THE JOURNAL 01' I NVESTIGATIVE 0 EI

OPHTHALMOLOGIC, BIOCHEMICAL, PLATELET, AND ULTRASTRUCTURAL DEFECTS IN THE VARIOUS TYPES OF OCULOCUTANEOUS *

C ARL J . WITKOP, JR., D.D.S., M.S., CHARLOTTE W. HILL, M.D. t , SUSAN DESNlCK, B.S., J UDlTH K. THIES, HATTIE L. THORN, B.S., MALCOLM JENKINS, PH.D .t, AND JAMES G. WHITE, M.D.§

INTRODUCTION bulbs in cubated in tyrosin e produce pigment (Fig. 4) . M ela nocytes contain early stage III premela no­ Mutations Ca using Generalized Hypopig menta­ somes (Fig. 5), which can be converted to normal­ tion in Man appearing, mature stage IV melanosomes by incu­ Previous studies have demonstrated that at least bation in !-tyros ine or !-dopa (Fig. 6). six mutations affecting the pigment sys­ M arriages of a ty-pos to a ty-neg a lbino indicate tem in man result in recessively inheri ted traits t hat t he genes are not all elic, s ince only norma ll y with features of oculocutaneous a lbinism, i. e., a pigmented offspring have res ul ted from such mat­ gen e r a l reduction of pigment in the skin, hair, and ings (Wi tkop, 1971). eyes w i t h n ystagmus, photophobia, and reduced 3. The yellow mutant (ym) a lbino resembles the visual acui ty (Witkop et al. , 1963; Witkop et a!. , ty-neg albino at birth (Nance et al. , 1970) but by'6 1970; Nance eta!., 1970; Witkop, 1971). In general , mont hs to one year of age has developed yell ow-red these mutations can b e distinguished by t he abili ty hair, a moderate tanning ability, a modera te red of epilated hair bulbs to form pigment when refl ex, nystagmus a nd photophobia, and vi u a l incubated in !-tyros in e, by their clinica l features, acui ty defect. Hair bulbs in cubated in !-tyrosine do and t h e ul t rastructure of . Va ri ous not form increased black pigment, but incubation featur es have been described in one or more of in !-tyros ine plus cysteine produces an intensifica­ these conditions, but a systematic study of all t ion of yellow or r ed pheomelanin. Melanocytes types for all of t hese cha racteristics has not been appear to be normally distributed and contain undertaken. unevenly pigmented stage Ill premelanosomes re­ se mbling those seen in red ha ir (Fig. 7). After Characteristics of the Types of Albinism incubation in !-tyrosin e, no increase in pigment is 1. The tyrosin ase-negative (ty-neg) a lbino has seen (Fig. 8). pink s kin, white hair, a pro minent red reflex, Recently, Wa lsh (1971) described " red" a lbinos severe nystagmus, photophobia, and a defect in among New Guinea natives who phenotypica lly visual acuity which d oes not vary with age or r ace. resemble y m American Negro a lbino . Figure 9 is a Hair bulbs incubated in tyrosine do not form photograph of a New Guinea native goldminer pigment (Fig. 1) . Melanocytes are present in nor­ which was sent to us by a geologist a nd probably mal numbers, but no evidence of tyrosinase activ­ represents t he same condition described by Walsh ity is present in cytoplasmic struct ures a nd only (1971). Walsh (1971) reported t hat t he urinary stage II early premelanosomes are present (Fig. 2). chromatograms of the " red" albinos conta ined a After incubation in either !- tyrosine o r !-dopa, the co mpound which stained with ninhydrin with a n prem e la nosomes do not demonstrate in creased Rf va lue s imilar to that of !-dopa. This compound pigmen t ( Fig. 3). was absent o r present o nly in small quantit ies in 2. Tyrosinase-positive (ty-pos) a lbinos have the urine of the black-skin subjects. phenotypic features that vary according to age and 4. Albinism with hemorrhagic diathesis was de­ the degree of pigmentation of the parents. Most scribed by Hermansky a nd Pudlak (1959) in two Ca ucas ian ty-pos a lbinos of a ll ages and infant sisters. A ceroid-li ke pigment was fou nd in the egro a nd Amerindian a lbinos phenotypically re­ reticuloendothelial system, a nd the bleeding disor­ semble ty-neg albinos. Wit h in creasing age small der was attributed to a vascul ar type of h emo­ amounts of pigment accumulate in the iris, skin , philia. Since t hen about 20 similar cases have been and h air and they develop fl axen to yell ow h a ir, reported or a re known (Verl oop et a l. , 1964; Har­ ve ry s lig h t tanning abili ty, pigmented nevi, a loss di sty and Hutton, 1967; Maurer et a l. , 1968; Mills of t he prominent red r eflex , moderate nystagmus and Hardisty, 1970; Muniz et al. , 1970; White et and photophobia, and even brown irides. Hair a !. , 1971; Logan et al. , 1971; White and Witkop, 1972). This investigation was supported by NIH Grants os. The bleeding disorder has now been ascribed to a AMI53 17 -01, HE-11880, AI-05153, DE-00179, the Card i· platelet defect (Mill s a nd Hardisty, 1970; White et avasc ular Clinical Resea rch Centers Program of t he al. , 1971; White a nd Witkop, 1972) with low Division of Resea rch R esources, NIH. take of serotonin, a * From the Di vision of Human and Oral Genetics, in t rinsic levels a nd poor up School of Dentistry, Un ive rsity of Minnesota; t the De­ decreased amount of nonmetabolic adenine nu­ partmen t o f Ophthalmology, School of Medicine, Uni ve r­ cleotide, and by e lectron microscopy a v irtual sity of Minnesota; t t he State Department of Hea lth, of platelet dense bodies (Maurer et al. , Department ofPed iatrics, absence State of Minnesota; and §the concen­ School of Medicine, University of Minnesota, Minneapo­ 1968; White eta!. , 1971) . The addition of lis, Minnesota. trations of aggregatin g agents such as ADP, epi - 44 3 444 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

A

B

ive albino shows no visible pigment. B. After incubation in !-tyrosine FIG. 1. A. H air bulb from a tyrosin ase-negat · 80 mg/100 ml of phosphate buffer at pH 6.8, for 12 hr there is no pigment formation.

report described nephrine, thrombin, co ll agen, a nd bacteria to the White and associates (1971). One al lymphocytes with platelet-rich plasma of patients, which normally a large proportion of peripher of albinism produces a biphasic response, results in a mono­ broken chromosomes in this type phasic or single wave response instead (White et (Maurer et a!., 1968). of albinism, al., 1971; White a nd Wit kop, 1972). 5. In addition to these four types erited hypopigmentary What has been described as ceroid pigment has two other recessively inh hypopigmenta­ been reported in most of the patients examined for disorders manifest a generalized photophobia, the Beguez­ this feature but the pigment was absent in the tion with nystagmus a nd ome (Beguez-Cesar, bone marrow of an 18-month-old boy examined by Cesar-Chediak- Higashi syndr 445

F IG. 2 . E lectron photomicrogra ph of a from a tyrosinase-negative a lbino shows in te rmediate vesicles and Stage II preme!anosomes but no evid ence of any pigment formation ( X 31,710) . F IG. 3. Electron photomicrograph of premela nosornes from a tyrosin ase- negative a lbino after incubation in !-tyrosine, 80 mg/ 100 ml o f phosphate buffer at pH 6.8, for 12 hours shows that the p1·emelano omes remain depigmented ( >< 74,700) .

1943; Stegma ier and Schneider, 1965) and t he The melanocytes co ntain giant preme\anosomes Cross syndrome (Cross et a!. , 1967) . In t he former, that cannot be passed properly via the melanocyte the defect, which is thought to be in t he mem­ dendrites to the keratinocytes. In addi tion, numer­ branes of lysosomal-like particles, res ults in giant ous polyphagosomes in the melanocyte cytoplasm cy toplasmic granules in granule-producing cells. consist of aggregates of giant melanosomes under- 446 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

A

B area in hair s haft FIG. 4. A. Ha ir bulb from a tyrosinase-positive albino shows faint yellow pi gment granules. Dark / 100 ml of phosphate at left is due to li ght scattering from bubbles in hair. B. After in cubation i n !-tyrosine, 80 mg buffer at pH 6.8, for 12 hours, there is in tense pigmentation.

go ing destruction by the surrounding lysosomes vere oligophrenia, and gingival fibromatosis (Wit­ (Windhorst et al. , 1968) . kop, 1971). are hypopig­ 6. Children with Cross syndrome Present Study mented with melanocytes in which scanty melano­ somes respond with increased pigmentation in A study of ty-neg, ty-pos, ym, and albinos with vitro to added ]-tyrosine or 1-dopa. In addition, bleeding tendency was undertaken to determine the children have microphthalmia, athetosis, se- which of the previously described abnormalitie OC ULOCUTANEOUS ALBINISM 447

F tc. 5. M elanocyte from a tyrosinase-pos itive a lbino shows in termediate vesicles, premelanosomes Stage II (a) a nd lightly pig mented premelanosomes Stage Ill (b). Ra rely a re ma ture Stage IV mela nosomes (c) observed ( x 16,500). Ftc .. 6. M elanocyte from a t yrosinase- positive albino prefix ed in 2% g lutar a ld e h~' d e and incubated in 80 mg or 1-tyrosm e/1 00 ml phosph ate bu tTer at pH 6.8 for 12 hours, ref'i xed and stain ed in os mi c acid : g lut a r a ld e h~ · d e shows that most of t h e premelanoso mes have converted t o mature melanosomes S tage IV ( '< 10.250). 448 THE JOURNAL OF INVESTIGATIVE DERMATOLOG Y

FIG. 7. Mela nocyte dendrite from a ye llow mutant albino shows unevenly pigmented premelanosomes similar to t hose seen in perso ns with red hair (x 41,500) . FIG. 8. Melanoso mes from a yell ow muta nt albino after incubation in 80 mg of 1-tyros in e/100 ml of phos phate buffer pH 6.8 for 12 hours show only questionable in crease in pigmentation ( x 37,500). OCULOCUTANEOUS ALBINISM 449

were shared among the various types. In addition, gotes for ty-neg type albinism. Iris transillumina­ obligate heterozygotes for each type were examined tion and nystagmus were graded on an arbitrary ophthalmologically to determine whether they had scale of 0 to 4+. All observations were made by the diaphanous irides as a possible sign of the carrier same investigator (C.W.H.) who had no previous state. knowledge about the type of albinism affecting the patient or the obligate heterozygotes. Slit lamp METHODS examination and fundus photographs were ob­ All albinos had a physical examination and were tained. photographed. They were tested with the hair bulb Chromosome analysis (for breakage) of cultured incubation test (Witkop, 1971) and had their hair peripheral lymphocytes was carried out by the bulbs examined by electron microscopy (Witkop et inspection of 100 metaphase cells of each patient. al., 1970). Ophthalmic examination was made with Citrated platelet-rich plasma (C-PRP) was pre­ dilation and included near and far visual acuity pared and the effects of various aggregating agents and Ishihara color vision. Transillumination of the (collagen, t\uombin, adenosine diphosphate irides was done in a dark room with a Finnhoff (ADP), epinephrine, and serotonin) added to C­ light that had been shown to elicit iris transillumi­ PRP on tlie platelet aggregometer were noted a nd nation in albinos and in some obligate heterozy- samples fixed for electron microscopy as detailed elsewhere (White, 1968). Serotonin determinations were made by the method of Murayama and Takemori (1970). All patients were instructed to a void any drug intake for at least 10 days before testing. Urinary glycolipids were determined by the method of Desnick et a!. (1970) and two-dimen­ sional paper chromatography was done for urinary amino acid (O'Gorman eta!., 1970).

RESULTS Clinical Studies Results of the ophthalmologic examination are given in Tables I- III. In general, proceeding from the severely affected ty-neg to the ty-pos to the ym type albinos, there was a lessening of severity of visual acuity defects. This was accompanied by evidence of differential pigment accumulation in the various types: the ty-neg albino- no accumula­ tion of melanin pigment and severe nystagmus and visual acuity defect; the ty-pos albino- some pig­ ment accumulation and a less severe nystagmus and visual acuity defect; the ym-the most pig­ ment, the least nystagmus, and the best visual acuity. Only among the Caucasian ty-neg heterozygotes was the number with iris translucency substan­ tially increased. In one subject with a variant of the Hermansky-Pudlak syndrome, only one melano­ cyte was found in serial electron microscopic sec­ FIG. 9. New Guinea nativ e go ld miner with " red" type albinism probably similar to that reported by Walsh tions of 10 hair bulbs. Both of his parents had the (1971) . most prominent translucent irides seen in any

TABLE I Ophthalmologic findin.r

Range Acuity Mean Mean Fundus No. Tested Mean Ac uity Transillum Nystagmus I Pigment. Homozygotes ,.,--- Caucasian 7 20/300 200- 400 3.0 2.9 0 Negro 3 20/400 400 3.0 3.0 0 Heterozygotes Caucasian 10 0.8 (8 individuals were + ) egro 7 0.3 (3 individuals were + ) 450 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

TABLE ll Ophthalmologic {indin{

TABLE [Jl Ophthal molo{

No. Tested Mea n Acui ty Range Ac ui ty Mean Mea n Fundus T ransillum . Nystagmus Pigmeni

H om ozygotes y m Caucasia n 6 20/200 25- 400 1. 5 1.0 + Negro 1 20/200 - 1. 0 1.0 ++ Herma nsky- P udla k Caucasia n 2 20/300 - 3.0 3.0 + Heterozygotes Caucasia n H- P 2 2. 0

TABLE IV Labora tory findinps in variou8 tvpes of alb inos (no. tested/no. with n.bnorma/ities)

Chromosome Abnorm al Ab normal Type Po l y ph a~oso m es Absent Pl atelet Platelet Hi gh Urin ary Breaks in Melanocytes Dense Bodies GI-l Urinary Cllfo- Aggrego mctry matography

T y- neg 2/0 6/0 1/0 - 3/0 - Ty-pos 13/1* ll/7 4/0 - 4/2 3/0 ym 2/l * 5/0 1/0 - 0/0 4/0 H- P 1/0 2/0 2/2 2/2 2/0 1/0

* Patients wit h infectious m ononucleosis; when retested, no breaks . obligate heterozygote of any alb ino type. Anot her polyphagosomes in the cytopl asm showing aggre­ s ubject, however, had yell ow- brow n ha ir, pig­ gates of phagosomes, mela nosomes, a nd endopla - mented lentigines in his skin, and ha ir bulb mic reticulum undergoing destructi on (Fig. 10) . In melanocytes t hat conta in ed numerous melano­ addition mela nocytes from these patien ts were cytes with many stage II a nd early stage III packed wi t h premelanosomes. These cells con­ phao melanoso mes ; his irides we re yellow- brown ta ined one to severa l giant mela nosome complexes, a nd showed onl y one plus transillumination. His so me of which were in va ri ous stages of destruction relatives were not availabl e for testing. in a utophagic vacuoles. Platelets from t he s ubjects wi t h H e rman­ Laboratory Findings sky- Pudlak (H- P ) syndrome showed a ma rked T he laboratory findings a re summari zed in decrease in dense bodies (Fig. 11) , which could not Ta ble IV . Increased chromoso me breakage was be recrui ted by incuba tion in serotonin-rich m edia. seen in only t wo individuals (ty-pos, 40 perc ent of Platelets from subjec ts with ty- pos, ty-neg, or ym ce lls; ym, 12 percent of cells). The day after the a lbinism appeared to ha ve norma l numbers of study, the ty-pos subject was found to have infec­ den se bodies. tious mononucleosis, and the ym subjec t had a Two s ubjects with the H- P syndrome showed possible ex posure to t he same vira l infection a nd to a bnorma l aggrego metry wi t h co ll agen, t hrom b in . drugs . When retested later, t he ce ll s from both epinephrine, and ADP (Fig. 12). Samples of C­ patients showed less tha n 2 percent breaks. PRP from patients with t his disorder ma nifested a In electron photomi crogra phs of mela nocytes normal prima ry response to aggregating agents. fr om 7 of 11 ty-pos a lbinos t here were gia nt but the second wave of aggrega tion, which is F IG. 1_0. Mela nosome co mplex from a tyrosinase-positive a lbino ha ir bulb mela nocyte a ppears to be undergo in g destructiOn. Elements whi ch a ppea r to be e ndopl asmic reticulum a re seen throughout t he co mplex ( x 41,500).

F IG. 11. Platelets from a Herma nsky- Pudlak type a lbino s howing t he lack of d ense bod ies whi ch a re storage orga nelles for serotonin . Only two dense bod ies a re seen in this photomicrograph (a rrows). Norma l cell s contain about 1.4 dense bodies/platelet in t hin section (x 21,500). 451 452 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

Correction of Aspirin Platelet (A) Epinephrine Response ( 5. 5 X 10-6 M) by Storage Pool Deficient Platelets ( HP)

•ll T- cha nge in light transmission

FIG. 12 . Response of patient's C-PRP to addit ion of coll agen in tracing 1 is co mpa red with the reaction of a norma l sample of C-PRP to same agent shown in tracing 2. Coll agen induced ea rl y c hanges in patients as in no rmal cell s, indicated by a na rrowing o f the baseline. However, instead of r apid increase in light t ra nsmission foll owed b y irreversible aggregation evident in tracin g of the norma l sa mple, patient's C- PRP developed a modi­ fi ed pattern of res ponse, Light t ransmission increased f----; steadily for the f irst 3 m in , t hen slowed to a g ra dua ll y *6T -c hange 1n lrght transmr ss ron 1 m.nute ascending phase, whi ch did not r each a max ima l decrease in opt ical density during t he period of r ecording. T he FIG. 13. Effects of C-PRP from a norma l ind iv idual pattern evident in the patient's tracin g suggests in ade­ after the_in gestion o_f aspirin an t he defective secondary quate avail abili ty of secretory p roducts essential fo r rapid aggregatwn o{ a pat1ent w1t h H- P syndrome to epineph­ development o f irreversibl e aggregation. ri ne. T racin g number 1 of the patient's C-PRP a lone i ident ical to t he reaction of C-PRP from the aspirin­ treated cont rol, and t he co mbination of 10 percent en tirely dependent o n chemical p roducts secreted aspirin p latelets (A) in tracing 2 does not alter t he defect by the cells, failed to occur. As a resul t t he in secondary aggregation. A mixture of 20 percent aspirin disassocia ted, as indicated b y t he pl atelets and 80 percent H-P cell s develops a sli ghtly aggregated cells in g second wave of line. P latelets delayed, but otherwise norma l-a ppear return of the tracing toward the base aggregation i n response to epin ephrine in tracin cr 3 from these patients adhered to collagen but did not T racings 4 a nd 5 o btain ed from samples combined i~ aggregate. T he a ddition of 10 percent normal ratios of HP6: 4A and HP5 : 5A respective ly a re identical C-PRP to C-P RP from a H- P patient corrected the to biphasic responses observed in sa mples of norm al C- PRP a lone follow ing addit ion of epinephrine. defect and produced a normal biphasic response. Aspirin-treated platelets from n ormal individuals ts in macrophage showed m onophasic responses to aggregating accumulation of lipid deposi be neutral, i.e., it agents similar to those of t he H- P patients. How ­ (Fi g. 14); the lipid appea red to ack B a nd, in addi­ ever, combining 50 perce nt o f H-P C-PRP and 50 stained intensely with Sudan bl ow ceroid-like ma­ percent o f normal aspirin-treated C-PRP restored tion, depos its of go lden yell n photomicrograph t he aggregation curves to normal biphasic re­ teri al. Figure 15 is a n electro one-marrow macrophage sponses (Fig. 13). of ceroid deposits in b e disease (Levine High urina ry excretion of GI-l fraction w as from a patient wi th c eroid storag s a n electron photom icro­ observed in 2 of the 4.ty- pos subjects tested : 0. 691 et al. , 1968) . F igure 16 i w m acrophage from the and 0.650 mmoles/24 hrs res pectively, compared graph of a bone- marro sm. In the latter the lipid with t he normal ra nge of 0.225 to 0.459 mmoles/24 subject with H- P albini ave a s mooth, uni­ hrs. The subject with H- P vari ant had high urinary deposits are in droplet form, h relatively e lectron GI -l fraction excretion on ini tial exa mination, but form appearance, and are its do not have a was well wi t hin the range of normal when r etested translucent. The ceroid depos ation, appear som ewh at (0.372 mmoles/24 hrs) . smooth dropl et co nfigur attern, a nd are rela­ None of the s ubjects tested had an a bnormal granular with a vermicul ar p nse than the deposits of a mino acid pattern nor an a bnormal a mount o f tive ly more e lectron d e !-dopa excretion products on two-dimensiona l neutral lipid. If opa itself accumul ated paper chromatography. d DISCUSSION in an albino, excessive 3- methoxy-4-hydroxy­ dihydroxyphenylacetic phenylacetic acid and 3, 4- Ophthalmologic Findings acid would be found in t he urine from individuals who have ingested d opa (O'Gorman et al. , 1970) . The ophthalmologic findings in the various type No such a bnormali ties were detected with the of albinos indicate in ge neral a n inve rse relation­ di azotized p-nitroanil ine method of O'Gorman et ship between the amount of pigment accumulation al. (1970) in urine fr om p atients with ty-pos, ym, a nd the severity of the defects in visual acui ty and a nd H- P albinism. nystagmus. Although the relationship between Investigation of the bone ma rrow of one a dult pigment accumulation, nystagmus, a nd decreased male s ubject with albinism, bleeding tendency, visual acuity follows t his general pattern by a lbino and a platelet defect (Fig. 13) showed the extensive type, vari ation d epends upon the ethnic back- OCULOCUTANEOUS ALBINISM 453

FJG. 14. Phase contrast photomicrographs of bone marrow cells from a patient with H- P a lbinism. The macrophages contain a bluish-green material whi ch stains intensely with Sudan black.

ground of the patient. Thus, ty-pos Negro albinos 1968) are not limited to this type of albinism and have more pigment, seen in hair bulbs, skin, a nd postulated that all a lbinos have this defect because iris color, with less nystagmus and better visual of increased ultraviolet radiation of the dermal acuity than some Caucasia n ym albinos . Some capillary bed insufficiently protected by melanin Caucasian ty-pos albinos cannot be distinguished pigment in melanocytes and keratinocytes. How­ by phenotypic pigment accumulation from ty-neg ever, we were unable to find chromosome breaks in Negroes, and have ocular defects of the same any of the types of albinos tested, including those degree of severity. with H- P syndrome. We plan to test albinos in the Iris translucency as an indicator of the carrier tropics to determine whether sunli ght is a factor state for a lbinism is probably not a reliable indica­ involved. tor of carriers for ty-pos and ym albinism. It was absent in about half of the Negro ty-neg obligate Polyphagosomes in Ty-pos Albinism heterozygotes in thi s series. Among the Zuni Indi­ Although we found giant polyphagosomes in ans, we have examined 11 obligate heterozygotes melanocytes of only seven of the 11 albinos tested for ty-pos albinism but have failed to find a ny with (Table IV ), serial sections of hair bulb from the diaphanous irides (Witkop eta!. , 1972). other four subjects could have shown them sin ce Waardenburg (1947) first reported that obli gate the keratinocytes of these subjects co ntained pre­ heterozygotes for albinism could be detected by melanosome complexes as well as normal-appear­ diaphanous irides, but Dodinval and associates ing melanosome complexes. Mottaz, Thorne, and (1965) failed to corroborate this finding. Later Zelickson (1971) demonstrated that after minor Waardenburg (1970) emphasized that examina­ trauma induced by cellophane tape stripping of the tions for iris translucency must be made with a stratum corneum of human epidermis melanocytes special light, no longer manufactured, and that the from normal subjects contain numerous melano­ use of any other device invalidates t he results. In some complexes, many in autophagic vacuoles. retrospect, this controversy probably arose not They attributed this phenomenon to the produc­ from a difference in technique but from the use of tion of edema around the melanocytes and to the different types of albino heterozygotes. Our experi­ inhibition of the passage of melanosomes to kera­ ence indicates that iris translucency is not a tinocytes. This suggests a defect in the passage of consistent trait in the heterozygote of any type of melanosomes from melanocytes to keratinocytes in albinism; hence we do not use it as a basis for the ty-pos type of albinism. Although some kera­ genetic counseling. t inocytes of ty-pos albinos contained melanosomes and the dendrites of melanocytes also had numer­ Chrom osomal Breaks ous premelanosomes, increased numbers of pre­ At one time we entertained the possibility that melanosomes and polyphagosomes suggest that breaks in the chromosomes of circulating lym­ failure to transfer melanosomes in adequate num­ phocytes reported in H- P syndrome (Maurer eta!. , bers is related to the albinism in this disorder. with ceroid storage FIG. 15. Electron photomicrograph of a portion of a bone marrow macrophage from a patient in Fi g. 15. Electron droplets. This sto red lipid does not have the lamin ated appearance of phospholipid present dense ceroid-like material Ii es adj acent to the clear vacuoles ( x l6, 150). - P a lbinism. The FIG. 16. E lectron photomicrograph of a . bone marrow macrophage from a patient with H nts, and la rge clear macrophage cytoplasm contains partially digested cell ula r d ebris, some erythrocyte fragme in Fig. 15. Electron droplets. This stored lipid does not have the laminated appea rance of phospholipid present dense ceroi d-like materia l li es adjacent to the clea r vacuoles ( x 16,150). 454 OCU LO CUTA NEOUS ALBINISM 455

Plate let Abnormalities glycolipids. The s li ght increase in the levels of the Gl-1 fraction in two patients could not be repeated The basis for the platelet a bnorma li ty in H- P in patients wit h the sa me type of albinism. Despi te e is now partially established . To date it is syndro m the large a mounts o f lipid in macrophages in the t he o nly known platelet defect in whi ch a mor­ bone marrow studies, it has t he c haracteristics of phologic abnormali ty has been correlated with a neutral lipid rather than of a glycolipid. chemical defect. In platelets of p atients wi th H - P syndrome, Ma urer et a l. (1 968) observed int ri si­ Urinary A mino Acids cally lo w levels a nd poor uptake o f serotonin and r the d efect ive ava il a bili ty of ADP-induced platelet fac­ The fa ilure to find any evidence of !-dopa o chro­ tor 3; s imilar findings were reported b y Mills a nd metaboli c products of !-dopa in the urinary H ardisty (1970). Measured by the Takemori matograms of albinos of any type prompted u s to m e t h o d (Murayama and T akemori , 1970) the sero­ communicate this f inding to Dr. Walsh, who had ton in content o f one o f the H- P p atients in the previously reported a ninhydrin staining com­ 9 !-dopa in " red" presen t seri es was 0.059 mg/10 cells, a bout o ne pound wi th a n Rf va lue s imilar to . Dr. tenth t h e concentration found by t his technique in albinos from N ew Guinea (Walsh, 1971) e was normal platelets (0.6-0.8 mg/10" ce lls) fr om chil­ Walsh r eplied that in further investigation h ported dre n of similar age (White et a l. , 1971) . Platelets una bl e t o substantiate his previously re from H - P p atients rarely contain dense bodies, findings. he storage organelles fo r serotonin. which a re t Lipid in B one Marrow Macrophages Abou t o ne dense body per 40 platelets was ob­ served in thin sections o f H - P platelets co mpared One 18- month old male a lbino patient wi th a wit h a b out 1. 4 per platelet in cells from n orma l bleeding disorder and a bnormal platelet function person s. and morphology gave no evidence of li pid accumu­ The rationale for examining the effect of aspirin­ lation in bone marrow m acrophages. A ym albino trea ted p latelets fr om n ormal p ersons o n H - P subject also had a normal-appearing bone marrow, platelets was based on the inherent difference and one adult H- P albino patient had extensive resp o n s ible for a bnormal release in t he t wo cell deposits of what a ppeared to be neutral l ipid types . H - P platelets have a n intact, operatin g associated with ingested erythrocytes in va ri ous cont r actile mechanism but fa il to r elease because stages of di sintegration in bone marrow macro­ secretory products are present in relative ly minute phages and, in addition, extensive deposits of amounts. Aspirin platelets contain secretory prod­ ceroid- like materi al in bone marrow macrophages, ucts but fail to secrete t hem b ecause of an im­ urine, and buccal mucosa. paired r esponse of the contractile mechani sm to the u s u a l concentrations o f aggregating agents. SUMMARY T h e fact that equal volumes of H -P and aspirin­ In summa ry, our findings indicate that the treat e d platelets mi xed together corrected the ty-n eg, ty- pos, ym, and H- P forms of albinism release d efe ct of aspirin platelets by storage pool­ sha re t he clinical features of a ge nerali zed decrease defi c ie n t H- P cell s indicates that different mech­ in pigmentation of the s kin, hair, a nd eyes as well anism s a re involved in t he fa ilure of the release as decreased visual acui ty, nystagmus, and photo­ reactio n in the t wo ce ll types. phobia. In general, t here is an inverse relationship Aspirin-treated normal pl atelets mixed in appro­ betwee n the a mount of pigment produced in the pria t e proport ions wi th H - P platelets will correct va ri ous syndromes and the severi ty of t he ophthal­ their mut ual defects, but t hese studies suggest that mologic defects; however, this may be modified in asp irin. given to a H- P p atient will cause him to the ty- pos, ym, and H- P a lbino by t he genera l regress f r o m a fa irly mild bl eeder to a more serious ethnic pigmentary background of the patient. one . A s pirin would be expected to bloc k t he rel ease Ty-pos albino melanocytes show dense accumu­ of th e s m all concentration of secretory products lations o f premelanosomes a nd melanosome co m­ present in the H- P ce lls. T he clinical histori es of plexes, which m ay indicate a defective abili ty to H-P p atients sometimes show what events first pass their products to keratinocytes. brou gh t t hem t o medical attention. Of the first 18 In addition to a pigment defect, the H- P albinos H- P p atients reported in the li terature o r know n show mild bleeding tendencies a nd the accumula­ by t h ese investigators, 15 were brought to medical tion of lipid in bone-ma rrow macrophages. T he atten tion after prolonged bleeding fr om tooth ex­ platelets do not undergo secondary wave aggrega­ tractio n or tooth injury. There is a di stin ct possi­ t ion wi th the a ddition of aggregating agents, lack bility t h at in the e s ituations the patient took dense bodi es , and are low in serotonin and non­ aspirin for too thache o r was given aspirin by the metaboli c nucleotides; however, they have an in ­ den t ist. tact release mechanism. The use of aspirin by this type o f albino may cause him to regress from a Urinary G lycolipid-] Fra ction mild bleeder to a more serious one by the bl oc kage According to our data, patients with a ny type of of t he release mechanism in chemica lly defi cient albinis m d o not have a bnormal levels of urinary pl atelets. 456 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

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