Recent observations that the sickle RBC are excessively susceptible to phagocytosis by macrophages in vitro prompted me to look for evidence of in vivo erythrophagocytosis (Ep) in patients with sickle cell anemia ( S S ) . Freshly prepared smears of unmanipulated blood of 27 patients with SS in steady state were examined for Ep by a 500-cell differential white blood cell (WBC) count performed in duplicate. Ten of 27 (37%) S S patients showed Ep (1-6/1,000 WBC or 1-10/100 monocytes). By contrast, no Ep was found in similarly prepared blood smears of 25 normal adult controls and nine splenectomized subjects. The mean hemotocrit value of the Ep(+) S S patients was significantly lower than that of the Ep(-) patients (21.0 f 1.7% vs 24.0 f 2.7% p < 0.01). Considering the rarity of spontaneous Ep in unmanipulated blood from normal subjects and the relative insensitivity of the method used, the finding of Ep in over one third of S S patients indicates a significant membrane injury of the sickle RBC and serves to validate the in vitro observations. The possible role of the %enescence" mechanism in the induction of Ep is discussed.Key words: sickle cell anemia, erythrophagocytosis, RBC senescence
INTRODUCTIONOne determinant of hemolysis in sickle cell anemia ( S S ) is the irreversibly sickled cell (ISC). Two studies [ 1,2] have shown an inverse relationship between the red cell lifespan and the proportion of ISCs in the circulating blood. However, this correlation is far from perfect. Furthermore, in doubly heterozygous sickling diseases, eg, sickle cell hemoglobin C disease and sickle cell Pthalassemia, hemolysis occurs in the absence of an appreciable number of ISCs. These observations imply that other determinants of hemolysis must exist. Recent studies of Hebbel and Miller [3] have shown that the SS red blood cells (RBC) are excessively susceptible to erythrophagocytosis by human macrophages in an in vitro system, suggesting a role for the phenomenon in hemolysis. Since spontaneous erythrophagocytosis is extremely rare in unmanipulated blood of normal individuals, I investigated the presence of erythrophagocytosis in the peripheral blood of patients with sickle cell anemia as a means to validate the in vitro findings and to examine the role of blood monocytes in the red cell removal in SS.
MATERIALS AND METHODSBlood smears of 27 patients with SS disease (age 19-51 years, mean 36.3) were examined for erythrophagocytosis (Ep) by a 500-cell differential white blood cell
354Solanki count performed in duplicate. Only those patients who were in steady state and had not received red cell transfusions in the preceding 3 months were included. The S S disease was diagnosed by hemoglobin electrophoresis showing a single band in the position of hemoglobin S and the absence of hemoglobin A on cellulose acetate or starch gel at an alkaline pH and agar gel medium at an acid pH, a positive sickling test, clinical evaluation, and family studies when possible. All blood smears were freshly prepared from a drop of blood at the needl...