A Case of Atransferrinemia and 35 Cases of ypotransferrinemia as Detected by Radioassay of

H Total -binding Capacity of the Serum

iroshiSaito, MD, Yoshiaki Kato, MD, Takashi Suzuki, MD, and Hajime Kato, MD

Department of Radiology, and Department of Internal Medicine, Nagoya University School of Medicine, Nagoya

Total iron-binding capacity (TIBC) of the serum was determined in 600 patients by the radioassay method devised by Saito. Fifty-four fig/dl of TIBC, which is as low as that of

previouslyH reported cases of congenital atransferrinemia, was found in a patient with marked hypoproteinemia probably due to protein losing enteropathy as shown by a high plasma RISA disappearance rate of 41 percent per day. The patient was diagnosed as having secondary atransferrinemia on the bases of hematological findings, iron metabolism and other tests. Thirty-five of 600 patients whose serum TIBC levels were determined by radio- assay had low TIBC level below 200 [tg/dl. Twenty-one of the 35 (60%) had diseases, 13 (37%) had malignancies and 7 (20%) had diseases of digestive organs. TIBC was markedly increased in , while it was normal or decreased in other diseases. IBC radioassay is a simple, highly accurate and efficient method of measuring .

T Key Words: Transferrin, Serum iron, Unsaturated iron-binding capcity of serum (UIBC), Protein losing enteropathy (PLE), Hypoproteinemia, Plasma RISA clear- ance, Radioiron utilization, Storage iron deposition, Mechanism of iron absorption, In vitro saturation assay.

Five cases of congenital atransferrinemia is nowcommercially available. Recently the have been reported so far. Besides, there authors performed determination of serum are 4 reports on secondary atransferrinemia TIBC on 600 patients using the TIBG kits and suspected atransferrinemia. and found 35 patients with TIBC levels To make diagnosis of atransferrinemia, below 200 ftg/dl, one of them had extremely immunoassay of transferrin (Tf) or measure- lowserum Tf level. ment of both serum iron (SI) and un- saturated iron-binding capacity (UIBC) is MATERIALS AND METHODS essential. Oneof the authors, Saito, devised TIBG and UIBC were measured by the method of TIBG radioassay10"125, and using Res-O-mat TIBC and UIBC kits es-O-mat TIBG kit based on the method produced by Dai-ichi Radioisotope Labora- tory, Ltd., Japan. The amount of Tf in R Received for publication March 2, 1977. Reprint requests to : Hiroshi Saito, Department mg/dl was obtained by dividing TIBC of Radiology, Nagoya University School of value in [tg/dl by 1.3. At the same timeTf Medicine, 65, Tsurumai-cho, Showa-ku, Na- was determined by using Behringwerke's goya, 466, Japan. Immunodiffusion Platten.

342 JapJ Med Vol 16, No 4 (Oct 1977) Atransferrinemia by TIBG-radioassay

TIBG was determined on 600 different on legs. Laboratory data were listed in sera which had been sent to the Radio- Table 1. Marked hypoproteinemia with isotope Laboratory of Nagoya University hypalbuminemia, increased a2-globulin level, Hospital for the determination of UIBC. , hyperlipemia and severe Plasmas or sera obtained from healthy stu- were the outstanding dents of Nagoya University School of Medi- features. High T3RU and somewhat low cine were used as normal controls. thyroxin level were noted, indicating de- letion of thyroxin binding protein. Case Report p Course in the Hospital: Despite severe M.N., 24-year-old Japanese girl, was ad- hypoproteinemia, edema was successfully mitted to Nagoya University Hospital with treated with 40-80mg of furosemide daily, suspected protein losing enteropathy on but recurred soon after the drug was with- September 9, 1974. drawn. On September 30, she had a brief Family history was not contributory. episode of shock followed by marked tachy- Past history was unremarkable except for cardia and tachypnea lasting for several passing 2 to 3 loose stools daily since she days. In December, she developed leg was a pupil of an elementary school. edema,ascites, fever and cough of several In July of 1970, she developed edema on days' duration. upper and lower limbs, general fatigue and Plasma protein level remained low and fever of about 39°C of 4 days' duration. rarely rose above 4g/dl. Striking hyper- Proteinuria and decreased plasma protein catabloic hypoproteinemia, as shown by a level were also noted. The edema dis- rapid RISA disappearance (Figure 1), appeared after diuretic therapy. She was strongly suggested the existence of protein admitted to Kariya Toyota Hospital with losing enteropathy (PLE), for urinary pro- a diagnosis of nephrotic syndrome on July 20, 1970 and was discharged in May of1971,

since physical and laboratory findings were 100% normalized. In July of 1973, edema and hypoproteinemia reccurred. She was treated Normal rate: less than 5%/day as inpatient at Anjo Kosei Hospital from August 22 to 27 inclusive. In May of 1974, she developed edema which increased steadily thereafter. In July, she was ad- mitted to Anjo Kosei Hospital with gene- Patient's rate: 41 %/day ralized edema, cough, pleural effusion, marked hypoproteinemia and elevated ESR.

By biopsy performed on July 31, a < pathologic diagnosis of membranous glo- CO merulonephritis was made, while urinary 3 protein was negative. Then she was moved to Nagoya University Hospital for further study. Physical findings at admission: The patient was rather small but normally de- veloped girl. Height was 148cm and body weight 44kg. BT 36°9/C. Pulse was 88 per minute and was regular. BP was 108/64 mmHg. Her conjunctiva appeared anemic 5 6 7 8 10 and striae cutis distensae were noted on Days abdominal wall. There was a mild edema Fig. 1. Plasma RISA disappearance curve.

Jap J Med Vol 16, No 4 (Oct 1977) 343 Saito et al

Table 1. Laboratory data.

1974 1975 Sept Oct Feb Apr Total protein (6.8-8.2)g/dl 3.6 3. 3.7 4.1 5.5 Albumin % 24.8 28. 22.5 25.3 38.7 <*-l globulin 6.7 5.0 5.4 6.1 6.5

SI ( 105±25) 29 .7 30 35 Prothrombin time (control 12.0) 10.6 Thrombo test (70-130)%/ll.7sec over 100 26.7 seconds Fibrinogen (200-400)mg/dl 688 D-xylose excretion test (4 -8)g 6.0 Glucose tolerance test normal curve T, resin uptake (25-35)% 38.1 THyroxin ( 5-14)jug/dl 4.6 RISA half time (14 < )days 1.7 fractional catabolic rate 41 131-I-trio.lein absorption blood counting (13<)% 30.8 stool ( 2>) 1.3 Schilling test 24hr urine (8.0<)% 16.6 Fe absorption (with 4rag of carrier in the form of FeSO4 (Japanese female by whole body counting) 33%, when retics = 0.3% 28±8%) Desferal test (lOOOmg desferrioxamine i.m. injection) 1.2mg Fe/day (1<) Ferrokinetics PID Tl/2 = 27min (60-120) PIT = 0.49mg/kg/day (0.4-0.9) %RCU = 91% (85-100) RCV = 724ml PV = 1550ml BV = 2274ml Erythroid marrow distribution : Larger over the abdomen and chest than pelvic region at 5 and 24 hours Radioiron deposition in the by transverse linear scan : Increased at 5, 24 and 10 days Radioiron deposition in the spleen by transverse linear scan : Increased slighthy at 10 days Intestinal blood loss by stool counting : 0.2-l.lml/day (normal) (reabsorption is neglected) Mean red cell life span with 59-Fe = 51days

tein was negative on repeated urinalysis. was often positive, blood loss in the gut However, UGI, BaE and X-ray examination determined with radioiron was 0.2 to 1.1 ml of the small intestine by means of duodenal per day, i.e., within normal range. RBC and intubation revealed no abnormalities in hemoglobin level were generally within gastrointestinal tract. Jejunal biopsy and normal limit. Ferrokinetics were performed absorption studies did not yield any posi- and the results are shown in Table 1, and tive results. Although occult blood in stool Figure 2.

344 Jap J Med Vol 16, No 4 (Oct 1977)

.16.3 1334.31063.5587,5003 Atransferrinemia by TIBC-radioassay

T a b l e 2. T h i r t y f iv e c a s e s h a v i n g T I B G v a l u e

> WithinV 6 minutes l o w e r t h a n 2 0 0 ju g / d l .

T I B C ;u g / a i 24ho (2 ) 1 7 2 , 1 8 6 P u r e r e d c e l l a p l a s i P a n c y t o p e n i a H em o s i d e r o s i s H e r e d . s p h e r o c y t o s i s (2 ) 1 6 9 , 1 8 1 e l l i p t o c y t o s i s (1 ) 1 8 7 P a r o x y sm a l n o c t u r n a l - B l o o d d i s e a s e s h em o g l o b i n u r i a H em o l y t i c a n e m i a Knee Pubis Nave] Xyphoid Chin Head u n k n o w n e t i o l o g y (2 ) 1 5 9 , 1 6 1 A) Quantitaive body section counting using a ring-type A n em i a u n i d e n t i f i e d H o d gk i n ' s d i s e a s e (3 ) 1 6 2 , 1 8 1 , 1 9 2 whole-body counter Ch r o n i c m y e l o c y t i c l e uk em i a (1 ) 1 6 0 .24hours E ry th r o l e u k em i a (3 ) 1 5 7 , 1 6 3 , 1 8 4 Deposition of 59Fe (3 ) 1 5 8 , 1 7 4 , 1 9 7 h M a l i g n a i in the liver L u n g c a n c e r C h or d om a (1 ) 1 5 3 Over the vertebra H e p a t ora a (1 ) 1 2 1 Over the spleen Over the liver L i v e r c ir rh o s i s _j i I D i s e a s e s o f (1 ) 1 3 6 r Left Mid Right P r o t e i n l o s in g (2 ) 1 4 6 , 1 7 6 B) Transverse linear scan in prone position H y p o p r o te in e m i a (2 ) 5 4 , 1 5 0 H y p e r t h y r o i d i si Fig. 2. Radioiron distribution along the Hyperpaathyroidi sm longitudinal body axis (A) and at the height of liver and spleen (B). In contrast, marked increase in TIBG was observed only in iron deficiency ane- From February 1, 1975 on, she suffered mia. TIBG tended to decrease in hemo- from persistent intractable tachycardia, chromatosis and renal failure, as seen in cough and dyspnea. She died on April 30 Table 3. in severe dyspnea. Curiously enough, serum protein level rose to 5.5 g/dl, albumin level Table3. TIBG, UIBG and SI as determined to2.7g/dl and serum cholesterol level de- by radioassay mathod. C a s e s T IB C U IB C S I creased to 178mg/dl at terminal stage. Per- u g / d l (T I B C - U I B C ) mission to perform autopsy was not ob- N o r m a l m a l e (4 8 ) 2 5 8 - 3 6 8 1 3 2 - 2 7 0 5 5 - 1 7 9 tained. N o r m a l f e m a le (1 7 ) 2 9 6 - 4 4 2 1 6 0 - 3 6 0 7 1 - 1 6 2 Cases of Low Serum TIBC Level P o l y c y t h e m i a v e r a (1 6 ) 6 2 + 5 5 1 9 9 A p l a s t i c Of the 600 patients whose serum TIBG R e n a l f a i l u r e (7 ) 2 5 4 + 41 1 6 1 + 4 9 levels were determined during the last one 1 8 + 4 1 3 8 9 + 4 1 - 3 1 and half years, TIBC was found lower than 200//g/dl in 35 patients. The underlying D IS C U S S IO N diseases are blood diseases such as aplastic anemia, erythroleukemia, chronic myelocytic A case of hypoproteinemia associated leukemia, hereditary spherocytosis, here- with marked Tf deficiency: The TIBG ditary elliptocytosis and paroxysmal noc- level of the case was aslow asthat of con- turnal hemoglobinuria, malignancies such genital atransferrinemia reported so far. as erythroleukemia, chronic myelocytic leu- In previously reported cases, the relation kemia, cancers and Hodgkin's disease, dis- of "TIBC(/ig/dl)=Tf(mg/dl) X 1.3 is not eases of digestive organs such as liver dis- seen; Tf values wTere 3 to 9mg/dl and eases, and protein losing enteropathy and TIBG were 24 to 50pg/dl Either over- endocrine diseases such as hyperthyroidism estimation of TIBC or inaccuracy of Tf and hyperparathyroidism. The details are measurement may account for such a listedin Table 2. marked discrepancy. TIBC value by radio-

JapJ Med Vol 16, No 4 (Oct 1977) 345 Saito et al

assay and Tf value by immunoassy cor- proteinemia, hypoalbuminemia, hyperlipemia related well9'12). Variation of Tf values and kidney biopsy finding were compatible measured by using Behringwerke's Partigen with nephrotic syndrome, absence of urinary Transferrin Immunodiffusion Platten can protein will exclude the possibility of kid- be significant12^ for very small amount of ney disease as a cause of plasma protein serum is used for immunoassay. The low depletion. Thus intestinal protein loss is Tf value as measured by immunoassay the most likely mechanism of hypoproteine- might be caused by the alteration of Tf mia in this case, but its etiology remains itself. It should be noted that TIBC radio- unknown. assay is accurate, highly reproducible and Although short red cell survival was free of possible iron contamination as ex- noticed in this case, it is not necessarily perienced in colorimetry. Radioassay is an assumed that deficient Tf is somewhat re- excellent and indispensable method for lated to hemolysis, for anemia due to iron measuring TIBC and Tf as confirmed by deficiency or other cause is usually accom- others13-16). panied by a certain degree of hemolysis. Rapid disappearance of intravenously Brief febrile episodes occasionally took administered RISA in this case cannot place during the course. Inflammation may simply be attributed to increased protein be a cause of hemolysis and sometimes it loss in the gut. Two factors should be taken may cause a decrease of Tf18). However, it into account, ie., increased degradation and seems unlikely that such a significant de- loss of protein. Measurement of plasma dis- crease of Tf level in this patient is caused appearance rate of 13T-Tf, detection of by inflammation. Mean red cell life span lymph in intestinal tract and measurement (RCLS) of the case measured with 59Fe was of 131I-PVP in stool were scheduled but not as short as that in the case reported by performed. Diagnosis of plasma protein loss Sakata et al3). Although radioiron loss in in the gut is madeby counting 131I-PVP in stool was normal, occult blood in stool was stool, however, actual amount of loss of often positive in this case. Furthermore, protein cannot be estimated. 51Cr-albumin RCLS obtained by using 59Fe tends to be is not superior to 131I-PVP,because the re- shorter than that determined by 32P-DFP19). lease of 51Cr and resultant short life are In view of these facts, actual RCLS in prominent. The test for PLE by using 67Cu- this case may be a little longer. ceruloplasmin is considered to be most re- A striking contrast to simple iron de- liable,but it was not available for us. In ficiency anemia was that the saturation rate this case, extremely low plasma protein (%Sat) was above the normal range in this level was observed in association with a case. In general, there is a positive relation- very rapid plasma RISA disappearance ship between plasma iron disappearance rate of41% per day, the highest ever ex- rate (PID Ty) and level of SI. On the perienced here. However, Yoshino et al.17) reported a plasma RISA disappearance rate otherhand, PID T-^- was short and SI of60% per day in PLE. was also low in this patient as in the case The results of absorption studies on of iron deficiency anemia. In most cases of vitamin B12, 59Fe and 131I-triolein were all emolytic anemia, PID T-^- is shortened normal or above normal in this patient.

Her nutritional state had been well main- h while SI and %Sat are increased. tained until persistent dyspnea developed. Generally speaking, increased body iron Hypoproteinemia due to a failure to synthe- stores is one of the factors decreasing % size protein, as seen in malabsorption synd- RCU. All cases of previously reported con- rome or liver cirrhosis, can be ruled out genital atransferrinemia1"^ had been trans- from rapid RISA disappearance rate and fused with blood, but our case received no laboratory data. Although profound hypo- bloodtransfusion. For this reason, perhaps,

346 JapJ Med Vol 16, No 4 (Oct 197X) Atransferrinemia by TIBC-radioassay

decrease in %RCU was not observed in atransferrinemia is concerned, UIBC does this case despite the decrease of Tf. In not seem to play an important role in iron cases of congenital atransferrinemia, it is absorption. As mentioned above, many not clear whether the same quantity of iron similarities and some differences were ob- was deposited as that supplied by trans- served between this and previously reported fusedblood, or larger quantity of iron than cases of atransferrinemia1"85, and iron de- that given by blood transfusion was de- ficiency anemia. On the basis of hematologi- posited owing to the developement of hemo- cal findings, especially of ferrokinetic study chromatosis. In this case, 59Fe appeared as mentioned above, this case can be called a peak of early incorporation in the eryth- atransferrinemia. roid marrow within 6 minutes after injec- Cases having TIBC level below 200fig/ tion and its distribution pattern 6 to 24 dl: It is well known that in normal subjects hours thereafter was similar to that of iron UIBG level is around 200fig/dl. Therefore, deficiency anemia except for the occurrence subjects having TIBG level lower than 200 ofa peak over the abdomen as shown in /ig/dl are unusual. We set up a tentative Figure 2A. Radioiron distribution pattern standard and found 35 cases whose TIBG differs from iron deficiency anemia in that was lower than 200/^g/dl. Twenty-one of some of radioiron deposition was actually the 35 cases had blood diseases, ll of which observed as shown in Figure 2B. If the were of non neoplastic nature. Thirteen patient had received a large amount of cases of the 35 had malignant diseases. blood, the amount of radioiron deposition Seven cases of the 35 had diseases of diges- would have been much larger. Radioiron tive organs, including 2 cases of PLE. was deposited in the liver in this case un- None of patients with kidney diseases had like the radioiron turnover as observed in decreasedTIBG level. Majority of patients patient with hemochromatosis, or in patient with hypotransferrinemia had blood diseases with extramedullary hematopoiesis. In view in our series. Kozuru9j20) reported that the of radioiron deposition in the liver and decrease of TIBG was frequently found in hemolysis as indicated by short RCLS, it tumors, nephrosis and PLE. Considering is not likely that %RCU of the patient is the factors influencing Tf level, hypotrans- 91%. Perhaps %RCU might have been ferrinemia may frequently be found in dis- overestimated. Of the previously reported easesof blood, digestive organs and kidneys cases of atransferrinemia, those in whom nd in malignant tumors. iron metabolism was thoroughly studied are If TIBG radioassay is adopted as routine listed in Table4. As seen in the Table, laboratory procedure, atransferrinemia will iron absorption is enhanced in all cases. be more frequently detected. The reason why iron absorption is markedly a enhanced in spite of increased iron storage ACKNOWLEDGEMENTS: We would like andlowUIBG is not known. As far as to express our cordial thanks to Dr. Mitsuo Kozuru, Third Department of Internal Table 4. Iron metabolism in congenital and Medicine, Kyushu University School of ecquired atransferrinemia. Medicine for his kindness in sending the

R e p o r t e d b y H e i l m e y e r H e l l m e y e r S a k a t a G o u y a W a l b a u m s a i t o literatures on atransferrinemia. 蝣 1 9 6 5 3 9 6 1 1 9 6 9 1 9 7 0 1 9 7 1 p r e s e n t c a

D i a P y o - " p T .F .? n e p h r o s i s i a T r a n s f e r r i n m g / d l 1 8 . 5 4 . 4 9 3 3 7 - 7 1 T I B C w / d l 2 4 3 3 5 0 4 6 3 3 5 4 - 9 1 REFERENCES S I 2 1 9 1 4 - 1 1 8 1 2 1 4 2 5 - 3 5 P I T m g / k g / d a y 1 . 6 3 0 . 7 3 0 . 4 9 Heilmeyer L, Keller W, Vivell O, Keiderl- P I D 2 1 5 4 2 2 5 5 2 7 K C U % 5 2 a t 7 d a y s 1 0 5 3 5 5 1 2 9 1 ing W, Betke K, Wohler F, Schultze HE: F e a b s o r p t i o n % 8 7 3 0 3 9 3 0 3 3 Kongenitale Atransferrinamie bei einem sie-

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