Pancytopenia with Congenital Defects (Fanconi's Anaemia)
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Arch Dis Child: first published as 10.1136/adc.35.182.367 on 1 August 1960. Downloaded from PANCYTOPENIA WITH CONGENITAL DEFECTS (FANCONI'S ANAEMIA) BY ROBERT McDONALD and BASIL GOLDSCHMIDT From the Department of Child Health, University of Cape Town and Groote Schuur Hospital, Observatory, Cape Town (RECEIVED FOR PUBLICATION OCTOBER 12, 1959) Fanconi (1927) drew attention to a syndrome of His parents were in good health. Their first child, a pancytopenia associated with congenital defects girl, was said to have had unilateral polydactyly on the which has since become known as Fanconi's anaemia. radial side, persistent patency of the ductus arteriosus Reports of other cases followed from different parts and subacute bacterial endocarditis and had died at the of the world, including one from South Africa age of 6 years. (Kessel and During the patient's 20 admissions to hospital the Cohen, 1953), but the condition remains following features were recorded: he was pale and a rare one. underweight for his age, weighing 33 lb. at 6 years, and We report here five cases of pancytopenia with was judged to be of normal intelligence. Microcephaly- accompanying congenital anomalies, seen in Cape head circumference was 19j in. at 8 years; microphthal- Town. Some unusual features are mentioned and mia, absent testes and hyperpigmentation of the skin by copyright. it will be shown that the syndrome may not be were noted. Both thumbs were grossly deformed (Fig. recognized when the associated defects are incon- 1) and attached to his hands by soft tissue only. Radio- spicuous. graphs showed maldevelopment of the metacarpals and phalanges of the thumbs and retarded ossification of the Case Reports carpal bones (Fig. 2). The radial pulse was not palpable Case 1. D.G., a white boy, was first admitted to at either wrist, but the pulsation of the ulnar arteries was Groote Schuur Hospital in January, 1951, at the age of forceful. Femoral artery pulsation was normal. A 6 years. systolic murmur, maximal in the pulmonary area, was From the age of 14 months he had had recurrent attacks heard at each admission. A systolic thrill in the second of bronchitis. He had also undergone tonsillectomy, right and third left interspaces and in the neck was occasionally http://adc.bmj.com/ inguinal herniotomy and dilatation for anal stenosis. recorded, but radiographs ofthe chest, screen examination For three months before admission he had been pale, of the heart and electrocardiogram were thought to be anorexic and irritable. within normal limits. on September 25, 2021 by guest. Protected FIGS. 1 and 2.-D.G., aged 7 years. Note abnormality of thumbs and delayed ossification of carpal bones. 367 Arch Dis Child: first published as 10.1136/adc.35.182.367 on 1 August 1960. Downloaded from 368 ARCHIVES OF DISEASE IN CHILDHOOD The original blood findings were as follows: Haemoglo- tests, plasma proteins, fractional test meal and intra- bin was 7 3 g.%; the peripheral blood smear showed venous pyelogram all resulted in normal findings. anisocytosis and poikilocytosis of the red cells; white A diagnosis of anaemia, neutropenia and thrombo- cells numbered 12,250/c.mm., of which 80% were cytopenia, possibly due to sulphonamide toxicity, was lymphocytes, 18% neutrophils, 1% monocytes and 1% made and during 14 subsequent admissions there was eosinophils; his blood group was A Rh positive and no reason to alter it. In retrospect, however, it should his E.S.R. 34 mm. (Westergren) in the first hour. Bone be mentioned that tendon reflexes were noted to be brisk marrow in January, 1953 was normal and a platelet on more than one occasion, that generalized hyper- count at the same time was 142,000/c.mm. Reticulocyte pigmentation of the skin was noticed at her 12th ad- counts varied between 0 5 and 50%. mission, and that pyuria was a frequent finding, suggesting The anaemia was unresponsive to haematinics and that there might have been some slight renal anomaly was uninfluenced by splenectomy, which was performed not demonstrated by intravenous pyelography. in April, 1953. Blood transfusions became necessary The majority of her admissions were on account of at increasingly short intervals. In June, 1955 he was gross anaemia with which epistaxis and infections were admitted for blood transfusion and shortly afterwards often associated. Neutropenia and thrombocytopenia developed pneumococcal meningitis from which he died. were constant findings. Prolonged courses of A.C.T.H., The occurrence of petechial cutaneous haemorrhages is cortisone, prednisone, vitamin B12, folic acid and iron first recorded at this time, when a platelet count was were without benefit, as was splenectomy, performed at 3,000/c.mm. No autopsy was performed. her seventh admission in October, 1954. Blood trans- fusion and antibiotics were the only effective forms of Case 2. R.W., a white girl, was first admitted to treatment, and, at the last, even these failed. She died Groote Schuur Hospital in July, 1953 at the age of 6 of staphylococcal pyaemia with widespread haemorrhagic years. manifestations, pneumonia and jaundice in August, 1957. It was not made known to us at the time that a super- No autopsy was performed. numerary thumb had been amputated when she was 18 months old. Since the age of 3 her parents had noticed Case 3. Ju.W., younger sister of R.W., was admitted that she bruised very easily and she had had recurrent in May, 1959, at the age of 11 years. respiratory infections, each temporarily responsive to For the preceding year increasing pallor and a tendency by copyright. sulphadiazine, of which her father, a farmer, kept a to bruise easily had been noted by her parents. Six stock primarily intended for veterinary use. Increasing weeks before coming under our care she had been pallor, fatigue and weight loss had been noticed for two admitted to hospital near her home with a sudden onset months. of fever accompanied by flitting pains in the knees and Both her parents and three younger siblings were ankles. The fever and joint pains were short lived, but reported to be well, although it was recalled that her her anaemia proved unresponsive to oral and intra- mother had been anaemic in her youth. muscular iron and to vitamin B12 and she was transferred On examination the child was judged to be of normal to Cape Town for further investigation. intelligence. She was pale and thin, weighing 40 lb. Her parents and three younger brothers were reported and petechial haemorrhages were noted in skin, mucous to be in good health. http://adc.bmj.com/ membrane of pharynx and ocular fundi. The Hess test for On examination she was a well grown and intelligent capillary fragility was positive. A soft systolic murmur, girl weighing 74 lb. Pallor of mucous membranes, a maximal at the cardiac apex, was constantly heard rather darkly pigmented skin and a short, soft systolic throughout her subsequent admissions. A mid-diastolic murmur, which was loudest at the lower left sternal murmur, described as blowing in character, was recorded border, were the only abnormal physical findings detected. at her first admission and again six months later, but on The haemoglobin was 7-5 g.%; the smear showed no other occasion. marked anisocytosis and poikilocytosis of the red cells; The peripheral blood showed a haemoglobin of 4-5 the white cells numbered 7,000/c.mm., of which 94% g.%. The smear showed anisocytosis and poikilocytosis were lymphocytes and 6% neutrophils. Platelets were on September 25, 2021 by guest. Protected of the red cells, and the white cells were 1,360/c.mm. scanty, the platelet count being 58,000/c.mm. E.S.R. (lymphocytes 78%, neutrophils 16%, staff cells 4%, was 36 mm. (Westergren) in the first hour and her blood monocytes 10% and eosinophils 1%). The platelet count group A Rh positive. Two attempts at bone marrow was 8,000/c.mm., reticulocyte count 1- 8%, E.S.R. 95 mm. aspiration having failed to produce more than a few mar- (Westergren) in the first hour and the blood group A Rh row cells, a bone biopsy was obtained by trephine from the positive. The bone marrow, frequently examined, was iliac crest. This specimen was pale, with scanty marrow thought on one occasion to show megaloblastic hyper- cells, which appeared to be normal and to be present in plasia, but on all other occasions, apart from the constant normal proportions. Radiographs of chest and long observation that platelets were scanty and megakaryo- bones and an electrocardiogram showed no abnormality. cytes absent, it was thought to be normal. Radiographs Blood culture was sterile, the Mantoux test negative and of chest, pelvis and long bones, screen examination the urine normal. of the heart, electrocardiogram, blood Wasserman re- Folic acid 10 mg. twice daily was given for 10 days action, osmotic fragility of red cells, serum bilirubin, without benefit. Two pints of blood were transfused direct Coombs test, Paul-Bunnell test, liver function and she was sent home. Arch Dis Child: first published as 10.1136/adc.35.182.367 on 1 August 1960. Downloaded from PANC YTOPENIA WITH CONGENITAL DEFECTS 369 FIG. 3.-Jo.W., aged 7 years. Note abnormal thumbs; Ju.W. aged 11 years, note difference in size of thenar eminences. It was felt that the occurrence of hypoplastic anaemia, graphs of her hands showed that the metacarpal and neutropenia and thrombocytopenia in the two sisters proximal phalanx of her right thumb was of equal length must have either a genetic or an environmental cause. but more slender than that of her left thumb. Intra- by copyright. Moreover it was suggested by their father in a letter to venous pyelography showed no abnormality.