Correspondence

in determining the identity of ANKL/L. Although the exact

nature of the phagocytosing factor(s) is still unknown, these
cytokine studies may shed more light on the possible
pathogenesis of haemophagocytic syndrome including
ANKL/L and other MH syndromes.
Division of Prdiutrics.
Childrrn's Resenrch Hospitul.
Departnrvnt q l I'rdiutrics,
Kyoto Prefecturul

UNIVERSITY OF MEDICINE.
Kyoto, urrd

SHINSAKII
IMASHUKU
TSIJKASA OKUDA
TAKAO
YOSHIHARA
SATOSHI IKIJSHIMA

SHIGRYOSHI
HIM

Departnrcnt of Internal Medicine.

Saisrikui Suitn Hospital.
Osuku. lapun
REFERENCES
Byrne. C.E.. Jr & Kappaport. H. (1973) Malignant histiocytosis.
Malipitif Diseuses ojthc Hrmatopoiefic S y s f c i n . pp. 145-1 62. Canii
Monograph on Cancer Research, 1 5. Ilniversity of Tokyo Press.
Iljeu. J . Y . , Stocks. N.. Zoon. K.. Stanton. C.J.. Timonen. T. &
Herberman. R.H. ( 19x2) Positive self regulation of cytotoxicity in
human natural killer cells by production of interferon upon
exposure to influenza and herpes virus. /oitriiul of Experimental
Mrdicirii~.I 56, 1222- 12 34.
Gattei. V.. Carbone. A,, Marotta. C.. DeRosa. L.. Mancardi. S..Alosi.
M.. Attadia. V.. Zagonel. V. & Pinto. A. (1989) Expression of
natural killer ( N K ) antigens in malignant histiocytosis and a subset

13 3

of acute myelomonocytic leukemias. Bone Marrow Transplantation.

4. ( S 3 ) . 22.
Gattei. V.. Carbone. A.. Zagonel. V., Pinto, A,. Imamura. N. &
Kuramoto. A. ( 1 990) Expression of natural killer antigens in a
subset of non-T. non-B-lymphoma/leukaemia with histiocytic
features. British lournalof Hnrmatology. 76. 443-446.
Hassinger. S.L.. Schiffer. C.A. & Sun. C.-C.J. (1989) Acute myelo-

blastic leukemia with extensive erythrophagocytosis mimicking

malignant histiocytosis. American /ourrial of Cliriical Puffiolo~g!y.
92,
696-700.
Imarnura. N.. Kusunoki. Y . . Kawa-Ha. K.. Yumura. K.. Hara. J.. Oda.
K.. Abe. K.. Dohi. H.. Inada. T.. Kajihara. H. & Kuramoto. A.
( 1990) Aggressive natural killer cell leukaemia/lymphoma:report
of four cases and review of the literature. British /ourrial i f
Harmatolugy. 7 5 , 49-59.
Imashuku. S.. Ikushima. S.. Esumi. N.. Todo. S. & Saito. M. (1991)
Serum levels of interferon-gamma. cytotoxic factor and soluble
interleukin-2 receptor in childhood hemophagocytic syndromes.
kukemia and Lgmplioma. 3. 287-292.
Jaffe. E.S.. Costa. J., Fauci. AS.. Cossman. J. & Tsokos. M. ( 198 3 )
Malignant lymphoma and erythrophagocytosissimulating nialignant histiocytosis. American Joirrnal of Mrdicinr. 7 5 , 741-749.
Reynolds, C.W. & Foon. K.A. ( 1 984) T gamma-lymphoproliferative
disease and related disorders in humans and experimental animals: a review of the clinical. cellular. and functional characteristics. Blood, 64. 1 146-1 158.
Risdall. R.J.. McKenna. R.W.. Nesbit. M.E.. Krivit. W.. Halfour. H.H..
Jr. Simmons, R.L. & Brunning. R.D. (1979) Virus-associated
hemophagocytic syndrome. A benign histiocytic proliferation
distinct from malignant histiocytosis. Cancrr. 44, 99 3-1002.

MYEI.OI)YSPI,ASIA PKESENTING AS AUTOIMMUNE HAEMDLYTIC ANAEMIA

There has recently been interest in vasculitides as epiphenomena of the myelodysplastic syndrome (MDS) (Green et ul,
1990; Pagliuca at ul. 1990). These are thought to reflect
disordered immune function in these patients: other manifestations of this immunological abnormality are less well
documented. We report a patient who presented with
anaemia thought to be due to autoimmune haemolysis, but
in whom bone marrow cytogenetic investigation revealed a
karyotypic abnormality commonly seen in myelodysplasia.
More recently. she has developed a motor peripheral neuropathy which may also have an immune aetiology.
A 58-year-old female was noted to have a n abnormal full
blood count when attending for routine cervical smear. On
examination. there was moderate splenomegaly. Full blood
count (FBC) showed: Hb 8.7 g/dl. mean cell volume (MCV)
~
neutrophils 2.67 x 1OY/1. platelets
121 fl. WBC 3 . 0 10q/l,
242 x IO"/l. Reticulocyte count was 6%. The blood film
showed polychromasia. macrocytosis and tear-drop poikilocytosis. The direct Coombs test (DCT) was positive with anti
IgG. Serological investigation revealed the presence of a cold
antibody with anti-c specificity. Serum haptoglobins were
< 5 0 nig/dl. Immunoglobulin levels were normal. but serum
electrophoresis showed a n IgG kappa band. The paraprotein
was not present on the surface of the red cells. Anti-doublestranded DNA antibody was weakly positive (30 units,
normal < 1 0 units). B I Z and folate were normal. Bone

marrow aspirate showed erythroid hyperplasia with mild

dyserythropoiesis but no ringed sideroblasts; niononuclear
megakaryocytes were present. There was no excess of
reticulin on bone marrow trephine.
The patient was treated with prednisolone 2 0 mg daily.
Within 5 months her haemoglobin had risen to 12.3 g/dl.
reticulocytes were 3% and the DCT was only weakly positive.
Splenomegaly was still present. Subsequently. cytogenetic
examination of bone marrow revealed a complex karyotype:
46XX/46.XX. d e l ( 5 ) (913q33)/46,XX. d e l ( 5 ) (91 3q33). del
(20)(pl1.2lpl1.22).
Following reduction in the steroid dosage, the patient
developed a peripheral neuropathy. which was associated
with raised CSF protein ( 1.12 g/l) and was thought to be of
immune aetiology.
This patient presented with a n autoimmune haemolytic
anaemia responsive to steroid therapy: there were associated
immunological abnormalities, including a paraprotein. antiDNA antibody and peripheral neuropathy. Cytogenetic
investigation of bone marrow revealed a clonal abnormality
commonly associated with MDS (5q - ). Immunological
abnormalities are well recognized in MDS. In one series (Mufti
et al. 1986) the direct antiglobulin test was positive in 8.1%,
and monoclonal gammopathy was present in 12.5% of
patients investigated, but the association of frank autoimmune haemolysis with myelodysplasia has only rarely been

134

Correspondence

reported (Martin-Vega et al, 1989). usually in cases of

chronic myelomonocytic leukaemia. Peripheral neuropathy
has been reported in association with chronic myelomonocytic leukaemia in a single case (Maeda et al. 1989). It is
postulated that the clonal abnormality in myelodysplasia
involves a stem cell precursor of both myeloid and lymphoid
cell lines (Prchal et al. 1978). This is supported by investigation of a patient with myelodysplasia who was heterozygous
for glucose 6-phosphate dehydrogenase (G6PD); the same
isoenzyme was present in all haemopoietic cells, including
lymphocytes. Peripheral blood lymphopenia, as in this case,
is often found, usually with a reduced number of T helper cells
(Bynoe et al, 1983).The resolution of anaemia in this patient
was most likely due to the control of the haemolytic process.
However, Bagby et a1 (1980) have reported that cytopenias in
l0-15% of patients with MDS do improve with steroid
therapy, although side-effects such as bleeding and infection
are common in this group. Although bone marrow failure is
the predominant cause of anaemia in MDS. a haemolytic
component may be important in some cases, since the bone
marrow response to shortened red cell survival is impeded by
the erythropoietic defect.
Depart mcnt of Clinical Haematology,
Manchester Royal Infirmary. and
*Department of Cytogenetics,
Paterson Znstitutefor Cancer Research,
Christie Hospital, Manchester

K. PENDRY
C. HARRISON.
C. G. GEARY

REFERENCES
Bagby, G.C.. Jr.Gabourel, J.D.& Linman. J.W.(1980) Glucocorticoid
therapy in the preleukemic syndrome (hemopoietic dysplasia).
Annals o/Internal Medicine, 92, 55-58.
Bynoe. A.C.. Scott, C.S.. Ford, P. & Roberts, B.E. ( 1 98 3 ) Decreased T
helper cells in the myelodysplastic syndromes. British journal of
Haematology, 54, 97-102.
Green. A.R., Shuttleworth. D.. Bowen. D.T. & Bentley. D.P. ( 1 990)
Cutaneous vasculitis in patients with myelodysplasia. British
journal o/Haematologg, 74, 364-365.
Maeda. T., Ashie. T., Kikuiri, K., Ishiyama, N., Takakura. M. & Ise. T.
( 1 989) Chronic myelomonocytic leukaemia with peripheral
neuropathy and IgA paraprotein. Japanesejournal 01Medicine. 28.
709-716.
Martin-Vega. C.. Vallespi. T.. Julia,A,. Zuazu. J. & Torrabadella. M.
( 1 989) Autoimmune hemolytic anemia and myelodysplastic
syndromes. Sangre-Barc, 34, 343-345.
Mufti. CJ.. Figes. A.. Hamblin. T.J..Oscier. D.C. & Copplestone. J.A.
(1986) Immunological abnormalities in myelodysplastic syndromes. I. Serum immunoglobulins and autoantibodies. British
journal o/Haernatology, 63, 143-147.
Pagliuca, A.. Higgins, E.. Samson, D.. Humphries. S. & Mufti. G.].
(1 990) Prodromal cutaneous vasculitis in myelodysplastic syndromes. British journal o/ Haematologg. 75, 444-446.
Prchal. J.T.. Throckmorton. D.W.. Carroll, A.J.. et al (1978) A
common progenitor for myeloid and lymphoid cells. Nature. 274,
590-591.

DETECTION OF MINIMAL RESIDUAL MYELOMA AFTER BONE MARROW TRANSPLANTATION

We recently described the immunoglobulin heavy chain
(IgH)gene fingerprinting method, a technically simple PCRbased method which allows discrimination of clonal B cell
populations on the basis of size of their IgH gene rearrangements at a level of sensitivity of 0*01-0.1%(Deane& Norton.
1991). Several applications of this method have been
illustrated. including the detection of minimal residual
disease in acute lymphoblastic leukaemia (Deane & Norton,
1991; Deane et al. 1991). More recently, we have used this
approach to study serial bone marrow samples from two
patients with multiple myeloma who were treated with VAD
(vincristine.adriamycin. dexamethasone) followed by allogeneic (patient M2) or syngeneic (patient M1) bone marrow
transplantation (BMT)(Samson et al. 1989). Patient M1 had
an IgGK myeloma and is now in complete remission on
conventional criteria (i.e. normal bone marrow aspirate and
trephine and no demonstrable paraprotein by immunohation) 2 years after BMT. Patient M2 had an IgAK myeloma
and is now in stable partial remission 2 years after BMT with
a paraprotein detectable at less than 5 g/1 and a marrow
plasmacytosis ranging between 4% and 10%.
DNA was extracted from stored bone marrow slides as
described previously (Dean & Norton, 1991) and serial
follow-up material from individual patients was prepared on
different occasions to reduce the likelihood of cross-contami-

nation. PCR gene amplification using a panel of heavy chain

variable region (V,) specific and a joining region OH)primer
was performed as described previously (Deane & Norton,
1991) and in each case clonal IgH rearrangements were
detected (V3-specific in M 1 and Vl,5-specific in M2) at
diagnosis. Fig 1 shows the results of high resolution gel
electrophoresis of the radiolabelled amplification products
from the serial studies together with normal bone marrow
DNA (C) amplified in parallel (lanes f and i). A ladder of
products is generated from IgH rearrangements in polyclonal
B cells and against this background a single more intense
product representing the clonal rearrangement can be seen
(lanes a-e, g, h). As expected, a clonal rearrangement of
identical size to that at disease presentation was detected 1
year post-BMT in the patient (M2) who was in partial
remission. Persistence of the original clone was also demonstrated up to 2 years post-BMT in patient M1 who had
achieved complete remission by conventional criteria. It
should be noted that since the fingerprinting method is not
quantitative, the intensity of a clonal product does not give an
indication of the size of that clone.
There is clearly a need for follow-up studies on groups of
patients receiving different treatment regimens for myeloma
to determine their efficacy in eradicating the disease and the
clinical significance of different levels of residual disease.