Spurious, marked leukocytosis in 2 cats with Heinz body hemolytic anemia.

Two domestic shorthair cats were presented with anorexia and dehydration following ingestion of caramelized onions. Shared key findings from a CBC (ADVIA 2120), serum biochemistry, and urinalysis included a spurious, marked leukocytosis with discordant basophil (BASO) channel and peroxidase channel WBC counts, normal manual leukocyte counts, mild, non-regenerative anemia with discrepancies between automated and manual reticulocyte counts, an abundance of large Heinz bodies (HBs), and highly irregular scattergrams. Case 1 also demonstrated a markedly elevated mean corpuscular hemoglobin concentration (MCHC) and discrepancies between RBC hemoglobin indices. Spurious leukocyte results were confirmed through re-analysis of samples (including the acquisition of a new sample, use of an alternate analyzer (Sysmex XT-2000iV; Case 1 only), and evaluation of scattergrams and blood films (Cases 1 and 2). Repeatedly discrepant reticulocyte counts were also identified. In both cases, the erroneous BASO WBC counts, discrepancies in reticulocyte counts and RBC indices, and atypical scattergrams were interpreted to result from various effects of the HBs. These cases emphasize the importance of reviewing blood films, interpreting scattergrams, and the usefulness of duplicate methods for determining various measurands on hematology analyzers.

Multimodal detection and analysis of a new type of advanced Heinz body-like aggregate (AHBA) and cytoskeleton deformation in human RBCs.

A new type of aggregate, formed in human red blood cells (RBCs) in response to glutaraldehyde treatment, was discovered and analyzed with the classical and advanced biomolecular imaging techniques. Advanced Heinz body-like aggregates (AHBA) formed in a single human RBC are characterized by a higher level of hemoglobin (Hb) degradation compared to typical Heinz bodies, which consist of hemichromes. The complete destruction of the porphyrin structure of Hb and the aggregation of the degraded proteins in the presence of Fe3+ ions are observed. The presence of such aggregated, highly degraded proteins inside RBCs, without cell membrane destruction, has been never reported before. For the first time the spatial differentiation of two kinds of protein mixtures inside a single RBC, with different phenylalanine (Phe) conformations, is visualized. The non-resonant Raman spectra of altered RBCs with AHBA are characterized by the presence of a strong band located at 1037 cm-1, which confirms that glutaraldehyde interacts strongly with Phe. The shape-shifting of RBCs from a biconcave disk to a spherical structure and sinking of AHBA to the bottom of the cell are observed. Results reveal that the presence of AHBA should be considered when fixing RBCs and indicate the analytical potential of Raman spectroscopy, atomic force microscopy and scanning near-field optical microscopy in AHBA detection and analysis.

Skunk musk causes methemoglobin and Heinz body formation in vitro.

BACKGROUND: A captive Red Panda developed a regenerative anemia with Heinz bodies after being sprayed by a skunk. A definite cause-and-effect relationship between skunk musk and oxidative erythrocyte damage has not been reported, but it was suspected in one reported case of a dog with Heinz body hemolytic anemia. OBJECTIVE: The objective was to determine whether skunk musk induces oxidative HGB damage in vitro. METHODS: Plasma and RBC were harvested from heparinized blood of 3 dogs, 3 cats, and a Red Panda. Skunk musk was solubilized in ethanol and mixed with plasma from each species to make stock solutions of 4% musk and 4% ethanol. Aliquots of RBC were resuspended in autologous stock solutions and solvent controls to yield musk concentrations of 0%, 0.04%, and 0.4% (by volume). Aliquots were incubated at 37°C for 4-72 hours and assessed for oxidative damage by visual inspection, optical absorbance spectroscopy, transmission electron microscopy, and light microscopy after Wright and vital New Methylene Blue staining. RESULTS: Dose-dependent brown color and absorption changes characteristic of methemoglobin were present by 4 hours and increased over 24 hours (Red Panda) and 72 hours (dog and cat). Similarly, there were time-dependent (all species) and dose-dependent (dog and cat) increases in the number of Heinz bodies, which were present by 4 hours and numerous by 24 hours. CONCLUSIONS: In vitro, skunk musk causes Heinz body and methemoglobin formation in canine, feline, and Red Panda RBC, supporting the clinical association between Heinz body hemolytic anemia and skunk spray exposure.

Heinz body haemolytic anaemia in a dog secondary to ingestion of a zinc toy: a case report.

A 6-year-old Labrador retriever was referred for investigation of severe lethargy and suspected immune-mediated haemolytic anaemia. Clinical examination revealed pale mucous membranes and jaundice. Haematology demonstrated large numbers of Heinz bodies and a marked anaemia, which was strongly regenerative. Serum zinc concentrations were markedly elevated. Analysis of a metal toy vomited by the dog 3 days prior to presentation revealed it to be composed of almost pure zinc. A diagnosis of haemolytic anaemia secondary to acute zinc toxicity was made and supportive therapy instigated. There was a subsequent decrease in numbers of Heinz bodies and a rise in the haematocrit, and the dog made an uneventful recovery. Acute zinc toxicity resulting in haemolytic anaemia is rarely observed, and this case was also unusual in that the main clinicopathological finding was the presence of numerous Heinz bodies without other evidence of oxidative damage to red blood cells.

Red maple (Acer rubrum) leaf toxicosis in horses: a retrospective study of 32 cases.

BACKGROUND: Ingestion of wilted red maple leaves by horses can result in severe hemolytic anemia and methemoglobinemia. Little is known about what factors influence the outcome of red maple leaf toxicosis in horses. HYPOTHESIS: Our hypothesis was that physical examination findings, clinicopathologic variables or therapeutic modalities may predict outcome in horses with red maple leaf toxicity. ANIMALS: Horses with red maple leaf toxicosis presented to referral hospitals in the southeast region of the United States. METHODS: A multi-institutional retrospective study was designed to identify factors that predict mortality in horses with red maple toxicosis. RESULTS: Thirty-two horses with red maple toxicosis were identified, 19 of which died. Twenty-nine horses presented with anemia and 24 had clinicopathologic evidence of systemic inflammation. Renal insufficiency was identified in 12/30 (41%) horses. Laminitis (9/28) and colic (13/30) also were identified in horses with red maple toxicosis, but development of these 2 conditions did not have a negative effect on short-term survival. Horses with red maple toxicosis that survived to discharge were likely to have developed pyrexia during hospitalization (P = .030). Horses that were treated with a corticosteroid had a significantly increased likelihood of death (P = .045). There was no significant relationship between initial serum hemoglobin concentration, methemoglobin concentration, or percentage methemoglobin and mortality in this horse series. CONCLUSIONS AND CLINICAL IMPORTANCE: This study suggests that information obtained on initial examination cannot be used to accurately predict survival in horses with red maple toxicosis, but horses that receive corticosteroids are unlikely to survive.

Hb Sallanches [alpha104(G11)Cys-->Tyr, TGC-->TAC (alpha2)]: an unstable hemoglobin variant found in an Indian child.

We report the fourth observation of Hb Sallanches [alpha104(G11)Cys-->Tyr, TGC-->TAC (alpha2)], an unstable alpha chain variant of intermediate severity in the homozygous state. Heterozygosity occasionally produces mild hypochromia and microcytosis in some patients. A balanced beta/alpha ratio, found in previously reported cases, points to unstable alphabeta dimers formed as a result of the Cys-->Tyr substitution at the alpha1beta1 contact site in this hemoglobin (Hb) variant. Our patient, and the previous two of the three cases reported in patients of Pakistani origin, points to a common population stock, separated by the mass population migration which occurred during the partition of Pakistan and India in 1947.

Association of maximum voluntary dietary intake of freeze-dried garlic with Heinz body anemia in horses.

OBJECTIVE: To characterize hematologic and clinical consequences of chronic dietary consumption of freeze-dried garlic at maximum voluntary intake in horses. ANIMALS: 4 healthy sex- and age-matched horses. PROCEDURE: An initial garlic dose (0.05 g/kg, twice daily) was fed to 2 horses in a molasses carrier as part of their normal ration and was gradually increased to maximum voluntary intake (0.25 g/kg, twice daily) over 41 days. Dietary supplementation then continued for a total of 71 days. Two control horses were fed molasses with no garlic with their ration. Blood samples were collected weekly and analyzed for hematologic and biochemical changes, including the presence of Heinz bodies. Recovery of affected blood values was followed for 5 weeks after termination of dietary supplementation with garlic. RESULTS: At a daily dose of > 0.2 g/kg, horses fed garlic developed hematologic and biochemical indications of Heinz body anemia, as characterized by increases in Heinz body score (HBS), mean corpuscular volume (MCV), mean corpuscular hemoglobin, platelet count, and serum unconjugated and total bilirubin concentrations and decreases in RBC count, blood hemoglobin concentration, mean corpuscular hemoglobin concentration, and serum haptoglobin concentration. Recovery from anemia was largely complete within 5 weeks after termination of dietary supplementation with garlic. Heinz body score and MCV remained high at the end of the 5-week recovery period. CONCLUSIONS AND CLINICAL RELEVANCE: Horses will voluntarily consume sufficient quantities of garlic to cause Heinz body anemia. The potential for garlic toxicosis exists when horses are chronically fed garlic. Further study is required to determine the safe dietary dose of garlic in horses.

Heinz body formation associated with ketoacidosis in diabetic cats.

Oxidative damage plays an important role in the pathophysiology of diabetes and diabetic complications. Feline hemoglobin is uniquely susceptible to oxidative denaturation; therefore, Heinz body formation is a highly sensitive indicator of in vivo oxidative stress in this species. Heinz bodies also contribute to anemia. We investigated hematological and clinical biochemical changes in 30 cats with spontaneous diabetes mellitus (as compared to 15 healthy control cats) and evaluated the relationship of these changes to erythrocyte oxidative damage. Cats were categorized as ketoacidotic or nonketoacidotic based on their clinical presentation and the presence of urine ketones. Ketoacidotic cats had significantly (P = .0009) more Heinz bodies (28.3% +/- 9.1%) than nonketotic diabetic cats (6.5% +/- 1.60%) and healthy control cats (0.6% +/- 0.2%). Percent Heinz bodies in diabetic cats directly correlated with plasma beta-hydroxy-butyrate concentration (r = .622; P = .0002), as well as with serum chloride concentration (r = -0.576; P = 0.0009) and the number of monocytes (r = .536; P = .0023). Percent Heinz bodies were negatively correlated with erythrocyte glutathione concentrations. Erythrocyte membrane lipid peroxidation was slightly but not significantly increased in diabetic cats. There were no significant associations between percent Heinz bodies and degree of anemia, hyperglycemia, or glycohemoglobin. These data indicate that ketones are associated with oxidative hemoglobin damage in cats, and suggest that ketone metabolism, ie by cytochrome P450 2E1, may be a potential source of in vivo oxygen radical generation in animals with ketosis.

Drug-associated "bite cell" hemolytic anemia.

PURPOSE: "Bite cell" hemolytic anemia is a variant of drug-related hemolysis usually associated with methemoglobinemia and Heinz body inclusions in red blood cells secondary to oxidant drug injury. Bite cells are morphologically characterized as poikilocytes with one or more semicircular portions removed from the cell margin. The purpose of this report is to emphasize the importance of peripheral smear examination in patients with possible drug-associated hemolytic anemia. The morphologic characteristics of bite cells by light microscopy and scanning electron microscopy are detailed in this study, and the pathophysiologic mechanism is discussed. PATIENTS AND METHODS: Clinical and laboratory data were retrospectively studied on eight patients (two men and six women, aged 29 to 85 years) who showed evidence of bite cell hemolytic anemia associated with drug exposure. Multiple standard hematologic laboratory evaluations for hemolytic anemia were performed. Five hundred red blood cells were counted from randomly selected peripheral smear fields for the calculation of bite cell percentage. RESULTS: Peripheral smears showed predominantly normochromic normocytic red cells with prominent bite cells and occasional blister cells. Bite cell counts ranged from 5.5% to 13.6% (mean, 8.7 +/- 3.0% SD) associated with a hematocrit reduction of 3.0% to 13.2% (mean, 8.5 +/- 3.8% SD) and concomitant reticulocytosis of varying degree from 2.3% to 15.4% (mean, 7.3 +/- 4.9% SD). Withdrawal of the offending drug(s) and treatment of underlying diseases resulted in improvement of hemolytic anemia and eventual disappearance of bite cells. A close correlation between hematocrit reduction, reticulocyte response, and bite cell percentage increase was seen. The usual biochemical markers of hemolysis were not consistently observed. Scanning electron microscopy confirmed the light microscopic evidence of bite cell morphology and revealed a keratocytic variant. CONCLUSION: This study emphasizes the importance of peripheral smear examination for early diagnosis and management of bite cell hemolytic anemia. Withdrawal of the putative offending drug(s) and treatment of underlying disorders should result in improvement of this form of drug-associated hemolysis.

The protective effect of vitamin E on the hemolysis associated with dapsone treatment in patients with dermatitis herpetiformis.

OBJECTIVE: This study looked at whether oral vitamin C and vitamin E would protect the erythrocyte from oxidant damage caused by dapsone in patients with dermatitis herpetiformis. DESIGN: Fifteen consecutive patients with dermatitis herpetiformis taking dapsone therapy received, in addition, 800 U/d of vitamin E for 4 weeks; then 1000 mg of vitamin C per day for 4 weeks, and, finally, combined vitamin E and vitamin C therapy for 4 weeks. Hemolysis indexes were assessed at baseline and after each 4-week period. RESULTS: Statistical analysis of the results suggests that oral administration of 800 units of vitamin E daily for 4 weeks confers partial protective effect against dapsone-induced hemolysis in patients with dermatitis herpetiformis. CONCLUSION: Partial protection against dapsone-induced hemolysis by orally administered vitamin E, if confirmed as being clinically relevant by further trials, may allow clinicians to continue dapsone therapy orally in patients who develop significant hemolysis. Prophylactic vitamin E to minimize potential hemolysis at the initiation of dapsone therapy may also be appropriate.

Erythrocyte pathology and mechanisms of Heinz body-mediated hemolysis in cats.

Despite the frequency of both oxidant drug-induced and spontaneous Heinz body formation in cats, the cellular and biochemical mechanisms by which Heinz bodies result in red blood cell (RBC) destruction and hemolytic anemia in this species remain unknown. Feline spleens are non-sinusoidal and inefficient at removing Heinz body-containing RBC from the circulation; therefore, alternative mechanisms must be involved in accelerated RBC destruction. Propylene glycol (PG) ingestion causes dose-dependent Heinz body formation and decreased RBC survival in cats. We investigated several aspects of Heinz body-containing RBC from three cats ingesting diets that provided 8.0 g PG/kg body weight for up to 3 weeks, in order to characterize cellular lesions that are associated with the presence of Heinz bodies and that might contribute to chronic, accelerated RBC destruction, as well as to gain insight into the mechanism by which PG induces Heinz body formation. Erythrocytes with PG-induced Heinz bodies had decreased levels of reduced glutathione and adenosine triphosphate and reduced deformability. There was no change in hemoglobin isoelectric focusing or membrane lipid peroxidation. Electrophoretic patterns of Heinz body-containing RBC membranes were significantly altered, and membrane surface charge distribution was disturbed. Progressively protruding Heinz bodies suggested that extrusion of Heinz bodies may be a means of cell healing and/or destruction in the absence of splenic pitting. When compared to results obtained using RBC from cats treated with the oxidant drug phenylhydrazine, significant differences were noted in packed cell volume, turbidity index, membrane heme, and morphologic appearance of Heinz bodies. Our results indicate that multiple cellular abnormalities develop in RBC with PG-induced Heinz bodies that do not cause acute hemolysis but that may shorten RBC survival. Propylene glycol-induced Heinz bodies provide an ideal model for studying the chronic effects of Heinz bodies on RBC structure and function and may be useful in understanding the mechanisms of formation and the consequences of endogenous Heinz bodies in cats.

Heinz bodies do not modify the membrane characteristics of common marmoset (Callithrix jacchus) erythrocytes.

The possibility was examined that the membrane function of erythrocytes obtained from healthy common marmosets (Callithrix jacchus) was modified by the presence in the cells of Heinz bodies. No significant differences were found in erythrocyte endogenous free malonyl dialdehyde (MDA) or reduced glutathione (GSH) between normal human erythrocytes and marmoset erythrocytes containing Heinz bodies. Membrane fluorescent chromolipids, surface charge and thiol levels were similar in both species but average membrane bulk lipid fluidity was slightly elevated in the marmosets. It was concluded that, in contrast to the situation in human erythrocytes, the presence of Heinz bodies in red cells of marmosets does not adversely affect the properties of the membrane.