1. Evidence of a marked difference in alkaline phosphatase activity in the leukocytes of normal subjects and individuals with chronic myelogenous leukemia has been provided by observations on the behavior of the enzyme following prolonged incubation and during pyogenic infection. 2. Therapy with radiation and radiomimetic drugs in chronic myelogenous leukemia and myeloid metaplasia resulted in a marked fall in leukocyte count but no change was observed in the relative population of alkaline phosphatase positive and negative cells. 3. In our laboratory histochemical and biochemical values for leukocyte alkaline phosphatase have been similar to those reported in the literature for typical cases of chronic myelogenous leukemia and most leukemoid reactions. However, in certain cases parodoxical findings have been noted in which histochemical and biochemical studies were inconsistent with the pathologic diagnosis. 4. The inadequacies of purely morphologic criteria in these atypical cases were noted and the desirability of the further development of cytochemical methods has been pointed out.
The interrelation of various disorders of the white blood cells has been well established. The transformation from one histologic picture of malignant lymphoma to another, and the coexistence of different histologic pictures in the lymph nodes of one subject, also have been well documented. Further, the intriguing problem of the evolution of the various myeloproliierative syndromes has been a frequent subject of discussion. However, reports on the coexistence of a myeloproliferative disorder and pernicious anemia in the same patient are rare.Recently we observed a patient with pernicious anemia who, four months after the institution of treatment with vitamin Blz parenterally, presented with the clinical picture of polycythemia Vera. The purpose of this paper is to report the case, review the pertinent literature, and discuss the possible interrelationship of the two diseases. CASE REPORT First hospital admissionA 75-year-old white male was first admitted t o the hospital on September 12, 1961, complaining of weakness , progressive dyspnea, anorexia , weight loss, epigastric distress and dizziness. Pertinent physical findings a t that time were recorded aa generalized pallor and periorbital edema.The past medical history revealed seasonal allergy (hay fever) since 1916, requiring some desensitization and antihistamine therapy. He also had had several episodes of allergic asthma requiring symptomatic therapy, but the last severe attack had occurred in 1948. Other than minor illnesses, the patient had had no other significant difficulty until August 1958, when he saw his family physician because of vertigo. His blood pressure was 130/90 mm. Hg, pulse 80, temperature 98.6" F., and weight 170% pounds. H i s hemoglobin level a t that time was 10 gm. per 100 ml. An electrocardiogram showed frequent premature beats. He was treated by his physician with one dose (100 micrograms) of B,z and was given ironvitamin capsules which he took for three consecutive weeks. He received no further medical attention until the present admission. Family history and social history were noncont ri but ory . X-ray ezamination:A chest roentgenogram showed no pulmonary parenchymal disease. The left ventricle of the heart was moderately enlarged. Roentgenograms of the gastrointestinal tract did not show any organic disease.Laboratory findings: The hemoglobin level was 4.5 gm. per 100 ml., hematocrit 15%, erythrocyte count 1,520,000 per cu. mm., and leukocyte count 2,700 per cu. mm., with 27% neutrophils, 6% myelocytes, 2% eosinophils, 3% basophils, 3% juvenile cells, and 56% lymphocytes. The erythrocytes exhibited anisocytosis and poikilocytosis, and the majority were macrocytic. The polymorphonuclear leukocytes showed hypersegmentation of the
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