An erythrocyte membrane-protein anomaly in march haemoglobinuria

March hemoglobinuria progressed to acute kidney injury after kendo practice: a case report

Background

March hemoglobinuria is caused by a hemolytic mechanism due to transient hematuria after physical exercise which, although rare, may lead to acute kidney injury. We report a case of a patient with march hemoglobinuria induced by kendo, which was diagnosed by the presence of Berlin blue iron staining in the proximal tubules through renal biopsy.

Case presentation

A 15-year-old male complained of fever (37 °C), general malaise, and nausea after hard kendo sessions. Laboratory findings revealed indirect bilirubin dominant hyperbilirubinemia (total bilirubin 3.8 mg/dL), high lactate dehydrogenase (LDH), and acute kidney injury (serum creatinine: 3.11 mg/dL and estimated glomerular filtration rate: 26 mL/min/1.73m2). Urine test was positive for occult blood but without hematuria. Renal biopsy was performed to clarify the cause of renal injury, which showed minor glomerular abnormalities. Meanwhile, hemosiderin deposition was identified in the proximal tubules by Berlin blue iron staining, and lysosomes were observed to contain granular iron. In addition to clinical background of strenuous kendo exercise, renal biopsy led to a definitive diagnosis of march hemoglobinuria.

Conclusions

March hemoglobinuria is a hemolytic disease that can occur after intense exercise, especially kendo. Considering its rarity due to the lack of critical symptoms, it is important to note that occult blood-positive findings may be indicative of march hemoglobinuria if the patient underwent strenuous exercise. Therefore, clinicians should be aware of this possibility to provide timely and appropriate treatment.

Percussion hemoglobinuria - a novel term for hand trauma-induced mechanical hemolysis: a case report

Introduction

Extracorpuscular hemolysis caused by mechanical trauma has been well described in relation to lower extremity use, such as in soldiers and runners. Terms such as "march hemoglobinuria", "foot strike hemolysis" and "runners hemoglobinuria" have previously been coined and are easily recalled. Newer cases, however, are being identified in individuals vigorously using their upper extremities, such as drum players who use their hands to strike the instrument. Given the increased recognition of upper extremity-related mechanical hemolysis and hemoglobinuria in drummers, and the use of hand drumming worldwide, we would like introduce a novel term for this condition and call it "percussion hemoglobinuria".

Case presentation

A 24-year-old Caucasian man presented with reddish brown discoloration of his urine after playing the djembe drum. Urine examination after a rigorous practice session revealed blood on the dipstick, and 0 to 2 red blood cells per high power field microscopically. The urine sample was negative for myoglobulin. Other causes of hemolysis and hematuria were excluded and cessation of drum playing resulted in resolution of his symptoms.

Conclusions

The association of mechanical trauma-induced hemoglobinuria and playing hand percussion instruments is increasingly being recognized. We, however, feel that the true prevalence is higher than what has been previously recorded in the literature. By coining the term "percussion hemoglobinuria" we hope to raise the awareness of screening for upper extremity trauma-induced mechanical hemolysis in the evaluation of a patient with hemoglobinuria.

Hematologic Disorders in the Athlete

Optimal athletic performance depends on proper function of many organs, including the blood. This is underscored by the focus of endurance athletes on increased hemoglobin through training at altitude or exogenous erythropoietin. Several other aspects of the hematologic system can also affect or be influenced by physical activity. In this article, the authors briefly discuss inherited abnormalities of the blood that can manifest themselves in athletes. We then discuss the effects of exercise on the blood, and acquired abnormalities of blood cells or coagulation parameters that occur in athletes, and that can influence performance or cause other symptoms.

Intravascular Hemolysis in Aerobic Dancing: The Role of Floor Surface and Type of Routine

In brief: The effect of aerobic dancing on intravascular hemolysis was studied in 65 healthy women (aged 18 to 50 years) who were assigned to one of four groups according to the type of routine performed and the hardness of the floor surface. All subjects participated in a 60-minute dance session; a subgroup participated in five successive 60-minute sessions with one hour of rest between sessions. Blood was tested for both groups before and after exercise; urine was tested similarly for the subgroup only. The findings indicated that intravascular hemolysis occurred and that it was influenced by the type of routine, hardness of the surface, and duration of dancing. However, the degree of hemolysis was small and unlikely to contribute to the development of anemia.

Marathon Running Fails to Influence RBC Survival Rates in Iron-Replete Women

In brief: As many as 80% of female long-distance runners show iron deficiency. One explanation is RBC fragmentation due to mechanical trauma. In this study, radiolabeling was used to measure RBC survival rates in six iron-replete female marathon runners. In addition, tests for urinary hemosiderin were conducted in a search for secondary evidence of RBC damage. Radioactivity counts on blood samples drawn before and after a standard 26-mile marathon failed to disclose traumatic RBC fragmentation, and the tests for urinary hemosiderin were negative. Other possible factors in iron deficiency, such as diet, therefore merit consideration.

A phenomenological difference between membrane skeletal protein complexes isolated from normal and hereditary spherocytosis erythrocytes

Membrane skeletons may be obtained from human erythrocytes by extraction with non-ionic detergent. When treated under defined conditions with a cAMP-independent kinase preparation from normal membranes, a suspension of these membrane skeletons sets to a gelatinous mass. Membrane skeletons from the cells of hereditary spherocytosis patients fail to show this response. Those from subjects with some other haemolytic anaemias do not share the abnormality. The gelation process could be shown also to occur with normal membrane skeletons, extracted at high ionic strength, and containing essentially only the structural protein constituents, spectrin, actin, 4.1 and 4.9. It also occurred rapidly when a column-purified kinase preparation was used, so that no significant amounts of contaminating proteins were introduced. Added spectrin, 4.1 or actin in moderate amounts did not induce gelation in the presence of ATP. Cytochalasin E did not perturb the gelation process. Gelation required ATP as well as kinase, and did not occur when the non-hydrolysable analogue, AMP X PNP, was used instead. Gelation was accompanied by phosphorylation of the spectrin alone, and is thus evidently a consequence of the modification of its properties by this means. Inhibition of phosphorylation by added adenosine retarded gelation. It may be inferred that phosphorylation of spectrin generates new, probably weak, non-covalent interactions between cytoskeletal constituents that cause association of the isolated cytoskeletons. A semi-quantitative method of observing the gelation process, based on the time of incubation before the membrane skeleton suspension ceases to flow under gravity at a low shear, is described.

Missing band 7 membrane protein in two patients with high Na, low K erythrocytes

We investigated the erythrocyte membrane proteins of two patients with congenital hemolytic anemia due to increased permeability of the erythrocyte membrane to Na and K (hereditary stomatocytosis and cryohydrocytosis). One-dimensional sodium dodecyl sulfate (SDS) gel electrophoresis resolved the band 7 erythrocyte membrane proteins into three components with approximate molecular weights of 30,000, 28,000, and 26,000. The 28,000-dalton component was decreased in both patients with permeability disorders. Two-dimensional electrophoresis (nonequilibrium pH gradient electrophoresis in the first dimension combined with SDS gel electrophoresis in the first dimension combined with SDS gel electrophoresis in the second dimension) resolved the 28,000-dalton component from normal erythrocyte membranes into two proteins with different isoelectric points, designated 22 x 8 and 60 x 8. In the patients with hereditary stomatocytosis and cryohydrocytosis, 22 x 8 was completely absent, whereas 60 x 8 was detected as usual. In contrast, all the band 7 proteins (including 22 x 8) were invariably present in a survey of normal subjects and reticulocytosis controls. The unique finding of a missing band 7 protein in the patients with hereditary stomatocytosis and cryohydrocytosis raises the possibility that the absence of this protein is responsible for the increased Na and K permeability in these disorders.

Hemoglobinuria after fraternity hazing

We describe a 19-year-old male who presented with traumatic hemoglobinuria. We hypothesize that this patient has a genetic haptoglobin variant with a low hemoglobin binding capacity which resulted in hemoglobinuria after physical fraternity hazing. A review of the literature regarding traumatic hemoglobinuria supports the association between decreased baseline plasma haptoglobin levels and hemoglobinuria after trauma.

Red cell membrane protein anomalies in congenital dyserythropoietic anaemia, type II (HEMP AS)

In all of six cases of congenital dyserythropoietic anaemia, type II (HEMPAS), gel electrophoresis in the presence of SDS revealed abnormally rapid migration of the preponderant integral membrane protein, band 3. After proteolysis of intact cells, the remaining part of the band 3, comprising the intramembrane segment and the cytoplasmic domain, migrated electrophoretically as a single band, identical in mobility to that from normal cells treated in the same manner. The anomaly thus resides in the extracellular domain of the protein, which is the glycosylated part of the chain. Peptide digests of the band 3 showed no evidence of a missing protein segment in the abnormal cells and the amino acid composition of the peptides derived from proteolysis of the extracellular protein of intact cells was also normal. We infer that the anomaly is one of glycosylation. The major glycoproteins, detected by carbohydrate-specific (PAS) stain appear normal in SDS gels. However, when the more sensitive procedure of reacting after electrophoresis with radioiodinated lentil lectin is employed, some additional minor protein components are revealed. In particular one species of apparent subunit molecular weight about 150 000 appeared in all cases of HEMPAS examined and in no normals. This component is not accessible to proteolysis by chymotrypsin or Streptomyces griseus protease, and may be associated with the inner membrane patches, characteristic of the HEMPAS condition. Overall cell shape and microviscosity of the membrane bilayer, as measured by fluorescence polarization of a lipid-soluble fluorophore, were substantially normal in HEMPAS cells.

Exercise-induced hemolysis in xerocytosis. Erythrocyte dehydration and shear sensitivity

A patient with xerocytosis was found to have swimming-induced intravascular hemolysis and shortening of erythrocyte life-span. In a microviscometer, xerocytes were more susceptible than normal erythrocytes to hemolysis by shear stress. Fractionation of normal and abnormal cells on discontinuous Stractan density gradients revealed that increasingly dehydrated cells were increasingly more shear sensitive. This sensitivity was partially corrected by rehydrating xerocytic erythrocytes by means of the cation-ionophore nystatin in a high potassium buffer. Conversely, normal erythrocytes were rendered shear sensitive by dehydrating them with nystatin in a low potassium buffer. This effect of dehydration was entirely reversible if normal cells were dehydrated for less than 4 h but was only partially reversed after more prolonged dehydration. It is likely that dehydration of erythrocytes results in shear sensitivity primarily because of concentration of cell contents and reduced cellular deformability. With prolonged dehydration, secondary membrane changes may potentiate the primary effect. This increased shear sensitivity of dehydrated cells may explain atraumatic exercise-induced hemolysis in xerocytosis as cardiac output is shifted to vessels of exercising muscles with small diameters and high shear rates.