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Acquired Pelger–Huët: What does it really mean?
Clinica Chimica Acta 411 (2010) 1587–1590
Contents lists available at ScienceDirect
Clinica Chimica Acta j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c l i n c h i m
Invited critical review
Acquired Pelger–Huët: What does it really mean? Luci Maria SantAna Dusse ⁎, Andréia Maria Braz Moreira, Lauro Mello Vieira, Danyelle Romana Alves Rios, Rívia Mara Morais e Silva, Maria das Graças Carvalho Clinical and Toxicological Department, Faculty of Pharmacy, Federal University of Minas Gerais, Brazil
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 5 April 2010 Received in revised form 12 July 2010 Accepted 13 July 2010 Available online 5 August 2010
Pelger–Huët anomaly (PHA) is a benign inherited condition characterized by hyposegmentation of the neutrophil's nucleus and excessive chromatin clumping. An acquired neutrophil dysplasia similar to PHA has been described in hematological diseases and in some clinical conditions. It has been known as acquired or pseudo PHA. Although some hypotheses have been proposed to explain this phenomenon, the mechanism of nuclear change is still unclear. Only the laboratory and clinical data combined will yield a better understanding on the need for follow-up and management of patients in the appropriate cases. In addition, a possible cause of pseudo PHA must always be investigated to add insights to the full understanding of this abnormality. Whether this neutrophil phenomenon has clinical implications remains to be elucidated. It is clear that only a small number of patients under drugs (immunosuppressive and others) may present these neutrophil abnormalities. Most of them do not show this phenomenon and we are unable to explain the different responses in drug users. Whether these patients display a predisposition for developing bone marrow or other diseases in the future, it is a very intriguing matter and only a follow-up will solve this question. © 2010 Elsevier B.V. All rights reserved.
Keywords: Pelger–Huët anomaly Pseudo Pelger–Huët Acquired Pelger–Huët
Contents 1. Introduction . 2. Conclusion. . Acknowledgments. References . . . .
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1. Introduction Pelger–Huët anomaly (PHA) is a benign inherited condition characterized by hyposegmentation of the neutrophil's nucleus and excessive chromatin clumping, classically described as “pince-nez” appearance. These alterations can also be seen in eosinophils, and cell function appears to be normal [1]. This anomaly was described in 1928 by Dr. Karl Pelger, a Dutch tuberculosis specialist who observed these neutrophil changes in two severely ill tuberculosis patients. These patients probably succumbed to tuberculosis. However the changes in morphological abnormalities of the associated neutrophils led Dr. Pelger to ascribe a
⁎ Corresponding author. Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Room 4104-B3, Av. Antônio Carlos, 6627, Belo Horizonte/Minas Gerais, Brazil 31270-901. Tel.: + 55 31 3409 6880; fax: + 55 31 3409 6985. E-mail address: [email protected] (L.M.S. Dusse). 0009-8981/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.cca.2010.07.011
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poor prognostic for PHA carriers [2]. Four years later, Dr. G.J. Huët, a Dutch pediatrician, observed a similar blood pattern in a child suffering from severe tuberculosis. Dr. Huët became apprehensive about the outcome of treatment. Nevertheless, to his surprise, the girl responded favorably to treatment and had a complete recovery. Her follow-up showed that hypolobulated neutrophils continued to be present. He deduced that these neutrophil changes were not a transient response to infection. Dr. Huët investigated the girl's first and second degree relatives and observed various similar cases on their peripheral blood smears. Therefore, based on these findings, he concluded that this anomaly was actually an autosomal-dominant inherited trait and with no clinical relevance [3]. The morphological abnormality in Pelger–Huët anomaly is caused by a genetic defect in the lamina B-receptor (LBR) on chromosome 1q41-43 [4]. The LBR is a protein responsible for the trafficking of the heterochromatin and nuclear lamins, which are scaffolding proteins that control the shape of the nuclear membrane [5–7]. Neutrophil hyposegmentation has been observed to occur when the amount of
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LBR is half the normal level, and the subject who was homozygous for the LBR mutation showed no nuclear segmentation [8]. Although hereditary PHA is not associated with a reduced leukocyte function and disease states, it is important that carriers be correctly diagnosed. Since this anomaly is symptomless, its diagnosis is casual. An acquired neutrophil dysplasia similar to Pelger–Huët anomaly, also characterized by hyposegmentation of the neutrophil nucleus and excessive chromatin clumping has been described in hematological diseases and in some clinical situations, especially under the effect of certain drugs. It has been known as acquired or pseudo Pelger–Huët anomaly and the neutrophils exhibit a different pattern including a number of band forms or with rodlike nucleus in addition to cells presenting usually two lobules only (Fig. 1a, b and c). Our group has reported the incidence of acquired PHA in kidneytransplanted patients and it constitutes the unique follow-up of patients with this anomaly found in the literature. We have evaluated 170 kidney-transplanted patients using immunosuppressive drugs (cyclosporine, azothioprine, mycophenolate mofetil, azothioprine and sirolimus). It was verified that nine of these patients presented acquired PHA, corresponding to an incidence rate of 5.3%. One year after, blood films of six out of these nine patients were reevaluated and only two of them persisted with the previous nuclear pattern [9]. A review of the pertinent literature in the Med Line data base using the terms “pseudo Pelger–Huët” and “acquired Pelger–Huët” yielded 68 and 44 articles, respectively. Most of them have reported hematological diseases as a cause of acquired PHA, six were reviews [10–15] and one article was limited only to eosinophil changes [16]. As shown in Table 1, the remaining articles are related to certain infections or diseases, including toxic angina [17], malaria [18], influenza A [19], mononucleosis [20], Mycoplasma pneumoniae infection [21], tuberculosis [22], severe respiratory infection [23], AIDS [24], parvoviruses [25], lupus erythematosus [26–28], myxedema [29], rheumatoid arthritis [30] and Addison's disease [31]. Finally, 12 articles were associated with use of drugs, including immunosuppressive therapy [9,32–36], CSF and IL-5 [37], nomifensine [38], ibuprofen [39,40], sulfonamide [41] and D-penicillamine [42]. Cunningham et al. [14] cited three hypotheses that could explain the pseudo PHA in hematological diseases. The first one is related to abnormalities in the sequence of lamin B receptor (LBR) gene that can result in a lack of LBR protein. This protein is essential for chromatin binding to the nuclear membrane. The second hypothesis suggests that the pseudo PHA is not actually an abnormality in neutrophil maturation, but represents an apoptotic cell, since pseudo PHA
Table 1 Pseudo Pelger-Huët and acquired Pelger-Huët cases reported in the literature. Articles Related to diseases
Related to drugs use
Number of articles Toxic angina Malaria Influenza A Mononucleosis Micoplasma pneumoniae infection Tuberculosis Respiratory infection AIDS Parvoviruses Erythematous lupus Myxedema Rheumatoid arthritis Addison's disease CSF and IL-5 Immunosuppressors Nomifensine Ibuprofen Sulfonamide D-penicillamine
CSF: colony stimulating factor; IL-5: interleukin-5. Source: Med Line, with no limit of time.
1 1 1 1 1 1 1 1 1 3 1 1 1 1 6 1 2 1 1
Fig. 1. Neutrophils with chromatin excessively clumped; a) band form, b) with rodlike and c) nucleus with two lobules.
neutrophils are ultrastructurally similar to mature cells undergoing apoptosis (compact chromatin shifted toward the periphery of the nucleus and condensation of the cytoplasm with abnormally shaped organelles). The third hypothesis results from a study evaluating patients with myelodysplastic syndrome with pseudo PHA in which increased incidence of 17p deletions among these patients was demonstrated. The mechanism of neutrophil alterations caused by immunosuppressive drugs seems to be different from those commented by
L.M.S. Dusse et al. / Clinica Chimica Acta 411 (2010) 1587–1590
hematological diseases. A direct toxicity of immunosuppressors, especially mycophenolate mofetil, is suggested [36]. Gondo et al. [35] suggested that alterations result from the combination of drugs metabolized by cytochrome P450, which alters the plasma concentration of the immunosuppressors. Other hypothesis presumed that neutrophil alterations could be related to inhibition of guanosine nucleoside synthesis by immunosuppressive drugs [34]. These authors related that neutrophil alterations preceded the development of neutropenia, which disappeared after the immunosuppressors were discontinued. They suggested that pseudo PHA could be a sign of hematological toxicity. However, the reason why these abnormalities appear only in some patients remains undetermined. A review of the literature revealed that almost all cases of pseudo Pelger–Huët anomaly associated with either the use of drugs or with several diseases were described until the middle of the 1980s. From 1985 to the present, almost all reported cases are associated with myelodysplastic syndrome or other hematological diseases, as well as with the use of immunosuppressors by grafted patients [9,32–36]. Curiously, automated hematological procedures, including differential leukocytes count, were widely diffused at the end of the 1980s. This fact raises an important question: “Can automatic blood cell counters reveal morphological changes of neutrophils consistent with pseudo Pelger–Huët anomaly such as abnormal bilobular or monolobular nuclear forms and excessive chromatin clumping?” This important question seems to us somewhat deserving an urgent elucidation. Pseudo PHA, whatever its cause, if it is not registered by automated counters, may constitute a serious problem because clinical laboratories do not examine most of the stained blood films on the microscope. If this is a fact, one can admit that pseudo PHA incidences may be underestimated. It is known that immature granulocytes (bands, metamyelocytes and myelocytes) exposed to EDTA anticoagulant for a long time may become altered, resembling a PHA in appearance. Therefore, it is recommended that smears should always be prepared as soon as possible after blood collection to avoid long exposure to EDTA. 2. Conclusion The contribution of this review is to alert laboratory professionals and clinicians for pseudo PHA diagnosis. Considering previous reports and our own experience, in addition to the frequent use of drugs with no clinical prescription (automedication), one can admit that other cases of pseudo PHA may frequently be occurring. Awareness of possible occurrence of these changes in circulating-neutrophils should motivate laboratory professionals to investigate this anomaly in target patients and report it correctly. A wider knowledge of either hereditary or acquired PHA will undoubtedly bring benefits for the diagnosis and management of this condition as a whole. It should be emphasized that poor segmentation and chromatin clumping may be observed in early stage neutrophils, as neutrophils shift left. Within this context, physicians may be induced to prescribe antibiotics to the patients. Considering the risk of bacterial resistance, antibiotic drugs, in these special cases, are not useful and may be harmful to the patients. In addition, this diagnosis may lead to disagreement between physicians and laboratory professionals, since clinical data may not be consistent with laboratory findings. To be aware of this possible abnormality is crucial, especially for those patients receiving graft transplantation. Banerjee et al. [34] suggested that clinicians should be alert since morphological abnormalities may indicate a sign of hematological toxicity caused by immunosuppressive therapy. Only the laboratory and clinical data combined will yield a better understanding on the need for follow-up and management of patients in the appropriate cases. In addition, a possible cause of pseudo PHA must always be investigated to add insights to the full understanding of this abnormality.
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Whether this neutrophil phenomenon has clinical implications remains to be elucidated. It is clear that only a small number of patients under drugs (immunosuppressive and others) may present these neutrophil abnormalities. Most of them do not show this phenomenon and we are unable to explain the different responses in drug users. Whether these patients display a predisposition for developing bone marrow or other diseases in the future, it is a very intriguing matter and only a follow-up will solve this question.
Acknowledgments The authors thank FAPEMIG and CNPq/Brazil. LMSD and MGC are grateful to CNPq Research Fellowship (PQ).
References [1] Handin RL, Lux SE, Stossel TP. Blood: principles & practice of hematology. Philadelphia: J.B. Lippincott; 1995. p. 575–9. [2] Pelger K. Ned Tijdschr Geneeskd 1928;72:1178. [3] Huet GJ. Uber eine bisher unbekannte familiaere Anomalie der Leukocyten. Klin Wochenschr 1932;2:1264–6. [4] Best S, Salvati F, Kallo J, Garner C, Height S, Thein SL, Rees DC. Lamin B-receptor mutations in Pelger–Huët anomaly. Br J Haematol 2003;123:542–4. [5] Cohen TV, Klarmann KD, Sakchairsri K, et al. The lamin B receptor under transcriptional control of C/EBPepsilon is required for morphological but not functional maturation of neutrophils. Hum Mol Genet 2008;17:2921–33. [6] Dechat T, Pfleghaar K, Sengupta K, et al. Nuclear lamins: major factors in the structural organization and function of the nucleus and chromatin. Genes Dev 2008;22:832–53. [7] Goldberg M, Harel A, Gruenbaum Y. The nuclear lamina: molecular organization and interaction with chromatin. Crit Rev Eukaryot Gene Expr 1999;9:285–93. [8] Hoffmann K, Dreger CK, Olins AL, et al. Mutations in the gene encoding the lamin B receptor produce an altered nuclear morphology in granulocytes (Pelger-Huet anomaly). Nat Genet 2002;31:410–4. [9] Dusse LM, Morais RMS, Freitas VM, Medeiros GM, Vieira LM, Carvalho MG. Pseudo Pelger–Huët in transplanted patients. Acta Haematol 2006;116:272–4. [10] Pusic G, Teodori S. Pelger-Huet nuclear anomaly and pseudo-Pelger anomaly. Haematologica 1957;42:527–46. [11] Meister H. The so-called pseudo Pelger cells. Folia Haematol Int Mag Klin Morphol Blutforsch 1969;92:173–81. [12] Salvati F, Troya C. The Pelger-Huet granulocytic anomaly. Minerva Med 1979;70: 977–80. [13] Kurokawa Y, Komiyama A. Pseudo Pelger–Huët anomaly. Ryoikibetsu Shokogun Shirizu 1998:94–5 (21 Pt 2). [14] Cunningham JM, Patnaik MM, Hammerschmidt DE, Vercellotti GM. Historical perspective and clinical implications of the Pelger-Hüet cell. Am J Hematol 2009;84:116–9. [15] Boron P, Wiechowski W. Pelger-Huet's pseudo-anomaly in the course of toxic angina. Przegl Epidemiol 1965;19:111–3. [16] Fossaluzza V, Tosato F. Acquired Pelger–Huët anomaly limited to eosinophils. Acta Haematol 1980;63(5):295. [17] Boron P, Wiechowski W. Pelger-Huet's pseudo-anomaly in the course of toxic angina. Przegl Epidemiol 1965;19:111–3. [18] Undritz E. Les malformations héréditaires des éléments du sang. Sang 1954;25: 250–6. [19] Elliot PW, Blackford F. Nuclear alteration of the cells in the peripheral blood associated with the virus of influenza A/Asian infection and inoculation. J Indiana State Med Assoc 1958;51:1651–5. [20] Cordas A, Briner DH. Acquired pseudo-Pelger anomaly associated with infectious mononucleosis. J Am Osteopath Assoc 1962;66:61–9. [21] van Hook L, Spivack C, Duncanson F. Acquired Pelger–Huët anomaly associated with Mycoplasma pneumoniae pneumonia. Am J Clin Pathol 1985;84:248–51. [22] Shekenberg TD, Rice L, Waddell CC. Acquired Pelger–Huët nuclear anomaly associated with tuberculosis. Aech J Clin Pathol 1962;37:294–301. [23] Kallo J, Malina A, Malinová V, Pennigerová S. A case of Pelger-Huet anomaly in a premature infant. Folia Haematol Int Mag Klin Morphol Blutforsch 1989;116: 145–9. [24] Ciaudo M, Ramon S, Jayle D, Kazatchkine M, Marie JP. Abnormal chromatin clumping in polymorphonuclears from a patient with AIDS. Am J Hematol 1996;52:62–3. [25] Yetgin S, Cetin M, Yenicesu I, Özaltin I, Uçkan D. Acute parvovirus B19 infection mimicking juvenile myelomonocytic leukemia. Eur J Haematol 2000;65:276–8. [26] Michael SR, Vural IL, Bassen FA, Schaefer L. The hematologic aspects of disseminated (systemic) lupus erythematosus. Blood 1951;6:1059–72. [27] Burkhardt R. The bone marrow in systemic lupus erythematosus. Semin Hematol 1965;2:29–46. [28] Oka Y, Kameoka J, Hirabayashi Y, et al. Reversible bone marrow dysplasia in patients with systemic lupus erythematosus. Int Med 2008;47:737–42. [29] Shanbrom E, Tanaka KR. Acquired Pelger–Huët granulocytes in severe myxedema. Acta Haematol 1962;27:289.
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[30] Yetgin S, Özen S, Saatci Ü, Bakkaloglu A, Besbas N, Kirel B. Myelodysplastic features in juvenile rheumatoid arthritis. Am J Hematol 1997;54:166–9. [31] Funato K, Kuriyama Y, Uchida Y, Suzuki A, Miyazawa K, Ohyashiki K. Myelodysplastic syndrome accompanied by Addison's disease and multiple autoimmune phenomena: steroid therapy resolved cytopenias and all immune disorders. Intern Med 2001;40:1041–4. [32] Kennedy GA, Kay TD, Johnson DW, et al. Neutrophil dysplasia characterised by a pseudo-Pelger-Huet anomaly occurring with the use of mycophenolate mofetil and ganciclovir following renal transplantation: a report of five cases. Pathology 2002;34:263–6. [33] Taegtmeyer AB, Halil O, Bell AD, Carby M, Cummins D, Banner NR. Neutrophil dysplasia (acquired pseudo Pelger anomaly) caused by ganciclovir. Transplantation 2005;80:127–30. [34] Banerjee R, Halil O, Brain BJ, Cummins D, Banner NR. Neutrophil dysplasia caused by mycophenolate mofetil. Transplantation 2000;70:1608–10. [35] Gondo H, Okamura C, Osaki K, Asano Y, Okamura T. Acquired Pelger-Hüet anomaly in association with concomitant tacrolimus and fluconazol therapy following allogeneic bone marrow transplantation. Bone Marrow Transplant 2000;26:1255–7.
[36] Daliphard S, Accard F, Delattre C, et al. Reversible abnormal chromatin clumping in granulocytes from six transplant patients treated with mycophenolate mofetil: a rare adverse effect mimicking abnormal chromatin clumping syndrome. Br J Haematol 2002;116:726–7. [37] Teshima T, Shibuya T, Harada M, et al. Effects of G-CSF, GM-CSF, and IL-5 on nuclear segmentation of neutrophils and eosinophils in congenital or acquired Pelger–Huët anomaly. Exp Hematol 1991;19:322–5. [38] Rüthlein J, Meesmann M, Gunzer U, Auer IO. Nomifensine-induced fever with pericardial effusion, basal lung infiltration and pseudo-Pelger-Huet anomaly. A case report. Med Klin (Munich) 1986;81:619–22. [39] Deutsch PH, Mandell GL. Reversible Pelger–Huët anomaly associated with ibuprofen therapy. Arch Intern Med 1985;145:166. [40] Moreira AMB, Vieira LM, Rios DRA, Carvalho MG, Dusse LMS. Acquired Pelger– Huët anomaly associated with ibuprofen therapy. Clin Chim Acta 2009;411:134–9. [41] Kaplan JM, Barret Jr O. Reversible pseudo-Pelger anomaly related to sulfisoxazole therapy. N Engl J Med 1967;277:421–2. [42] Leven JM. Pelger–Huët anomaly and D-penicillamine. J Rheumatol 1980;7: 418–20.
Contents lists available at ScienceDirect
Clinica Chimica Acta j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c l i n c h i m
Invited critical review
Acquired Pelger–Huët: What does it really mean? Luci Maria SantAna Dusse ⁎, Andréia Maria Braz Moreira, Lauro Mello Vieira, Danyelle Romana Alves Rios, Rívia Mara Morais e Silva, Maria das Graças Carvalho Clinical and Toxicological Department, Faculty of Pharmacy, Federal University of Minas Gerais, Brazil
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 5 April 2010 Received in revised form 12 July 2010 Accepted 13 July 2010 Available online 5 August 2010
Pelger–Huët anomaly (PHA) is a benign inherited condition characterized by hyposegmentation of the neutrophil's nucleus and excessive chromatin clumping. An acquired neutrophil dysplasia similar to PHA has been described in hematological diseases and in some clinical conditions. It has been known as acquired or pseudo PHA. Although some hypotheses have been proposed to explain this phenomenon, the mechanism of nuclear change is still unclear. Only the laboratory and clinical data combined will yield a better understanding on the need for follow-up and management of patients in the appropriate cases. In addition, a possible cause of pseudo PHA must always be investigated to add insights to the full understanding of this abnormality. Whether this neutrophil phenomenon has clinical implications remains to be elucidated. It is clear that only a small number of patients under drugs (immunosuppressive and others) may present these neutrophil abnormalities. Most of them do not show this phenomenon and we are unable to explain the different responses in drug users. Whether these patients display a predisposition for developing bone marrow or other diseases in the future, it is a very intriguing matter and only a follow-up will solve this question. © 2010 Elsevier B.V. All rights reserved.
Keywords: Pelger–Huët anomaly Pseudo Pelger–Huët Acquired Pelger–Huët
Contents 1. Introduction . 2. Conclusion. . Acknowledgments. References . . . .
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1. Introduction Pelger–Huët anomaly (PHA) is a benign inherited condition characterized by hyposegmentation of the neutrophil's nucleus and excessive chromatin clumping, classically described as “pince-nez” appearance. These alterations can also be seen in eosinophils, and cell function appears to be normal [1]. This anomaly was described in 1928 by Dr. Karl Pelger, a Dutch tuberculosis specialist who observed these neutrophil changes in two severely ill tuberculosis patients. These patients probably succumbed to tuberculosis. However the changes in morphological abnormalities of the associated neutrophils led Dr. Pelger to ascribe a
⁎ Corresponding author. Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Room 4104-B3, Av. Antônio Carlos, 6627, Belo Horizonte/Minas Gerais, Brazil 31270-901. Tel.: + 55 31 3409 6880; fax: + 55 31 3409 6985. E-mail address: [email protected] (L.M.S. Dusse). 0009-8981/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.cca.2010.07.011
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poor prognostic for PHA carriers [2]. Four years later, Dr. G.J. Huët, a Dutch pediatrician, observed a similar blood pattern in a child suffering from severe tuberculosis. Dr. Huët became apprehensive about the outcome of treatment. Nevertheless, to his surprise, the girl responded favorably to treatment and had a complete recovery. Her follow-up showed that hypolobulated neutrophils continued to be present. He deduced that these neutrophil changes were not a transient response to infection. Dr. Huët investigated the girl's first and second degree relatives and observed various similar cases on their peripheral blood smears. Therefore, based on these findings, he concluded that this anomaly was actually an autosomal-dominant inherited trait and with no clinical relevance [3]. The morphological abnormality in Pelger–Huët anomaly is caused by a genetic defect in the lamina B-receptor (LBR) on chromosome 1q41-43 [4]. The LBR is a protein responsible for the trafficking of the heterochromatin and nuclear lamins, which are scaffolding proteins that control the shape of the nuclear membrane [5–7]. Neutrophil hyposegmentation has been observed to occur when the amount of
1588
L.M.S. Dusse et al. / Clinica Chimica Acta 411 (2010) 1587–1590
LBR is half the normal level, and the subject who was homozygous for the LBR mutation showed no nuclear segmentation [8]. Although hereditary PHA is not associated with a reduced leukocyte function and disease states, it is important that carriers be correctly diagnosed. Since this anomaly is symptomless, its diagnosis is casual. An acquired neutrophil dysplasia similar to Pelger–Huët anomaly, also characterized by hyposegmentation of the neutrophil nucleus and excessive chromatin clumping has been described in hematological diseases and in some clinical situations, especially under the effect of certain drugs. It has been known as acquired or pseudo Pelger–Huët anomaly and the neutrophils exhibit a different pattern including a number of band forms or with rodlike nucleus in addition to cells presenting usually two lobules only (Fig. 1a, b and c). Our group has reported the incidence of acquired PHA in kidneytransplanted patients and it constitutes the unique follow-up of patients with this anomaly found in the literature. We have evaluated 170 kidney-transplanted patients using immunosuppressive drugs (cyclosporine, azothioprine, mycophenolate mofetil, azothioprine and sirolimus). It was verified that nine of these patients presented acquired PHA, corresponding to an incidence rate of 5.3%. One year after, blood films of six out of these nine patients were reevaluated and only two of them persisted with the previous nuclear pattern [9]. A review of the pertinent literature in the Med Line data base using the terms “pseudo Pelger–Huët” and “acquired Pelger–Huët” yielded 68 and 44 articles, respectively. Most of them have reported hematological diseases as a cause of acquired PHA, six were reviews [10–15] and one article was limited only to eosinophil changes [16]. As shown in Table 1, the remaining articles are related to certain infections or diseases, including toxic angina [17], malaria [18], influenza A [19], mononucleosis [20], Mycoplasma pneumoniae infection [21], tuberculosis [22], severe respiratory infection [23], AIDS [24], parvoviruses [25], lupus erythematosus [26–28], myxedema [29], rheumatoid arthritis [30] and Addison's disease [31]. Finally, 12 articles were associated with use of drugs, including immunosuppressive therapy [9,32–36], CSF and IL-5 [37], nomifensine [38], ibuprofen [39,40], sulfonamide [41] and D-penicillamine [42]. Cunningham et al. [14] cited three hypotheses that could explain the pseudo PHA in hematological diseases. The first one is related to abnormalities in the sequence of lamin B receptor (LBR) gene that can result in a lack of LBR protein. This protein is essential for chromatin binding to the nuclear membrane. The second hypothesis suggests that the pseudo PHA is not actually an abnormality in neutrophil maturation, but represents an apoptotic cell, since pseudo PHA
Table 1 Pseudo Pelger-Huët and acquired Pelger-Huët cases reported in the literature. Articles Related to diseases
Related to drugs use
Number of articles Toxic angina Malaria Influenza A Mononucleosis Micoplasma pneumoniae infection Tuberculosis Respiratory infection AIDS Parvoviruses Erythematous lupus Myxedema Rheumatoid arthritis Addison's disease CSF and IL-5 Immunosuppressors Nomifensine Ibuprofen Sulfonamide D-penicillamine
CSF: colony stimulating factor; IL-5: interleukin-5. Source: Med Line, with no limit of time.
1 1 1 1 1 1 1 1 1 3 1 1 1 1 6 1 2 1 1
Fig. 1. Neutrophils with chromatin excessively clumped; a) band form, b) with rodlike and c) nucleus with two lobules.
neutrophils are ultrastructurally similar to mature cells undergoing apoptosis (compact chromatin shifted toward the periphery of the nucleus and condensation of the cytoplasm with abnormally shaped organelles). The third hypothesis results from a study evaluating patients with myelodysplastic syndrome with pseudo PHA in which increased incidence of 17p deletions among these patients was demonstrated. The mechanism of neutrophil alterations caused by immunosuppressive drugs seems to be different from those commented by
L.M.S. Dusse et al. / Clinica Chimica Acta 411 (2010) 1587–1590
hematological diseases. A direct toxicity of immunosuppressors, especially mycophenolate mofetil, is suggested [36]. Gondo et al. [35] suggested that alterations result from the combination of drugs metabolized by cytochrome P450, which alters the plasma concentration of the immunosuppressors. Other hypothesis presumed that neutrophil alterations could be related to inhibition of guanosine nucleoside synthesis by immunosuppressive drugs [34]. These authors related that neutrophil alterations preceded the development of neutropenia, which disappeared after the immunosuppressors were discontinued. They suggested that pseudo PHA could be a sign of hematological toxicity. However, the reason why these abnormalities appear only in some patients remains undetermined. A review of the literature revealed that almost all cases of pseudo Pelger–Huët anomaly associated with either the use of drugs or with several diseases were described until the middle of the 1980s. From 1985 to the present, almost all reported cases are associated with myelodysplastic syndrome or other hematological diseases, as well as with the use of immunosuppressors by grafted patients [9,32–36]. Curiously, automated hematological procedures, including differential leukocytes count, were widely diffused at the end of the 1980s. This fact raises an important question: “Can automatic blood cell counters reveal morphological changes of neutrophils consistent with pseudo Pelger–Huët anomaly such as abnormal bilobular or monolobular nuclear forms and excessive chromatin clumping?” This important question seems to us somewhat deserving an urgent elucidation. Pseudo PHA, whatever its cause, if it is not registered by automated counters, may constitute a serious problem because clinical laboratories do not examine most of the stained blood films on the microscope. If this is a fact, one can admit that pseudo PHA incidences may be underestimated. It is known that immature granulocytes (bands, metamyelocytes and myelocytes) exposed to EDTA anticoagulant for a long time may become altered, resembling a PHA in appearance. Therefore, it is recommended that smears should always be prepared as soon as possible after blood collection to avoid long exposure to EDTA. 2. Conclusion The contribution of this review is to alert laboratory professionals and clinicians for pseudo PHA diagnosis. Considering previous reports and our own experience, in addition to the frequent use of drugs with no clinical prescription (automedication), one can admit that other cases of pseudo PHA may frequently be occurring. Awareness of possible occurrence of these changes in circulating-neutrophils should motivate laboratory professionals to investigate this anomaly in target patients and report it correctly. A wider knowledge of either hereditary or acquired PHA will undoubtedly bring benefits for the diagnosis and management of this condition as a whole. It should be emphasized that poor segmentation and chromatin clumping may be observed in early stage neutrophils, as neutrophils shift left. Within this context, physicians may be induced to prescribe antibiotics to the patients. Considering the risk of bacterial resistance, antibiotic drugs, in these special cases, are not useful and may be harmful to the patients. In addition, this diagnosis may lead to disagreement between physicians and laboratory professionals, since clinical data may not be consistent with laboratory findings. To be aware of this possible abnormality is crucial, especially for those patients receiving graft transplantation. Banerjee et al. [34] suggested that clinicians should be alert since morphological abnormalities may indicate a sign of hematological toxicity caused by immunosuppressive therapy. Only the laboratory and clinical data combined will yield a better understanding on the need for follow-up and management of patients in the appropriate cases. In addition, a possible cause of pseudo PHA must always be investigated to add insights to the full understanding of this abnormality.
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Whether this neutrophil phenomenon has clinical implications remains to be elucidated. It is clear that only a small number of patients under drugs (immunosuppressive and others) may present these neutrophil abnormalities. Most of them do not show this phenomenon and we are unable to explain the different responses in drug users. Whether these patients display a predisposition for developing bone marrow or other diseases in the future, it is a very intriguing matter and only a follow-up will solve this question.
Acknowledgments The authors thank FAPEMIG and CNPq/Brazil. LMSD and MGC are grateful to CNPq Research Fellowship (PQ).
References [1] Handin RL, Lux SE, Stossel TP. Blood: principles & practice of hematology. Philadelphia: J.B. Lippincott; 1995. p. 575–9. [2] Pelger K. Ned Tijdschr Geneeskd 1928;72:1178. [3] Huet GJ. Uber eine bisher unbekannte familiaere Anomalie der Leukocyten. Klin Wochenschr 1932;2:1264–6. [4] Best S, Salvati F, Kallo J, Garner C, Height S, Thein SL, Rees DC. Lamin B-receptor mutations in Pelger–Huët anomaly. Br J Haematol 2003;123:542–4. [5] Cohen TV, Klarmann KD, Sakchairsri K, et al. The lamin B receptor under transcriptional control of C/EBPepsilon is required for morphological but not functional maturation of neutrophils. Hum Mol Genet 2008;17:2921–33. [6] Dechat T, Pfleghaar K, Sengupta K, et al. Nuclear lamins: major factors in the structural organization and function of the nucleus and chromatin. Genes Dev 2008;22:832–53. [7] Goldberg M, Harel A, Gruenbaum Y. The nuclear lamina: molecular organization and interaction with chromatin. Crit Rev Eukaryot Gene Expr 1999;9:285–93. [8] Hoffmann K, Dreger CK, Olins AL, et al. Mutations in the gene encoding the lamin B receptor produce an altered nuclear morphology in granulocytes (Pelger-Huet anomaly). Nat Genet 2002;31:410–4. [9] Dusse LM, Morais RMS, Freitas VM, Medeiros GM, Vieira LM, Carvalho MG. Pseudo Pelger–Huët in transplanted patients. Acta Haematol 2006;116:272–4. [10] Pusic G, Teodori S. Pelger-Huet nuclear anomaly and pseudo-Pelger anomaly. Haematologica 1957;42:527–46. [11] Meister H. The so-called pseudo Pelger cells. Folia Haematol Int Mag Klin Morphol Blutforsch 1969;92:173–81. [12] Salvati F, Troya C. The Pelger-Huet granulocytic anomaly. Minerva Med 1979;70: 977–80. [13] Kurokawa Y, Komiyama A. Pseudo Pelger–Huët anomaly. Ryoikibetsu Shokogun Shirizu 1998:94–5 (21 Pt 2). [14] Cunningham JM, Patnaik MM, Hammerschmidt DE, Vercellotti GM. Historical perspective and clinical implications of the Pelger-Hüet cell. Am J Hematol 2009;84:116–9. [15] Boron P, Wiechowski W. Pelger-Huet's pseudo-anomaly in the course of toxic angina. Przegl Epidemiol 1965;19:111–3. [16] Fossaluzza V, Tosato F. Acquired Pelger–Huët anomaly limited to eosinophils. Acta Haematol 1980;63(5):295. [17] Boron P, Wiechowski W. Pelger-Huet's pseudo-anomaly in the course of toxic angina. Przegl Epidemiol 1965;19:111–3. [18] Undritz E. Les malformations héréditaires des éléments du sang. Sang 1954;25: 250–6. [19] Elliot PW, Blackford F. Nuclear alteration of the cells in the peripheral blood associated with the virus of influenza A/Asian infection and inoculation. J Indiana State Med Assoc 1958;51:1651–5. [20] Cordas A, Briner DH. Acquired pseudo-Pelger anomaly associated with infectious mononucleosis. J Am Osteopath Assoc 1962;66:61–9. [21] van Hook L, Spivack C, Duncanson F. Acquired Pelger–Huët anomaly associated with Mycoplasma pneumoniae pneumonia. Am J Clin Pathol 1985;84:248–51. [22] Shekenberg TD, Rice L, Waddell CC. Acquired Pelger–Huët nuclear anomaly associated with tuberculosis. Aech J Clin Pathol 1962;37:294–301. [23] Kallo J, Malina A, Malinová V, Pennigerová S. A case of Pelger-Huet anomaly in a premature infant. Folia Haematol Int Mag Klin Morphol Blutforsch 1989;116: 145–9. [24] Ciaudo M, Ramon S, Jayle D, Kazatchkine M, Marie JP. Abnormal chromatin clumping in polymorphonuclears from a patient with AIDS. Am J Hematol 1996;52:62–3. [25] Yetgin S, Cetin M, Yenicesu I, Özaltin I, Uçkan D. Acute parvovirus B19 infection mimicking juvenile myelomonocytic leukemia. Eur J Haematol 2000;65:276–8. [26] Michael SR, Vural IL, Bassen FA, Schaefer L. The hematologic aspects of disseminated (systemic) lupus erythematosus. Blood 1951;6:1059–72. [27] Burkhardt R. The bone marrow in systemic lupus erythematosus. Semin Hematol 1965;2:29–46. [28] Oka Y, Kameoka J, Hirabayashi Y, et al. Reversible bone marrow dysplasia in patients with systemic lupus erythematosus. Int Med 2008;47:737–42. [29] Shanbrom E, Tanaka KR. Acquired Pelger–Huët granulocytes in severe myxedema. Acta Haematol 1962;27:289.
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L.M.S. Dusse et al. / Clinica Chimica Acta 411 (2010) 1587–1590
[30] Yetgin S, Özen S, Saatci Ü, Bakkaloglu A, Besbas N, Kirel B. Myelodysplastic features in juvenile rheumatoid arthritis. Am J Hematol 1997;54:166–9. [31] Funato K, Kuriyama Y, Uchida Y, Suzuki A, Miyazawa K, Ohyashiki K. Myelodysplastic syndrome accompanied by Addison's disease and multiple autoimmune phenomena: steroid therapy resolved cytopenias and all immune disorders. Intern Med 2001;40:1041–4. [32] Kennedy GA, Kay TD, Johnson DW, et al. Neutrophil dysplasia characterised by a pseudo-Pelger-Huet anomaly occurring with the use of mycophenolate mofetil and ganciclovir following renal transplantation: a report of five cases. Pathology 2002;34:263–6. [33] Taegtmeyer AB, Halil O, Bell AD, Carby M, Cummins D, Banner NR. Neutrophil dysplasia (acquired pseudo Pelger anomaly) caused by ganciclovir. Transplantation 2005;80:127–30. [34] Banerjee R, Halil O, Brain BJ, Cummins D, Banner NR. Neutrophil dysplasia caused by mycophenolate mofetil. Transplantation 2000;70:1608–10. [35] Gondo H, Okamura C, Osaki K, Asano Y, Okamura T. Acquired Pelger-Hüet anomaly in association with concomitant tacrolimus and fluconazol therapy following allogeneic bone marrow transplantation. Bone Marrow Transplant 2000;26:1255–7.
[36] Daliphard S, Accard F, Delattre C, et al. Reversible abnormal chromatin clumping in granulocytes from six transplant patients treated with mycophenolate mofetil: a rare adverse effect mimicking abnormal chromatin clumping syndrome. Br J Haematol 2002;116:726–7. [37] Teshima T, Shibuya T, Harada M, et al. Effects of G-CSF, GM-CSF, and IL-5 on nuclear segmentation of neutrophils and eosinophils in congenital or acquired Pelger–Huët anomaly. Exp Hematol 1991;19:322–5. [38] Rüthlein J, Meesmann M, Gunzer U, Auer IO. Nomifensine-induced fever with pericardial effusion, basal lung infiltration and pseudo-Pelger-Huet anomaly. A case report. Med Klin (Munich) 1986;81:619–22. [39] Deutsch PH, Mandell GL. Reversible Pelger–Huët anomaly associated with ibuprofen therapy. Arch Intern Med 1985;145:166. [40] Moreira AMB, Vieira LM, Rios DRA, Carvalho MG, Dusse LMS. Acquired Pelger– Huët anomaly associated with ibuprofen therapy. Clin Chim Acta 2009;411:134–9. [41] Kaplan JM, Barret Jr O. Reversible pseudo-Pelger anomaly related to sulfisoxazole therapy. N Engl J Med 1967;277:421–2. [42] Leven JM. Pelger–Huët anomaly and D-penicillamine. J Rheumatol 1980;7: 418–20.