Thrombopoiesis in patients with Korean hemorrhagic fever
[한글]유행성 출혈열은 출혈성 소인과 신장 장애를 주 증상으로 하면서, 발열, 전신적인 통증 쇽크, 심 혈관계 장애 등이 동반되고, 발열기 후반에 현저한 혈소판 감소를 일으키는 급성 질환이다. 이때 나타나는 혈소판 감소의 원인에 대해서는 아직 명확히 밝혀진 바가 없음은 물론, 동반되는 골수조직의 거핵세포 변화에 대해서도 의견이 구구하여 Powell(1953)과 Lukes(1954)는 거핵세포의 증식을 朴등(1973)은 거핵세포의 감소를 주장하고 있다.
따라서 저자는 유행성 출혈열 환자의 골수내 혈소판 생성상태를 규명하기 위하여 25명의 유행성 출혈열 환자를 대상으로 말초혈액내 혈소판의 수 및 거대혈소판 출현율을 측정하고, 20명의 환자에서 혈소판 수가 감소된 시기(제1기), 혈소판 수가 증가하여 최고에 도
달한 시기(제2기), 혈소판 수가 정상으로 돌아온 직후(제3기) 및 환자가 완전히 회복된 시기(제4기)에 4차의 골수천자를 시행하여 거핵세포의 크기, 수, 핵엽수 및 성숙상태를 관찰하여 다음과 같은 결과를 얻었다.
1. 입원당시 측정한 혈소판 수는 43,000±26,400/mm**3 으로서 제4기 281,000±34,300/ mm**3 에 비해 현저히 감소되어 있었으며, 병일이 경과할수록 점차 증가하여 발병 13일째 385,000±83,500/mm**3 으로서 최고에 도달하고, 그후 점차 감소하여 발병 18일째부터 정상범위에 도달하였다.
2. 거대혈소판 출현율은 입원당시에 51.9±12.1%로서 제4기 9.1±2.3%에 비해 현저히 증가되어 있었으며 병일이 경과할수록 점차 감소하여 혈소판 수가 정상으로 돌아온 때에는 14.1±3.7%로 제4기에 가까워지고 있었다.
3. 거핵세포의 크기는 제1기에서 48.6±3.0μ, 제2기에서는 49.9±2.4μ으로 제3기 41.3±2.5μ에 비해 현저히 큰 것을 알 수 있었고 제3기에서는 43.2±2.4μ으로 제4기에 근사하였다.
4. 유핵골수세표 10,000개당 거핵세포의 수는 제1기에서는 15.4±4.8개, 제2기에서는 18.8±5.1개로서 제4기 9.6±2.9개에 비해 증가되어 있었으며, 제3기에선 10.7±2.7개로 제4기와 비슷하였다.
5. 거핵세포의 핵엽수의 변화를 보면 제4기에서는 8개의 핵엽을 가진 거핵세포가 가장 많은 반면 제1기와 제2기에서는 16개의 핵엽을 가진 세포가 가장 많아, 핵엽수가 제1기와 제2기에서 증가되어 있음을 알 수 있었고 제3기에서는 제4기와 비슷하였다.
6. 거핵세포의 성숙도는 각 시기별 상호간에 차이가 없었다.
이상의 결과로 보아 유행성 출혈열 환자에서 골수내 혈소판 생성부전은 없었고 혈소판 수가 감소됨에 따른 일반적인 반응으로서 혈소판 생선이 증가된 것으로 사료된다.
[영문]Korean hemorrhagic fever is an acute fulminating, often fatal, otherwise self-limited disease characterized by fever, toxemia, widespread capillary damage and hemorrhagic diathesis, with resulting symptoms, signs and sequelae thereof, particularly renal involvement.
Many investigators have discussed the hemorrhagic tendency in patients with Korean hemorrhagic fever. Furth (1954) reported that most such patients had thrombocytopenia and that this was the important cause of hemorrhagic tendency and coagulopathy. Dennis and Conrad (1968) and Kim (1970) observed thrombocytopenia and deficiency of coagulation factors in patients with Korean hemorrhagic fever. Dennis and Conrad (1968) claimed disseminated intravascular coagulation would be the cause of the hemorrhagic tendency, after detection of fibrinogen degredation products in
the serum of a case of this disease.
The picture of bone marrow which would constitute the most important basic evidence of the causes of thrombocytopenia is still unclear. Powell (1953) and Lukes (1954) said the megakaryocytes of the bone marrow of patients with Korean
hemorrhagic fever were hyperplastic, and Hullinghorst (1953) reported the megakaryocytes were variable but slightly increased in number. Kim(1972), however, claimed no abnormal patterns of megakaryocytes could be found in the marrow, and Park et al. (1973) observed a decreased number of megakaryocytes in the bone marrow of patients with Korean hemorrhagic fever, compared to that of normals, and suggested that insufficient thrombopoiesis could be the cause of thrombocytopenia.
The purpose of the present study is to evaluate the thrombopoietic status in patients with Korean hemorrhagic fever by observing the number, size, number of nuclear lobes and maturation status of megakaryocytes.
Materials and Method
Twenty-five patients who had typical clinical symptoms and signs of Korean hemorrhagic fever were selected for the study.
A. Platelet count was performed with a phase contrast microscope by the method of Brecher and Cronkite (1950) at intervals of 1-3 days form the day of admission to the convalescent phase. The size of 300 platelets on each peripheral blood smear, stained with Wright stain at the same intervals, were measured and the percentage of megathrombocytes over 2.5μ was counted under the light microscope with a microgrid. Control study was performed when the patients were completely recovered
from the disease (recovery phase).
B. Bone marrow aspiration was performed from the posterior iliac crest with a Vim Silverman needle four times: first, when the platelet count was the lowest(on admission); second, when the platelet count reached the highest; third, when it returned to the normal range; fourth, when the patients had recovered completely from the disease (recovery phase). The material obtained were smeared and stained with Wright and Giemsa stain.
1. The sizes of 100 megakaryocytes were measured using microgrid and the mean values were calculated.
2. The numbers of megakaryocytes ere obtained during counting 10,000 nucleated cells of bone marrow.
3. The numbers of the nuclear lobes of 100 megakaryocytes were counted and classified into groups of 2, 4, 8, 16, 32, and 64 lobes.
4. Megakaryocytes were classified morphologically into three groups, and their appearance suggested that these were successive stages of maturation. In group Ⅰ megakaryocytes, the nucleus occupied most of the cell, it was not segmented, and the cytoplasm had a clear basophilic appearance. In group Ⅱ, the nuclear cytoplasmic ratio was lower, the nucleus was usually lobulated, and the cytoplasm had a foamy basophilic appearance. Some cells in group Ⅱ had azurophilic granules in localized areas of the cytoplasm. Group Ⅲ contained all other megakaryocytes including those which were breaking up into platelets; its distinguishing characteristic was diffuse azurophilic granulation of the cytoplasm.
Results and Summary
1. The mean value of th platelet count on admission, mostly in the febrile or hypotensive phase was 43,000±26,400/mm**3 and it increased to the peak (439,000±57,900/mm**3 ) about two weeks from the onset. Then it decreased to a normal level (259,000±37,100/mm**3 ) about three weeks from the onset. The value of recovery phase was 281,000±34,300/mm**3
2. The percentage of megathrombocytes in peripheral blood was 51.9±12.1% on admission.
3. The size of megakaryocytes was 48.6±3.0μ on admission and when the platelet count reached the highest level, it was 49.9±2.4μ, which was much larger than that of recovery phase (41.3±2.5μ). When the platelet count returned to normal, it
became much smaller(43.2±2.4μ) and near to that of recovery phase.
4. The number of megakaryocytes per 10,000 nucleated cells of marrow was 15.4±4.8 cells on admission, but increased to 18.8±5.1 cells when the platelet count was at the highest level. Then it decreased to 10.7±2.7 cells when the platelet count returned to normal, and it was almost the same as that of recovery phase(9.6±2.9 cells).
5. The numbers of nuclear lobes of megakaryocytes on admission and when the platelet count reached the highest level were much more than that of recovery phase, but they returned to near that of recovery phase when the platelet count returned to the normal range.
6. There was no recognizable difference in morphological appearance of megakaryocytes among the four samples.
From the above observations, it may concluded that thrombopoiesis in the bone marrow of the patients with Korean hyemorrhagic fever seemed to be increased.