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Parvovirus B19 (PVB19) infection can induce transient anaemia in patients with increased erythropoiesis. However, the dynamic change within the bone marrow after PVB19 infection is not well understood. Increased erythropoiesis is a physiological phenomenon in puerperital women. Nevertheless, anaemia as a result of PVB19 infection in puerperital women has never been reported. We report one patient with eclampsia and two patients with pre-eclampsia who had transient, severe anaemia during the puerperital period because of PVB19 infection. Viral genomes were detected in the peripheral blood during the anaemic period by polymerase chain reaction and became undetectable after the anaemia was resolved. Viral genomes and protein could also be detected in bone marrow by in situ hybridization and immunohistochemical staining, respectively. Serial aspiration cytology of bone marrow showed severe dysplastic change involving erythroid precursors with a few apoptotic cells at the initial onset of anaemia, markedly increased apoptotic cells that was confirmed by the increased expression of activated caspase 3, around the nadir of anaemia, and a normal marrow picture without features of apoptosis after recovery from anaemia. Our data indicates that PVB19 infection can induce transient, severe dyserythropoietic anaemia in puerperital women with pre-eclampsia/eclampsia and the pathogenetic mechanism may probably involve the induction of apoptosis following PVB19 infection.

Congenital dyserythropoietic anemia type II (CDA II) is the most frequent type of congenital dyserythropoietic anemia. More than 200 cases have been described, but with the exception of a report by the International CDA II Registry, these reports include only small numbers of cases and no data on the lifetime evolution of the disease. Since 1967, we were able to follow 48 cases of CDA II from 43 families for up to 35 years. All patients exhibit chronic anemia of variable severity requiring regular red cell transfusions only in a minority of children; 60% developed gallstones before the age of 30 years, and 16 patients had cholecystectomy between 8 and 34 years of age. Iron overload was a frequent complication. In 16 cases, iron depletion started between 7 and 36 years. Three patients died from secondary hemochromatosis. Splenectomy, performed in 22 cases, led to moderate increases in hemoglobin values and eliminated the need for transfusions but did not prevent further iron loading. The current recommendation is to consider splenectomy if the anemia compromises patients' performance, and to manage iron overload according to the guidelines derived from patients with thalassemia. (Blood. 2003;102:4576-4581)

Here, we report the case of a child who, since birth, showed persistent macrocytosis and elevated mean corpuscular volume of the erythrocytes. Bone marrow biopsy revealed gross disorganisation of the erythroblastic series both at the light and electron microscopic examination, with complete absence of dysplastic features in the granulocytic and megakaryocytic series. Common causes of macrocytosis were excluded. The spectrum of morphological findings were not consistent with any of the classical types of congenital dyserythropoietic anaemias (CDAs) and serological findings of CDA type II were absent. The most outstanding feature was a marked irregularity of the nuclear outline of the late erythroblasts that presented thick-ending finger-like projections. The combination of macrocytosis without anaemia and these morphologic erythroblastic changes have not been previously reported in the setting of classical and variant forms of CDAs.

Congenital dyserythropoietic anemias (CDAs) constitute a rare group of inherited red-blood-cell disorders associated with dysplastic changes in late erythroid precursors. CDA type I (CDAI [MIM 224120], gene symbol CDAN1) is characterized by erythroid pathological features such as internuclear chromatin bridges, spongy heterochromatin, and invagination of the nuclear membrane, carrying cytoplasmic organelles into the nucleus. A cluster of 45 highly inbred Israeli Bedouin with CDAI enabled the mapping of the CDAN1 disease gene to a 2-Mb interval, now refined to 1.2 Mb, containing 15 candidate genes on human chromosome 15q15 (Tamary et al. 1998). After the characterization and exclusion of 13 of these genes, we identified the CDAN1 gene through 12 different mutations in 9 families with CDAI. This 28-exon gene, which is transcribed ubiquitously into 4738 nt mRNA, was reconstructed on the basis of gene prediction and homology searches. It encodes codanin-1, a putative o-glycosylated protein of 1,226 amino acids, with no obvious transmembrane domains. Codanin-1 has a 150-residue amino-terminal domain with sequence similarity to collagens and two shorter segments that show weak similarities to the microtubule-associated proteins, MAP1B (neuraxin) and synapsin. These findings, and the cellular phenotype, suggest that codanin-1 may be involved in nuclear envelope integrity, conceivably related to microtubule attachments. The specific mechanisms by which codanin-1 underlies normal erythropoiesis remain to be elucidated.

We describe a new case of congenital dyserythropoietic anemia (CDA) type III. This least common type of CDA was diagnosed at the age of 59 in a 70-year-old woman who suffered from a young age from mild macrocytic anemia, while the long follow up since diagnosis documented a benign clinical course. No family history of blood diseases was obtained and no anemia was documented in the medical records of any of her four children. The bone marrow (BM) examination on light microscopy revealed a severe erythroid hyperplasia with the presence of giant multinucleated erythroblasts. Ultrastructural examination of the BM disclosed the presence of many large multinucleated erythroblasts bearing a variety of ultrastructural findings: nuclear clefts, autophagic vacuoles, iron-loaded mitochondria, and intracytoplasmic myelin figures. In addition, extensive hyperlobulation of the nucleus and partial loss of nuclear membrane with “spilling” of nuclear material to the adjacent cytoplasm was also noted in some of the erythroblasts. These last two findings have not been previously described in CDA III. Am. J. Hematol. 70:72–76, 2002. © 2002 Wiley-Liss, Inc.

We report, for the first time, an unusual case of congenital anaemia with the clinical diagnosis of haemoglobin H disease complicated by morphological features at the light and electron microscopy level very similar to those of CDA-I. The red cell indices and the globin chain biosynthetic ratio were not characteristic of the defective haemoglobin genotype. The haematological, clinical and morphological data strongly suggest the novel coexistence of the two defects in a patient. The disease is characterised by a unique dyserythropoietic phenotype of diagnostic importance, which possibly brings new data regarding the reciprocal interaction between the two diseases, especially concerning a specific abnormality in globin chain synthesis in CDA-I, as previously suggested.

The discovery of the gene responsible for most cases of hereditary haemochromatosis has made it possible to evaluate the role of this gene in iron accumulation in other conditions. Previous observations in patients with various inherited anaemias are suggestive of a role of the haemochromatosis gene in the noniatrogenic form of iron overload that may occur in these conditions.We studied two brothers with congenital dyserythropoietic anaemia type II, presenting with marked noniatrogenic iron overload. Young age, familial occurrence, concordance of iron overload, and histology were all suggestive of a genetic basis for the iron overload. A search for C282Y, H63D, S65C, and IVS3 + 1G?T mutations was performed by polymerase chain reaction after extraction of genomic DNA from whole blood.A search for the C282Y, H63D, S65C, and IVS3 + 1G?T mutations in the HFE gene proved to be negative. Despite the existence of ineffective erythropoiesis with mild anaemia, both patients were treated with regular phlebotomies in order to prevent long-term complications of their iron-overload. This treatment was well tolerated.1. C282Y, H63D, S65C, and IVS3 + 1G?T mutations were negative in two brothers with congenital dyserythropoietic anaemia, in whom young age, familial occurrence, concordance of iron overload, and the histological pattern were all suggestive of hereditary haemochromatosis. 2. Treatment with regular phlebotomies, in order to prevent complications of iron overload, was well tolerated despite the existence of mild haemolytic anaemia.

Objectives Congenital dyserythropoietic anemia (CDA) type I is a rare autosomal recessive macrocytic anemia whose natural history is not well documented. The aim of the present study was to evaluate the clinical picture of the disease in young adults. Methods The study sample consisted of 17 patients of mean age 11.9 +/- 5.4 yr (range 18-33 yr) and one older patient (age 44 yr), all Israeli Bedouins. The degree of anemia was evaluated as well as the extent of development of gallstones and iron overload. In each subject we determined the hemochromatosis gene mutations and the uridine dyphosphate-glucoronosyltransferase (UGT-1A) gene polymorphism associated with Gilbert's syndrome. Results The patients were found to have moderate anemia, with the women displaying lower mean hemoglobin levels than the men (8.2 +/- 0.9 g dL(-1) vs. 10 +/- 1.3 g dL(-1); P=0.0059). The majority of patients (59%) had received at least one blood transfusion, with the women having a significantly higher transfusion requirement. Although delayed puberty was noted, final height and weight were within normal limits, and eight patients had progeny. Biliary stones were found in three of 16 patients, two of whom were homozygous for UGT-1A gene polymorphism. None of the patients carried the common hemochromatosis gene mutation, although serum ferritin levels were moderately elevated (788 +/- 332 ng mL(-1)). Conclusions CDA type I in young adults is characterized by moderate macrocytic anemia, more severe in women, and a tendency to cholelithiasis and secondary progressive iron overload. We suggest that iron overload in this patient population should be monitored and chelation therapy initiated when indicated to prevent organ damage

Congenital dyserythropoietic anemias (CDAs) are a group of relatively rare inherited anemias. They are characterized by ineffective erythropoiesis and classified as three major groups and a number of variants. CDA type II, also known as hereditary erythroblastic multinuclearity with a positive acidified serum test (HEMPAS), is the most frequent one. A number of associations with CDA II have been reported, although each described only one or a few patients. Here we presented a piebald woman with vaginal atresia who was tested for anemia and diagnosed as CDA type II. Piebaldism and anemia association were previously described in the mouse. Our case was the first that shows the features of both piebaldism and CDA in the same patient. This association may suggest a stem cell defect to cause both hematopoietic and cutaneous manifestations.

GATA1 is the X-linked transcriptional activator required for megakaryocyte and erythrocyte differentiation. Missense mutations in the N-terminal zinc finger (Nf) of GATA1 result in abnormal hematopoiesis, as documented in four families: the mutation V205M leads to both severe macrothrombocytopenia and dyserythropoietic anemia, D218G to macrothrombocytopenia and mild dyserythropoiesis without anemia, G208S to macrothrombocytopenia and R216Q to macrothrombocytopenia with beta-thalassemia. The three first GATA1 mutants display a disturbed binding to their essential transcription cofactor FOG1, whereas the fourth mutant shows an abnormal direct DNA binding. In this study, we describe a new family with deep macrothrombocytopenia, marked anemia and early mortality, if untreated, due to a different GATA1 mutation (D218Y) in the same residue 218 also implicated in the above mentioned milder phenotype. Zinc finger interaction studies revealed a stronger loss of affinity of D218Y-GATA1 than of D218G-GATA1 for FOG1 and a disturbed GATA1 self-association. Comparison of the phenotypic characteristics of patients from both families revealed that platelet and erythrocyte morphology as well as expression levels of the platelet GATA1-target gene products were more profoundly disturbed for the hemizygote D218Y mutation. The D218Y allele (as opposed to the D218G allele) was not expressed in the platelets of a female carrier while her leukocytes showed a skewed X-inactivation pattern. We conclude that the nature of the amino acid substitution at position 218 of the Nf of GATA1 is of crucial importance in determining the severity of the phenotype in X-linked macrothrombocytopenia patients and possibly also in inducing skewed X inactivation. ispartof: Human Molecular Genetics vol:11 issue:2 pages:147-52 ispartof: location:England status: published

Background: Peripheral blood smear examination and other routine laboratory assays are not always sufficient to diagnose various diseases which affect the blood and bone marrow. A bone marrow aspirate examination is essential in most of the cases.Methods: This work was a hospital-based cross sectional analytical observational study carried out in the department of pathology at the Chitwan Medical College, Teaching Hospital, Nepal, over a period of 3 years from January, 2013 to December 2015. Bone marrow was aspirated from posterior superior iliac crest under local anesthesia; sternum was the alternative site in obese patients. Univariate analysis was performed for each variable using frequency distribution and means with the help of Statistical Package for Social Sciences 20.0 (SPSS 20.0) software.Results: One hundred and fifty-nine patients were included in the study. Eight cases of 'dry tap' were excluded, for whom bone marrow biopsy was advised. Anemia was the largest group followed by malignancy, infection and miscellaneous diseases. Among anemia, megaloblastic anemia was the most common, followed by aplastic anemia, dyserythropoietic anemia and myelopthisic anemia. The category 'malignancy' consisted of leukemia, multiple myeloma and myelodysplastic syndrome. Regarding individual diseases, megaloblastic anemia was the most common haematological disorder followed by immune thrombocytopenic purpura, leukemia and aplastic anemia.Conclusions: Bone marrow aspiration cytology is a mildly invasive technique which can diagnose many haematological and non-hematologic diseases that can be confirmed by more advanced investigations, if needed: serological, biochemical or molecular. However, bone marrow sample cannot be obtained (dry tap) in a proportion of cases. In such cases, a bone marrow biopsy needs to be performed.

Congenital dyserythropoietic anemia (CDA) represents a genotypically and phenotypically heterogeneous group of disorders. CDA type II, the most frequent variant, was recently shown to be caused by mutations in the gene encoding the secretory COPII component SEC23B. We report two siblings hailing from Punjab in northern India with classical CDA type II where this mutation was demonstrated.A 7-year-old girl presented with transfusion-dependent anemia, splenomegaly, and progressive growth failure since 1 year of age. Her 5-year-old brother was similarly afflicted, but there was no other family history. Extensive prior work-up for hemolytic anemia, storage and metabolic disorders, and infectious diseases was negative. Hemoglobin was 71 g/l with normal leukocyte, platelet, and corrected reticulocyte counts. Bone marrow examination revealed marked normoblastic erythroid hyperplasia with dyserythropoiesis (36%) and the presence of bi- and multinucleated erythroblasts with equal-sized nuclei. Many pseudo-Gaucher cells were also seen. Iron stores were increased although ring sideroblasts were absent. Hereditary erythrocyte multinuclearity with positive acidified serum (HEMPAS) test revealed lysis of the red cells in four out of five control sera.Genomic DNA sequencing of the SEC23B exon 12 revealed homozygosity for c.1385 A → G; Y462C mutations in both siblings.CDA has traditionally been a difficult diagnosis to establish, since it requires exclusion of other causes of dyserythropoiesis and the performance of complex tests including HEMPAS and electron microscopy for confirmation. The availability of molecular genetic testing for SEC23B promises to streamline and hasten the diagnostic process for this rare and intriguing disease.

Congenital dyserythropoietic anaemia type II (CDA II) is well known for glycosylation abnormalities affecting erythrocyte membrane glycoconjugates that encompass hypoglycosylation of band 3 glycoprotein and accumulation of glycosphingolipids: lactotriaosylceramides, neolactotriaosylceramide and polyglycosylceramides. These abnormalities were not observed in erythrocytes from patients with CDA of either type I or III. Recently, however, we have described a CDA type I patient in Poland with identical, though less pronounced, glycoconjugate abnormalities to those observed in patients with CDA type II. The abnormalities included partial unglycosylation of O-linked glycosylation sites in glycophorin A. These abnormalities are now reported in three Bedouin patients from Israel with CDA type I. In addition, the erythrocyte membranes of these patients exhibited highly increased globotetraosylceramide content. Glycoconjugate abnormalities were also present in erythrocyte membranes from three patients from Northern Sweden with CDA type III but they almost exclusively affected glycosphingolipids. In erythrocytes of all patients examined including one with CDA type II, polyglycosylceramides were significantly hypoglycosylated although, on a molar basis, their contents in erythrocyte membranes were increased. Thus, glycoconjugate abnormalities of varying intensity occur in erythrocyte membranes from all patients with CDA that were investigated.

Congenital dyserythropoietic anaemia type II (CDA II) is the most common congenital dyserythropoietic anaemia. CDA II is frequently misdiagnosed as Hereditary Spherocytosis (HS) due to the presence of mild chronic haemolytic anaemia with splenomegaly, increased osmotic fragility, and presence of microspherocytes. Accurate diagnosis of CDA II is important to prevent severe iron overload. Erythrocyte and reticulocyte indices were assessed in 10 patients from six families with CDA II, 18 patients from eight families with HS, and 50 normal controls. Characteristic increases in distribution width were present in CDA II for cell volume (RDW, anisocytosis) and in HS for cell haemoglobin concentration (HDW, anisochromia), resulting in an RDW/HDW ratio which was significantly greater in CDA than HS (P < 0.0002). A cut-off value for RDW/HDW of 5.34 resulted in 89% sensitivity and 70% specificity in distinguishing CDA II from HS. Distribution width for cell haemoglobin content of reticulocytes (CHDWr) was characteristically increased in CDA II, resulting in a CHDW/CHDWr ratio significantly lower in CDA II than HS (P < 0.0002). A cut-off value of 0.98 provided 89% sensitivity and 80% specificity in distinguishing CDA II from HS. These differences in distribution widths of flow-cytometric parameters of reticulocytes and mature erythrocytes reflect the different pathogeneses of the two diseases and are helpful for the differential diagnosis of these two conditions.

Congenital dyserythropoietic anemias (CDAs) are a group of hereditary refractory anemias characterized by ineffective erythropoiesis, typical morphological abnormalities of erythroblasts, a low or no reticulocyte response, hyperbilirubinemia, and splenomegaly. A massive hydropic newborn born with a very severe anemia (Hb 4.8 g/dL), diffuse edema, hepatosplenomegaly, ascites, pulmonary edema and respiratory distress, and shortness and hallux varus deformity of the great toe of the right foot was diagnosed to have congenital dyserythropoietic anemia on the basis of the hematological (macrocytosis, anisopoikilocytosis, fragmented red cells and erythroblastosis in the peripheral blood, and erythroid hyperplasia with erythroblastosis and erythroblasts with double nuclei and thin chromatin bridges connecting these nuclei in the bone marrow) and serological (negative acidified serum lysis test and no agglutination with anti-i antibodies) findings. In this article the seventh case of neonatal congenital dyserythropoietic anemia presenting with a very severe (lethal) form of hydrops fetalis and a new (hallux varus) deformity of the great toe of the right foot is presented. Congenital dyserythropoietic anemia should be considered in the differential diagnosis of hydrops fetalis presenting with a very severe anemia and a skeletal abnormality of the great toe.

The congenital dyserythropoietic anemias comprise a group of very rare hereditary disorders characterized by ineffective erythropoiesis and by distinct morphological abnormalities of the erythroblasts in the bone marrow. The classification proposed in 19681 is still used today.2, 3 Morphological analysis is the first step in the diagnosis of all types of congenital dyserythropoietic anemia, to be followed by confirmatory tests. The morphological hallmarks of the erythroblasts are not per se specific, but may also be observed as single abnormalities in other disorders of erythropoiesis. We, therefore, attempted to evaluate the quantity of the characteristic morphological abnormalities in patients with CDAI and CDA II. Smears of peripheral blood and aspirated bone marrow were obtained from the German Registry on Congenital Dyserythropoietic Anemias. All specimens were originally used for diagnostic purposes. Patients were asked for informed consent for their use for scientific research, in agreement with the decision of the ethical committee of the University of Ulm. All patients were analyzed using a unique patient’s number (CDA-UPN) that does not permit recourse of identifying data. Specimens were stained by May-Grunwald Giemsa stain: 1,000 cells were examined for abnormalities. Occurrence of basophilic stippled cells or nucleated erythrocytes in the peripheral blood was listed but not quantified. The relative fraction of erythroblasts was expressed as the ratio of erythroblasts to granulopoietic cells. Macrophages were examined for birefringence under polarized light. The Mann-Whitney –U-test was used to compare cases and controls. The diagnosis was based on parameters described previously.4,5 Confirmation of the diagnosis of CDA I required a mutation of the CDAN1-gene and/or typical aberrations seen by electron microscopy.2,6 Confirmation of the diagnosis of CDA II required a mutation of the SEC23B-gene or at least one of the following parameters: positive acid serum lysis test with ABO-compatible sera,7 a typical abnormality of band 3 shown by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE),8,9 or a discontinuous double membrane in mature erythroblasts seen by electron microscopy.2 Specimens of 19 (5 males, 14 females) and 36 patients (21 males, 15 females) with CDAI and CDA II, respectively, were available. Specimens of 10 patients with distinct erythroid hyperplasia were selected as controls (6 with hemolytic anemia, 2 with myeloid dysplastic syndromes, one with thalassemia intermedia, and one with bleeding and iron deficiency). Peripheral blood showed distinct anisopoikilocytosis in all cases, with grade 2 (25–50% poikilocytes) in 19 (34%), and grade 3 (> 50%) in 36 (66%) patients. There was no difference between types I and II (P=0.34). A few mature erythroblasts were seen in specimens of 31 and basophilic stippled red cells in 36 cases. These changes are highly sensitive but in no way specific. All types of poikilocytes such as ovalocytes, microspherocytes, tear drop cells or irregularly contracted cells are seen. In CDA I, large irregularly shaped macrocytes are seen and may suggest megaloblastic disease. The variegated appearance as described permits the exclusion of hereditary spherocytosis, an erroneous diagnosis that was often made before the diagnosis of CDA I or II was recognized.4,5 Mature erythroblasts may also be found in other types of severe anemia, but rarely in moderate anemias with a hemoglobin concentration of 90–110 g/L characteristic for most patients with congenital dyserythropoietic anemias.2,3 Marrow hypercellularity and distinct erythropoietic hyperplasia were present in all patients. The relative frequency of the pertinent abnormalities of erythroblasts, as compared to controls, is shown in Tables 1 and ​and2.2. Highly significant differences were found for binucleated cells, abnormalities of chromatin structures, chromatin bridges between erythroblasts, incompletely divided and large polyploid cells (See Online Supplementary Appendix). Table 1. Erythroblasts in specimens of patients with CDA I (n =19) and controls (n = 10). Data except E:G ratio are given in % of all erythroblasts. Table 2. Erythroblasts in specimens of patients with CDA II (n =36) and controls (n = 10). Data except E:G ratio are given in % of all erythroblasts. Pseudo-Gaucher cells containing birefringent needles were seen in 23 (63%) cases with CDA II. Also, in 3 patients with CDA I but not in controls some birefringent material in macrophages was detected. In clinical practice, evidence of any type of congenital dyserythropoietic anemias is primarily based on the morphology of peripheral blood and bone marrow, although confirmation of the diagnosis of the two most frequent types CDA I and CDA II is based on more refined tests. These tests are expensive and available in only a few specialized laboratories. The correct diagnosis of congenital anemias is often delayed.4,5 Many hematologists or clinical pathologists have never seen a case of CDA and do not recognize the well known morphological abnormalities or because, by misinterpretation of clinical and laboratory findings, a bone marrow biopsy is not performed. On the other hand, the diagnosis of a congenital dyserythropoietic anemia is often erroneously suspected, since the observer overvalues the presence of abnormalities that can be seen in the CDAs but also in other more common red cell disorders. If an appropriate technique of preparation of bone marrow is used, hypercellularity can be recognized, and is always seen in histobiopsies (data not shown). The relative frequency of red cell precursors in the bone marrow is increased, with a mean E:G ratio of 4 and 8 times the normal in CDA I and CDA II. Previous experience in normal adults showed a range of 0.2 –1.0, corresponding to data on 50 and 67 adults published by Bain10 and den Ottolander,11 respectively. These investigators found a range of 0.2–0.9 ( mean 0.42, 95% confidence limits 0.2–0.9) and a range of 0.24–0.80 (mean 0.46, 95% confidence limits 0.42–1.2), respectively. The diagnosis of CDA I can be made with high specificity from morphological analysis by light microscopy alone, when aberrations of the erythroblast nuclei as listed in Table 1 are present in more than 20% of these cells. Abnormal chromatin structure and the fine chromatin bridges are the most specific changes. They are not seen in normal bone marrow, but are occasionally observed in single cells in patients with myelodysplastic syndromes or erythroleukemia. In CDA II, the most specific finding is the presence of binucleated cells with equal size of two nuclei. As shown in Table 2, the fraction of such binucleated cells is usually more than 10% of all erythroid precursors. If the fraction of binucleated erythroblasts is related to the compartment of late polychromatic and mature oxyphilic erythroblasts, the 95% confidence interval is 13–16%. No more than 2% of binucleated cells may be found in normal individuals10 or a variety of red cell disorders with erythroid hyperplasia. If more than 10% of typical binucleated erythroblasts are seen, together with more than 2% of cells with karyorrhexis, the diagnosis of CDA II is almost confirmed, and confirmatory tests such as sequencing the SEC23B gene are indicated. Pseudo-Gaucher macrophages containing birefringent needles are found in the majority of cases, but in contrast to previous belief do not permit the differential diagnosis as compared with CDA I. In conclusion, the diagnosis of CDA I and CDA II can be made with high reliability from diligent analysis of peripheral blood and technically appropriate specimens of aspirated bone marrow. However, the results of this study clearly demonstrate that their specificity for the diagnosis of a congenital dyserythropoietic anemia relies not on their presence but rather on the mosaic of morphological aberrations and the frequency of their occurrence.

Congenital dyserythropoietic anaemias (CDAs) are rare hereditary disorders characterized by ineffective erythropoiesis and multinuclearity of erythroblasts. Three main types of the disease have been described. Glycoconjugate abnormalities in erythrocyte membrane glycoconjugates, consisting of hypoglycosylation of band 3 and accumulation of certain glycosphingolipids including lactotriaosylceramide, neolactotriaosylceramide and polyglycosylceramides, have been described only in patients with CDA type II (CDA-II). We report on identical, although less pronounced, abnormalities in erythrocyte glycoconjugates from a patient with CDA-I. A low degree of hypoglycosylation of band 3 in our patient with CDA-I suggests that hypoglycosylation is not a cause, but, most probably, a consequence of dyserythropoiesis.

The congenital forms of dyserythropoiesis comprise a group of hereditary disorders characterized by ineffective erythropoiesis as the predominant mechanism of anaemia and morphologically abnormal erythroblasts. Up to now three major forms and four variants have been described. Group VII is characterized by dyserythropoiesis with intraerythroblastic precipitation of a non-globin protein. Here we described a case of dyserythropoietic anaemia presenting neonatally and requiring regular blood transfusions. Optical and electronic microscopy studies confirmed that this case was very similar to those in two previously reported transfusion-dependent patients with an unusual type of congenital dyserythropoietic anaemia.

The congenital dyserythropoietic anemias (CDA) are hereditary diseases characterized by a lifelong, mostly moderate anemia. CDA can be diagnosed already in early childhood. However, diagnosis is complicated due to poor knowledge of morphological criteria and the large number of differential diagnoses that have to be excluded. CDA type I is characterized by macrocytic anemia with megaloblastic changes in erythropoiesis and chromatin bridges between isolated erythroblasts. Type II shows a normocytic anemia with a positive acidified serum test and increased agglutination with anti-i. Erythroblasts can present with 2 or more nuclei. CDA type III presents with a macrocytic anemia and erythroblasts with up to 12 nuclei, the so called gigantoblasts. Some patients lack the typical morphological abnormalities of type I-III (variants or type IV). Besides light microscopic abnormalities, CDA type-specific changes in electron microscopy are described. The clincal picture of the patients vary between the different forms: signs of hemolysis and ineffective erythropoiesis such as icterus, splenomegaly and gall stones can be present. Most important is the tendency of a part of patients to have an increased iron absorption and iron storage. Patients with and without transfusion dependency are described. Supportive care such as iron chelation can be necessary in some patients. The CDA are inherited in an autosomal recessive manner; in type III an additional autosomal dominant variant exists. Recently, the determination of gene loci for type I, II and III was enabled by linkage analysis on different regions of chromosome 15 and 22. It is considered that CDA I and II are genetically heterogeneic. Until now no gene has been identified in either type of CDA. In CDA type II, a glycosylation defect of erythrocyte membrane proteins is present. An international group plans to do further research. Therefore, identification and registration of patients in a registry is necessary. Patients' data and material would enable gene characterization. The results would allow an extented classification according to genotype and prediction of the course of the disease. Additionally, information on the regulation and control of normal and abnormal erythropoiesis could be obtained.

Clinical phenotypes associated with abnormal globin chain biosynthesis may result in thalassemia (deficient quantity) or hemolytic anemia (abnormal hemoglobins). However, the phenotypic expression of hyperunstable hemoglobin variants often includes features of thalassemia, along with variable peripheral hemolysis. Hemoglobinopathies caused by highly unstable beta-chain variants have a dominant thalassemia-like phenotype, in which carriers have a clinical expression of thalassemia intermedia, but highly unstable alpha-globin variants are usually only phenotypically apparent when they interact with other alpha-thalassemia mutations. In a child with clinical and hematological features consistent with beta-thalassemia intermedia, DNA analysis excluded any beta-globin gene mutations but characterized a novel deletion cd37(C2)Pro>0 (Hb Heraklion) in the alpha1 globin gene, in trans to a common Mediterranean nondeletion alpha-thalassemia mutation (alpha(Hph)alpha). The deletion of proline at alpha37(C2) is predicted to result in severe instability of the variant hemoglobin, which on interaction with a synthesis-deficient alpha-thalassemia mutation causes a relatively severe dyserythropoietic anemia, representing an alternative phenotype associated with highly unstable alpha-chain variants. Hb Heraklion is the fourth highly unstable alpha-globin variant that we have observed in patients from Greece and Albania. Two variants involve the alpha2-globin gene: Hb Agrinio (alpha29(B10)Leu>Pro) and Hb Adana (alpha59(E8)Gly>Asp), and two the alpha1-gene: Hb Aghia Sophia (alpha62(E11)Val>0) and (Hb Heraklion a37(C2)Pro>0). Each has been observed on interaction with a different alpha-thalassemia mutation and the phenotypes associated with these highly unstable alpha-variants are presented.

We report a case of congenital dyserythropoietic anaemia, type I, with severe pre- and postnatal manifestations. Exchange transfusions were required for fetal anaemia (3.5 g/dl) at 28 and 30 weeks of gestation. Transfusions were administered at birth (Caesarean section at week 35) and at regular intervals thereafter. At 14 months, alpha-interferon therapy was initiated (106 units three times a week). This resulted in stabilization of the haemoglobin at or above 11 g/dl and a reduction in the percentage of erythroblasts with ultrastructurally abnormal heterochromatin. After 9 months, the dose of alpha-interferon was decreased to 106 units twice a week. No relapse of anaemia was noted during an additional 4 months of follow-up.

Haematopoietic development is regulated by nuclear protein complexes that coordinate lineage-specific patterns of gene expression. Targeted mutagenesis in embryonic stem cells and mice has revealed roles for the X-linked gene Gata1 in erythrocyte and megakaryocyte differentiation. GATA-1 is the founding member of a family of DNA-binding proteins that recognize the motif WGATAR through a conserved multifunctional domain consisting of two C4-type zinc fingers. Here we describe a family with X-linked dyserythropoietic anaemia and thrombocytopenia due to a substitution of methionine for valine at amino acid 205 of GATA-1. This highly conserved valine is necessary for interaction of the amino-terminal zinc finger of GATA-1 with its essential cofactor, FOG-1 (for friend of GATA-1; refs 9-12). We show that the V205M mutation abrogates the interaction between Gata-1 and Fog-1, inhibiting the ability of Gata-1 to rescue erythroid differentiation in an erythroid cell line deficient for Gata-1 (G1E). Our findings underscore the importance of FOG-1:Gata-1 associations in both megakaryocyte and erythroid development, and suggest that other X-linked anaemias or thrombocytopenias may be caused by defects in GATA1.

Defective lymphocyte apoptosis caused by mutations of the Fas gene can result in an autoimmune lymphoproliferative syndrome (ALPS) in humans. We report two cases of dyserythropoiesis associated with a Fas-deficient condition in childhood. In both cases, dyserythropoiesis predominated on the more mature erythroblasts, and was associated with a lymphoproliferative syndrome as well as with haemolytic anaemia, hypergammaglobulinaemia and the expansion of an unusual population of CD4- CD8- T cells that express the alpha/beta T-cell receptor. The regression of dyserythropoiesis under steroid therapy suggested that it resulted from an autoimmune mechanism, itself secondary to the lymphocyte Fas apoptosis deficiency. Fas-defective apoptosis may be a new aetiology for childhood dyserythropoiesis.

Erythroblastic synartesis is a rare form of acquired dyserythropoiesis, first described by Breton-Gorius et al in 1973. This syndrome is characterized by the presence of septate-like membrane junctions and “glove finger” invaginations between erythroblasts, which are very tightly linked together. This phenomenon, responsible for ineffective erythropoiesis, leads to an isolated severe anemia with reticulocytopenia. In the following report, we describe 3 new cases of erythroblastic synartesis associated with dysimmunity and monoclonal gammapathy. In all cases, the diagnosis was suggested by characteristic morphological appearance of bone marrow smears, and further confirmed by electron microscopy. Ultrastructural examination of abnormal erythroblast clusters showed that these cells were closely approximated with characteristic intercellular membrane junctions. The pathogenesis of the dyserythropoiesis was modeled in vitro using crossed erythroblast cultures and immunoelectron microscopy: when cultured in the presence of autologous serum, the erythroblasts from the patients displayed synartesis, whereas these disappeared when cultured in normal serum. Moreover, synartesis of normal erythroblasts were induced by the patient IgG fraction. Immunogold labeling showed that the monoclonal IgG were detected in, and restricted to, the synartesis. A discrete monoclonal plasmacytosis was also found in the patient bone marrow. The adhesion receptor CD36 appeared to be concentrated in the junctions, suggesting that it might be involved in the synartesis. These experiments indicated that a monoclonal serum immunoglobulin (IgG in the present cases) directed at erythroblast membrane antigen was responsible for the erythroblast abnormalities. Specific therapy of the underlying lymphoproliferation was followed by complete remission of the anemia in these cases.

Seven untransfused patients with congenital dyserythropoietic anaemia type I were investigated to assess the determinants of both iron overload and serum bilirubin levels. The serum ferritin concentration was increased in all patients and non-transferrin-bound iron (NTBI) was increased in all but one patient. None of the patients showed the C282Y mutation in the hereditary haemochromatosis gene, HFE. One patient was homozygous for the H63D mutation in this gene. The data indicated that differences in the extent of iron overload were not mediated by co-inheritance of the C282Y mutation in the HFE gene but could largely be explained by differences in the severity of anaemia and ineffective erythropoiesis, and in the age of the patient. In one patient an unusually high plasma bilirubin level was associated with the variant A[TA]7TAA configuration in the TATA box of the uridine diphosphate glucuronosyltransferase (UGT-1A) gene promoter, the mutation found in most patients with mild Gilbert's syndrome.

The CDAN2 gene, responsible for congenital dyserythropoietic anaemia, type II (CDA II), was recently mapped to 20q11.2. We report data on an additional member of a previously studied CDA II family. This member had always been regarded as haematologically normal. Unexpectedly, she had the same microsatellite assortments around the CDAN2 alleles as her three sisters with CDA II. In particular, she was a homozygote for microsatellites D20S863 and D20S841. This prompted an analysis of all facets of her phenotype. The Ham test was negative. The bone marrow smears contained a normal proportion of binucleate erythroblasts. Electron microscopy revealed the absence of extensive stretches of cisternae beneath and parallel to the inner surface of the erythroblast plasma membrane. Proteins of the endoplasmic reticulum, which contaminate the reticulocyte plasma membrane in CDA II patients, were missing. Only the shape of the band 3 peak appeared slightly altered. This case exemplifies that homozygosity (or compound heterozygosity) for a deleterious gene may be silenced, or almost completely silenced. In recessively inherited diseases, suppressed phenotypes tend to be overlooked in siblings where both patients and unaffected individuals are expected.

Congenital anaemias due to ineffective erythropoiesis may be associated with excessive iron absorption and progressive iron loading. We investigated whether the soluble transferrin receptor (TfR) level was related to the degree of iron overload in 20 patients with thalassaemia intermedia, six patients with congenital dyserythropoietic anaemia type II (CDA II) and four patients with X-linked congenital sideroblastic anaemia (XLSA). All but two patients had increased serum ferritin levels (median 601 microgram/l, range 105-2855 microgram/l). Multiple regression analysis showed that 62% (P0.0001) of the variation in serum ferritin was explained by age and by changes in soluble TfR.

OBJECTIVE:To report a case of multisystemic hypersensitivity reaction to carbamazepine.CASE SUMMARY:An 81-year-old white man was admitted to our hospital because of fever, morbilliform pruritic rash, and jaundice. Fifty days before admission he had taken carbamazepine 200 mg po tid because of seizures. During the first few days following admission, a maculopapular rash progressed to generalized erythroderma with subsequent extensive skin exfoliation. After discontinuing carbamazepine the fever disappeared within 72 hours and hepatic function tests returned to normal within four days. Moreover, after admission the hemoglobin values gradually fell to 6.7 g/100 mL. A bone marrow aspirate showed hypercellularity with marked dyserythropoietic abnormalities, and the bone marrow biopsy showed large and diffused infiltration due to the presence of a low-grade small lymphocytic lymphoma. No specific therapy for the lymphoma was undertaken. The biochemical follow-up showed a total improvement of hemoglobin values. Eight months after drug discontinuation, the patient was asymptomatic; peripheral blood cell count and hemoglobin concentrations were persistently normal.DISCUSSION:To the best of our knowledge, this is the first published case report implicating carbamazepine as the cause of anemia associated with bone marrow hypercellularity and dyserythropoietic changes, instead of hypocellularity and reduction of erythroid precursors. An interesting point raised by our observation is the possible relation between carbamazepine intake and actual lymphoproliferative disease. The development of non-Hodgkin's lymphoma following carbamazepine treatment has been reported, with regression after the drug was discontinued. However, in our case, a bone marrow biopsy repeated eight months after drug discontinuation confirmed the diagnosis of low-grade lymphoma.CONCLUSIONS:This case report describes a severe multisystemic reaction, characterized by generalized erythroderma; and renal, hepatic, and bone marrow failure in a patient who started carbamazepine therapy 50 days beforehand.

Congenital dyserythropoietic anemia (CDA) type I is a rare inherited bone marrow disorder characterized by moderate to severe macrocytic anemia with pathognomonic cytopathology of nucleated red blood cells. Previous studies have suggested that serum erythropoietin levels in affected patients are lower than expected for the degree of anemia. An earlier study demonstrated a substantial increase in the number of CFU-E in CDA type I pattern on addition of exogenous erythropoietin. The present study reports on the response to recombinant human erythropoietin in 8 patients with CDA type I. Eighteen weeks of treatment, starting at 300 IU/kg twice a week and gradually increasing to 500 IU/kg three times a week, did not have a substantial effect on the mean hemoglobin value. These results indicate that recombinant human erythropoietin (rHuEpo) is not beneficial to patients with CDA type I and that the relatively low levels of serum erythropoietin probably play no major role in the pathogenesis of the disease.

The in vitro effects of interferon (IFN)-α on erythroid progenitor cells derived from the peripheral blood of five patients with congenital dyserythropoietic anaemia (CDA) type I and seven healthy adults were studied. Ficol-hypaque-separated mononuclear cells were cultured for 14 d in StemGEM-1d medium with 0, 1, 10 and 100 U/ml of recombinant IFN-α2a, recombinant IFN-α2b, the genetically-engineered hybrid molecule IFN-α1-8 or the laboratory-designed molecule IFN-αconsensus. Erythroid bursts and colonies were counted, picked and processed for electron microscopy. In the experiments employing IFN-α2a there were no differences in the numbers of erythroid bursts or colonies between four patients with CDA type I and seven healthy adults. All five patients with CDA type I showed the ‘Swiss-cheese’ ultrastructural abnormality of the heterochromatin in a proportion of the erythroblasts when the progenitor cells were cultured in the absence of added IFN-α. A statistically significant reduction in the proportion of erythroblasts showing the ‘Swiss-cheese’ defect was seen when the erythroid progenitors were cultured in the pre-sence of 0.01–0.5 U/ml IFN-α2a (five patients), or 0.1 U/ml of IFN-α2b (two patients). In contrast, no reduction was seen in cultures containing 0.1–100 U/ml of either IFN-α1-8 or IFN-αconsensus or 20 μM hydroxyurea (two patients). The partial correction of the ‘Swiss-cheese’ abnormality by low concentrations of IFN-α2ain vitro provides an experimental model with which the mechanisms underlying the haematological response that occurs after the in vivo administration of this species of IFN-α may be investigated.

Two non-anaemic subjects, a father and daughter, with a new form of congenital dyserythropoiesis are reported. The features of their disorder are: (1) an abnormal blood film with basophilic stippling of red cells and oval macrocytes, (2) various dysplastic changes in the erythroblasts, including internuclear chromatin bridges, (3) ultrastructurally-normal erythroblast heterochromatin, (4) normal serum thymidine kinase activity, and (5) a probable autosomal dominant inheritance. The last three features distinguish this disorder from CDA type I.

Complex cytokine interactions occur during blood-stage malaria which offer a unique opportunity to study their influence on the pathogenesis of malarial anaemia. Plasmodium chabaudi AS susceptible A/J mice experience severe and fatal anaemia whereas resistant C57BL/6 (B6) mice survive following moderate anaemia. In this study we analysed the role of IL-12 in erythropoiesis and tested whether the levels of IL-12 produced in these mice correlated with the extent of anaemia. In vitro, IL-12 significantly enhanced the numbers of erythroid burst (BFU-E) and colony forming units (CFU-E) in bone marrow and spleen cells from normal and day 7 infected A/J and B6 mice. Despite the presence of IL-12 in vitro, the level of splenic erythropoiesis in infected A/J mice was significantly lower than in B6 mice. Moreover, sera from infected B6 mice, but not A/J mice, significantly up-regulated erythropoiesis in vitro and this enhancement correlated with several fold higher levels of IL-12 in the sera of B6 compared to A/J mice. Furthermore, the erythropoietic potentiating effect of sera from infected B6 mice was abrogated following depletion of IL-12. Taken together, these findings suggest that defective IL-12 production in A/J mice during the early course of infection may result in fatal anaemia.

Summary Congenital dyserythropoietic anemias (CDA) are a rare group of red-blood-cell disorders of unknown etiology that are characterized by ineffective erythropoiesis, pathognomonic cytopathology of the nucleated red blood cells in the bone marrow, and secondary hemochromatosis. In CDA type I, bone-marrow electron microscopy reveals characteristic findings in erythroid precursors, including spongy heterochromatin and enlarged nuclear pores. Since the genetic basis of CDA type I is not evident, we used homozygosity and linkage mapping to localize the genetic defect responsible for CDA type I in 25 Bedouins from four large consanguineous families. We report the linkage of this disease to markers on chromosome 15 located at q15.1-q15.3. Fourteen markers within a 12-cM interval were typed in the relevant family members. Nine of the markers yielded maximum LOD scores of 1.625–12.928 at a recombination fraction of .00. Linkage disequilibrium was found only with marker D15S779. Haplotype analysis revealed eight different carrier haplotypes and highlighted the existence of a founder haplotype. Identification of historical crossover events further narrowed the gene location to between D15S779 and D15S778. The data suggest localization of the CDA type I gene within a 0.5-cM interval. The founder mutation probably occurred ≥400 years ago. Sequence analysis of the coding region of protein 4.2, the only known erythroid-specific gene in the locus, did not reveal any change in the CDA type I patients. Future analysis of this locus may lead to the identification of a gene essential to normal erythropoiesis.

To evaluate the quantitative aspects of the shift in production from fetal hemoglobin (HbF) to adult hemoglobin (HbA), the HbF and HbA mass were estimated in a preterm infant (gestational age 29 weeks) for 22 weeks after an exchange transfusion the second day of life, leading to an initial HbA% of 100. Up until the estimated time of delivery, the HbA mass declined continuously, at a rate corresponding to a survival time of the transfused HbA erythrocytes of 100 days, and the rise in total hemoglobin mass could be ascribed solely to a rise in the HbF mass. HbF% maximum was reached 3 weeks before HbF mass maximum, and, thus, the HbF% and HbA% time courses gave no basis for evaluation of the production/destruction balance of HbF and HbA erythrocytes. The applied quantitative approach seems to be a useful additional procedure for evaluating the switch from HbF to HbA production and for estimating HbA erythrocyte survival time in preterm infants.

The lack of correlation between parasitaemia and anaemia in severe malaria indicates that factors in addition to schizont rupture or erythrophagocytosis contribute to anaemia. We asked whether malaria toxin (MT) from Plasmodium berghei or P. chabaudi might impair erythropoiesis. Daily intraperitoneal injection of MT into C57BL/6 mice induced a transient reduction of RBC values by 25–30% after about 2 weeks, followed by increased haematopoiesis in the spleen as compared to mice receiving uninfected RBC preparations. There was a 3 (P. berghei) to 8-fold (P. chabaudi) increase of total proliferative activity in the spleen. Flow cytometric analyses showed that this was accompanied by some differentiation of TER-119 positive erythroid cells and of Gr-1 positive myeloid cells. Erythroid and myeloid progenitor cell-derived colony assays confirmed these results and revealed an increase in the number of CFU-E ([les ]200-fold), BFU-E ([les ]10-fold) and CFU-GM ([les ]20-fold) in the spleen of MT treated mice, as compared to controls.

Alpha-mannosidase-II (alphaM-II) catalyzes the first committed step in the biosynthesis of complex asparagine-linked (N-linked) oligosaccharides (N-glycans). Genetic deficiency of alphaM-II should abolish complex N-glycan production as reportedly does inhibition of alphaM-II by swainsonine. We find that mice lacking a functional alphaM-II gene develop a dyserythropoietic anemia concurrent with loss of erythrocyte complex N-glycans. Unexpectedly, nonerythroid cell types continued to produce complex N-glycans by an alternate pathway comprising a distinct alpha-mannosidase. These studies reveal cell-type-specific variations in N-linked oligosaccharide biosynthesis and an essential role for alphaM-II in the formation of erythroid complex N-glycans. alphaM-II deficiency elicits a phenotype in mice that correlates with human congenital dyserythropoietic anemia type II.

We describe a case of congenital dyserythropoietic anaemia (CDA) presenting at week 20 of pregnancy with hydrops fetalis and very severe anaemia. Fetal blood examination showed marked erythroblastosis with morphologic alterations while the basic haematological and biochemical tests were in the normal range. The fetus received intravascular red blood cells transfusion at 20 and 25 weeks of gestation. After a caesarean section at week 33 the child became transfusion dependent. Haematological investigations demonstrated that the child is affected by a CDA-like picture which, although morphologically similar to CDA II, is Ham test negative and does not show the typical membrane proteins alterations.

Four patients with congenital dyserythropoiesis characterized by marked macrocytosis, little or no anaemia, and vitamin B 12 - and folate-independent megaloblastic erythropoiesis are reported. Their erythroblasts also showed various dysplastic changes but not those diagnostic for congenital dyserythropoietic anaemia (CDA) types I or III. The haematological features of the four patients, who included two siblings, resemble those of a previously reported patient and together these patients form a recognizable subgroup within those cases of CDA not belonging to CDA types I-III. In two of the cases studied, and possibly a third, the inheritance was as an autosomal recessive character.

Ultrathin sections of bone marrow cells from two patients with homozygous beta-thalassaemia, two patients with haemoglobin H (HbH) disease, a patient with congenital dyserythropoietic anaemia (CDA) type III and two patients with severe congenital dyserythropoietic anaemia of an unusual type were reacted with mouse monoclonal antibodies against various globin chains and the reaction visualized using a gold-labelled goat antibody against mouse IgG. The multiple rounded intra-erythroblastic inclusions found in homozygous beta-thalassaemia reacted with the monoclonal antibody against alpha-globin chains but not beta-globin chains, thus confirming that they consisted of precipitated alpha-globin chains. The branching intra-erythroblastic inclusions found in HbH disease and CDA type III reacted with the monoclonal antibody against beta-globin chains but not alpha-globin chains, indicating that they consisted of precipitated beta-globin chains. The two patients with severe CDA had been transfusion-dependent since infancy, had a normal alpha:beta globin chain synthesis ratio or parents with normal red cell indices, displayed prominent dysplastic changes in their erythroblasts, and had intra-erythroblastic inclusions resembling those seen in homozygous beta-thalassaemia. However, unlike those in beta-thalassaemia, the inclusions in these two patients did not react with the monoclonal antibody against either alpha- or beta-globin chains. The inclusions reacted with antibody against zeta-globin chains, but detailed studies in one of the patients indicated that the antigen involved was not zeta-globin. These patients have features not reported in the condition known as dominantly inherited inclusion body beta-thalassaemia and appear to suffer from a novel type of CDA in which the intra-erythroblastic inclusions may consist of some non-globin protein or structurally-abnormal alpha-globin chains.

To compare the pharmacokinetics and effectiveness of continuously administered recombinant erythropoietin (Epo) in total parenteral nutrition (TPN) solution with daily subcutaneously administered Epo.Forty preterm infants in the first 72 hours of life were randomly assigned to receive Epo (200 units/kg per day for 10 consecutive days), either subcutaneously (20 infants, 1051 +/- 40 gm, 28.3 +/- 0.4 weeks of gestation; mean +/- SEM), or added daily to their TPN fluids (20 infants, 1028 +/- 36 gm, 27.9 +/- 0.4 weeks of gestation). Both groups received iron supplementation (1 mg/kg per day iron dextran in the TPN solution). Absolute reticulocyte counts and complete blood cell counts with differentials were measured, and transfusions and phlebotomy losses were recorded. Pharmacokinetics were determined in the first 16 infants.In the infants who received Epo subcutaneously, the elimination half-life was 17.6 +/- 4.4 hours on day 3 and 11.2 +/- 1.5 hours on day 10; the volume of distribution was 802 +/- 190 ml/kg on day 3 and 1330 +/- 243 m/kg on day 10. Serum Epo concentrations were higher on day 3 than on day 10 for both groups (subcutaneous: 400 +/- 64 mU/ml vs 177 +/- 29 mU/m, p0.05; TPN: 395 +/- 64 vs 194 +/- 41 mU/ml, p0.05). Clearance did not differ between the two groups with regard to route of administration and increased significantly from days 3 to 10 in both groups. Reticulocyte counts were similar in both groups. There were no differences between groups in the number of transfusions given, and the overall decline in hematocrit was similar. No adverse effects of Epo were noted in either group.Adding Epo to the TPN solution in this population results in similar Epo concentrations, clearance, and effectiveness as subcutaneous dosing.

Congenital dyserythropoietic anemia (CDA) type I is a rare macrocytic anemia of unknown etiology. In the present study, we redefined the clinical and laboratory picture of CDA type 1, some of its pathogenic aspects, and the association with thalassemia-like features in 20 patients, all of whom belong to one Bedouin tribal group and are probably descended from a common ancestor. In each case ultrastructural studies of bone marrow (BM) erythroblasts showed the classic morphological findings of CDA type 1. Serological tests for CDA type II were negative. The clinical picture was variable, but mostly benign. Some patients displayed elevated hemoglobin A2 levels or a high ratio of a-to non-a ONGENITAL dyserythropoietic anemias (CDAs) are a C rare group of red blood cell (RBC) disorders of unknown etiology characterized by ineffective erythropoiesis, pathognomonic cytopathology of the nucleated RBCs in the bone marrow (BM) and secondary hemochromatosis. In 1968, Heimpel and Wendtl classified these disorders into three types, which were later confirmed by electron microscopy and serological findings.' Type I is characterized by congenital macrocytic anemia, megaloblastoid erythroid hyperplasia, and the presence of nuclear chromatin bridges between erythroblasts. More than 60 sporadic cases of CDA type I have been reported in the literat~re.~" The typical morphological ultrastructural studies accompanied by negative acidified serum lysis and adult i/l agglutination test constitute the major diagnostic features. The more common type 11, also known as hereditary erythroblastic multinuclearity with a positive acidified serum test (HEMPAS): is characterized by normocytosis or macrocytosis with binucleated and multinucleated marrow erythroblasts and karyorrhexis. Type 111 is manifested by macrocytosis and erythroblastic multinuclearity with prominent gigantoblask3 More than 30 documented cases could not be clearly assigned to type I, 11, or III.3 Type IV was the classification used in four reports in which BM morphology resembling that in type I1 was accompanied by negative acid serum tests5 CDA in association with thalassemia has been described in 17 patients.'.' Members of more than a dozen other families had CDAs that were even more difficult to cla~sify.~ Anselstetter et a19 in 1977 were the first to report that band 3 glycoproteins from HEMPAS erythrocyte membranes migrate faster than those obtained from normal erythrocyte membranes. Reduced levels of N-glycans in HEMPAS erythrocyte membranes with low N-acetylglucosaminyltransferase I1 activity have been documented in some patients," and a defect in the a-mannosidase I1 gene was reported in one patient." Faulty glycosylation of transfemn, a glycoprotein produced in the liver, has also been described.I2 The molecular basis for the defects in other CDAs is not known. In the following study, we describe 20 patients with CDA type I who belong to seven Bedouin families living in the Negev (the southern part of Israel). The aim of the study was to redefine the clinical and laboratory characteristics of globin. However, neither family studies nor complete sequence analysis of the p-globin was compatible with pthalassemia. Increased erythropoiesis was manifested by a high number of BM erythroid burst-forming units. Serum erythropoietin was also elevated. BM flow cytometry studies demonstrated arrest of erythroid precursors in the S phase of the cell cycle. The ultrastructural morphological features of the erythroid precursors, showing peripheral chromatin condensation, suggest apoptosis. AddiCional studies are indicated to define the molecular basis of this disease. 0 1996 by The American Society of Hematology. CDA type I in this homogeneous population in an attempt to clarify the pathogenesis of the disorder and its association with thalassemia. MATERIALS AND METHODS Twenty patients (14 men, 6 women), aged 1 to 23 years (median, 10 years) from seven families were evaluated. Three patients were originally diagnosed and followed at our center, and the medical records of the 11 patients followed for anemia at the Soroka Medical Center in Beersheva were reviewed. Six additional patients were identified in the course of family studies. Each of the 20 patients underwent a complete physical examination. Bone age was determined in six patients. Control BM samples for culture studies and flow cytometry studies were obtained from healthy children who were donors for BM transplant. &thalassemia major BM samples were obtained at diagnosis. The following blood and BM examinations were performed for each patient.

This study describes two siblings (a boy and a girl) affected with congenital dyserythropoietic anaemia type I. It is the seventh familial occurrence reported. The girl presented in the neonatal period with anaemia, jaundice and hepatosplenomegaly and required 4 blood transfusions in the first 7 months of life, while her brother was discovered to be anaemic and jaundiced only at the age of 2 years and did not receive any blood transfusion.

Congenital dyserythropoietic anemia, type III (CDA III) is a rare autosomal dominant disorder characterized by macrocytic anemia, bone marrow erythroid hyperplasia and giant multinucleate erythroblasts. We have genetically characterized a large Swedish family in which the concurrence of CDA III and myeloma or benign monoclonal gammopathy is significantly higher than expected and have found that the causative genetic defect for CDA III maps to an 11 cM interval within 15q21-q25.

A child was admitted to our hospital for repair of a ventricular septal defect (VSD) characterized by a predominantly right-to-left shunt and a severe stenosis of the right ventricular outflow tract (Tetralogy of Fallot). Severe congenital anemia (hemoglobin 72 g/L), thrombocytopenia (42×G/L) and profound platelet dysfunction led a stem cell defect to be suspected. X-linked thrombocytopenia (GATA-1 mutation) was diagnosed. GATA-1 defect may complicate medical interventions due to excessive bleeding and partial or complete bone marrow failure. Maintaining a platelet count of 100 G/L and a maximal clot firmness (EXTEM-MCF) >50 mm allowed repair of the congenital heart defect without bleeding or hematological complications. Anemia and thrombocytopenia persisted after cardiac surgery, while the spontaneous bleeding tendency improved.

The congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis characterized by anemia with ineffective erythropoiesis and morphological abnormalities of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II or HEMPAS is the more frequent type. It is rare in adults. Extra medullary hematopoiesis is also a rare entity; it is a physiological response to chronic anemia observed in certain hemopathies like congenital dyserythropoietic anemia type II. We report the observation of a patient for who diagnosis of extra medullary hematopoiesis associated to congenital dyserythropoietic type II was made in adulthood.

Blackfan-Diamond anemia is a congenital hypoplastic anemia with a birth prevalence of about 1 in 200,000, usually presenting in the first few months of life and commonly associated with cardiac, urogenital and digital anomalies. Congenital dyserythropoietic anemias are a group of rare congenital anemias characterized by ineffective erythropoiesis. We report on two cases of congenital fetal anemia, one with Blackfan-Diamond anemia and one with dyserythropoietic anemia, presenting with increased nuchal translucency at 12 weeks of gestation.

Objective To compare the effectiveness of different types of splenectomy in children with congenital hemolytic anemias. Study design We constructed key questions that addressed outcomes relevant to clinicians and families on effects of partial or total splenectomy, including hematologic effect, splenic function, and the risk of adverse events. We identified from Pubmed and Embase 703 studies that evaluated different types of splenectomy and accepted 93 studies that satisfied entry criteria. We graded the quality of each report and summarized the overall strength of research evidence for each key question. Results We did not identify any randomized clinical trials. All types of splenectomy have favorable clinical outcomes in most diseases. We did not identify any hematologic advantage of laparoscopy compared with laparotomy. Adverse events are uncommon in most studies and are minimized with use of laparoscopy. Conclusions There is a need for randomized clinical trials and improved data collection of different types of splenectomy in congenital hemolytic anemias. Outcomes studied should address the concerns of families and clinicians to assess the risks and benefits of various treatments.

PURPOSE OF REVIEW: Congenital dyserythropoietic anemias (CDAs) are rare hereditary disorders characterized by ineffective erythropoiesis and by distinct morphological abnormalities of erythroblasts in the bone marrow. Characteristic morphological aberrations were the cornerstone of diagnosis, but following the identification of several causative genes, the molecular approach could represent a rapid tool for the identification of these conditions. This review presents advances in diagnosis and classification of CDAs. RECENT FINDINGS: The classification of CDAs has long been based on morphological features. Now, the discovery of some of the responsible genes allows reconsideration of part of the classification. The first CDA partly accounted for genetically has been CDA 1, through the discovery in 2002 of the gene responsible, CDAN1, encoding codanin-1. Recently, the dramatic identification of the genes responsible for CDA II, SEC23B, and for a hitherto unnamed CDA, KLF1, took place. SEC23B encodes SEC23B which is a component of the coated vesicles transiting from the endoplasmic reticulum to the cis compartment of the Golgi apparatus. A unique mutation in KLF1, which encodes the erythroid transcription factor KLF1, causes major ultrastructural abnormalities, the persistence of embryonic and fetal hemoglobins, and the absence of some red cell membrane proteins. SUMMARY: Studies of genotype-phenotype relationship, as has already been done for CDA II, will allow a more accurate prognosis. Identification of the responsible genes has opened new vistas for research on CDAs.

Abstract 1003 Introduction: The Congenital dyserythropoietic anemias (CDAs) are a heterogeneous group of rare inborn disorders mainly affecting erythropoiesis. Distinct from other inherited bone marrow failure syndromes, they are marked by morphological abnormalities of the erythroblasts leading to ineffective erythropoiesis/dyserythropoiesis, while the other hematopoietic lineages appear to be unaffected. Based largely on the dysplastic changes observed in erythroblasts by light and electron microscopy, the CDAs have been divided into 3 major types (CDA-1, 2 and 3). Causative genes have been identified for CDA-1 (CDAN1/15q15) and CDA-2 (CDAN2/20p11), while the chromosomal locus is known for CDA-3 (15q22). The majority of CDA-1 cases are associated with CDAN1 missense mutations, leading to single amino-acid substitutions in the 134 kDa Codanin-1 protein. Electron microscopy of CDA-1 erythroblasts reveals a characteristic pattern of spongy (“Swiss cheese”) heterochromatin. We investigated the chromatin in CDA-1 patients, the localization, distribution and interactions of Codanin-1 and generated a murine knock-out model for CDAN1. Results: Given the grossly abnormal chromatin ultrastructure in CDA-1 erythroblasts, we examined its overall content. No gross differences between normal and patient samples were seen, both in the amounts of histone proteins or various epigenetic marks of histone tails, suggesting that histone signatures, involved in maintenance of chromatin structure and epigenetic regulation, are globally maintained CDA-1. We confirmed the latter by ChIP-on-chip analysis where immunoprecipitated H4 acetylated, H3K4 dimethylated, H3K9 trimethylated and H3K27 trimethylated chromatin from CDA-1 erythroblasts and normal controls was hybridized to ENCODE genome-wide microrrays. Using a hybridoma technique, we produced 3 novel monoclonal antibodies to Codanin-1. These consistently demonstrate its distribution in both nucleus and cytoplasm of cells by immunofluorescence and Western Blotting. While Codanin-1 is found in the nucleus, it is more abundant in the cytoplasm in primary human erythroblasts. This localization pattern was unchanged in CDA-1 erythroblasts. Within the nucleus, Codanin-1 is localized in foci, while in the cytoplasm it shows an aggregated distribution, with the endoplasmic reticulum and Golgi apparatus being the most likely locations. No differences were found in the distribution patterns of RNA-polymerase-II, PML, nucleophosmin, HP1β and HP1γ between patients' and control erythroblasts. However, the localization of HP1α, a key component of heterochromatin, was found to be markedly perturbed. HP1α accumulates in the Golgi apparatus of CDA-1 but not normal erythroblasts. This was not seen in lymphoblasts derived from CDA-1 patients, nor in erythroblasts from a patient with CDA-2. We confirmed that the abnormal localization of HP1α in CDA-1 patients is confined to the intermediate erythroblast maturation stage, where the characteristic ultrastructural chromatin pattern of CDA-1 is observed. Immunoprecipitation of erythroblast protein extracts with anti- HP1α antibodies co-precipitated Codanin-1, suggesting that an abnormality in Codanin-1 could be responsible for the aberrant localization of HP1α. By confocal immunofluorescence, we also found Codanin-1 to co-localize partially with SEC23B, the protein mutated in CDA-2, suggesting a molecular link between the two major types of CDA. We generated the first murine Cdan1 gene-trap model demonstrating its widespread expression during embryonic development. Cdan1gt/gt homozygotes die in-utero before the onset of primitive erythropoiesis, suggesting that Cdan1 has other critical roles during embryogenesis. Adult heterozygous Cdan1wt/gt mice had normal hematopoietic function and morphology, normal life expectancy and fertility. No extra-hematopoietic macroscopic phenotype could be identified. Conclusions: Our results show that the absence of the highly conserved and ubiquitously expressed Codanin-1 is embryonic lethal, and suggest that missense CDAN1 mutations are responsible for the erythroid specific phenotype of CDA-1 via the abnormal cellular trafficking of the heterochromatin protein HP1α. Moreover, our findings suggest that common molecular pathways underlie the CDAs. Disclosures: No relevant conflicts of interest to declare.

The relative excess of alpha- over beta-globin chains in the erythroid precursors is the chief pathophysiological factor of homozygous beta-thalassemia. The clinical picture is usually characterized by a transfusion-dependent dyserythropoietic anemia (thalassemia major). However, some patients present with moderate anemia that does not require regular blood transfusions (thalassemia intermedia). The molecular heterogeneity of beta-thalassemia mutations and changes of alpha- and gamma-globin gene expression play an important role in modifying the clinical phenotype. We report here on a female Greek patient with homozygous beta-thalassemia but normal growth and development, excellent exercise tolerance, and no need of blood transfusions. She is thus mildly affected clinically, although there is marked pallor, jaundice, and hepatosplenomegaly. These signs correspond to her marked hypochromic, microcytic anemia with erythroid hyperplasia of the bone marrow. beta-Globin genotyping shows here to be compound heterozygous for the codon 39 C-->T beta zero-nonsense mutation and for the T-->C beta(+)-mutation at position 6 of the splice consensus at the exon 1/intron 1 junction (CD39 C-->T/IVS1-6 T-->C). alpha-Globin gene mapping demonstrates the presence of a 3.7-kb alpha (+)-thalassemia deletion on one allele (-alpha 3.7/alpha alpha). Taken together, this study identifies a complex interaction of genetic factors that do not significantly alter the clinical phenotype when present alone but ameliorate the course of homozygous beta-thalassemia when inherited in combination.