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A Clockface
Chromatin
in the
Intermediate
of Vitamin
B12
By
II
ECOGNITION
mm B12 or
megaloblast”
often
becomes
attempts
face
to
chromatin
loblasts
similar
reduce
clockface
this
with
with
the
a
however,
pattern
more
by
nuclear
of
of megaloblastic
subjective.1
The
demonstrating
membrane
B12,
in
folate,
clockboth.
A
megaloblasts
of vitamin
B12
megaor
intermediate
deficiencies
sign” in an intermediate
a deficiency
of vitamin
present
a unique
of fully-developed
vitamin
appeared
confirmed
in deficiency
of vitaof the “intermediate
identification
and
deficiency
subsequently
a “clockface
clue to
megaloblast
In the case
subjectivity
chromatin
patients
In this way,
a morphologic
cell,
Deficiency
KASS
difficult,
along
patients
or Folate
fully-developed
is not difficult.
more
pattern
from
from
of the
acid
Megaloblast
LAWRENCE
or “megaloblastoid”
changes
study
folic
Pattern
megaloblast
or folate.
B12 or folate.
might
provide
METhODS
Sternal
or
with suspected
marrow
was obtained
by needle
aspiration
from
twelve
patients
of vitamin
B12 or folate.
Simultaneous
determinations
of serum
B12 and folate were performed
on each patient
by Dr. J. Hines, Cleveland
MetroGeneral
Hospital.
Control
marrow
samples
were
taken
from
three
patients
(J.W.,
A.T.) with nonhematologic
conditions
(arteriosclerosis,
cerebellar
degeneration,
and
vitamin
politan
C.N.,
traumatic
iliac crest
deficiencies
hematuria)
with
patients
deficiency
and
normal
refractory
(6),
hemoglobin.
megaloblastic
sideroachrestic
Control
anemia
anemia
(4),
chronic
filter,
which
admits
of nuclear
appearance
wave
chromatin
lengths
of
light
and connections
were
anemia
due
granulocytic
(5), chronic
lymphocytic
leukemia
(5), and erythroblastosis
The
specimens
were
stained
with
Wright’s
or
with a Zeiss Planapo
100 X 1.3 oil immersion
lens,
This
samples
(3),
also
to
obtained
leukemia
(4),
fetalis (2).
tetrachrome
stain
and
and a Kodak
99 Wratten
from
520
between
mi
to
chromatin
620
from
uncomplicated
m,
iron
myelofibrosis
photographed
green
filter.
accentuates
the
strands.
RESULTS
In all cases
ings
were
of deficiency
identical.
scribed.2-4
Chromatin
strands
which
First
B!ooD,
threads.
adhere
arrangement
submitted
LAWRENCE
Western
partment
Ill.
strands
by delicate
appeared
to
circumferential
of vitamin
Fully-developed
B12,
folate,
or both
megaloblasts
were
widely-separated
and
Especially
prominent
to the interior
of the
of these
particles
(Table
appeared
as
linked
1),
the
classically
findde-
to neighboring
were
chromatin
particles
nuclear
membrane.
The
resembled
minute
markings
on
1, 1968; accepted
for publication
June 10, 1968.
Formerly
Fellow
in Hematology,
Department
of Medicine,
Case
Reserve
University
Schcol
of Medicine,
Cleveland,
Ohio.
Present
address:
Deof Medicine,
Division
of the Biological
Sciences,
University
of Chicago,
Chicago,
VOL.
February
KAss,
32, No.
M.D.:
5 (Novsnsn),
1968
711
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712
L4SS
Table
1.
Hemoglobin
(Gm./l00
ml.)
Serum
Serum
Folate
B12
Age
Sex
OS.
27
M
6.0
0.1
470
W.N.
42
M
5.3
0.2
LB.
J.T.
J.W.
JR.
W.O’L.
LB.
AC.
B.T.
L.F.
39
F
2.0
0.2
585
830
46
34
75
12.7
4.05
6.7
10.45
3.7
8.02
9.05
5.4
2.6
0.4
1.6
2.8
11.2
29.0
14.2
7.2
815
100
30
105
10
15
25
50
7.45
Patient
70
F
F
M
M
M
F
F
F
M
9.4
100
(normal)
31
M
15.6
8.8
945
(normal)
47
4.0
78
M
M
14.05
(normal)
13.0
6.6
610
430
49
67
80
68
43
A.B.
J.W.
C.N.
AT.
Serum
folate
Serum
1312
the
face
(L. casei)
(E. gracilis)
of a clock.
“hillocks,”
with
Particles
frequently
not
strands,
it was
observed
row. The
convex
present.
to
in
sors.
Bone
marrows
mediate
megaloblasts.
were
smaller
appeared
to
intermediate
from
ficiency
in each
anemia
(Fig.
nuclear
size.
oped
cent
hibited
chromatin.
filament
instance
4)
In
megaloblasts
of erythroblasts
a clockface
When
of
forms
from
or
(B.T.
cells
appeared
(Table
were
(Fig.
latest
and
megaloblasts
In both
)
and
cases,
other
were
chromatin
pat-
these
were
precursors
normoblast
contained
described
1).
in each
marin basophiic
megaloblast
J.T.
as
to
changes
when
corresponding
round
appeared
were
joined
A clockface
by
did
precur-
mostly
inter-
others.5’6
their
chromatin
30-50
per cent
They
strands
of the
clockface
chromatin
patterns
(Figs.
folate
assays
subsequently
confirmed
2, 3).
a de-
1).
from
three
patients
widely-separated
cells
with
chromatin
appeared
very
of vitamin
B12 or folate
deficiency.
from
patients
with
refractory
chromatin
nucleus
metamyelocytes
and
the
patients
exhibited
B12 and
these
they
megaloblasts.
stab
earliest
general,
the
examined
prominent
the
showed
of
like
stalks
or “pedicles”
also
and
“pedicle”
configurations
of 500 red cell precursors
pattern
appeared
most
different
erythroblasts
center
appeared
These
giant
two
often
chromatin.
than
fully-developed
be less widely-separated.
megaloblasts
of serum
vitamin
the
other
These
Results
Developing
toward
a thin
of both
significantly
masses
to narrow
“hillock”
polychromatophiic
appear
Chromatin
appear
by
per cent
chromatin
and
not
chromatin
surfaces
often
in 50-70
clockface
did
small
attached
Both
the
connected
megaloblasts
not
These
of chromatin
(Fig.
1).
usually
tern
: 4-18 nanograms/mi.
: 160-900
picograms/mi.
pattern.
refractory
megaloblastic
strands
similar
and
to the
However,
megaloblastic
increased
fully-devel-
only 2-3
anemia
per
ex-
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CLOCKFACE
cHROMATIN
713
PATrE1N
Fig. 1.-Patient
L.B.
(vitamin
B12, deficiency)
The cell
megaloblast.
Arrows
point
to “hillock”
and
“pedicle”-shaped
arranged
in a clockface
pattern.
( x 1700)
Fig. 2.-Patient
megaloblast
exhibits
Fig.
seen
3.-Patient
in this
In
B.T. (vitamin
B12 deficiency)
a clockface
chromatin
pattern
late
three
levels
from
basophilic
large
clumps
Isolated,
clumps
due to
deficiency)
intermediate
without
(Table
appeared
joined
(folate
basophilic
patients
folate
clump
always
J.T.
1
), the
anemia
erythroblast
around
were
infrequent.
uncomplicated
A cloekface
and
(
with
interior
chromatin
normal
of
the
serum
membrane
toward
the center
of the nucleus,
clumps
of chromatin
by thick,
chromatin
Red
iron
clumps
or
cell precursors
deficiency
(Fig.
connected
6)
iron
does
not
deficiency
appear
was
(Fig.
be
can
B12
and
precursors
arranged
5).
in
Each
and was almost
rope-like
strands.
chromatin
from
six patients
with
anemia
were
often
smaller
than
red
5.-Patient
J.W.
(normal)
In this basophilic
to the nuclear
membrane
is arranged
in
to each other by heavy
strands
of chromatin.
Fig. 6.-Uncomplicated
basophilic
erythroblast
in Figure
5. (x 1800)
cell
delicately-connected
Fig. 4.-Refractory
megaloblastic
anemia.
These
late
and early
polychromatophilic
megaloblasts
appear
similar
1-3. However,
a clockface
chromatin
pattern
is not apparent.
Fig.
adjacent
intermediate
vitamin
red
normoblast
nuclear
basophilic
clumps
pattern
x 1700)
of normal-appearing
to polychromatophilic
the
to radiate
to neighboring
unconnected
This late basophilic
(arrows).
( x 1700)
megaloblast.
chromatin
is a large
chromatin
anemia.
significantly
basophilic
megaloblasts
to the cells in Figures
(x 1800)
erythroblast,
large
radial
(x 1800)
the
clumps.
The
pattern
from
the
chromatin
different
chromatin
They
are
of this
normal
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714
KASS
Fig.
present
7.-Sideroachrestic
in the cytoplasm.
Fig.
anemia,
( x 1800)
8.-Chronic
granuloeytic
Fig.
precursors
from
types
were
indistinguishable.
did
(Fig.
not
normal
differ
9),
basophilic
basophilic
patients,
(Fig.
7
chronic
),
but
the
chromatin
of both
from
and
the
1800)
x
patterns
cell
patients
leukemia
leukemia,
from
(
are
( x 1800)
granulocytic
in appearance
vacuoles
erythroblast.
erythroblasts
chronic
lymphocytic
significantly
Several
erythroblast.
Developing
anemia
elofibrosis
erythroblast.
leukemia,
9.-Myelofibrosis,
cell
sideroachrestic
basophilic
with
8),
(Fig.
erythroblastosis
myfetalis
normal.
DIscussIoN
It is unlikely
that
the
since
photomicrographs
der the phase
contrast
mal
living
sign.”8
all
present
vitamin
or
regardless
folate
preponderance
Although
of
many
blastic
anemias
2-3
per
cent
per
cent
These
of vitamin
suggest
The
in normal
chromosomal
when
pattern,
B12 or folate
pathogenesis
the
that
rather
cells
of the
cells
did
than
can
one
“clockface
suggest,
abnormalities
to these
classic
of
the
or
folate
In
are
contained
patterns.
megaloonly
contrast,
30-50
documented
cases
chromatin
more
strongly
other
of
folate
patterns.
megaloblasts
suspect
varieties
ex-
a deficiency
of
anemia
in
be found.
is unknown.
analogy,
seen
cent
in
serum
megaloblasts,
clockface
more
and
refractory
patterns.
per
sign”
by
or
their
chromatin
subsequently
may
sometimes
B12
anteseen
appearance
B12
with
exhibit
30
one
or
initial
patients
from
B12 or folate
chromatin
vitamin
chromatin
megaloblasts”
of vitamin
“megaloblastoid”
similar
clockface
the
clockface
from
strikingly
showed
of
“clockface
was
of vitamin
an-
Nor-
sign”
anemia
correlate
exhibiting
precursors
of “intermediate
observations
servations
cell
appeared
a clockface
which
and
red
of their
levels
deficiency
megaioblasts
of them
of deficiency
hibit
with
to
serum
the
“clockface
hypersegmentation
degree
Attempts
specific
lack
the
staining,
viewed
patterns.7
conditions
whether
since
and
chromatin
identical
to say
of the
levels.
of fixation
megaloblasts
clockface
under
possible
the “clockface
sign”
with
currently
in progress.
Marrows
from
patients
a
artifact
living
of neutrophils,
studied,
B12
is an
exhibit
observed
it is not
hypersegmentation
patients
sign”
microscope
erythroblasts
At
dates
“clockface
of supravitally-stained
in
that
deficiency
However,
both
the
of
certain
“clockface
vitamin
B12
obsign”
or
fo-
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CHROMATIN
CLOCKFACE
late#{176} might
tron microscope,
of
reflect
an abnormality
of megaloblast
histone.
Under
preparations
of nucleohistones
appear
as a delicate
anastomosing
nections
fibrils.12
and
tone
ing
band
can
be
do
not
is added.1
in starch
show
gel
appearance
reconverted
such
Chicken
electrophoresis
of their
to dense
intercon-
erythrocyte
his-
while
and liver
histone,
suggesting
calf
thymus
lymphocyte
clumped
the
strands
the elecmeshwork
that
nuclei
erythrocyte
depleted
chromatin.
chromatin
lacking
of
The
result-
by
adding
to
megaloappear
clumps
histone.15
or
could
to the
may
lose
chromatin
By analogy,
blast
of vitamin
loose
histone
present
in spleen
be unique.14
Also,
histone
loose
DNA
unless
a characteristic
a component
histone
may
lysine-rich
Isolated
aggregations
contains
lysine-rich
715
PATIERN
one might
postulate
that
B12 or folate
deficiency
widely-separated.
encourage
nuclear
fail
nuclear
Faulty
an abnormal
could
cause
histone
histone
in
its chromatin
crosslinkages
the
DNA
between
the formation
of isolated
“hillocks”
of chromatin
membrane
in a clockface
pattern.
These
clumps
of
to unite
with
membrane,
chromosomes,
and
cause
disappear
distorted,
during
broken
mitosis
or
strands
adherent
chromatin
along
missing
with
the
chromosomes9
to appear.
SUMMARY
In the
fully-developed
alterations
occur
chromatin
is often
and
the
gives
appears
only
megaloblastic
the
tenuously
nucleus
of vitamin
chromatin
of anemias
ogenesis
of the
connected
a clockface
do
cause
both
abnormalities.
megaloblast,
not
“clockface
the
it may
the
this
deficiency,
nuclear
to or separated
from
A clockface
chromatin
chromatin
“clockface
clue
This
chromatin,
chromatin
pattern
Although
the
in megaloblast
pattern
and
sign”
appears
a morphological
other
cases
of refractory
erythroblasts
from
pattern.
alterations
unique
membrane.
erythroblasts
from
and developing
is unknown,
clockface
When
the
provide
to
appearance.
exhibit
sign”
B12 or folate
adherent
rarely
in “megaloblastoid”
anemia.
Normal
erythroblasts
a variety
might
somal
megaloblast
in
to
pathhistone
subsequent
chromoin an intermediate
a deficiency
of vitamin
B12 or folate.
IN
SUMMARIO
INTERLINGUA
In le plenmente
disveloppate
megaloblasto
ab subjectos
con carentia
de vitamina
B12
0 de folato,
alterationes
de character
unic
occurre
in le chromatina
adherente
al membrana
nucleari.
Iste
chromatina
es frequentmente
separate
o non plus
que
laxemente
connectite
con altere
chromatina
e produce
in le nucleo
le apparentia
de un disco
a
cifras
de horologio.
Iste
configuration
appareva
solo
rarmente
in erythroblastos
“megalo-
blastoide”
ab casos
blastos
in
configuration
stato
cognoscite,
alterationes
del
de
de
refractori
anemia
disveloppamento
chromatina.
in
Ben
le
megaloblastic.
ab
histona
que
le
un
Erythroblastos
variatate
pathogenese
megaloblastic
del
es
causa
de subsequente
anormalitates
chromosomal.
in un megaloblasto
intermedie,
illos representa
pote suggerer
le diagnose
de carentia
de vitamin
normal
anemias
de
“signo
non
del
possibilemente
e
horologio”
su
Quando
le “signo
del
forsan
un constatation
B1, o de folato.
causa
erythro-
exhibeva
e
horologio”
morphologic
iste
non
es
etiarn
le
appare
ACKNOWLEDGMENTS
The
and
author
is indebted
to Drs. D. Horrigan
to Mr. D. N. Schad for photomicrographs.
and
R. Kellermeyer
for
valuable
suggestions,
que
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716
KASS
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1204-1212, 1965.
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1968 32: 711-716
A Clockface Chromatin Pattern in the Intermediate Megaloblast of Vitamin
B 12 or Folate Deficiency
LAWRENCE KASS
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Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of
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Copyright 2011 by The American Society of Hematology; all rights reserved.