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Annotation: THE HAEMATOLOGICAL STRESS SYNDROME

Patients with a wide variety of systemic diseases show haematological abnormalities. These may be mild, but sometimes the blood changes are severe enough to dominate the clinical picture. They vary from patient to patient, and thus a number of separate syndromes have been described, such as the anaemia of chronic disease, hypercoagulabihty, an associated leucocytosis, and leukaemoid reactions. The term ‘haematological stress syndrome’ is suggested to emphasize that a patient may respond by producing multiple phenomena such as anaemia, increased thrombopoiesis and myelopoiesis, hypocholesterolaemia, hypersideraemia and hyperfibrinogenaemia, but the term does not include stress polycythaemia. Most of the changes occur in acute as well as in chronic states although the anaemia will require time to develop. The anaemias of chronic diseases are probably among the most common forms of anaemia in developed countries; they are known by at least nine different names, thus illustrating the lack of an established concept. In the elderly they are commonly confused with iron deficiency. The accompanying changes can be convieniently divided into three groups. The first group of signs includes anaemia, haemolysis of an extracorpuscular nature, and decreasing serum concentrations of transferrin, iron, albumin, folates, ascorbates, zinc and cholesterol. The relationship of these changes to an increased reticuloendothelial activity will be discussed below. The second group includes leucocytosis in the peripheral blood and a left-shift of granulocyte precursor cells in the bone marrow. Whereas leucocytosis is rare in anaemias of chronic diseases, bone marrow myelocytosis and plasmocytosis are common (Pillers et al, 1956; Stoger, 1941). Colony stimulating factor, which recruits stem cells to form myeloid cells, is formed by monocytes and possibly by other cells belonging to the reticuloendothelial system. One could therefore speculate that the myeloid reaction, like the thtombocytosis described below, is due to a stem cell recruitment, similar to that implicated in immunotherapy, and secondary to reticuloendothelial formation of colony stimulating factor. I t is possible to see the reticuloendothelial, myeloid, and plasmacellular reactions in the first two groups of symptoms in the haematological stress syndrome as a preparedness against infection. The hyposideraemia, making iron unavailable to bacteria (Ganzoni & Puschmann, 1977) might also be seen as a defence mechanism. The third group of changes in the stress syndrome includes thrombocytosis, increasing concentrations of fibrinogen and factor VIII, and an increased platelet adhesiveness. An increased erythrocyte sedimentation rate often accompanies the fibrinogen increase. In the bone marrow, megakaryocytosis often accompanies the peripheral thrombocytosis. It is possible to see this third part of the haematological stress syndrome as a preparedness against bleeding or for increased coagulation.