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VITAMIN B 12 and FOLATE BINDING PROTEINS Victor RELEASE OF VITAMIN BINDING PROTEINS FROM GRANULOCYTES BY LITHIUM: VITAMIN B12 AND FOLATE BINDING PROTEINS Victor Herbert and Neville Colman Hematology and Nutrition Laboratory Bronx Veterans Administration Medical Center Bronx, New York, and Department of Medicine SUNY - Downstate Medical Center Brooklyn, New York In 1968, Dr. Seymour Rosenblatt, a psychiatrist using lithium in the treatment of manic-depressive psychosis at the Mount Sinai Hospital in New York City called our attention to the fact that some of his patients receiving lithium appeared to have mild leukocytosis. Joint investigation of this phenomenon with him confirmed that such was the case, and we learned that this phenomenon had been observed as far back as 1955 (Bille and Plum). Since various agents are known to induce peripheral blood granulocy- tosis by bringing about demargination of leukocytes from blood vessel walls into the bloodstream, without stimulation of granulopoiesis or retardation of granulocyte egress from the bloodstream (Boggs and Winkelstein, 1975), we first addressed ourselves to the question of whether the effect of lithium was simply to induce demargination. Since lithium was known to produce a rise in serum cortisol (Platman and Fieve, 1968), and cortisol was known to induce demargination, this seemed a likely explanation, and indeed was suggested by Shopsin et ale (1971). If the sole effect of lithium was to induce demargination, lithium 61 A. H. Rossof et al. (eds.), Lithium Effects on Granulopoiesis and Immune Function © Plenum Press, New York 1980 62 VICTOR HERBERT AND NEVILLE COLMAN should not stimulate an increase in granulocyte pool size. We chose measurement of B12 binding capacity to measure granulocyte pool size, since our laboratory had at that time just demonstrated that transco- balamins I and III, which constituted a significant portion of vitamin B12 binding protein in human serum, were largely products of granulocytes (Corcino et al., 1970) and, when used as an index of granulocyte pool size, gave results essentially identical to those of the more elaborate DFp32 labelling procedure (Chikkappa et al., 1969; Chikkappa et al., 1971). Vitamin B12 binding capacity proved to be elevated in patients receiving lithium therapy, supporting the concept that lithium in fact did enlarge the granulocyte pool and therefore must in some direct or indirect way stimulate granulopoiesis. At this point in January, 1970, we moved our laboratory from Mount Sinai Hospital to the Bronx VA Medical Center, where after six months we were joined by Dr. Glenn Tisman, a highly enthusiastic, energetic and bright young research fellow. He quickly set up leukocyte cultures by the technique of Kurnick and Robinson (1971) and demonstrated that adding lithium to such cultures significantly increased new colony formation. These data, along with those on the elevated serum vitamin B12 binding protein levels produced by lithium therapy (and the granulocytosis so produced) were finally published in 1973 in the British Journal of Haematology (Tisman et al., 1973) after being rejected in 1972 by two American journals, as was our application to a major granting agency to fund further studies. Were it not for the British Journal of Haematology, there might have been no Workshop on "Effects of Lithium on Granulo- poiesis and Immune Function" here at Eagle River. In that article, as in our preliminary report in 1972 (Tisman et al., 1972), we first proposed the use of lithium to treat cyclic and other neutropenias, including those induced by chemotherapy and, Dr. Tisman having by then gone off to California, he and we continued to investigate the use of lithium in treating various neutropenias, including those associated with chemotherapy and malignancies (Jacob and Herbert, 1974; Tisman, 1974). In our preliminary clinical studies, oral doses of lithium RELEASE OF VITAMIN BINDING PROTEINS FROM GRANULOCYTES 63 carbonate sufficient to sustain a serum lithium level of 0.5 to 1.5 meq/l appeared to improve effective granulopoieisis in subjects with neutropenia alone, neutropenia and splenomegaly due to cirrhosis and portal hyperten- sion, and neutropenia anticipated during a course of cyclophosphamide therapy (Jacob and Herbert, 1974). Our eight years of experience in treating various neutropenias with lithium has not yet been prepared for publication, beyond our first preliminary report (Jacob and Herbert, 1974), but it may be of value to mention a patient of Dr. E. Amorosi of New York University Medical Center. This young man had cyclic neutropenia with recurrent infections, and, when treated in 1975 through one cycle with lithium, still had his neutropenia but did not get his usual infections and showed some rise in plasma vitamin B12 binding protein before, during, and after his neutropenic phase. Now we are discussing with Dr. Amorosi re-treating him through a number of cycles, in view of the report by Hammond and Dale (1979) that the cyclic neutropenia of grey collie dogs is favorably influenced by lithium in terms of measurable neutrophil count only after several cycles, but clinical infections during neutropenic periods did not occur, the report by Perez et ale (1979) that lithium can correct defective chemotaxis in human neutrophils and the report by Buckley et ale (1978) that elevated cyclic AMP in granulocytes reduces their adherence and their migration into infected tissues. Lithium lowers adenylate cyclase (Perez et ale 1979), and may modulate cyclic AMP-dependent effects in leukocytes (Gelfand et al., 1979). LITHIUM AND HEMATOLOGIC MALIGNANCIES We early feared (Tisman et al., 1972; Tisman et al., 1973) that lithium might induce leukemia, and so carried out with Frenkel in Texas a study of the frequency of granulocytic leukemia in populations drinking high- vs low-lithium content water (Frenkel and Herbert, 1974). Communities with high and low lithium content of their drinking water were initially identified from the U.S. Geologic Survey of the 100 largest cities in the United States (Durfor and Becker, 1964). This survey 64 VICTOR HERBERT AND NEVILLE COLMAN identified two cities in Texas with a consistent lithium content of their water supply considerably higher than any of the rest: EI Paso and Amarillo. Of the other 100 cities surveyed, only Los Angeles, California, had a consistently elevated value in the range identified for these Texas cities. A more extensive and current analysis of the lithium content of drinking waters carried out by the more sensitive atomic absorption spectrophotometry demonstrated that the high levels of lithium in EI Paso and Amarillo were unchanged over the past decade. The water supply has multiple origins in EI Paso, Texas but the year-round average drinking water lithium content for the average EI Pasoan is 66 llg/L (Trieff et al., 1973). These more recent, careful and serial studies further identified Amarillo, Texas as another geographic area with a consistently high lithium content (44 llg/L) in the drinking water (Trieff et al., 1973). Data from this same study revealed that the average lithium content of water supplying the Dallas - Fort Worth area was 1.8 llg/L and current weekly assays since that survey have been below the level of detection (Frenkel, personal communication). The cases of leukemia from the Dallas - Fort Worth Metropolitan Area were compiled from the data from the Third National Cancer Survey (1975) which utilized this area as one data base (Frenkel, 1975). The El Paso data were compiled from the EI Paso County Tumor Registry and Survey and corroborated by Epidemiologic Survey for EI Paso conducted through M.D. Anderson Hospital, Houston, Texas (data provided by Dr. E.J. MacDonald of M.D. Anderson HospitaI). Leukemia incidence data and the population base covered for Amarillo, Texas were obtained from the Texas Department of Health Resources Cancer Surveillance Program and corro- borated by Cancer Registry evaluation. In each geographic area, only resident cases were recorded. The levels of lithium ingested by residents of EI Paso did not approach the usual therapeutic dose. At 66 «giL, and an intake of three liters a day, this is only 200 llg of lithium per day, or 0.2 mg. Lithium carbonate is supplied in 300 mg tablets, and the usual daily dose is 900 mg, or 170 mg of lithium, over 800 times the dose from El Paso water. RELEASE OF VITAMIN BINDING PROTEINS FROM GRANULOCYTES 65 The frequency of chronic (CGL) and acute (AGL) granulocytic leukemia was determined in the population of Dallas - Fort Worth (no lithium in water) vs El Paso (mean 66 llg/L Li in water). As shown in Table I, the frequency of AGL was substantially lower in the population drinking water containing lithium. The frequency of CGL was similar in both populations. Whether these findings were irrelevant coincidence or represent a lower incidence of AGL in populations with drinking water containing lithium awaits study of a larger number of paired populations in whom mean granulocyte and lymphocyte levels would also be of interest (Tisman et al., 1973). Other cities with high lithium-content drinking water include Phoenix, Los Angeles, and Lubbock. Cities with low lithium- content water include San Francisco, New York, Memphis, and Milwaukee. According to Durfor and Becker (1964), content does not change much from year to year, but most cities have more than one major source of drinking water. For example, the Croton supply to New York City has only 0.16 llg Li/L but the Catskill and Delaware supply has 0.27 llg Li/L and the Jamaica Wells supply has 1.5 llg Li/L (personal communication from L.J. McCabe, Water Supply Research Laboratory, US EPA, National Environ- mental Research Center, Cincinnati, Ohio 45268). McCabe indicated the highest content in the U.S. water was 170 llg Li/L at the Rio Grande treatment plant at El Paso, Texas. Should such Li intake prove to be associated with lower incidence of AGL, this could support the possibility that such doses of Li may stimulate blast cell differentiation and maturation, and thereby protect against AGL.
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