Inclusions In Neutrophils Research Articles

Heavy chain myosin 9-related disease (MYH9-RD): Neutrophil inclusions of myosin-9 as a pathognomonic sign of the disorder

MYH9-related disease ( MYH9-RD) is an autosomal dominant thrombocytopenia with giant platelets variably associated with young-adult onset of progressive sensorineural hearing loss, presenile cataract, and renal damage. MYH9-RD is caused by mutations of MYH9 , the gene encoding for non-muscle heavy-chain myosin-9. Wild-type and mutant myosin-9 aggregate as cytoplasmic inclusions in patients' leukocytes, the identification of which by immunofluorescence has been proposed as a suitable tool for the diagnosis of MYH9-RD. Since the predictive value of this assay, in terms of sensitivity and specificity, is unknown, we investigated 118 consecutive unrelated patients with a clinical presentation strongly consistent with MYH9-RD. All patients prospectively underwent both the immunofluorescence assay for myosin-9 aggregate detection and molecular genetic analysis of the MYH9 gene. Myosin-9 aggregates were identified in 82 patients, 80 of which (98%) had also a MYH9 mutation. In the remaining 36 patients neither myosin-9 aggregates nor MYH9 mutations were found. Sensitivity and specificity of the immunofluorescence assay was evaluated to be 100% and 95%, respectively. Except for the presence of aggregates, we did not find any other significant difference between patients with or without aggregates, demonstrating that the myosin-9 inclusions in neutrophils are a pathognomonic sign of the disease. However, the identification of the specific MYH9 mutation is still of importance for prognostic aspects of MYH9-RD.

Peripartum Management of Women with Suspected Hereditary Thrombocytopenia.

Introduction: Hereditary macrothrombocytopenic disorders are rare syndromes characterized by mild to moderate thrombocytopenia, large platelets, and a variable bleeding phenotype. In general, the diagnosis must be made clinically and management is empiric. Because of the autosomally inherited nature of these disorders, peripartum management must take into account the risk of bleeding for both mother and baby, during the pregnancy and at delivery. Study Purpose: To describe the peripartum management and bleeding complications in pregnant women with suspected inherited macrothrombocytopenic disorders and their children. Study Design: We performed a retrospective review of all mothers referred to our tertiary care hospital from 2004 to 2007 for evaluation of macrothrombocytopenia in pregnancy where hereditary thrombocytopenia was suspected. The diagnosis was confirmed if at least 2 of the following clinical features were present: life-long thrombocytopenia; family history of thrombocytopenia that spanned at least 2 generations; and the lack of a platelet count response to IVIG or corticosteroids. Data relating to bleeding and therapies used to treat or to prevent bleeding before or during delivery for mother and child were extracted from medical charts. Blood films were reviewed with experts in morphology, and diagnostic testing was performed when possible. Results: A total of 5 mothers and 8 babies were included. The median platelet count of mothers at delivery was 54 x 109/L (range 15–83 x 109/L) and the median MPV was 9.8 fL (range 7.4–11.3 fL). Of the 8 babies, 4 were thrombocytopenic with a median platelet count at birth of 50 x 109/L (range 9–93 x 109/L) and a median MPV of 9.4 fL (range 8.9–9.6fL). One mother and her baby had neutrophilic Dohle body inclusions, and none had skeletal, neurologic or renal abnormalities. Three mothers were previously treated with IVIG, including one who also received prednisone, with no platelet count response. During pregnancy, fetal blood sampling for platelet count measurements was not done. None of the mothers had epidural anesthesia, all delivered vaginally and 7 of 8 labours were induced. Two mothers received prophylactic tranexamic acid at the time of active labour and 1 received DDAVP. Prophylactic platelet transfusions were not given. One mother had bleeding associated with spontaneous rupture of membranes, and one had a post partum hemorrhage associated with uterine atony and vaginal laceration. The latter was repaired surgically and treated with platelet transfusions and DDAVP. None of the babies bled, but 1 was given a platelet transfusion because of severe thrombocytopenia at birth (platelet count = 9 x 109/L) with persistent platelet clumping. Conclusions: The frequency of pregnancy-related bleeding in mothers with hereditary macrothrombocytopenia was low in this cohort even in the absence of prophylaxis. There is a need for improved diagnosis and risk stratification of mothers with hereditary macrothrombocytopenia. A multicentre prospective study would assist in determining optimal peripartum management.

Le syndrome MYH9 : à propos d'une nouvelle observation et de la mise en évidence d'une nouvelle mutation du gène MYH9

Introduction Familial macrothrombocytopenias are a group of rare autosomal dominant platelet disorders including many syndromes in particular the May-Hegglin anomaly. They are characterized by thrombocytopenia with giant platelets and in some cases neutrophilic inclusions in peripheral blood granulocytes. Recently these different clinical entities have been demonstrated to be linked to mutations in the same gene, MYH9. Case report We report in a young African woman presenting as a May-Hegglin anomaly a new mutation of the MYH9 gene. In regard of this case we present a brief review of the MYH9 syndrome. Conclusion The MYH9 syndrome includes now several clinical entities who share some common clinical and biological characteristics such as a thrombocytopenia with giant platelets, presence or absence of other manifestations including Dohle like bodies, nephritis, sensineural hearing loss, cataract. We report a new case in which a new mutation of the MYH9 gene was evidenced.

Pathologic Quiz Case: Twin Neonates With Thrombocytopenia

Pathologic Quiz Case: Twin Neonates With Thrombocytopenia

Acute Clinical, Hematologic, Serologic, and Polymerase Chain Reaction Findings in Horses Experimentally Infected with a European Strain of Anaplasma phagocytophilum

Six horses were experimentally infected by administration of horse blood containing a Swedish strain of Anaplasma phagocytophilum. The polymerase chain reaction (PCR) signal was consistently detected 2-3 days before appearance of clinical signs and persisted 4-9 days beyond abatement of clinical signs, whereas diagnostic inclusion bodies were 1st noted on average 2.6 +/- 1.5 (SD) days after onset of fever. Clinical signs and hematologic changes were largely indistinguishable from those previously reported for diseases caused by A phagocytophilum (formerly Ehrlichia equi--"Californian agent") and the human-derived human granulocytic ehrlichiosis agent. Horses 1st demonstrated antibody response 12-16 days after inoculation, 2 cases of which were still febrile, and serotiters rapidly peaked within 3-7 days of clinical illness. One horse died during the acute stage of disease, but initial clinical signs and hematologic changes were similar to those of other infected horses. This report shows that, despite minor genetic differences, a European equine-derived strain of A. phagocytophilum may be similar in pathogenicity to the Californian agent. The PCR used holds promise to widen the diagnostic window and would also be diagnostic during the initial days of clinical disease when inclusions in neutrophils in blood smears are not yet apparent.

MYH9 spectrum of autosomal-dominant giant platelet syndromes: unexpected association with fibulin-1 variant-D inactivation.

The autosomal-dominant giant platelet syndromes (Fechtner, Epstein, and Sebastian platelet syndromes and May-Hegglin anomaly) represent a group of disorders characterized by variable degrees of macrothrombocytopenia with further combinations of neutrophil inclusion bodies and Alport-like syndrome manifestations, namely, deafness, renal disease, and eye abnormalities. The disease-causing gene of these giant platelet syndromes was previously mapped by us to chromosome 22. Following their successful mapping, these syndromes were shown to represent a broad phenotypic spectrum of disorders caused by different mutations in the nonmuscle myosin heavy chain 9 gene (MYH9). In this study, we examined the potential role of another gene, fibulin-1, encoding an extracellular matrix protein as a disease modifier. Eight unrelated families with autosomal-dominant giant platelet syndromes were studied for DNA sequence mutations and expression of the four fibulin-1 splice variants (A-D). A mutation in the splice acceptor site of fibulin-1 exon 19 was found in affected individuals of the Israeli Fechtner family, whereas no MYH9 mutations were identified. Unexpectedly, fibulin-1 variant D expression was absent in affected individuals from all eight families and coupled with expression of a putative antisense RNA. Transfection of the putative antisense RNA into H1299 cells abolished variant D expression. Based on the observation that only affected individuals lack variant D expression and demonstrate antisense RNA overexpression, we suggest that these autosomal-dominant giant platelet syndromes are associated, and may be modified, by aberrant antisense gene regulation of the fibulin-1 gene.

Sebastian Platelet Syndrome: A Hereditary Macrothrombocytopenia

Sebastian platelet syndrome is a rare autosomal dominant disorder characterized by macrothrombocytopenia with granulocyte inclusions similar to those in patients with Fechtner platelet syndrome but without evidence of hereditary nephritis and sensorineural hearing loss that characterizes the latter. Although by light microscopy the granulocyte inclusions in these disorders appear morphologically similar to those found in May-Hegglin anomaly, another autosomal dominant macrothrombocytopenia, by electron microscopy the inclusions are distinct. Studies of platelet function usually suggest normal or near-normal platelet function, although mild bleeding symptoms can be associated with each of these disorders. We describe a 38-year-old woman and her 11-year-old daughter who presented with lifelong histories of mild thrombocytopenia and easy bruising. Detailed hemostatic studies showed prolonged bleeding times in the child and the mother, with the child having absent secondary wave platelet aggregation responses to epinephrine, also reflected by testing with the platelet function analyzer (PFA-100 device). The mother's hemostatic studies were normal including platelet aggregometry, PFA-100 testing, and platelet flow cytometry. By light microscopy the blood smears of both individuals showed neutrophil inclusions, and their platelets were mildly enlarged but were not giant. Electron microscopy showed the neutrophil inclusions seen in classic Sebastian platelet syndrome or Fechtner platelet syndrome. These 2 cases expand the description of Sebastian platelet syndrome to include individuals with large but not giant platelets and mild or minimal thrombocytopenia. The differential diagnosis of hereditary thrombocytopenias is reviewed briefly.

Howell-Jolly body-like inclusions in neutrophils.

47-year-old white woman who had previously undergone lung transplant presented with a past medical history significant for chronic obstructive pulmonary disease, asthma, and diabetes mellitus. The patient was on multiple medications related to her lung transplant. Her blood smear was referred for pathologist review based on the presence of atypical cytoplasmic inclusions in the neutrophils. The white blood cell count was 2.6 3 10 3 /mL, hemoglobin 9.2 g/dL, mean corpuscular volume 89 fL, and platelets 202 3 10 3 /mL. Review of the smear revealed mild poikilocytosis of the red blood cells with occasional elliptocytes, acanthocytes, and rare schistocytes with a white blood cell differential of 6% band neutrophils, 80% segmented neutrophils, 2% lymphocytes, 11% monocytes, and 1% basophils. The neutrophils demonstrated toxic granulation, Dohle bodies, and Howell-Jolly body‐like inclusions (Figures 1 and 2). Bain 1 in 1989 described detached nuclear fragments within the cytoplasm of neutrophils as a feature of dysplastic granulopoiesis secondary to immunosuppressive

Immunofluorescence Analysis of Neutrophil Nonmuscle Myosin Heavy Chain-A in MYH9 Disorders: Association of Subcellular Localization with MYH9 Mutations

The autosomal dominant macrothrombocytopenia with leukocyte inclusions, May-Hegglin anomaly, Sebastian syndrome, and Fechtner syndrome, are rare human disorders characterized by a triad of giant platelets, thrombocytopenia, and characteristic Döhle body-like cytoplasmic inclusions in granulocytes. Epstein syndrome is another autosomal dominant macrothrombocytopenia associated with Alport syndrome but without leukocyte inclusions. These disorders are caused by mutations in the same gene, the MYH9, which encodes the nonmuscle myosin heavy chain-A (NMMHCA). The term, MYH9 disorders, has been proposed, but the clinicopathologic basis of MYH9 mutations has been poorly investigated. In this study, a total of 24 cases with MYH9 disorders and suspected cases were subjected to immunofluorescence analysis by a polyclonal antibody against human platelet NMMHCA. Abnormal subcellular localization of NMMHCA was observed in every neutrophil from individuals with MYH9 mutations. Comparison with May-Grünwald-Giemsa staining revealed that the NMMHCA always coexisted with the neutrophil inclusion bodies, suggesting that NMMHCA is associated with such bodies. In three cases, neutrophil inclusions were not detected on conventional May-Grünwald-Giemsa-stained blood smears but immunofluorescence analysis revealed the abnormal NMMHCA localization. In contrast, cases with Epstein syndrome and the isolated macrothrombocytopenia with normal NMMHCA localization had no MYH9 mutations. An antibody that recognizes the C-terminal 12 mer peptides showed similar immunoreactivity from the patients heterozygous for truncated mutations that abolished the C-terminal epitope, suggesting that normal NMMHCA dimerizes with abnormal NMMHCA to form inclusion bodies. We further propose that the localization pattern can be classified into three groups according to the number, size, and shape of the fluorescence-labeled NMMHCA granule. Immunofluorescence analysis of neutrophil NMMHCA is useful as a screening test for the clear hematopathologic classification of MYH9 disorders.

Effects of Anaplasma phagocytophila on NADPH oxidase components in human neutrophils and HL-60 cells.

The human granulocytic ehrlichiosis agent, Anaplasma phagocytophila, resides and multiplies exclusively in cytoplasmic vacuoles of granulocytes. A. phagocytophila rapidly inhibits the superoxide anion (O(2)(-)) generation by human neutrophils in response to various stimuli. To determine the inhibitory mechanism, the influence of A. phagocytophila on protein levels and localization of components of the NADPH oxidase were examined. A. phagocytophila decreased levels of p22(phox), but not gp91(phox), p47(phox), p67(phox), or P40(phox) reactive with each component-specific antibody in human peripheral blood neutrophils and HL-60 cells. Double immunofluorescence labeling revealed that p47(phox), p67(phox), Rac2, and p22(phox) did not colocalize with A. phagocytophila inclusions in neutrophils or HL-60 cells, and p22(phox) levels were also reduced. A. phagocytophila did not prevent either membrane translocation of cytoplasmic p47(phox) and p67(phox) or phosphorylation of p47(phox) upon stimulation by phorbol myristate acetate. The inhibitory signals for O(2)(-) generation was independent of several signals required for A. phagocytophila internalization. These results suggest that rapid alteration in p22(phox) induced by binding of A. phagocytophila to neutrophils is involved in the inhibition of O(2)(-) generation. Absence of colocalization of NADPH oxidase components with the inclusion further protects A. phagocytophila from oxidative damage.

A variant of the Sebastian platelet syndrome with unique neutrophil inclusions

The Sebastian platelet syndrome (SPS) is a hereditary giant platelet disorder characterized by thrombocytopenia and the presence of neutrophil inclusions identical to those present in neutrophils of patients with another giant platelet disorder, the Fechtner platelet syndrome (FPS). Patients with SPS differ from those with FPS in that they lack the clinical features of the Alport syndrome (high frequency hearing loss, congenital cataracts and chronic interstitial nephritis). The present study has evaluated six patients who resemble individuals with SPS, but have uniquely different neutrophil inclusions. Ultrastructural features of the neutrophil inclusions of the new variant are presented and compared with those found in other giant platelet disorders including classic SPS, FPS and the May-Hegglin anomaly, as well as the Chediak-Higashi syndrome.

Autosomal-dominant giant platelet syndromes: a hint of the same genetic defect as in Fechtner syndrome owing to a similar genetic linkage to chromosome 22q11-13

Families with 3 different syndromes characterized by autosomal dominant inheritance of low platelet count and giant platelets were studied. Fechtner syndrome is an autosomal-dominant variant of Alport syndrome manifested by nephritis, sensorineural hearing loss, and cataract formation in addition to macrothrombocytopenia and polymorphonuclear inclusion bodies. Sebastian platelet syndrome is an autosomal-dominant macrothrombocytopenia combined with neutrophil inclusions that differ from those found in May-Hegglin syndrome or Chediak-Higashi syndrome or the Dohle bodies described in patients with sepsis. These inclusions are, however, similar to those described in Fechtner syndrome. Other features of Alport syndrome, though, including deafness, cataracts, and nephritis, are absent in Sebastian platelet syndrome. Epstein syndrome is characterized by macrothrombocytopenia without neutrophil inclusions, in addition to the classical Alport manifestations—deafness, cataracts, and nephritis—and it is also inherited in an autosomal-dominant mode. We mapped the disease-causing gene to the long arm of chromosome 22 in an Italian family with Fechtner syndrome, 2 German families with the Sebastian platelet syndrome, and an American family with the Epstein syndrome. Four markers on chromosome 22q yielded an LOD score greater than 2.76. A maximal 2-point LOD score of 3.41 was obtained with the marker D22S683 at a recombination fraction of 0.00. Recombination analysis placed the disease-causing gene in a 3.37-Mb interval between the markers D22S284 and D22S693. The disease-causing gene interval in these 3 syndromes is similar to the interval described recently in an Israeli family with a slightly different Fechtner syndrome than the one described here. Recombination analysis of these 3 syndromes refines the interval containing the disease-causing gene from 5.5 Mb to 3.37 Mb. The clinical likeness and the similar interval containing the disease-causing gene suggest that the 3 different syndromes may arise from a similar genetic defect.

Autosomal-dominant giant platelet syndromes: a hint of the same genetic defect as in Fechtner syndrome owing to a similar genetic linkage to chromosome 22q11-13

AbstractFamilies with 3 different syndromes characterized by autosomal dominant inheritance of low platelet count and giant platelets were studied. Fechtner syndrome is an autosomal-dominant variant of Alport syndrome manifested by nephritis, sensorineural hearing loss, and cataract formation in addition to macrothrombocytopenia and polymorphonuclear inclusion bodies. Sebastian platelet syndrome is an autosomal-dominant macrothrombocytopenia combined with neutrophil inclusions that differ from those found in May-Hegglin syndrome or Chediak-Higashi syndrome or the Dohle bodies described in patients with sepsis. These inclusions are, however, similar to those described in Fechtner syndrome. Other features of Alport syndrome, though, including deafness, cataracts, and nephritis, are absent in Sebastian platelet syndrome. Epstein syndrome is characterized by macrothrombocytopenia without neutrophil inclusions, in addition to the classical Alport manifestations—deafness, cataracts, and nephritis—and it is also inherited in an autosomal-dominant mode. We mapped the disease-causing gene to the long arm of chromosome 22 in an Italian family with Fechtner syndrome, 2 German families with the Sebastian platelet syndrome, and an American family with the Epstein syndrome. Four markers on chromosome 22q yielded an LOD score greater than 2.76. A maximal 2-point LOD score of 3.41 was obtained with the marker D22S683 at a recombination fraction of 0.00. Recombination analysis placed the disease-causing gene in a 3.37-Mb interval between the markers D22S284 and D22S693. The disease-causing gene interval in these 3 syndromes is similar to the interval described recently in an Israeli family with a slightly different Fechtner syndrome than the one described here. Recombination analysis of these 3 syndromes refines the interval containing the disease-causing gene from 5.5 Mb to 3.37 Mb. The clinical likeness and the similar interval containing the disease-causing gene suggest that the 3 different syndromes may arise from a similar genetic defect.

Absence of ocular manifestations in autosomal dominant Alport syndrome associated with haematological abnormalties

Most patients with Alport syndrome have X-linked or autosomal recessive disease that is characterised by renal failure, hearing loss, and, in nearly 75% of the cases, a dot-and-fleck retinopathy and anterior lenticonus. There are only case reports of individuals with the rare autosomal dominant form, who can have haematuria or renal failure, deafness, and, in addition, low platelet counts and neutrophil inclusions. The ocular features of autosomal dominant inheritance have not been described. We have examined the eyes in the members of two families where Alport syndrome was diagnosed on the basis of the clinical features and family history, and where autosomal dominant inheritance was confirmed by father-to-son disease transmission, the associated haematological abnormalities, and haplotypes that segregated with the recently described locus at chromosome 22q. In Family A, the eyes of two individuals with haematuria, hearing loss, and haematological abnormalities and of nine unaffected family members were examined. In Family B, the eyes of two individuals with renal failure, normal hearing, and haematological abnormalities were examined. None of the affected or unaffected members in either family had a dot-and-fleck retinopathy, anterior lenticonus, a history suggesting recurrent corneal erosions, or corneal dystrophy. These results indicate that the protein abnormality in autosomal dominant Alport syndrome does not produce the retinopathy and lenticonus typical of X-linked and autosomal recessive disease. This may be because the abnormal protein is not present or is less important in the ocular basement membranes than elsewhere, or because the presence of a normal allele in autosomal dominant disease compensates for the defective allele.

Hematopathology in dogs experimentally infected with a Swedish granulocytic Ehrlichia species.

Seven, adult, female beagles were inoculated with a Swedish granulocytic Ehrlichia organism closely related to Ehrlichia equi and E. phagocytophila. Blood and bone marrow changes were evaluated throughout the acute phase of infection. All dogs developed moderate to severe thrombocytopenia during the parasitemic period. The mean platelet volume and platelet distribution width increased, and large platelets were seen on blood smears when platelet numbers were low. In bone marrow, absolute numbers of megakaryocytes and immature megakaryocytes were increased. These results suggested the thrombocytopenia was caused by increased platelet destruction. The dogs also developed mild, normocytic, normochromic anemia, with simultaneous decreases in serum iron concentration and total iron-binding capacity that resembled the anemia of inflammation. In bone marrow, there was a slight increase in immature erythroid cells and no erythroid hypoplasia; iron stores were normal to increased. Myeloid hyperplasia was seen in all infected dogs, despite neutropenia in peripheral blood. Lymphopenia occurred early in the parasitemic period, but lymphocytes responded strongly and numbers increased above baseline levels by the end of parasitemia. Blast-transformed lymphocytes (5% to 20%) were seen in peripheral blood for a few days. Experimentally-induced canine granulocytic ehrlichiosis caused cytopenias of short duration, coincident with the appearance of ehrlichial inclusions in neutrophils.

Human Granulocytic Ehrlichiosis in the Upper Midwest United States

To characterize the clinical presentation and course, laboratory findings, and treatment outcome of 12 patients with human granulocytic ehrlichiosis. The 12 patients were male, ranged in age from 29 to 91 years, and contracted their illness in Wisconsin or Minnesota. Cases were recognized by the presence of intracytoplasmic inclusions (morulae) in peripheral neutrophils of patients presenting with temperature of 38.5 degrees C or higher, chills, severe headache, and myalgias. All patients had a complete blood cell count and blood chemistry profile. Blood smears were examined by light microscopy. All available paired serum samples were analyzed for presence of indirect fluorescent antibodies against Ehrlichia chaffeensis, Ehrlichia phagocytophila, and Ehrlichia equi. Blood samples from 12 patients were subjected to polymerase chain reaction analysis using primers specific for the E phagocytophila/E equi group, primers that include the agent identified in our patients, as well as E chaffeensis. Varying combinations of leukopenia, anemia, and thrombocytopenia were found in all but one patient. All 12 patients demonstrated morulae in the cytoplasm of neutrophils, but not in mononuclear white blood cells. Serum assays failed to detect antibodies against E chaffeensis, but eight of 10 patients and seven of 10 patients tested had antibody titers of 1:80 or more for E phagocytophila and E equi, respectively. Polymerase chain reaction products obtained with primers for E phagocytophila, E equi, and the granulocytotropic Ehrlichia revealed that seven patients were infected with the same agent. The results of serological assays or polymerase chain reaction strongly suggest that all 12 patients were infected by E phagocytophila, E equi, or a closely related Ehrlichia species. Two of the 12 patients died. The other 10 patients improved rapidly with oral doxycycline treatment. We believe that all 12 patients have been infected with a granulocytic Ehrlichia species, reflecting a recently described new disease entity. The infective organism appears to be closely related to E phagocytophila and E equi. The geographic domain of human granulocytic ehrlichiosis is currently unknown. This novel granulocytic Ehrlichia species is capable of causing fatal infections in humans. Early detection and treatment with tetracycline drugs appear to offer the best chance for complete recovery.

Human granulocytic ehrlichiosis in the upper Midwest United States. A new species emerging?

<h3>Objective.</h3> —To characterize the clinical presentation and course, laboratory findings, and treatment outcome of 12 patients with human granulocytic ehrlichiosis. <h3>Setting.</h3> —The 12 patients were male, ranged in age from 29 to 91 years, and contracted their illness in Wisconsin or Minnesota. <h3>Methods.</h3> —Cases were recognized by the presence of intracytoplasmic inclusions (morulae) in peripheral neutrophils of patients presenting with temperature of 38.5°C or higher, chills, severe headache, and myalgias. All patients had a complete blood cell count and blood chemistry profile. Blood smears were examined by light microscopy. All available paired serum samples were analyzed for presence of indirect fluorescent antibodies against<i>Ehrlichia chaffeensis, Ehrlichia phagocytophila</i>, and<i>Ehrlichia equi</i>. Blood samples from 12 patients were subjected to polymerase chain reaction analysis using primers specific for the<i>E phagocytophila/E equi</i>group, primers that include the agent identified in our patients, as well as<i>E chaffeensis</i>. <h3>Results.</h3> —Varying combinations of leukopenia, anemia, and thrombocytopenia were found in all but one patient. All 12 patients demonstrated morulae in the cytoplasm of neutrophils, but not in mononuclear white blood cells. Serum assays failed to detect antibodies against<i>E chaffeensis</i>, but eight of 10 patients and seven of 10 patients tested had antibody titers of 1:80 or more for<i>E phagocytophila</i>and<i>E equi</i>, respectively. Polymerase chain reaction products obtained with primers for<i>E phagocytophila, E equi</i>, and the granulocytotropic<i>Ehrlichia</i>revealed that seven patients were infected with the same agent. The results of serological assays or polymerase chain reaction strongly suggest that all 12 patients were infected by<i>E phagocytophila, E equi</i>, or a closely related<i>Ehrlichia</i>species. Two of the 12 patients died. The other 10 patients improved rapidly with oral doxycycline treatment. <h3>Conclusions.</h3> —We believe that all 12 patients have been infected with a granulocytic<i>Ehrlichia</i>species, reflecting a recently described new disease entity. The infective organism appears to be closely related to<i>E phagocytophila</i>and<i>E equi</i>. The geographic domain of human granulocytic ehrlichiosis is currently unknown. This novel granulocytic<i>Ehrlichia</i>species is capable of causing fatal infections in humans. Early detection and treatment with tetracycline drugs appear to offer the best chance for complete recovery. (<i>JAMA</i>. 1994;272:212-218)

Howell-Jolly body-like inclusions in the neutrophils of patients with acquired immunodeficiency syndrome.

The authors have observed discrete, densely basophilic inclusions in the peripheral blood neutrophils of 10 patients with acquired immunodeficiency syndrome (AIDS) and two additional patients without documented evidence of human immunodeficiency virus seropositivity. These inclusions were seen in 3 of 25 (12%) patients with AIDS in a retrospective review. Gram, periodic acid-Schiff, and Gomori methenamine silver stains failed to demonstrate staining of these bodies; however, the Feulgen reaction was positive. The inclusions may represent "apoptotic" nuclear fragments and thus may be similar to Howell-Jolly bodies of normoblasts in abnormal erythropoiesis. An association of these inclusions with nucleoside analogue antiviral therapy is indicated. These inclusions must be differentiated from intracytoplasmic infectious agents, Döhle bodies, and inclusions of inherited disorders.

Dysequilibrium/ataxic diplegia with immunodeficiency.

A girl with purine nucleoside phosphorylase (PNP) deficiency is described. The nature of the motor disorder is similar to other children since found to have PNP deficiency. It is suggested that the diagnosis be considered in any child with unexplained dysequilibrium/ataxic diplegia. Other previously unreported features are intracytoplasmic neutrophil inclusion bodies and an improvement in the neutropenia after intravenous immunoglobulin.

Sebastian platelet syndrome: A new variant of hereditary macrothrombocytopenia with leukocyte inclusions

This report describes a new variant of hereditary macrothrombocytopenia combined with the presence of neutrophil inclusions that differ from those found in patients with May-Hegglin anomaly, the Chediak-Higashi syndrome or individuals with septicaemia and toxic Döhle bodies in polymorphonuclear leukocytes (PMN). The PMN inclusions in the family described in this report are similar to those found in patients with the Fechtner syndrome, a variant of Alport's syndrome. However, other features of Alport's syndrome, including high frequency deafness, congenital cataracts, and chronic interstitial nephritis are absent in the members of the family described here. We have named this anomaly the Sebastian platelet syndrome. The macrothrombocytopenia and neutrophil inclusions observed in this family can occur in the absence of other congenital anomalies and therefore represent a unique syndrome.