Effect of chloroquine on serum vitamin B12 and its binding proteins in patients with plasmodium vivax.

Chloroquine (CQ) is widely used as an antimalarial agent. It is accumulated in the lysosomes of various types of cells and inhibits the intralysosomal degradation of a wide range of proteins. CQ is found to interfere with vitamin B12 transportation in vitro and in the experimental animal. The present study was performed in order to determine such interference in humans receiving CQ. Serum vitamin B12 and vitamin B12 binding proteins were determined in 13 patients with P.vivax, both before and after receiving six tablets and 10 tablets of CQ. There were no significant differences between serum vitamin B12, UBBC, TBBC and TC values in patients before and after taking 6 tablets of CQ. A slight but not significant decrease in serum vitamin B12 and a significant increase in serum TCII were found after taking 10 tablets of CQ. The low serum vitamin B12 could be due to the effect of CQ on prevention of lysosomal degradation of intrinsic factor, leading to the accumulation of IF-B12 in the intestinal mucosa. As CQ also inhibits the intracellular degradation of TCII, therefore, more TCII levels are synthesized and secreted from various organs by the feedback mechanism. All these findings indicated the CQ had some effects on vitamin B12 absorption and transportation. However, these effects were relatively unsevere for the required dose of CQ in the treatment of P.vivax malaria.

Increased circulating levels of transcobalamin II in typhoid fever.

Many previous studies have shown that serum transcobalamin II (TCII) is usually elevated in patients with a stimulated and proliferative reticuloendothelial system resulting from such diseases as multiple myeloma, systemic lupus erythrematosus, dermatomyositis, rheumatoid arthritis and Gaucher’s disease. As reactive macrophage hyperplasia with monocytosis also occurs in patients with typhoid fever, we therefore studied TCII in these patients. The mean value of serum TCII was significantly higher in the typhoid patients’ group, and 15 out of 35 patients had serum TCII values over 2,000 pg/ml. There was no relationship between serum TCII and white blood count, haemoglobin or haematocrit values. The increased serum TCII level in typhoid patients was possibly due to increased synthesis by the proliferative mononuclear cells derived from reticuloendothelial tissue in various organs such as the spleen, liver and mesenteric lymph nodes. This supposition is supported by a previous report that TCII is synthesized in part by mouse peritoneal macrophages, as well as by human monocytes and macrophages which produced and secreted considerable amounts of TCII into the medium. Findings of increased serum TCII in typhoid patients therefore add a new area of information which has never been studied before.

Elevated serum transcobalamin II levels in patients with prolonged fever.

Serum transcobalamin II levels were determined in 70 patients with prolonged fever. Twelve patients were found to have elevated serum TCII levels, i.e., 8 patients with salmonellosis, 3 patients with scrub typhus and 1 patient with pyrexia of unknown origin. There were no relationships between serum TCII levels and white blood cells, lymphocytes or monocytes. The possible mechanism producing increased serum TCIII levels in patients with salmonellosis and scrub typhus is the increased synthesis and release of TCII by the proliferative mononuclear phagocytic cells of the reticuloendothlial tissues such as spleen, liver, bone marrow and lymph nodes. This study gives the additional data that elevated serum TCII may occur not only in inflammatory disorders, autoimmune diseases, lymphoproliferative disorders, malignant histiocytosis and neoplasms, but also in infection with salmonellosis and scrub typhus.

A case with acute myelofibrosis and acute promyelocytic leukemia.

A 65-year-old man was admitted to a provincial hospital repeatedly over a period of years with a history of weakness, tiredness and progressive anemia. One occasion a bone marrow aspiration was found to contain normal marrow elements. On admission four months later, the patient was pale with pitting edema on both legs. His liver was barely palpable and the spleen was palpable 2 cm below the costal margin. He was anemic and peripheral blood showed anisopoikilocytosis, burr cells, ovalocytes and macrocytosis. The platelet level was very low, with some giant cells. The white blood cell count was normal, with some immature granulocytes. Bone marrow biopsy confirmed the diagnosis of acute myelofibrosis. The patient had very high levels of serum vitamin B12 and vitamin B12 binding proteins, especially transcobalamin I. After treatment with blood transfusion and prednisolone, his white cell count increased considerably. He died nine days after admission because of bronchopneumonia. This patient is an example of the simultaneous occurrence of acute myelofibrosis and acute promyelocytic leukemia that can terminate as acute myeloblastic or other stem – cell leukemia.

Excessively high serum vitamin B12 level in patients with a provisional diagnosis of megaloblastic anemia.

High serum vitamin B12 level has been reported in patients with liver diseases ad some hematological disorders. It has been observed that some patients diagnosed as megaloblastic anemia have high serum vitamin B12 with low serum unsaturated vitamin B12 binding capacity (UBBC). The objective of the present study was to investigate in these patients. A retrospective study in 9 patients with a provisional diagnosis of megaloblastic anemia showed extraordinarily high serum vitamin B12 with very low UBBC. Their past history showed that these patients were treated with 1,000 g vitamin B12 intramuscularly 10-24 hours before serum samples were taken for vitamin B12 determination. Study in another 3 patients showed that within 12 hours after a single injection of 1,000 g cyanocobalamin, their serum vitamin B12 raised considerably with an extremely low UBBC level. These findings indicated that the injected vitamin B12 saturated all transcobalamins and then exceeded to bind to other serum proteins such as albumin and gamma globulin. Serum vitamin B12 was maintained at a very high level with a very low unsaturated vitamin B12 binding capacity. Therefore the past history of receiving vitamin B12 must be exactly known in any patients who were taken blood sample for vitamin B12 determination.

Serum transcobalamin II in childhood histiocytosis syndromes.

It has been shown in a previous report that an extreme high serum TCII level was found in patients with malignant histiocytosis and patients with proliferative histiocytosis. The objective of the present study was to Langerhans cells histiocytosis and 6 patients with malignant histiocytosis. Serum TCII levels in both groups of patients were not significantly different from those of normal subjects. Furthermore, serum vitamin B12 and other transcobalamins levels were also within the normal limits. These findings do not support the results reported earlier in adult patients either with malignant histiocytosis or with proliferative histiocytosis. The suggestion that determination of TCII may be a useful indicator of activity and size of the macrophage/histiocyte system is therefore not proved in childhood histiocytosis syndromes.

Differential diagnosis of myelofibrosis from polycythemia vera and chronic myelogenous leukemia by vitamin B12 determination.

Myelofibrosis (MF) has a close pathogenic relationship to polycythemia vera (PV), chronic myelongenous leukemia (CML) and primary thrombocythemia (PT). Sometimes, clinical, hematological and radioisotopic studies in these patients cannot give a definite diagnosis. As serum vitamin B12 and vitamin B12 binding proteins in patients with PV and CML show their own specific pattern. It would be of interest to see whether these determinations could separate MF from PV and CML. Serum vitamin B12 and vitamin B12 binding proteins were determined on 6 patients with MF. It was found that serum vitamin B12, UBBC and TBBC levels were elevated. Both TCI and TCIII were increased while TCII decreased. A shift to the left of the increased granulocytes in MFR resulted in an increased TCI synthesized by the myelocytes and metamyelocytes while in PV, the increased number of granulocytes, most of which are mature granulocytes is characterized by increased serum TCII resulting in a reverse ratio of TCI/TCIII. In CML, serum vitamin B12, UBBC, TCI and TCII are much more sharply elevated than those of MF. Therefore determination of serum vitamin B12 and vitamin B12 binding proteins with other hematological, bone marrow and clinical studies could be used for a differential diagnosis of MF from PV or CML.

Serum folate and vitamin B12 levels in chronic alcoholics.

Anemia is common in alcoholics. Folate deficiency occurs commonly in association with the chronic use of alcohol. The incidence of folate deficiency in chronic alcoholic patients varies considerably from country to country. The purpose of the present study was to report the incidence of folate and vitamin B12 deficiencies in Thai chronic alcoholics. Serum folate and vitamin B12 levels were determined in 75 chronic alcoholics as well as in 80 apparently healthy Thai subjects. The mean Hb, Hct and serum folate levels were significantly lower in the alcoholics. Thirty-five percent and 84 percent had serum folate levels lower than 3 ng/ml and 6 ng/ml, respectively. On the other hand, the mean value of serum vitamin B12 in the alcoholic patients was significantly elevated, with 49 percent of them having serum vitamin B12 over 1,000 pg/ml. These findings indicated that the incidence of folic acid deficiency in the chronic alcoholics was quite high, which was probably due to dietary deficiency, folate malabsorption and interference by alcohol in folate metabolism. All these patients had a tendency to have a high serum vitamin B12 level, probably as a result of the increased release of vitamin B12 from storage in the injured liver.

Folates and vitamin B12 status in patients with multiple myeloma.

Serum and red cell folate, serum Vitamin B12 and Vitamin B12 binding proteins were multiple myeloma. Half of these patients were anaemic with a predominant macrocytic type. Altogether 17 and 33 percent had low serum and red cell folate levels, respectively. Low serum Vitamin B12 level was found in one third of these patients. Both TCI and TCIII increased while TCII decreased, while was different from the previous report of extremely elevated TCII in some patients with multiple myeloma. There was a direct relationship between serum Vitamin B12 and saturation of TCI. These finding indicated that folic acid and Vitamin B12 deficiency were relatively common in patients with multiple myeloma. The possible mechanisms of these vitamins deficiency were discussed in this paper.

Polycythaemia vera and secondary polycythaemia: Differential diagnosis by serum vitamin B12 and Its binding proteins.

That the suggested criteria for diagnosis of polycythaemia vera (PV) are rather complicated, therefore accurate diagnosis of PV from other types of polycythaemia is needed. Serum Vitamin B12 and Vitamin B12 binding proteins were determined in a patients with PV and other 5 patients with secondary polycythaemia. Both serum Vitamin B12 and unsaturated Vitamin B12 binding capacity (UBBC) increased considerably. TCIII and TCI increased also markedly, i.e., 16 and 8 folds, respectively, resulting in a decreased ratio of TCI/TCIII from the normal value of 1.34 to 0.71. Patients with secondary polycythaemia had slightly increased serum Vitamin B12 while serum UBBC, TCI and TCIII levels showed no significant alteration from those of normal subjects. These findings indicated that not only increased serum Vitamin B12 and UBBC but also an increase of TCIII and the ratio of TCIII/TCI are the positive findings in patients with PV. Therefore determinations of serum Vitamin B12 and its binding proteins can be used as a criteria for the differential diagnosis of PV from secondary polythaemia.

Vitamin B12 deficiency in a patient with total gastrectomy.

A 31-year-old female was admitted to the hospital with a history of weight loss, weakness and exertional dyspnoea lasting for three months. Four years prior to admission, she had consumed half a glass of cleaning solution and had been admitted to hospital for a total gastrectomy. Physical examination showed markedly pale, cachexia and generalized muscle wasting. Oedema of both legs and hepatomegaly about 2 FB were noted. No abnormal neurologica,l findings were detected. Her blood picture and bone marrow showed megaloblastic changes. Serum vitamin B12 was low but serum and red-cell folate levels were within normal limits. Vitamin B12 (1 mg) was given intramuscularly and it produced a remarkable improvement in the clinical and haematological findings. The patient was discharged nine days after admission and attended the out-patient clinic where she received 1 mg of vitamin B12 intramuscularly once a month. The patient is now healthy with normal haematological findings, but she still receives vitamin B12 therapy monthly.

Transition from polycythaemia vera to myelofibrosis with myeloid metaplasia: A case report.

An 80-year-old woman was admitted to the hospital with of pain in the right upper abdominal region. She had splenomegaly and CT scan showed gall stones and splenic infarction. Blood examination revealed erythrocytosis, raised LAP, elevated serum vitamin B12, vitamin B12 binding proteins and reversed TCI/TCIII ratio. All these findings confirmed the diagnosis of polycythaemia vera. After splenectomy and cholecystectomy, a leucoerythroblastic blood picture with teardrop poikilocytosis was detected in the peripheral blood smear. The haemoglobin concentration decreased but leucocytosis and thrombocytosis still persisted. Bone marrow aspirate showed erythroid hypoplasia, decreased megakaryocytes and some degree of fibrosis. This was compatible with the criterial diagnosis of myelofibrosis with myeloid metaplasia. Blood transfusions and myleran were given. Peritoneal dialysis was performed and the patient had severe bleeding and died from cardiac failure due to septic shock. This patient is an example of the transition from polycythaemia vera to myelofibrosis with myeloid metaplasia.

Pure red cell aplasia associated with chronic neutrophilic leukemia: A case report.

A 79-yesr-old woman was admitted to the hospital with evidence of pure red cell aplasia and chronic neutrophilic leukemia. Bone marrow aspiration showed almost absence of erythropoiesis, marked hyperplastic granulopoiesis with normal maturation and normal megakaryocytes. Serum vitamin B12, unsaturated vitamin B12 binding capacity, transcobalamin I and transcobamin III increased considerably. Chronic myelocytic leukaemia could be ruled out by the blood and bone marrow examination and a high leucocyte alkaline phosphatase score. This case of pure red cell aplasia accompanied by proliferative feature in other cell lines is an example of a link between erythrodysplastic and myeloproliferative disorders.

Serum zinc and copper levels in vegetarians.

Zine (Zn) and copper (Cu) are important trace elements that play a vital role in biochemical and physiological function in humans. However, vegetarians comprise a population at risk for Zn deficiency because of a marginal Zn intake and the low availability of Zn in vegetarian diets. The objective of the present study was to determine serum Zn, Cu and vitamin B12 levels in 35 vegetarians, and to correlate all these parameters. Results showed that serum Zn, Cu and Zn/Cu ratio in 120 control subjects were in the same order of magnitude as those in results reported previously. By contrast, the serum Zn levels in the 35 vegetarians was found to be significantly lower than that of the control subjects (p<0.01) The serum Cu level and Zn/Cu ratio in these vegetarians were within normal limits. No correlations between serum Zn and Cu, or between serum vitamin B12 level and serum Zn and Cu were demonstrated. The low serum Zn concentration in vegetarians was probably due to low dietary Zn intake and the depressed absorption of Zn from the vegetarians, diet which was high in phytate and/or fiber. Although serum vitamin B12 concentration was also decreased, there was no relationship between this vitamin and serum Zn level. Therefore, there was no connection between serum vitamin B12 and serum Zn or Cu in these vegetarians.

A case with multiple myeloma, polycythemia vera and acute myelomonocytic leukemia.

An 83-year-old man with evidence of multiple myelome was admitted to the hospital with a history of weakness. His serum protein immunoelectrophoresis demonstrated monoclonal IgA lambda and bone marrow aspiration revealed plasma cells 20%. Two months alter, hematological examinations showed erythrocytosis, luecocytosis and thrombocytosis. The bone marrow showed hypercellular with increased plasma cells and monoblasts. Serum vitamin B12 and vitamin B12 binding proteins confirmed the diagnosis of polycythemia vera. After treatment with Busulfan, Prednisolone and Endoxan for 6 months, his blood examination revealed increased monocytes, metamyelocytes and myelocytes. Bone marrow examination confirmed the diagnosis of acute myelomonocytic leukemia with plasma cells. This patient is an example of the simultaneous occurrence of lympoproliferative and myeoproliferative disorder.

Serum vitamin B12 and vitamin B12 binding proteins in patients with polycythemia vera.

Serum vitamin B12 and vitamin B12 binding proteins (Transcobalamin, TC) were determined in 11 patients with polycythemia vera (PV) and each patient with PV asso ciated with multiple myloma (PV/MM) and acute myelomonocytic leukemia (PV/AMML). The study was also performed on 60 normal subjects for comparison Serum vitamin B12 level and total vitamin B12 binding capacity (TBBC) were found to be significantly increased while serum unsaturated vitamin B12 binding capacity (UBBC) was slightly but not significantly higher than that of normal subjects. Both TCI and TCIII in creased 2 and 4 fold, respectively, while TCII decreased to haft the value of the normal level. This resulted in the alteration of the ratio of TCI/TCIII from 1.34 in normal subjects to 0.75 in these patients. This finding is quite specific for PV, because another 2 patients with PV associated with MM and AMML also showed a similar TCI/TCIII ratio. Although increased serum vitamin B12 UBBC, TCI and TCIII are also found in some patients with myeloproliferative disorders and leucocytosis, in no situation is it characterized by a predominantly increased TCIII with a reverse ration of TCIII/TCI as in PV. Therefore, the assay of serum vitamin B12 UBBC and TC should be a useful tool in the confirmed diagnosis of PV.

Serum vitamin B12 and vitamin B12 binding in children with leukaemia and lymphoma.

Serum vitamin B12 and vitamin B12 binding proteins (transcobalamin, TC) were determined in 78 patients with acute lymphocgtic leukemia (ALL), acute myeloblastic leukemia (AMI), chronic myelicyitc leukemia (CML) and lymphoma. Their ages raged from 5 to 12 years. The study was also performed on 60 normal subjects for a comparison. Serum vitamin B12 levels in CML patients were found to be 12 times higher while they were normal in patients with lymphoma and lower than normal in patients with AML and ALL. The unsaturated vitamin B12 binding capacity (UBBC) and total vitamin B12 binding capacity (TBBC) were 4 and 6 time, respectively, higher in patients with CML while they were slightly elevated in patients with ALL, AML and lymphoma. Both TCI TCIII were 20 and 4 times, respectively, higher while TCII was slightly but not significantly lower in patients with CML. Similar alterations were seen in patients with ALL, AML and lymphoma but were not as obvious as in CML patients. These findings indicate that the marked increase in serum vitamin B12' UBBC and TCI was found only in patients with CML. Therefore, the measurements of these parameters could be used for the differential diagnosis of CML from other types of leukemia and lymphoma.

Erythrocyte superoxide dismutase and catalase activities in red cell infected with plasmodium vivax.

It has been shown that erythrocytes infected with asexual forms of malarial parasites are more sensitive to oxidant strees than normal red cells. Many studies reported a great alterations of SOD and catalase levels in red cells of subjects infected with different species of plasmodium indication the significant role of oxidant stress in the host defence mechanism against the parasites. In order to study these effects in patients with P.vivax, SOD and catalase activites were determined in red cells of 40 patients in comparison to 40 normal human subjects. Both mean erythrocyte SOD and catalase values in the patient group showed no significant difference from those of the normal group. There was a direct relationship between parasitemia and SOD cativity. AII these findings indicated that P.vivax parasites did not nave any effect on these enzymes of the host erythrocytes. It was therefore possible that the increased susceptibility of P.vivax infected red cells to oxidant damage was not a result of reduced functioning of the SOD and catalase. These findings could also explain the reasons why the symptoms of patients with P.vivax were less severe than those of patients with P.falciparum.

Acetylcholinesterase activity in the amniotic fluid of normal Thai pregnant women.

Acetylcholinesterase (AChE) activity was determined for 112 amniotic fluid samples obtained by amniocentesis from normal Thai pregnant women at gestational ages of 34 to 40 weeks. The method for estimation was based on inhibition the of non-specific cholinesterase (ChE) with ethoprorpazine and the expression of residual AChE activity as a percentage of total cholinesterase activity. The mean values of AChE and total ChE activities were found to be 3.65ฑ1.97 U/1 (range 1.10-7.72 U/1) and 7.61ฑ 2.55 U/1 (range 3.31-14.34 U/1) respectively. These values were in the same order of magnitude as results reported earlier in normal pregnant women. There were no relationships between gestational ages and amniotic fluid AChE, ChE or total ChE activities. As the concentration of AChE in the amniotic fluid is the index of the secreted AChE from neurons, it therefore increases considerably in fetus with open neural tube defect (NTD). The results for this pregnant women study is a base-line data for normal Thai pregnant women which will be useful in detecting the NTD in the fetus.

Acetylcholinesterase activity in cord serum and human milk.

Acetycholinesterase (AChE) and pseudocholinesterase (ChE) were determined on 44 cord serum and 72 human milk samples. The mean values of AChE were found to be 87 U/1 (rang 66-176 U/1 (range 1.1-6.6 U/1) in the cord serum and human milk respectively. There were no significant difference between the mean values of AChE in the milk samples collected on day 3 to day 12 after delivery. There was a tendency for increased AChE in the milk in the multi-gravidas more than in the first gravida. As the function of AChE in the milk is not exactly known at the neonatal gut because such systems required for the degradation of various amino acids are still not fully developed in the newborn. As AChE could not be detected in the neonatal serum aged 5 days, this indicatied that the enzyme in the milk. Cord serum contained a significantly lower ChE level than that of adult serum. As this low level rose in the first day and reached a double value within 3 weeks after delivery, this could not be due to the intake of the relatively low ChE in the human milk.