Hb Sun Prairie or alpha(2)130(H13)Ala----Pro beta 2, a new unstable variant occurring in low quantities.

A severe hemolytic anemia with microcytosis and hypochromia was present in a young adopted Indian patient. Reversed phase high performance liquid chromatographic methodology and heat stability tests detected an unstable alpha chain which was present in 3 to 5% of the total hemoglobin. A larger quantity of the alpha X chain was obtained by preparative reversed phase high performance liquid chromatography. Structural analyses identified an Ala----Pro replacement at position 130 of the alpha chain. The instability of the variant, named Hb Sun Prairie, is comparable to that of Hb Bibba [alpha 136 (H19)Leu----Pro]. Gene mapping failed to detect an alpha-thalassemia deletion (alpha alpha/alpha alpha), while dot-blot analysis of amplified DNA with synthetic probes localized a G----C mutation in codon 130 (resulting in the Ala----Pro mutation) of the alpha 2-globin genes of both chromosomes. These results suggest a homozygosity for the G----C mutation and the condition alpha 2(G----C)alpha 1/alpha 2(G----C)alpha 1 adequately explains the rather severe clinical status of this child, including the marked microcytosis and hypochromia. Unfortunately, family studies to exclude the presence of a large deletion involving all zeta- and alpha-globin genes were not possible.

Sickle cell trait revisited.

Variability in the clinical severity of sickle cell diseases is often genetically determined. Coexistent alpha-thalassemia decreases some, but not all, associated morbid complications. Polymorphisms within the beta-globin-like gene cluster influence disease severity by varying gamma-gene expression and the amount of Hb F within the cells. Few persons with the sickle cell trait experience adverse consequences attributable to the beta s gene. Is this also due to genetic factors? A literature search failed to answer this question. It is intriguing, however, that reported associations of sickle cell trait and splenic infarction have occurred exclusively in males and mostly in whites. Plausible but scanty data suggest that splenic infarction, hematuria, and reduced renal concentrating ability may be associated with higher amounts of Hb S. Therefore, alpha-thalassemia may be protective. No evidence was found that the amount of Hb S influenced the incidence of sudden death after exertion or that increased amounts of Hb F accounted for protection against any complications. More detailed reporting of biochemical and genetic evaluations of persons with sickle cell trait who experience related clinical events may lead to a better understanding of risks in subpopulations of persons carrying a single beta s gene.

Two successful pregnancies in a woman with chronic thrombotic thrombocytopenic purpura treated by plasma infusion.

A 21-year-old primigravida in her 20th week of pregnancy developed TTP. She was managed with weekly or semiweekly plasma infusions and delivered a healthy 1.6 kg baby 2 weeks prior to the expected date of delivery. After delivery she continued to have active TTP with thrombocytopenia which responded repeatedly to plasma infusion though their frequency gradually decreased to about one unit every 3-4 weeks. Three years after the birth of the first child she conceived again and was easily managed with repeated plasma infusions although the frequency and amount of plasma required to prevent thrombocytopenia were increased. She delivered a normal 3.4 kg term baby after which she again had a decreased plasma requirement. This is the first report of a woman with 5 years of active TTP managed with plasma alone. She experienced two pregnancies in which both mother and infant survived. We believe that the use of plasma in the management of TTP during pregnancy will improve the survival rate of both mother and infant. At the time of second birth, the platelet count was low in the mother but normal in the baby. This suggests that the platelet depressing factor of this patient does not cross the placental barrier.

Studies on avian erythrocyte metabolism. XII. The synthesis and degradation of inositol pentakis (dihydrogen phosphate).

The pathway(s) of synthesis and degradation of inositol 1, 3, 4, 5, 6 pentakis (dihydrogen phosphate) (inositol-P5), found predominantly in the avian erythrocyte, are unknown. Myo-inositol (inositol), D-glucose, inosine, and phosphate have been studied as potential precursors of inositol-P5 synthesis in chicken erythrocytes. Whole blood from chickens at several ages has been incubated for prolonged periods and the concentration of inositol-P5 measured to determine the ability of the avian erythrocyte to catabolize inositol-P5. Incubation of erythrocyte suspensions from 5-day chicks with [U-14 C]myo-inositol (inositol) for 17 hr lead to the appearance of 19.8% of the radioactivity in the aqueous acid-soluble extract of the erythrocytes (RBC). Fractionation of this extract on an anion exchange column yielded five major radioactive peaks, three of which represent 1) free myo-inositol, accounting for 63.5% of the radioactivity; 2) myo-inositol monokis (dihydrogen phosphate) (inositol-P), representing 1.6% of the radioactivity; and 3) inositol 1, 3, 4, 5, 6 pentakis (dihydrogen phosphate) (inositol-P5), representing 27.0% of the label in the erythrocyte. Sodium fluoride did not inhibit the incorporation of [U-14 C]myo-inositol into inositol-P5. Similar incubations with D-[U-14 C]-glucose and [U-14 C]-inosine yielded no incorporation of radioactivity into inositol-P5. These data are consistent with the interpretation that inositol is the major precursor for synthesis of inositol-P5 in chick red cells. Incubation of whole blood from 1-, 5-, and 42-day chicks and mature birds at 40 C for as long as 72 hr resulted in increases in RBC inorganic phosphate (Pi) thought due primarily to depletion of adenosine triphosphate (ATP). Inositol-P5 content of RBC of 5- and 42-day birds decreased 28 and 20%, respectively, after 72 hr, but no change was noted in inositol-P5 levels of RBC from mature birds. The red cells of the mature bird appear to be unable to catabolize inositol-P5 at significant rates. The apparent inability of the chicken erythrocyte to alter readily its concentration of inositol-P5 suggests that the hemoglobin oxygen delivery system of birds may be less adaptable to changing oxygen requirements by regulating the concentration of hemoglobin modulator than is that of the mammals.

Regulation of hemoglobin function and whole blood oxygen affinity by carbon dioxide and pH in the loggerhead (Caretta caretta) and green sea turtle (Chelonia mydas mydas).

The oxygen affinity of suspensions of erythrocytes from juvenile and adult loggerhead (Caretta caretta) and green sea (Chelonia mydas mydas) turtles decreased markedly with increasing concentrations of carbon dioxide (0 to near 15%) or hydrogen ion (pH 7.6 to pH 7.2). The P50's were higher with increases in pCO2, particularly at pH near 7.4, than were the P50's with increases in hydrogen ion concentration at any given CO2 concentration. Solutions of hemoglobins from the juvenile loggerhead (8-9 mos.) and green sea (10 mos.) turtles responded to 2, 3-DPG, ATP, or inositol-P5 when added at molar ratios of phosphate to hemoglobin of 4:1 and 20:1 in 0% and 6.29% CO2 but showed no decrease in oxygen affinity at these two CO2 levels in the green turtle when the molar ratio of phosphate to hemoglobin was 0.4. These compounds had little effect on the P50 of these hemoglobins in 14.6% CO2. The P50 of the adult loggerhead turtle hemoglobin did not increase in the presence of organic phosphates beyond the effect induced by CO2 alone. The P50 of hemoglobin from the adult green sea turtle increased only slightly when the molar ratio of phosphate to hemoglobin was 20:1 and at 0 and 6% CO2 concentration; little effect was observed at 14.6% CO2. These data demonstrate that blood oxygen affinities and hemoglobin function in these two species of marine turtles are altered significantly by CO2 and to a lesser degree by pH. It is suggested that such alterations may be of significance in vivo during prolonged diving when there are dramatic rises in blood pCO2 and [H+] and profound decreases in pO2.

Hazard of platelet transfusion in thrombotic thrombocytopenic purpura.

A patient with thrombotic thrombocytopenic purpura (TTP) showed for the first time catastrophic signs and symptoms of CNS involvement immediately after infusion of platelets. Postmortem examination revealed extensive deposits of platelet aggregates within the small blood vessels of the brain, whereas lesions elsewhere in the body consisted of platelets as well as fibrin and were associated with endothelial proliferation and microaneurysm formation. These findings are consistent with the view that the initial event in TTP may be platelet aggregation. The plasma of this patient contained platelet-aggregating activity. We conclude that platelet transfusions in patients with TTP may aggravate the disease process.

Studies on the in vivo elution of 51Cr from baboon red blood cells.

Four anticoagulant solutions were added to baboon red blood cells prior to labeling with 51Cr to determine how each would influence the distribution of 51Cr within the red blood cells, the loss of 51Cr from the red blood cells after transfusion, and the calculated red cell survival value. The 51Cr label was detected in the hemoglobin and in the low molecular weight compounds within the red blood cells. The elution of 51Cr from labeled baboon red blood cells following transfusion could not be explained by the distribution of 51Cr between hemoglobin and low molecular weight compounds within the red blood cells.

In vitro interactions of 51Cr in human red blood cells and hemolysates.

The intracellular distribution of radioactivity was studied in normal and sickle erythrocytes labeled with sodium 51Cr chromate. Both types of cells had a higher fraction of 51Cr bound to hemoglobin when labeled in the presence of ACD at a pH of 7.09 than when labeled in the presence of CPD at a pH of 5.96. Citrate at a pH of 5.96 or less entered the red blood cells and decreased the 51Cr binding hemoglobin. Binding of 51Cr to hemoglobin within the red cells was also reduced when the ATP and DPG levels in the red blood cells were elevated. Studies with hemoglobin solution showed that 51Cr binding to hemoglobin was influenced by 2,3-DPG, ATP and citrate.

Novel studies on a "silent" high affinity mutant hemoglobin (San Diego, beta 109 Val replaced by Met).

A patient with a "silent" mutant hemoglobin characterized by high oxygen affinity and erythrocytosis is described. A novel approach was used to identify the mutant chain. Functionally active alpha and beta chains were prepared from hemolysates of the patient and a normal control. Hybrid tetramers of patient's beta chain were prepared. Functional studies revealed that the patient's beta chains had a higher oxygen affinity (P50, 1.1 torr) than normal beta chains (P50, 1.7 torr) and the hybrid containing the patient's beta chains had a P50 similar to the patient's "stripped" hemolysate. It was assumed therefore that the mutation was in the beta chain; structural studies using cyanogen bromide cleavage revealed that the patient had Hb San Diego, beta 109 Val replaced by Met, and that the patient's cells contained approximately 50 percent mutant hemoglobin.

'Storage pool disease' of platelets. Association with multiple congenital cavernous hemangiomas.

A women with congenital cavernous hemangiomas and a bleeding diathesis since childhood was found to have a qualitative platelet defect characterized by the absence of a second-phase aggregation induced by epinephrine, adenosine diphosphate (ADP), and collagen, accompanied by decreased levels of adenosine triphosphate (ATP) and ADP, with a high ATP-ADP ratio consistent with the diagnosis of "storage pool disease" of the platelets. There was no evidence of disseminated intravascular coagulation or circulating antiplatelet antibodies. The bleeding tendency responded to platelet transfusion.

Depression of intramyocardial oxyhemoglobin dissociation by angiographic contrast media.

The effect of the addition of radiographic contrast material (Renografin) to blood on the oxyhemoglobin dissociation curve and P50 was measured by a metabolic deoxygenation technique in a strongly buffered red cell suspension. With incubation time constant, increasing doses produced progressive decreases in P50. With incubation time varied at a constant dose, a decrease in P50 was seen after only one minute. In addition, in vivo studies were performed on 11 patients undergoing cardiac catheterization. Simultaneous proximal coronary sinus and aortic samples were drawn as controls, and then at one minute and five minutes after injection of the left coronary artery. In eight patients studies were performed after, and in three prior to left ventriculography. At one minute after left coronary injection there was a significant decrease of coronary sinus as compared to aortic P50 (p less than .10) (only when left ventriculography was performed prior to coronary arteriography). The magnitude of these effects in vivo is unknown, but they would be expected to be more severe in areas distal to a critical coronary lesion due to stasis of blood flow and ischemic metabolic changes.

Hematological and clinical features of sickle cell diseases: a review.

The differentiation, hematologic features and clinical manifestations of patients with the various sickling disorders are reviewed. The deficiencies in our current knowledge about the spectrum of the clinical course of patients with these conditions is discussed. The interaction of alpha thalassemia with sickle cell anemia and its possible effect upon the severity of the disease is summarized. The apparent milder disease in certain groups of patients with sickle cell anemia in whom there is an associated elevation of hemoglobin F is contrasted with the controversy surrounding the effects of hemoglobin F levels in the patients of African origin.

Presence of a platelet aggregating factor in the plasma of patients with thrombotic thrombocytopenic purpura (TTP) and its inhibition by normal plasma.

Three patients with thrombotic thrombocytopenic purpura (TTP) were treated by infusion of normal plasma with dramatic responses. The plasmas collected from these patients during relapse induced in vitro aggregation of washed platelets from both normal donors and the patients during remission. The platelet aggregating factor was not dialyzable or adsorbable by Al(OH)3 and was not inactivated by diisopropylfluorophosphate, hirudin, or heparin in the presence of normal amounts of antithrombin. In contrast to the platelet aggregation induced by platelet isoantibody, the platelet aggregating activity of TTP plasma diminished as a function of time when it was incubated with normal plasma at 37 degrees C. These observations suggest that at least some instances of TTP appear to be due to deficiency of a plasma inhibitor to counteract a platelet aggregating factor demonstrated to be present in the plasma of these patients.

Oxygen binding of fetal and adult bovine hemoglobin in the presence of organic phosphates and uric acid riboside.

The P50 values of "stripped" fetal and adult bovine hemoglobin were 18.4 and 28.9 respectively. Neither the oxygen-hemoglobin dissociation curve nor the Hill coefficient, n, of fetal or adult bovine hemoglobin was affected by uric acid riboside (UAR), 2,3-diphosphoglyceric acid (2,3-DPG), adenosine triphosphate (ATP), or inositol pentaphosphate (IPP). Combinations of UAR and ATP with adult bovine hemoglobin or 2,3-DPG and ATP with fetal hemoglobin also had no effect. It was concluded that neither adult nor fetal bovine red cells contained an identifiable compound which affects the binding of oxygen to hemoglobin.