?T rA1:ryl9tJRn1t$tlylg rdrv'luri May i972 EI'I.I.E1EI\[ OF CIITATIIG IVIAI IUEDIC:AI. TECTI\IOI,OGY Vol. 5 No. 2
HYPERSEGMENTED NEUTROPHILS AND GIANT MYELOCYTES IN PROTEIN CALORIE MALNUTRITION By e Trwat Tositrnt, B.Sc. ( Mod' Tecb. )' Prnie Kulepolgs, M.D.' Dip. Amcr. Bd. P€d. r'
Abstr.ci
Thc qurlitetive lculocttc chalgcs suggestire of erythroid l[turation fsctor (folstes, vitamin B12) deficicncy as eridenccd bv the presctrce of giant neutrophilic bmds alld nrctaml cioc] tos' r high lo:e average, higher perc€nt of thc hJpcrsegnented ncu trophils are frequently obs€ od ir PCM childrcn. Their signi. ficance and rclationship rith the deficiency strte of iron, follatcs, Yitrmins B 12 rnd E were investigotcd. Ii is concluded thrt sl tbough those lerkoctte chenges rre the well known signs of mcgelobhstic rnemias their prescnce in children with PCM arc among tho most common flndings and rpparortly heve no rehtlon- ship with thc yitrrin B 12, yit.min E or folrte deficicncy. The results suggested that it mry rclatcd to the associsted infectiors end iron rleficicncy.
INTRODUCTION protein caJoric malnutrition (pCM) is thcn manv dtscriptions have appeared in thc mo8t prevalent disease of nutritional the literature. (4,5'6,7) In thc majority deficiency in the woricl. (l) Although it of uncomplicrted PCl4 tho ancmie ob- affccts primarily thc youog children, older setved are of normochromic normccytic childrcn and adults ere not spared. (2,3) tvpe. Horvever, the periphcral smear very lirom the earlist clinical dcscription of often shows anisocytosis, poikilocytosis, I"JM, pallor and anernia have been among occasional target ccllg with normal whitc the chief signs described. (4,5,9) Since crits and platelct counts.(8-21 ) Ntany
'Chief l-echnoiogist, llemgtologv Lrb., .\ncmia and \fulnutrition Research Ccnter. " IIcrn:tclcgist, itepr. of Pcdiatrics. li:icultl' of Nledicine, Chirng N{ai University. 70 M"y 1972 invcatigetorc also obserycd PCM children and giant metamyelocytes in bonc marrow with hypochromic microcytic ancmir. (14- smcats. This ig the analysis iovestiga- 16,18,19,22,23 ) Macrocytic rncmir ic a of the prominent part of PCM in certain parts tion of the significance of the ebcve-men- of the world (3, 11,12.1-1.,15,18,21,24-27) tioned lcukocytic changcs in relrtion to the such rs in Indir, (14,21) Egypt, (19) South abnotmalitiec in ,h. 1,'t," :rcid, vitamin America, (26) and Africa, (27) B 12, vitamin E and iron slrtus obseryed in childrcn with PC\t. PCM i8 still one of the mrjor pedia. tric problem in Northern Thailand. (28 ) MATERIALS AND METHODS previous ( 23 indicated that Our studies ) Twenty two childrcn bctween I - 3 thc etiologies of anemir in thtsc children vear of age rvith clinical evidence of severe protein and cleficiencies aithcugh are iron PCM accordiog to Gomez's criteria ( 29 ) the striking leukocrtic chrng.e liDc$n to and a hemoglobin of Lss than 10.2 gmf be associated rvith the erythroid matura- 100 ml. were admittcd to the Pedietric ( tion fxctor EtrlF) deficiencies (esp. folic Ward of Chiang \Iai St. I-ouis Research acid, r'itamio B 12) were noted, l'his Center. 'l'h.y rvere diridcd into 4 etudy presence incluled th: of hvpsrscgrnented grcup. Thc twclve wctk protocol w'as neutr.philic leukccvtes in blood smear, consisting of 2 six-rveek pe:iods as follorv. the obrerv.:t.o:r of large proer)'throbiasts
SCHEDUI,E FOR SUPPLEMENT HEMATINICS
FIRST 6 WEEKS SECOr.,-D 6 WEEKS
GROUP I None None
GROUP II Iron + \rit. E Iron + Yit. E
GROUP III vit. E Iron \-it. E GROUP IV Iron Iron vit. E Vol. 5 No. 2 7l
Whole blood hemoglobin levels rvere sr,rears prcpared by squash tcchnic wcre determined bv the method of crosby, (30) rtained for hemosidcrin and stainablc f,ron microhematocrit was done by the method with thc Prussian Blue stain(36) thcn of lttcGovern et al. (31) Whitc ccll count scorcd according to the critcria of Rrth rnd platelet count wcrc carried out by thc and Finch (37) Agar gcl clectrophoresir strsdrrd technics. ( 32,33 Raiculocyte ) of hcmoglobins was done by thc method countr werc donc with thc Ncw methylene of Yahulis et rl. (38) Heinz body prepa. blue mcthod. (3+) Bonc marrow rspiration rations werc made utilizing mcthy! violct from the spinous proccses wcre carried out in saline. (39) Gluccse-6-phoephate dchy- at interval. Defferential ccll counn wcrc drogenase levcls were alro esrimatcd. (40) done on the bonc marrorv aod pcriphenl Blood volume, rcd cell mass rnd 5l Cr. blood smears stained with \yright s starn. red cell survival wcre measurrd rt rntcr. 'Ihe stained pcriphcral blood smearr were val. ( 11 ) Scrum folat"s, ( +2 ) viramin cxarnincd carefullv for the pctcentrgc of B r2, (13) vitanin I.), (+.{) serum iron rnd hypcrucg.ncntcd ncutrophils, lopc counts total iron binding crpacitv ( +5 ) qrerc and lopc rveragce. ( gonc 35 ) mrrrow mert'Jrcd at interr-als. fr'laY 16'12 72
TABLE I : LABORATORY IiINDINGS ON ADMISSION
l-ib. Stainable gmli 00 ;1't ir'tsc r-oi,,t.l B vit. n tc I 1.' i Iron ml 720 10.40 S 3.3 + + 1 MK z 0 z K 3.r. lr d6o io.lo I 2.+ + : 3 K i.+l - 10,10 2.9 + 'r + l( 2.r | 65E lo.lo I 0 2.6 0 0 J M s.r, l- lo.lo 2.9 + +++ 6 MK Irr5 8.1 I - 10.2+ 2 0 2.3 + + 7 M z3z 7.ri | 625 lo.3o 0.3 s 0 2.1 i+ +++ 8 M IJJ 2.0 126 20 I 0 2.6 0 + 9 K 8.6 | 100 t0z s.s I 3+6 lo.lo 2.9 ++ U 10 MK 268 l2.s 13+30 10.10 2.8 + ll M 125 r +.0 lr oro lo.ro 6 + 2.E 0 tz M | 0.1 I 40 3s0 16.7 l- 10.43 0 ta MK 136 3.+ ll2eo 10.22 z +.+ ++ + t+ M 10.0 | +4 196 s.0 | s70 10.10 0 2.3
3 3.2 + l5 K 7Z 4.7 11 l2l 10.10 tl + l6 K 9.S ll12 186 5.s [l 5E2 lo.lo 5 + + L,t) ++ 17 MK 1.8 | 238 |o.lo f, L,) 0 18 MK 9E 3.0 | - | 0.27 0 I 2.7 -l- IJ 19 K lt) 3.5 I 331 lo.ls 2 J- 1 2,3 20 MK 2.0 12075 lo.3o 2l M 10.0 I s2 s.s I 74J lo.2o 8 3.0 z2 K 9.6 ll00 3.0 I +80 lc.l s 6 3.3
NOTE *1. Serum Fe, TIBC and vitamin E levels are reported to ,ng/too Serum folate levels are reported in ng/ml' Serum vitamin B1r levels are reported in pg/ml' Vol. 5 No. 2 73
TABI,E II: LABORA?ORY FINDINGS AFIER RECOVERY FROI, PCM
S"tu. -\_o: ,r" i 'I'lBC ! Folate B1r giant Stainable I lIit. iron
I i 1.0 )n 484 27.5 0.4 0 6 to 0 0
2 11.3 \)+ +t9 I )-O 0.7 0 2 0 0
3 8.9 2+ .120 3 2.0 7 62 0.5 0 5 2.9 t, 0
+ I 0.7 5+ 238 +2.0 4 +7 0.4 0 5 3.3 + 0
7"7 _i 1- .9 +)u 2+.0 0.3 7 7 0 0
6 10.1 56 +20 28.0 0.5 2 z 2.8 + 0
7 1 1.8 100 410 t 2.0 '+92 1.40 1 0 0
8 I 0.8 9+ 7 !,) 630 r.9 + , ,o 0 0
I 0.6 r00 320 2 8.0 483 1.+8 3 3.2 0 0
10 10.6 70 40+ t7 .5 695 l.t5 + 0 0
1l 11.0 71 338 24.5 1.90 J-l 0 0 12 12.0 100 J)J 16.+ 0 2.8 0 0
l3 10 .i l++ 328 J J.) 426 1.20 l7 0
1+ 1t.z 9+ 384 52.0 s5 6 0 0 I
12.0 120 400 3 2.0 4it0 1.50 3.0 0 0
t6 I 0.8 54 Jt) 26.0 265 1.37 0 3.0 0
_t- 17 11.6 66 398 1 9.0 1.30 2 3.0 0
18 12.3 84 ?1r l.+8 3 0 .0
19 1 0.5 68 +20 1Z.O So 1.12 3 2.t 0 0 20 80 365 31.0 1030 t.)J I 3.1 0 :
21 12.+ 90 3 6.8 820 1.+0 6 3.t 0 -i 22 l1.r- 58 3 2.0 0.9 0 l) 0 74 Mr.y 1972
TABLE III : COIIRELATIO)i EETWEEN " LOW " SEitU\I t:OLA'rE
AND I}CIDENCE OF HYPERSEGMENTED ( 5 i,I. OR MORE ) ^.EUTROPHILS I.\..IDE\CE OF H'PERSEGM!:N I'EI) NEUTROPHII.S SERUIVI FOLATE LEVEL ON ADMISSION AFTER RECOVERY
LESS THAN 3 ngf d. 0
MORE THAN 3 ngl ml. +fta af zz
Note: There js no correlation bet.ween the presence of hypersegmented " neutrophils ( 5 ti or more ) and the lorn, " ."rurn folate level.
TABLE l\': CORRELATIO\ BETWEEN Sf,RUM IROri SATURATIO)i AND D,ICI.
DENCE OF HYPERSECME.\TED NEUTROPHILS ( 5.i', OR MONE I DURING RECOVER FROM PCI\I
SERUM IRON SATURATION PATIENTS LESS THAN I5.,; h5-2O ; MORE THAN 20.',. IVITH HYPERSEGMENTED NEUTR0PHTLS (8)
WITHOLT HYPERSEGMENTED NEUTRoPHTLS (u)
RESULTS o{ vitamin 812, foletes, vitamia !l and From the 'l'ables I to IY as showc iron. Thus, the interpretation of the above it is evidelt that: prerence of hypersegmcntcd ncutrophilc l. The presence of giant myeloid and giant myeloid cells as thc indicetioo megaloblastic cellg in the bone marrow and hyperseg- of dysplasia and or defic- iencv ebovc rncnted neutrophih (5S or more) is the of - menrion henrrtinics in children with severe PCM mry be mis. common finding in childrcn u,ith severe leadiog. protein calorie malnutrition especiallv brfore 3, I'he patients rvho cxhibit hyper- tleatmenl. segmented neutrophil more than 5fi, seem 2. 'l here is no definite correlltion to hare lower scrum iron siturrtion thin, t':tween these findings and the bjood jevsls the othcrs. Vol. 5 No. 2 to
.COMMENTS rnarrow aspirat€a. (56) Herbert (-i5) stated 'I'he most constant leukocytic abnor- that rhe lobe everage is of special vaiue malitr in oernicious ancmia and othcr as a dianostic feature since ir is not ,-neglloblastic anemias is rhe presence nf r-.r:r,sked by concomitt.nt iron deficiency hvpers gmented neutrophilic gr:nu to- hut the other u'orkers rvho srudied preg- 'ctt( (+6) or Cocke's macrnpolycyte. (47 ) nert wornen with folic acid and and iron Thcy mrv hrve ll, l0 or more nuc jerr deficiencies found that it mav rot be lobcs. ("7,+i) '1-hcir rbnormal dimersions always true. (57) l'asker (58) had demon- hase been e:ipl;rined on the basis of plcu- strated that whea iron deplction is the rituc!e:rrltr. (:.9) Such crlls are rarely limiting factor in hemopoiesis the nrorpho. seen in hr.lrh b.rt are found in the blood logic ch.rnge in m:rrrow znd peripheral in thc folic n-.J deficiencl, or pernicious blood rvili b: thosc of iron deficicncy. anenr i:r. .fhc \Yhen edequrte amount of iron are supplied c:r:roges in the ncurrophilic the morphol,rgical chrnge may be then loly.rrorphonuciear leukocvtes mav bc rcilect the pres-nre of other -:.existin! assers hy noting tl:c v11i1gi1,1 ig "it'rcr d,ficiencies such as that of folic acid (53, zyerrge yxlu(!. lobe index or lobe (50-.i3) s7, s9) i;e t\e tct,ll n'rmher of nuclear lobes in Recently, thc occurrence of grint :n ll)0 neurophils dir.ided by 100) and :1ret'mv-locttcs and increased c(l'ncntxtion bv the "rule of fives" ie. noting the of poivmorphonuclear leukocytes ialc bcen proPortioo of neutrophilic leukocttes ncted p:rtients with iron d.ficlcr.cr rnemia. havrng 5 or more nuclear lobes. T.hrce (45, 53, 60-6+) An experim(r-t in the perceot bcing suggested as the upper limir rats has demonstrated that iron deficiency {or such cells in normal subject. (53) led to a redu:ed fromimincrranBferasc Herbert has used 3.17:0.25 as the normil .ctivity and an incrcase in l.lGI-U excre- v:rlue but hls suggcsted that the normal tion (tj5) sirrilrr to those obser;rd in the lobe aver:rgc must be sepir.tely dctermined iron drficielt p!tients. (62) ,r.rrl-arua ct al by e:rch irb. (52) It is ncted rhc that rr0) rlso dr.scribcd thc pitiert niri: conge- crrliest h:mrtologicrl evidence foJ:rtc of iital forrnimi:1otr:r.nsfcrlsir rlcl rciercv :rsso. Ccficiency is incree,se ,,lobe ln in aycra!,:" c:lt'.1'vit\ ncutrop'ril,c hrpers..;mcntr,rion. 'l'his -;1,55) increrse in the lobc aver,rge Orher studies also suggcstcd the intg113le1i6n s xppare:tt rreeks 7 aftcr the onset of betrrecn the metabolisnr of ircrr rnd vitlmin :rlrfe deprivrtion. Such hvpersegrrrentarron U 12 (5t), and iron end fclrtes 45,67) Ir n.rv be r,rted I rvecks earlier in thc b,,ne is fosrul.ted, th€refore, thrt l,r,e iron MaY 1972
the deficiency impaired tl.re activity of thc 23,73,7+,79-81 ) but its role in forrnim inot raosferase enzyme and that this prthogcnesis of megaloblastic dysplasia in prr-,ducc both the changes seen ln n' itro- thcse children is still unsettled. (82) phiis and the incregsetl liltiLt' ercr'rion The question whether thc hyperseg- The otirer striLing qualitative ch:rnges mented neutrophils noted in our Paticnts in leukocy-r..s of thc patients lvith mcga- are actullly the polycl'tes of Ponder but loblastic anemias is the prescnce of thc not the classic macropoiy':yte wag raised. cxtraordiosriiy large leukocyte in the bono 'l'he former havc bcen obscrve in cases of marrow and periphcral blood. T'hiE infectiong but not related to m.galobhstic rbnqrmal cellular devcloprnent nl:;y occu! anemias as do the latter, The hyperseg. xt anji state in the mycloid seri!'s but it mented ncutrophil observtd in cur children is perticuirrly commoo among tlc netam- werc larger n'ith lesg compact nuclear yeiocytcs. It was thought that the chroinxtin and more acidophilic cytoplasnr macropo:', c)'tes are probabll' derived from gimiiar to the classic macropolycvtes. these cells, (+7) 'Ihe frequent appearance Thcr were also found even when there oi gaint neutrophilic band from and mctam' is no eridenc: of inlecrion or ritamin relocytes with loose chromatin rxhich is deficiencl. n-t typicrl of the Ehrlich megaloblzst in On admission, most of our childen children with PCM is also notcd by many bad serutn iroa levels below the normal inves.igators. (7, 14, 19,68-73,76't Our rrnqe comparable to the previous expc- patierlts as Iell as the other had their riences (23,76) and supported the conclusion :rdmission folate levels in the lower normal rnade errlicr thrt irl'n d.f:ciency rs a r.cge or very lol''l. t21,23-26,71,75) but conspicuous problem in PCM in Northern the bone marrorv picturo wcre normal Thailand. (84) Serum iron lovels are almost with occasional giant m
'r,. r r.r aot(d',,r rs and mrnv cthrr._. (5,i1r, the h( rr oglcb.in relrt:.r.1ilr. Vol. 5 No. 2 77
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