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This report describes a 26 year old woman, of Pakistani origin, who presented five months postpartum with severe megaloblastic anaemia as a result of nutritional folate deficiency. This case was unusual in that a small number of myeloblasts were present in the peripheral blood at presentation, and this circulating population temporarily increased in size when folate replacement was begun. We also highlight the need to recognise the non-linear relation between haematocrit and red blood cell folate concentration when the haematocrit is very low (< 0.15) and emphasise the importance of the clinical history.

Aims: To evaluate the incidence and outcome of acute myeloid leukaemia (AML), FAB M6 (erythroleukaemia)., Methods: A demographic study in the Northern Health Region of England between 1983 and 1999., Results: Thirty three cases were diagnosed and registered prospectively. The overall incidence was 0.077 cases/100,000/year. There was a pronounced rise in incidence in patients aged 56 years or more: 6.6 times higher than that in younger patients. Overall survival was poor; median survival was 11 months for those aged less than 56 years, and three months for patients aged 56 years and above (p = 0.045). Acquired karyotypic abnormalities were found in 17 of 27 patients where analysis was attempted. When classified according to the criteria of the Medical Research Council AML trials, karyotype predicted survival, with a median overall survival of 14 months for those with "standard risk" cytogenetic results and two months for "poor risk" results (p = 0.005)., Conclusion: This study demonstrates a worse survival for patients with erythroleukaemia than that reported in some published trials of selected patients.

Failure to obtain sufficient material from marrow aspiration (dry tap) posed a diagnostic problem in two patients with pancytopenia. By using collagenase digestion of the trephine biopsy specimen, a precise diagnosis was reached. This technique is very useful because it permits flow cytometric and immunocytochemical analyses of cell suspensions obtained after collagenase digestion of the trephine biopsy specimen core. Acute leukaemia presenting with a dry tap can therefore be accurately immunophenotyped. The technique is easy to perform and merits wider use.

Forty-one patients who had undergone bone marrow transplantation were examined. Nineteen (63%) of the 30 who had received fractionated total body irradiation (TBI) had cataracts in comparison with only 1 (9%) of the 11 non-irradiated patients. No significant differences in steroid therapy were demonstrated between these groups of patients. Dry eyes were observed in eight irradiated patients, seven of whom had preceding graft-versus-host disease. Superficial punctate staining of the bulbar conjunctiva was observed in 25 (83%) of the irradiated group and, in milder form, in five (45%) of the non-irradiated group. Our data suggest that the incidence of cataract following fractionated TBI is influenced not only by the total dose of radiation but also by its rate of administration (defined by midline tissue dose rate and fractionation schedule). In addition dry eyes and conjunctival staining may be exacerbated by TBI, though other aspects of conditioning may also be implicated.

Over three years 81 consecutive bone marrow transplant recipients (32 allogeneic and 49 autologous) who received prophylaxis with acyclovir, were studied for symptomatic virus infection. Thirty nine infections were documented in a total of 28 patients. Thirty two infections were mild, five were moderately severe, and two were severe. Cytomegalovirus infection occurred in only six allogeneic recipients. Herpes simplex virus and varicella zoster virus infections occurred infrequently. Seven patients who were considered at the time of death to have died due to an infectious cause were studied virologically at necropsy. In only one patient was a virus infection thought to have been the cause of death. Prophylaxis with acyclovir may have influenced the rate and clinical prominence of herpes virus infections. In this study viruses were considered to have had a relatively minor role in causing morbidity and mortality.

Factors V, VII, VIII, X, XI, and XII of the coagulation system, platelet count, and antithrombin III levels were assayed in 20 healthy volunteers aged 20-40 years and 61 elderly subjects aged 66-96 years whose skinfold thickness was also measured. Factors XI, XII, and antithrombin III levels tended to increase in women and decrease in men while factors X, VII, and V tended to increase in both males and females with advancing years. No age or sex differences were found in platelet counts or factor VIII levels. Factor VIII levels were inversely correlated with obesity in elderly males (r = -0.56, p < 0.005).

With the advent of electronic particle counters of the Coulter S type the mean cell volume (MCV) has become an integral and useful feature of the red cell profile. Abnormally high values, often of minor degree, are particularly common but their precise clinical significance may be difficult to establish. This study defines the normal range and determines the incidence and distribution of the high MCV in routine hospital practice. Two hundred consecutive adult patients with an MCV of 100 fl or more were identified from the Coulter S analysis of 6542 blood samples and the underlying cause was established in 80%. Some of the clinical and economic implications of these findings are presented and briefly discussed.

Using standard one stage clotting assays the concentrations of factors II, VII, IX and X were determined in 37 patients stabilised on warfarin for between three months and 17 years. Contrary to popular belief, the concentrations were not equally depressed, with factor X the lowest, factor II at intermediate value, factors VII and IX the highest. Some 71% of the variance of the British corrected ratio (BCR) could be accounted for by measurement of the factors assayed. Analysis of this variance showed 91% of the explained variance attributable to factor II, 7% to factor VII, 1.6% to factor IX and 0.4% to factor X. With the sudden and recent withdrawal of human thromboplastin, investigation of the sensitivities of the animal thromboplastins to changes in vitamin K dependent factors in orally anticoagulated patients is needed to ensure that the potentially alarming falls in factors II and X in these patients are being adequately detected.

The histological appearances of skin and rectal biopsy specimens were studied in 31 bone marrow transplant recipients (13 autologous, 18 allogeneic) before transplant, at 28 days, at six months, and as soon as graft versus host disease (GVHD) was clinically suspected. Grades I and II skin changes were commonly seen in patients before transplant and in the autologous group after transplant, as well as in most of the allogeneic recipients with suspected GVHD. Epidermal lymphocytic infiltration was seen only in allogeneic recipients, with clinical GVHD following transplant, but this was not a consistent finding and no other histological features were seen which would distinguish early GVHD from changes caused by cytotoxic agents. Rectal biopsy specimens, however, were normal in patients before transplant and in autologous recipients at 28 days; single cell necrosis of crypt cells was seen only in six of 13 allogeneic recipients studied after transplant with clinical skin GVHD but no gastrointestinal symptoms. Skin changes greater than I and II are required for the histological diagnosis of GVHD. Rectal changes are more specific and may be present despite a lack of intestinal symptoms.

The clinical course and necropsy findings are described of an 11-year-old child found to have active cytomegalovirus infection at the time of bone marrow transplantation for acute lymphoblastic leukaemia. Attention is drawn to the presence of primitive mononuclear cells of uncertain origin in the regenerating bone marrow.

Components of the fibrinolytic enzyme system, FR-antigen and fibrinogen, were measured in 20 healthy volunteers aged 20-40 years and in 61 elderly subjects aged 66-96 years. Plasminogen activator levels did not significantly differ between the 20-40 and 66-75 age groups, but were higher in those over 75. Plasminogen showed no change with age except for a fall in those over 75. Fibrinogen, FR-antigen, alpha(1)-antitrypsin, and alpha(2)-macroglobulin all rose with age, but the mean fibrinogen concentration fell in the very elderly.

Positive serum tests for infectious mononucleosis (IM) unaccompanied by the clinical syndrome or blood changes characteristic of the disease were detected in 39/177 (22%) mentally subnormal patients investigated with three different commercially available IM slide tests. Slide positively was still detectable six months later in 27/35 (77%) positive reactors. Positive IM slide tests were significantly associated with anticonvulsant, primarily phenobarbitone therapy and with concomitant elevations of immunoglobulins IgG and IgM. Epstein Barr virus antibodies were not detectable in the sera of 8/38 (21%) positive slide reactors. The implications of these observations are discussed and attention is drawn to the variations in sensitivity, specificity, and comparability of different IM slide tests.

A man with apparently quiescent Hodgkin's disease presented with acute severe isolated thrombocytopenic purpura. Splenectomy revealed macroscopic involvement with Hodgkin's tissue and cured the thrombocytopenia.

The blood of 104 medical inpatients was examined at various intervals during storage for 72 hours using a Coulter S counter. Over this period remarkable stability of the white cell count, red cell count, haemoglobin, and mean cell haemoglobin was demonstrated. This permits a useful interpretation of indices obtained in routine postal samples sent to the laboratory by general practitioners for screening. Furthermore, the implications of high correlations between red cell indices in freshly examined blood are considered and the regression line MCV = 2.5 MCH + 16 is derived. Using this relationship the normal range of the Coulter S MCHC is defined as 32.6-33.7 g/dl. The significance of the Coulter MCHC in present-day practice is reassessed and the importance of recognizing values for MCV and MCH not coinciding with the regression line is briefly discussed.