Thalassemia Intermedia, with Iron Overload,
`Cardiac Failure, Diabetes Mellitus,
`Hypopituitarism and Porphyrinuria*
`
`RoBIN M. BANNERMAN, D.M., GERALD KEuscH, M.D., t MARTHA KREIMER-BIRNBAUM, PH.D. ,
`VERNON K. VANCE, M.D. and STUART VAUGHAN, M.D., PH.D.
`Buffalo, New York
`
`A patient of Sicilian ancestry who had thalassemia intermedia was seen intermittently
`from the time he was six to forty-one years of age. He had inherited at least one allele
`for the "high hemoglobin F, normal hemoglobin A2" type of 13-thalassemia. Splenec(cid:173)
`tomy had been carried out during his childhood; he was also given iron medication
`orally and deliberately ate iron-rich foods. Although he had had only 6 units of blood
`by transfusion, by the age of forty-one severe iron overload had developed, with the
`clinical picture of hemochromatosis, including skin pigmentation, liver disease,
`cardiac failure and multiple endocrine deficiencies. Desferrioxamine was used to
`demonstrate the degree of iron load and in an attempt to reduce it. The anemia was
`further complicated by folic acid deficiency and improved with folic acid therapy.
`Porphyrinuria and urinary excretion of d ipyrroles were additional features, probably
`due to the severe degree of ineffective erythropoiesis. The pathologic mechanisms
`underlying these various complications are discussed. The danger of administering
`iron orally to such patients is emphasized.
`
`T HALASSEMIA intermedia is a useful phrase to
`
`describe a c linical form of intermediate
`severity. It may represent homozygous thalas(cid:173)
`semia in mild form or be a particularly severe
`expression of the heterozygous state. It is an
`appropriate diagnosis for the patient described
`herein. As indicated in the title, the complica(cid:173)
`tions in this patient included cardiac failure,
`diabetes mellitus and hypopituitarism, as well
`as hepatic dysfunction a ll presumed
`to be
`secondary to iron overload.
`Iron overload in thalassemia was first recog(cid:173)
`nized by Whipple and Bradford [7] and indeed
`Cooley's anemia has been referred to as "hemo(cid:173)
`chromatosis in the child" [2]. Such complica(cid:173)
`tions have become increasingly common in
`severe thalassemiia major in childhood since
`survival is prolonged by blood transfusion and
`antibiotic therapy, and intractable cardiac fail(cid:173)
`ure is now a familiar terminal event [3-5].
`
`Endocrine complications are less well docu(cid:173)
`mented. I t is of particular interest that the
`patient here described received very few blood
`transfusions and his iron overload therefore
`must h ave been acquired by intestinal absorp(cid:173)
`tion. Marked porphyrinuria was an additional
`feature in this case, and the urine also con(cid:173)
`sistently contained another brown pigment,
`probably a dipyrrole.
`
`CASE REPORT
`A forty-one year old man of Sicilian ancestry was
`admitted to the Buffalo Veterans Administration
`Hospital in December 1964 with the chief com(cid:173)
`plaints of increasing shortness of breath and swell(cid:173)
`ing of the legs for two months.
`His first hospital admission was in 1930 at the age
`of six years, when he entered a pediatric hospital be(cid:173)
`cause of "adenoids and large tonsils." It was recorded
`that birth and development up to the age of one year
`had been normal. Thereafter, he had been "chroni-
`
`* From the Department of Medicine, State University of New York at Buffalo, Buffalo Veterans Administration
`Hospital and Buffalo General Hospital, Buffalo, New York. This work was supported by U.S.P.H.S. Grant AM 05581
`and grants from the United Health Foundation of Western New York. M anuscript received June 7, 1966.
`t Present
`address: SEAT O Medical Research Laboratory, United States Army Component, APO San
`Francisco 96346.
`
`476
`
`AMER I CAN J 0 URN AL 0 F MED I C IN E
`
`
`1 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`Thalassemia Intermedia- Bannerman el al.
`
`477
`
`TABl..E I
`HEMATOLOGIC DAT A
`
`Red Blood Cells
`x 1()1
`{per cu. mm.)
`
`Hemoglobin
`(gm./100 ml.)
`
`Hem:ltocrit Platelets X I 03
`<%>
`(per cu. mm. )
`
`Rcticulocvks
`<%).
`
`4.59
`4.23
`5 . 15
`4.03
`3.50
`4.25
`3.22
`4.10
`4.10
`
`3.70
`
`7 .6
`10.9
`12. 1
`8 .9
`10.9
`12.9
`9.4
`10. 7
`9.3
`6.0
`10.0
`
`164
`112
`266
`620
`547
`
`383
`620
`
`-~ . {)
`I 2
`
`; . 2
`
`4 0
`3. 7
`
`31
`39
`
`20
`33
`
`Datt>
`- --·----
`1?30
`1')31
`1931
`1932
`1933
`1940
`1945
`1?50
`1960
`1964t
`1965t
`
`Age
`(yr.)
`
`6
`7
`7•
`8
`9
`17
`22
`27
`37
`41
`41
`
`•After splcncctomy.
`t December.
`t July.
`
`cally run down" and was unable to keep up with other
`boys at play. Dark-colored morning urine had been
`noted. He was described as listless and icteric, ap(cid:173)
`peared to be poorly nourished, and the spleen was
`enlarged to the level of the umbilicus. Laboratory
`data are reported in Table 1. Although the records
`are incomplete, marked anisocytosis and poikilocytosis
`of the erythrocytes were reported and fragility studies
`showed increased osmotic resistance. Normoblasts
`comprised 10 per cent of the total nucleated cell
`count. The urine was negative for bile and urobilino(cid:173)
`gen. On discharge, ferric ammonium citrate (12 cc.
`of 10 per cent solution, three times a day) and copper
`sulfate were prescribed and he continued to take the
`iron mixture for an unknown, but possibly prolonged
`period.
`The patient was next seen in 1931 because of
`anorexia, nausea, vomiting, abdominal distention
`and jaundice. The icterus index was 75 and he was
`am·mie. The diagnosis of "an atypical type of con(cid:173)
`genital hemolytic anemia" was made and splenectomy
`was performed. He received 6 units of blood by trans(cid:173)
`fusion during surgery. This was his first and only blood
`transfusion until the age of forty-one. The spleen was
`desc ribed as "a chronic splenic tumor in some respects
`resembling the picture of so-called Banti spleen, dif(cid:173)
`fering from that in a smaller amount of fibrosis of
`stroma." After splenectomy the red blood cell a nd
`platl'iet counts increased and normoblasts rose to
`47 per cent of the total nucleated cells.
`The patient was first seen by one of us (S.V.) in
`19 32 and the diagnosis of Cooley's anemia was made.
`In 1933 he was "feeling pretty well" and attending
`school regularly, but experiencing periodic attacks
`about one week in duration during which marked
`apathy occurred, associated with yellow coloring of
`the skin.
`
`VOi.. 42, MARCH 1967
`
`In 1940 at the age of seventeen, the patient was in
`his third year of high school and participating ac(cid:173)
`tively in sports. In a phot0graph taken about chat
`time his features were normal, with no suggestion of
`the mongoloid facics, prognathism or malocclusion
`which are see n in childhood Cooley's anemia. It was
`noted that at times there was faint scleral icterus and
`that the liver was palpable. Pubic hair was scanty.
`with a female distribution. Oral administration of
`iron had definitely been di5continued by this time.
`but ic wa~ uncertain whether the patient had been
`taking iron consistently over the previous ten years.
`However, he continued to eat large quantities of
`iron-rich foods, such as liver and spinach.
`In September 1944 the patient was inducted into
`the U.S. Army. On physical examination at induction
`the splenectomy scar was the only abnormality re(cid:173)
`ported. The liver was not palpable. During che four(cid:173)
`teen weeks of basic training he had sharp pain in the
`lower part of the abdomen associated with exercise,
`particularly long hikes. Because of this complaint and
`a "cold" he was admitted to an Army hospital in
`January 1945. He was slightly jaundiced and again
`no hcpatomegaly was noted. Blood examination on
`admission revealed anemia (Table 1) with aniso(cid:173)
`cytosis, poilcilocytosis, polychromasia and target cells
`in the blood film and increased osmotic resistance
`of the erythrocytes. The icterus index was 19 and the
`serum bilirubin was 1.8 mg. per 100 ml. Roentgeno(cid:173)
`grams of the skull were reported as showing slight
`thickening of the diploe with thinning of the inner
`and outer tables. The long bones were roentgeno(cid:173)
`logically normal. Because of the diagnosis of Cooley's
`anemia, he received an honorable discharge from the
`service.
`The patient was next seen i n 1950. The blood film
`showed
`target cells, with many orthochromatic
`
`
`2 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`478
`
`Thalassemia Intermedia-Bannerman et al.
`
`2
`
`Fro. 1. Patient J .G., sh owing diffuse and mottled facial p igmentation and youthful
`appearance.
`
`FIG. 2. Patient J .G. on atlmissiuu Lu husµiLal iu Dcccmucr 1964, with cardiac failure and
`severe edema. Sparse body hair and splenectomy scar can also be seen.
`
`normoblasts and increased numbers of platelets with
`many gia nt forms. Aspiration of the bone marrow
`revealed a very cellular marrow with a tremendous
`increase in erythropoiesis. The myeloid: erythroid
`ratio was 0.2.
`In 1960, while living in California, he was seen at a
`hospital because of discomfort in the lower right quad(cid:173)
`rant of the abdomen. His skin \.vas reported to be
`sla te gray in color, there was scleral icterus, and the
`liver edge was firm and palpable at the iliac crest. He
`was found to be anemic and the blood film showed
`target cells and many
`macrocytes, microcytes,
`nucleated red cells. The serum bilirubin was 2.5 mg.
`per 100 ml. with 2.3 mg. indirect reacting. The
`serum total protein was 7.3 gm. per 100 ml., albumin
`3.1 and globulin 4 .2 gm. per 100 ml. The serum
`alkaline phosphatase was 22 King-Armstrong units,
`prothrombin time was 20 per cent of normal, and the
`thymol turbidity was 7.6 units. Serum iron was 299
`µg. per 100 ml. and the total iron-binding capacity
`was 595 µg. per 100 ml. The tentative diagnosis of
`thalassemia intermedia with secondary hemochroma-
`
`tosis was made and liver biopsy was advised, but
`refused.
`Since that time the patient noticed gradually in(cid:173)
`creasing darkening of the skin and, for one year, loss
`of libido and thinning of the axillary and pubic hair.
`Swelling of the legs started two months before admis(cid:173)
`sion and increased rapidly. For the month before
`admission he experienced nocturia, increased sweating
`and dyspnea on exertion, and orthopnea developed.
`He complained of vague discomfort in the lower part
`of the abdomen, particularly at night, and periodic
`"spasms" of the calf muscles and hands which were
`relieved by massage. There was no history of al(cid:173)
`coholism.
`On examination, the patient was a thin, ill-looking
`man with remarkably intense brown-gray color of
`the skin, particularly of the exposed areas. The dis(cid:173)
`tribution of the pigmentation was somewhat irregular
`with a mottled appearance (Fig. 1) and his features
`were lean and aquiline. H e looked younger than his
`chronologic age. Facial and body hair were very
`sparse, with female distribution of pubic hair (Fig.
`
`AMER I CAN J OURNAL O F MED I CINE
`
`
`3 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`Thalassemia Intermedia-Bannerman el al.
`
`479
`
`Fm. 3. Blood film with very marked anisocytosis and poikilocytosis, hypochromia and
`target cells, inclusion bodies (Howell-Jolly bodies and iron granule~ }. cellular fr:i~ments
`and normoblasts. Wright's stain, original magnification X 1,350.
`
`2). There was scleral iCLcrus, and sli t-lamp examina(cid:173)
`tio n revealed bilateral early subcapsular cataracts.
`The patient was very breathless. The pulse rate was
`120 per minute and the blood pressure 120/ 70 mm.
`Hg. The heart was enlarged, a left ventricular heave
`was palpated, and a gallop rhythm and a grade 2/ 6
`ejection systolic murmur were heard at the left
`sternal border. The jugular venous pressure was
`raised, and there were signs of a right-sided pleural
`effusion. The liver was very large, extending to
`below the umbilicus in the midline, and an enlarged
`Riedel's lobe extended to the right iliac crest. There
`was a left paramedian scar from previous splenectom y.
`The testes were small and soft. There was slight ascites
`and severe pitting edema of the legs extending into
`the penis and scrotum (Fig. 2).
`The hemoglobin was 6 gm. per 100 ml., hematocrit
`20 per cent and reticulocyte count 4 per cent. Of the
`nucleated cells, 71 per cent were normoblasts, and the
`corrected white cell count was 13,000 per cu. mm.,
`with a normal differential except for 3 per cem
`eosioophils. The direct total eosinophil count was
`782 per cu. mm. The blood film showed marked aniso(cid:173)
`cytosis and poikilocytosis with hypochromia and
`occasional target cells (Fig. 3), and staining for iron
`(6 J revealed many siderocytes and sideroblasts.
`Staining for fe tal hemoglobin (7] demonstrated un(cid:173)
`even distribution with variation in the intensity of
`staining from cell to celJ. (Fig. 4) .
`Further hematologic data are summarized in Table
`n. Bone marrow aspiration showed erythroid hypcr-
`
`v o L. 42, MARCH 1967
`
`plasia with m<'gaioblastic changes, principally giant
`band neutrophils. The Diagncx® blue test and direct
`examination of fasting gastric juice were negative for
`free hydrochloric acid without stimulation. Scrwu
`folic acid was low; the vitamin 8 1! level was normal
`11). Hemoglobin electrophoresis did not
`(Table
`reveal any abnormal hemoglobins. Hemoglobin F
`was greatly increased [6 I and hemoglobin A2 was
`normal (Tat..Le m). The plasma hemoglotin was 57
`mg. per 100 ml.
`
`Fie. 4. Blood lilm stained by the Kleihauer and Bctke
`method [7] for fetal hemoglobin showing that it is u:(cid:173)
`regularly distributed from cell to cell and is present in
`normoblasts. Original magnification X 1,350.
`
`
`4 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`480
`
`Thalassemia Intermedia- Bannerman et al.
`
`T ABLE II
`SPEC IAL BLOOD STUDIES
`
`TABLE lII
`HEMOGLOBIN ST UDIES IN PATIBNT AND RF.LATIV\l.S
`
`Test
`
`Results
`
`. . 135
`
`S<mm iron (µg./100 ml.). .
`S<ruw total iron-binding capacity
`(pg./ 100 ml.) . .. .. . .. . . . . .. ... . .. 150
`Plasma hemoglobin (mg./100 ml.) . . . . 57
`Pla sma haptoglobin (mg./100 ml.) ... . 15.6
`S<rum folic acid (mµg./ml.)
`On admission (12/ 64) .. . . ..... . . 4.9 (norma l range 7- 27*)
`After lapse of therapy (10/ GS) . . . .. 2.0 (norma l range 3- 271)
`S<rum vitamin B1t (µµg./ml .)
`.284 (nor!llal rang< 200-350*)
`12/ 64 . . .. . . . .
`. .. . . 987 (normal range 150-1,500 t)
`10/64. ... . . . . ... ..... .
`Scrum bilirubin (mg./100 ml.) .. ... .. 7.8 (6.1 indirect)
`Scrum total protein (gm./1 00 ml.) .
`.. 6.8 (albumin 3.1,
`globulins 3.7)
`. 21.5 (control 12.5)
`Pro thrombin 1imc (sec.) .. .
`. .. ... 85
`SG OT( units) ...
`SG PT (units) . .
`. ....... . . . . . ... .41
`LDH (units) .... . . . .. . ....... . . .. .. >2,000
`
`•Bio-Analytical LaboratoriC!, Inc., Albany, New York.
`t Courtesy of Dr. K. B. Taylor, Stanford University School of
`Medicine.
`
`The urine contained no protein or sugar, and no
`cells or casts were seen in the spun sediment. It was
`almost invariably a rich deep brown. The fasting
`blood sugar was 106 mg. per 100 ml., blood urea
`nitrogen 25 mg. per 100 ml. and creatinine 1.5 mg.
`per 100 ml. Serum sodium concentration varied from
`126 to 135 mEq. per L. and potassium from 4.3
`to 6.0 mEq. per L. Serum bilirubin was increased to
`7.8 mg. per 100 ml. with 6.1 mg. indirect reacting,
`and urinary urobilinogen was increased. Total serum
`protein was 6.8 gm. per 100 ml. with a reversal of
`the albumin: globulin ratio (3.1 : 3. 7). The one-stage
`prothrombin time was 21.5 seconds (control 12.5
`seconds). Alkaline phosphatase, serum glutamic
`oxalic (SGOT) and glutamic pyruvic transaminase
`(SGPT) levels were slightly elevated. The lactic
`dehydrogenase was increased to >2,000 units.
`A roentgenogram of the chest on admission con(cid:173)
`firmed the presence of card iac enlargement and a
`small right pleural effusion. Roentgenograms of the
`upper gastrointestinal tract gave no evidence of
`esophageal or gastric varices. The stomach and second
`portion of the duodenum were displaced to the left
`and the hepatic flexure was displaced medially and
`inferiorly by the large liver. The colon was normal
`in appearance on roentgenogram. The skull was nor(cid:173)
`mal roentgenologically but there was some demineral(cid:173)
`ization of the femurs and of the bones of the hands.
`A punch biopsy specimen of the skin showed excess
`melanin deposited in the basal layer of the epithelium
`but no stainable iron. Although it was desired to
`carry out an aspiration biopsy of the liver, this was
`not done because of the prolonged prothrombin time,
`which was not significantly altered by vitamin K
`therapy. However, on a subsequent admission pri(cid:173)
`marily for dental extractions, a gastric biopsy speci(cid:173)
`men was obt11in1ed ann thte rteport ""'" a.• follows:
`
`Subjec t a nd Sc,
`
`Hemoglobin
`At ( %)
`
`Hemo(cid:173)
`globin
`F ( % l
`
`Diagnosis
`
`J.G . (propositus), M
`
`R.G. (sister), F
`S.A. (maternal au n1), F
`L.S. (maternal au.m). F
`
`1. l *
`Normalf
`Normalf
`Normalf
`
`44 .0
`
`I. 7
`l.9
`9 . 3
`
`T halassemia io1cr-
`mcdia
`Normal
`Normal
`Thala..-scroia minor
`
`* Determined by starch block electrophor~si.•.
`f Estimated by pa per electrophoresis.
`
`"section shows a segment of gastric mucosa, the
`glandular epithelium being diffusely and markedly
`infiltrated by golden brown pigment, which on spe(cid:173)
`cial stain is identified as iron."
`
`SPECIAL STUDIES AND COURSE
`Family Investigation. The patient's parents
`were born in Sicily and d ied in Buffalo, New
`York, where the patient was born. He was not
`aware of any history of anem ia, jaundice or other
`symptoms suggesting thalassemia in his parents
`or in any other member of the family. Few living
`members were accessible for testing, but two
`maternal aunts and the patient's 'only sibling,
`an unmarried sister, were seen (Table m). No
`abnormality was detected in their blood films,
`and the hemoglobin electrophoresis patterns
`were normal, with no increase in the A2 fraction.
`One aunt showed 9.3 per cent hemoglobin F by
`the alkali denaturation method [6], suggesting
`that she is a heterozygous carrier of a gene for
`the "high-F, normal-Ai" type of ,8-thalassemia.
`Treatment and Hospital Course. The initial
`d iagnosis was thalassemia major or intermedia,
`complicated by iron overload and associated
`cardiac failu re and hepatic disease. An addi(cid:173)
`tional complication was secondary megaloblastic
`anemia, thought to be due to relative folic acid
`deficiency, as confirmed by the subsequent re(cid:173)
`port of low serum levels of folic acid. At first
`treatment was d irected towards reversal of the
`cardiac failure by administration of digitalis
`and mercurial and thiazide diuretics. There was
`little improvement until a marked diuresis
`followed blood transfusion (3 units of packed red
`cells) and continued during treatment with
`hydrochlorothiazide and triampterene. The pa(cid:173)
`tient's initial weight was 143 pounds and it
`fell after diuresis to 105 pounds, remaining at
`about th is level over the subsequent months.
`The changes in hematologic findings are
`
`A M ERICAN .JOURNAL OF MEDICINE
`
`
`5 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`Thalassemia Intermedia- Ba11nerman el al.
`
`481
`
`DEC.
`1964
`
`JIW
`1966
`
`FEB.
`
`MAR.
`
`JULY
`
`AUG.
`
`SEPT.
`
`OCT.
`
`DEC.
`
`Fm. 5. Hematologic changes in patient J.G. After blood transfusion, the reticulocyte
`count fell to 0.3 per cent. The bone marrow was initially megaloblastic and had become
`normoblastic by the seventh day after folic acid therapy was started. When folic acid ther(cid:173)
`apy was unintentionally. discontinued, there was a decrease in hematocrit and hemoglobin.
`
`shown in Figure 5. After blood transfusion the
`reticulocyte count fell from 10 per cent to only
`0. 3 per cent. In view of the patient's serious con(cid:173)
`dition, folic acid therapy (15 mg. orally daily)
`was started at this time. R eticulocytes increased
`to around the initial values and there was no
`further rise in hemoglobin and hematocrit.
`However, repeat bone marrow examination
`one week after folic acid therapy was started
`showed normoblastic erythropoiesis. Serum lac(cid:173)
`tic dehydrogenase (LDH) fell to 350 units.
`After the initial period of intensive investiga(cid:173)
`tion and treatment, there followed a longer per(cid:173)
`iod of continued observation and metabolic in(cid:173)
`vestigation during which the patient remained in
`the hospital. Although his general condition
`gradually improved, there was little apparent
`change or fluctuation in the degree of anemia
`and jaundice. During this relatively unchanging
`period, and subsequently, special studies were
`performed, including endocrinologic investiga(cid:173)
`tions, serial biochemical studies and observations
`on iron excretion, which will be detailed sub(cid:173)
`sequently. I n addition, an extensive investigation
`of hemoglobin and pyrrole metabolism was
`carried out by means of C14 labeling and will be
`described elsewhere.
`Endocrine Studies. Baseline twenty-four hour
`urinary 17-hydroxycorticosteroid excretion (17-
`
`v o L. 42, MARCH 196 7
`
`O H CS) was low and did not increase after
`administration of methopyrapone, 750 mg. every
`six hours for two days [8]. After stimulation with
`ACTH there was a definite but submaximal in(cid:173)
`crease, indicating limited adrenal responsiveness
`(Table rv). ACTH was not detectable in the
`blood [9).
`Serum protein-bound iodine was 2.8 µg. per
`100 ml. R adioactive iodine uptake was 13 per
`cent and increased to 23 per cent after admin(cid:173)
`istration of thyroid stimulating hormone, 10
`L U. daily for six days. Urinary gonadotropins
`were less than 6 mouse uterine units per twenty(cid:173)
`four hours. A standard oral glucose tolerance
`test was abnormal, with a blood glucose level
`of 260 mg. per 100 ml. two hours after the ad(cid:173)
`ministration of glucose. The disappearance rate
`after the rapid intravenous administration of
`glucose was 0.31 percent per minute [10).
`These studies were interpreted as showing
`deficiencies of anterior pituitary (thyroid stimu(cid:173)
`lating hormone, ACTH, gonadotropin) function,
`as well as primary thyroid, adrenal, pancreatic
`and possibly testicular functions.
`Biochemical Observations. During the period of
`study complete stool and urine collections were
`obtained continuously for more than seventy
`days. T otal fecal urobilinogen was estimated by
`a modification of the standard method [ 7 7]
`
`
`6 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`482
`
`Thalassemia Intermedia-Bannerman el al.
`
`Tl\BL~ IV
`ENDOCRINE STUDIES
`
`Data
`
`Treat ment
`
`Results of Studies
`
`None
`None
`~etho pyrapone, 750 mg. every 6 hr.
`Methopyrapooe, 750 mg. every 6 hr.
`None
`ACTH, 40 units intravenously in 8 hr.
`ACTH, 40 units intravenously in 8 hr.
`
`None
`TSH, 10 l.U. / day
`
`Pituitary-adrenal function"'
`Day 1
`Day 2
`Day 3
`Day 4
`Day 5
`Day 6
`D ay 7
`Pituitary-thyroid function
`Day 11
`Days 12- 17
`Pancreatic function
`
`Pituitary-gonadal function
`
`Urinary excretion of 17-0HCS
`0.5 mg./ 24 hr.
`0.7 mg. / 24 hr.
`
`0.6 mg./24 hr.
`0.7 mg./24 hr.
`3.1 mg.;24 hr.
`9.5 mg./24 hr.
`1131 uptake
`Protein-bound iodine
`133
`2.8 µg. / 100 ml.
`233
`Oral glucose tolera nce test, 260 mg. ·3 at
`2 hr.
`Intravenous glucose tolerance test, disap(cid:173)
`pearance rate = 0.3%/min.
`Urinary gonadotropin = <6 mouse units/
`24 hr.
`
`* Plasma ACTH w as not detectable on day 1. Plasma cortisol w.u 8 µg. per cent before and t 7 µg. per cent after
`treatment with ACTH (40 units intravenously over an eight hour period on day 7).
`
`daily for seventy-seven days. AJl values were
`considerably elevated , ranging from 436 to 4,912
`mg. per day with a mean value of 1,744 mg.
`Urinary porphyrins were determined daily
`[12] and the excretion was 1,000 to 2,000 µg.
`per day with a mean value of 1,344 µg. The
`porphyrins isolated were composed of over 98
`per cent coproporphyrins (1 and m) with traces
`of uroporphyrin-m and possibly other inter(cid:173)
`mediate porphyrins as demonstrated by paper
`chromatography [13,74]. It was of great in(cid:173)
`terest that a considerable quantity of another
`pigment was also present in the urine and prob(cid:173)
`ably accounted for the invariable brown color
`which it showed. This pigment accompanied the
`porphyrins in extraction procedures, but could
`be separated by column chromatography. I t is
`thought to be a dipyrrole and investigations
`of its exact nature and metabolic role are con(cid:173)
`tinuing [75).
`Free erythrocrte protoporphyrin was also
`measured [76] at frequent intervals and con(cid:173)
`sistently showed slightly elevated values ranging
`from 30 to 200 µg. per 100 ml. of red cells, with
`a mean value of 63 µg. per 100 ml.
`Iron Excretion Studies. Urine was collected
`directly in iron-free acid-washed plastic beakers
`and collecting bottles, the volumes were meas(cid:173)
`ured and the iron content of an aliquot was
`determined by an acid digestion method [77].
`Two baseline twenty-four hour urinary iron
`
`values were 0.6 and 1.37 mg. (normal up to
`0.2 mg. per twenty-four hours). After admin(cid:173)
`istration of 500 mg. Desferal® (desferrioxamine)
`the value rose to 7 .0 mg. in the twenty-four hour
`period, and after 1,000 mg., to 17.7 mg. per
`twenty-four hours. Subsequently in the hospital,
`and after the patient's discharge from the hos(cid:173)
`pital, he was given a series of short courses,
`five to ten duys in duration, of Dcsfcral therapy,
`1,000 mg. per day by intramuscular injection.
`Urine was collected for several days, including
`the first and last days, for iron determinations
`and the values obtained were averaged to pro(cid:173)
`vide an estimate of the daily urine iron excretion
`for each five to ten day period. The quantity of
`iron excreted was greatly increased above base(cid:173)
`line values, rising as high as 79.0 mg. per day.
`The total amount of iron removed over several
`weeks was approximately 1.0 gm., but although
`the patient claimed subjective benefit during
`the courses, there was no objective evidence of
`improvement.
`Subsequent Course. The patient was discharged
`from the hospital in June 1965, taking digitalis,
`diuretics, folic acid, and hydrocortisone and
`thyroid hormone. He was able to carry on
`limited activity. However, a few weeks later he
`began to notice increasing diuresis and weak(cid:173)
`ness, and when seen was noted to be weaker
`than usual, mildly dehydrated and emitting an
`odor of acetone. His urine contained sugar and
`
`AMERICAN JOURNAL 01' ){ED!ClNE
`
`
`7 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`Thalassemia Intermedia-Bannerman et al.
`
`483
`
`th e biood sugar vvas 568 mg. per cent. He was
`readmitted co the hospital and insulin was added
`to his medicines. The diabetes was stabilized
`with difficulty and, after further dental treat(cid:173)
`ment, he was again discharged in August 1965.
`On this occasion folic acid was not prescribed
`and it was subsequently noted on October
`12 that the film was more macrocytic and
`that there had been an apparent slight fall
`in hemoglobin and hematocrit (Fig. 5). Blood
`was drawn for serum folic acid determination
`(subsequently reported as low, Table u) and
`folic acid therapy was immediately reinstituted.
`
`COMMENTS
`This patient's lifetime encompasses the whole
`history of thalassemia, since he was born in
`1923, two years before Cooley described the
`major form and R ietti a minor form of the dis(cid:173)
`ease. The first diagnosis made in 1931 was "an
`atypical form of congenital hemolytic anemia."
`In l 932, when first seen by one of us, the diag(cid:173)
`nosis of Cooley's anemia was made. The m inor
`fon11 was not redescribed independently in the
`United States until 1940 (for historical refer(cid:173)
`ences, see Bannerman [781).
`\Ve have used the tern1 thalassernia inler(cid:173)
`mcdia to descr ibe the case, meaning a form of
`thalassemia intermediate in severity between the
`major and minor forms [79). The term has also
`been used to include some of the doubly heter(cid:173)
`ozygous states such as thalassemia-sickle cell
`disease [20]. The family study suggests that the
`patient could have received a gene for a {3
`form of thalassemia from the maternal side but,
`unfortunately, the family study is necessarily
`incomplete so that it is impossible to decide
`whether he might also have received another
`thalassemia gene from his father. I n fact, even if
`both parents of a patient also show evidence of
`thalassemia it may not be possible to determine
`with certainty whether the patient is homozy(cid:173)
`gous or heterozygous. Only a rare family ar(cid:173)
`rangement, one in which the suspected homozy(cid:173)
`gote is married to a normal subject, would allow
`a certain decision, since all of a homozygote's
`offspring should show evidence of the presence
`of the gene. Thus, although patients of this type
`are described as examples of the adult with
`Cooley's anemia [21-24], with the implication
`that they are homozygotes, this is rarely suscep(cid:173)
`tible to proof. We have tended to regard our
`patient as heterozygous because of his relatively
`benign earlier course, but he has shown many of
`
`VOi. . . 42, MAR C H 1967
`
`the features of Cooley's anemia, including eryth(cid:173)
`roblastosis (even before splenectom) ), inter(cid:173)
`mittent jaundice and splenomegaly. The hemo(cid:173)
`globin pattern, too, would indicate this diag(cid:173)
`nosis. H e showed only m inor bone changes at
`the age of forty-one.
`The next question that arises is why his con(cid:173)
`dition became so much worse at the: age of
`forty since he had had relatively minor symp(cid:173)
`toms after splenectomy at six years of age despite
`hemoglobin levels apparently varying f'rom 7.6
`to 12.9 gm. per 100 ml. \ Ve have explained this
`as a cumulat ive effect of increasing iron overload
`on many organs, leading to concurrent cardiac
`failure, hepatic dysfunction and multiple endo(cid:173)
`crine deficie ncies. Some degree of coronary ar(cid:173)
`tery atherosclerosis could well have contributed,
`as did the complication of folic acid deficiency
`with further slight fall in the hemoglobin level
`to 6.0 gm. per 100 ml.
`Relative folic acid deficiency, sometimes with
`megaloblastic changes, has been reported previ(cid:173)
`ously in thalassemia major [25-28), intermedia
`[29) and minor during the additional stress of
`pregnancy [30]. T he elevated serum levels of
`lactic dehydrogenase (LDH) in this ~ituation
`have been a ttributed to inc.-eased desti ucliu11 uf
`red cell precursors in the bone marrovv [37 ].
`Severe iron overload was demonstrated by
`iron deposition in the gastric mucosa on biopsy
`and by the urinary iron excretion induced by des(cid:173)
`ferrioxamine therapy, and the skin pigmentation
`and high saturation of the iron-binding capacity
`are consistent with this diagnosis. Although
`a precise relationship between desferrioxamine
`response and body iron load has not yet been
`documented, a rough proportionality probably
`exists, and the results in this patient were in the
`range expected in idiopathic hernochroma tosis
`and in severe secondary he rnochrornatosis due
`to blood transfusion [32- 35]. The few blood
`transfusions given at the time of splenectomy
`would not account for iron overload. The iron
`medication, given for an unknown total period
`but probably for several years, provided a daily
`oral dose of 500 mg. iron. Patients with thalas(cid:173)
`semia continue to absorb iron eYen when they
`are already iron laden [36]. If we assume that
`only 5 per cent of the iron in medications was
`absorbed, it could have led to iron accumulation
`in the body at the rate of 10 gm. per year. Fur(cid:173)
`thermore, the patient deliberately chose iron(cid:173)
`rich foods, such as liver, for many years of his
`life. T hese sourct:s, medication and diet, are
`
`
`8 of 11
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1016
`
`

`

`484
`
`Thalassemia Intermedia-Bannerman et al.
`
`assumed to be the causes of his serious iron load.
`The possible danger of administering iron to a
`patient of this type is evident.
`Although the unavoidable accumulation of
`iron in patients given t ransfusions is well known
`and is regarded as a major cause of serious com(cid:173)
`plications [3-5,37], reports of its occurrence in
`patients with thalassemia who have received no
`or few transfusions are uncommon [7,38- 40].
`Some pathologists are skeptical of the role of
`iron overload in producing tissue damage and
`point to the paucit y of animal experiments which
`can be inter preted as showing this effect [47,42] .
`It is clear, too,