erythroleukemia a variety of hemoglobin abnormalities have been reported in addition to increased fe ta l hemoglobin, including a decreased hemoglobin A 2 (15) and a G Y / & ra t io higher than the normal adult and approaching tha t of the newborn (16). Erythroleukemia with ex t reme elevation of fe ta l hemoglobin as in this pat ient has been reported chiefly in children. Huisman and Schroeder (16) described a 6 year old girl with

erythroleukemia with a hemoglobin composition and globin synthetic pa t te rn similar t o this patient. Occurrence of the combination in an adult is distinctly unusual.

This patient's hemoglobinopathy resembles 6 B-thalassemia which is characterized by a decreased S/ a synthetic ra t io (0.4-0.6), a decreased percentage of hemoglobins A and A2, increased hemoglobin F, and a n increased G y / A y ra t io (17). However, the acquired form manifested by this patient differs from the hereditary form in the much greater severity of the anemia and the grea te r elevation of fetal hemoglobin.

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76 MARKHAM ET AL.

A decreased B/ a globin synthetic ratio is distinctive of the pthal- assemias as a whole. An increased B/a synthetic ratio, characteristic of B -thalassemia, also has been reported in acute erythroleukemia (18).

Two explanations have been proposed for the elevation of fetal hemo- globin synthesis seen in hematologic malignancies. The first is that the abnormal properties characterize exclusively the malignant clone. In keeping with this theory is the observation that the switch from B to y

synthesis frequently becomes more complete as the disease progresses (14,191. The second theory is that increased fetal hemoglobin represents a response of normal marrow to stress. Increased production of fetal hemo- globin has been found, not only in hematologic disease, e.g. aplastic anemia treated with androgens (20) and following marrow irradiation and transplan- tation (211, but also in normal individuals following hemorrhage (22). From a boy with leukemia characterized by high fetal hemoglobin and unbalanced globin synthesis, cells have been separated into a normal blood group A-

positive cell population which had no detectable Y synthesis and a blood group A-negative cell population which had high Y synthesis (23). Thus, in at least that case, the abnormal globin synthetic properties were a marker for the malignant clone.

Three of the globin synthetic abnormalities seen in this patient, increased v/B , decreased 6 / B , and increased GY/AY are characteristic of fetal life. If these abnormalities are indeed attributable to the malignant clone, the correlation between properties of malignant cells and fetal cells is impressive. I t will be important to determine the lesion responsible for this type of abnormal globin gene expression. Chromosome 11, the site of the B gene complex, had a normal banding pattern in this patient. DNA restriction fragment mapping has shown that most cases of 6 bthalassemia are due to deletion of the 6 and B genes (24). In future patients like the present one, it may be instructive to apply similar methods to isolated nucleated cells of the malignant clone.

ACKNOWLEDGMENTS

We thank Frank Gardner, M.D., for performing the lllindium and 59Fe studies and Camille Abboud, M.D., for the marrow colony assays.

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ERYTHROLEUKEMIA 77

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6.

7 .

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9. 10. 11.

12.

13. 14.

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