648
LETTERS TO THE EDITOR
The medium can be stored indefinitely
at 4 - 6 C; small amounts have been kept
at 20-24 C for several weeks without
any noticeable change in properties.
DAVID A. L E N N E T T E , P H . D .
Virology Section
Clinical Microbiology and
Immunology
The Hahnemann Medical College
and Hospital
230 North Broad St.
Philadelphia, Pennsylvania 19102
References
I. Gardner PS: Rapid virus diagnosis. J
Gen Virol 36:1-29, 1977
A.J.C.P. • May 1978
2. Pital A, Janowitz SL: Enhancement of
staining intensity in the fluorescent
antibody reaction. J Bacteriol 86:
888-889, 1963
3. Rodriquez J, Deinhardt F: Preparation of a semipermanent mounting
medium for fluorescent antibody
studies. Virology 12:316-317, 1960
Rapid Screening for LE Cells with
Cytocentrifuge-prepared Buffy
Coat Monolayers
To the Editor:—Reference is made to
a recent paper by Garnet, Atkinson,
Bonner, and Wurzel2 concerning a rapid
screening test for lupus erythematosus
(LE) cell detection using the Cytocentrifuge.
We had published' a similar report in
1976, in which we stressed the following:
(1) The possibility of concentrating
in monolayered specimens the leukocytes of a sample of venous blood,
obtaining well-preserved morphologic
features: the cells are spread in a
significantly decreased area, compared
with smears.
(2) The use of ammonium oxalate,
Received December 27, 1977; accepted
for publication January 23, 1978.
Address reprint requests to Dr. Boccato.
Key words: Rapid screening; Cytocentrifuge; LE cells.
Chronic Monocytic
1% solution, to hemolyze the buffy coat
(Garnet and associates used a standard
platelet Unopette, containing only ammonium oxalate diluent).
(3) The possibility of identifying
probable LE cells with the lOx objective (63x magnification); identification can be confirmed under oil immersion.
(4) The shortening of the time necessary to obtain good specimens with our
technic (washing-hemolysis with
ammonium oxalate, cytocentrifugation,
slides stained with May-GriinwaldGiemsa).
(5) The possibility of identifying
morphologically the "natural history"
of the LE phenomenon, i.e.: pre-LE
cells, globs, rosettes, LE cells, post-LE
cells. It is also possible to identify
monocytes as the phagocytic elements
in LE cells; this finding is more
frequent in cytocentrifuged specimens,
compared with smears, in which neutrophilic granulocytes are usually described in this role.
PROF. PAOLO BOCCATO,
LUCIANO PASINI,
M.D.
M.D.
Laboratorio di Patologia Clinica
Ospedale Civile
30027 San Dona di Piave
Venezia, Italy
References
1. Boccato P, Pasini L: Sulle applicazioni
della Citocentrifuga, Parte I. La
ricerca del fenomeno L.E. LAB. Ill,
2, 229-238, 1976
2. Garnet RF Jr, Atkinson BF, Bonner H,
et al: Rapid screening for lupus
erythematosus cells using cytocentrifuge-prepared buffy coat monolayers.
Am J Clin Pathol 67:535-537, 1977
Leukemia
To the Editor:—Skinnider and associates are to be congratulated for their
clear separation of chronic myelomonocytic leukemia from both chronic granulocytic leukemia and acute myelomonocytic leukemia. 5 Prior to the reports of
Geary and of Miescher, this was an
extremely confused subject. 1,3 Saarni,
for example, did not distinguish a
chronic form, even though noting that
myelomonocytic leukemia was the
most common leukemia seen at the
Received December 1, 1977; accepted for
publication January 16, 1978.
Address reprint requests to Dr. Burdick:
Department of Pathology, Valley Memorial
Hospital, 1111 E. Stanley Blvd., Livermore,
California 94550.
Key words: Monocytic leukemia.
Mayo Clinic. 4 The separation is vital,
as treatment seems contraindicated.
We saw a patient just prior to these
reports, who, in retrospect, clearly had
chronic myelomonocytic leukemia, and
whose course emphasizes the advice
of Skinnider and co-workers.
Report of a Case
A 75-year-old native of the Azores, being
studied for bronchitis, was found to have
63,000 leukocytes/cumm, with 33% monocytes and 61% neutrophils. Physical examination showed only moderate hepatomegaly. Successful treatment of the bronchitis lowered the leukocyte count only to
45,000/cumm. The bone marrow was highly
cellular and included increased monocyte
and granulocyte precursors. Chromosomal
analysis showed 46 (XY), without a Phila-
delphia chromosome. Leukocytic alkaline
phosphatase was 67 Kaplow units (about
normal). Peroxidase was positive in neutrophils, uric acid was 9.2 mg/dl, and there
was a polyclonal elevation of gamma globulin, which eventually reached 5.1 g/dl
(total protein 9.3 g/dl).
Scanning and transmission electron
microscopy showed early monocytes with a
few cytoplasmic projections, short endoplasmic reticulin profiles, small mitochondria, and prominent Golgi apparatuses.
Granulocytes had more tabulated nuclei
with clumped chromatin, and prominent
granules.
The patient refused therapy, and did fairly
well for nearly four years in spite of
bronchiectasis and a leukocyte count that
eventually reached 106,000/cumm. He died
three weeks after the initiation of therapy
with chlorambucil.
Vol. 69 • No. 6
LETTERS TO THE EDITOR
Comment
Chronic myelomonocytic leukemia
is clearly different than chronic granulocytic leukemia and acute myelomonocytic leukemia. Patients lack splenomegaly, have normal leukocytic alkaline
phosphatase, always lack the Philadelphia chromosome, tend to be very old,
and have a fairly bland course. Our
patient showed a polyclonal gammopathy not previously reported, except
possibly in the case of Meuret, reported
prior to the clear separation of chronic
myelomonocytic leukemia from other
leukemias. 2 The importance of making
the diagnosis is that treatment with
Paternity Blood Grouping Tests
Using Legally Unacceptable
Testing Systems
To the Editor: — A recent reprint
from the Family Law Quarterly entitled
"Joint AMA-ABA Guidelines: Present
Status of Serological Testing in Problems of Disputed Paternity" was
gratuitously circulated recently to many
general pathologists, serologists and
lawyers. Although it is specifically
stated in the preface that there are
limitations to the current state of capabilities, the report, nevertheless, goes
on to include more than the acceptable
and proven blood group tests, those
involving HLA systems, serum protein
systems, and erythrocyte enzyme systems.
The ABO, MNSs, Rh-Hr, and Kell
systems are now routine tests employed
and accepted for the determination of
non-paternity. To include the Duffy and
Kidd systems, where there exist "silent" alleles such as Fy and Jk,
could easily lead to serious error in
conclusions of non-paternity unless
first-order exclusions exist (i.e., where
a child has a blood factor not present in
the blood of either the mother or the
putative father). In addition, the relative scarcity of sera such as anti-Jk b
Received November 29, 1977; received
revised manuscript January 23, 1978: accepted for publication January 23, 1978.
Address reprint requests to Dr. Sussman.
Key words: Erythrocyte enzymes: Serum
protein: HLA testing; Legally unacceptable
systems.
chlorambucil appears, at best, worthless.
C L A U D E O. BURDICK,
M.D.
LUIS D E CARVALHO, Lie.
MED.
(LISBON)
JAY CARSON,
M.D.
Departments of Pathology and Internal
Medicine
Valley Memorial Hospital
HUE. Stanley Blvd.
Livermore. California 94550
and
Electron Microscopy Laboratory
Veterans Administration Hospital
Martinez California 94553
makes this system impractical for most
laboratories.
To further destroy the infallibility of
blood grouping tests in matters of nonpaternity, the erythrocyte enzyme,
blood protein and HLA systems have
not been subject to the thorough
study and research that the 100% acceptable systems have undergone. All
the probable variants, nonspecificity of
sera, influence of modifying genes,
and other factors are not known or
clearly understood. Obviously, this unreliability can only lead to erroneous
conclusions and grave miscarriages of
justice. The misuse of the scarce monospecific HLA testing serum (previously reserved for pre-transplant
selection of donors) makes this suggestion most impractical.
The response of less-than-expert
individuals such as general pathologists, lawyers and even litigants to this
pamphlet has lead to a rash of consultations and requests for these tests,
demonstrating the confusion and lack
of understanding that has been created.
To complicate the problem, the
pamphlet itself has several typographical errors, omissions and half-truths,
as follows:
(1) Page 259, IV, Types of exclusion,
# 5 , line 3: "For example, a person of
phenotype (group) A, is either genotype A ^ , or of genotype A , 0 . "
[Omitted is the possibility of genotype
A,A 2 .]
(2) Page 266: Example: "the child's
genotype r'r(Cde/Cde)" [error in converting from Rh-Hr genotype to CDE].
649
References
1. Geary CG, Catovsky D, Wiltshaw E,
et al: Chronic myelomonocytic leukemia. Br J Haematol 30:289-302,
1977
2. Meuret G, Bundsch-Lay A, Senn HJ, et
al: Functional characteristics of
chronic monocytic "leukemia." Acta
Haematol 52:95-106, 1974
3. Miescher PA, Farquet JJ: Chronic myelomonocytic leukemia in adults.
Semin Hematol XI 2:129-139, 1974
4. Saarni MI, Linman JW: Myelomonocytic leukemia: Disorderly proliferation of all marrow cells. Cancer 27:
1221-1230, 1971
5. Skinnider L, Card RT, Padmanabh S:
Chronic myelomonocytic leukemia.
Am J Clin Pathol 67:339-346, 1977
(3) Page 267, 1st line: Accordingly
the only: R'r (CDe/cde) or r'r (Cde/
cde) [but the error is that the child is
truly of genotype r'r' (Cde/Cde)].
(4) Page 271: The rarity of the antiserum anti-Fy b and anti-Jkb makes these
systems impractical for most laboratories. Failure to test may suggest
incompletness of the blood test. In
addition, minus-minus phenotypes
make only 1st order exclusion reliable.
(5) Page 272: HLA anti-sera as a
monospecific antiserum is rare and
usually limited for use in transplant
surgery.
(5) Page 272: Fourth line from bottom, states: "Currently available tissue
typing trays (for transplantation only)
is provided by N . I . H . "
(6) "Likelihood of Paternity" presents a threat to the utmost accuracy
in all matters pertaining to blood grouping. Difficulties in calculating the figure
on page 261 could easily lead to misuse and errors in justice.
These problems mandate that a revision be undertaken promptly. It is
hoped that such a revision, in collaboration with the serologists practicing in
this field, will be more representative
of the actual existing practical possibilities and will restore the confidence
that existed in this special field of medicolegal science.
LEON N. SUSSMAN,
M.D.
Director, Blood Bank
Beth Israel Medical Center
16th St. and First Avenue
New York, New York 10003