- On the other hand, when the increase in demand for erythrocyte is acute, the sinus sieve is overwhelmed and some nucleated red cells may escape into circulation before the development of significant erythroid hyperplasia. This may be the mechanism of erythroblastemia in severe blood loss with attendant hypotension and hypovolemia. This mechanism is probably mediated by an increase in production of erythropoietin as a result of hypoxia. Increase in erythropoietin output may also be responsible for erythroblastemia accompanying hypoxia of severe cardiac failure, pulmonary embolism or severe cor pulmonale. In these situations, the findings of erythroblastemia is often indicative of unfavorable prognosis. Slight to moderate reticulocytosis (up to 8 percent) may be present. Erythroblastemia is restricted to fairly mature nucleated red cells, but occasional immature granulocytes may also be seen. Morphologic abnormalities of red cells are usually absent.
- A third cause of erythroblastemia is mechanical disruption of the normal marrow structure by infiltrative diseases, notably metastatic carcinoma. This form of erythroblastemia is usually accompanied by the presence of circulating immature granulocytes and severe anemia (leukoerythroblastic anemia) and carries a poor prognosis. The circulating nucleated red cells may be in all stages of developmental maturation. It is of interest that not every metastatic carcinoma with marrow involvement is associated with erythroblastemia. Some tumors (prostate, breast, lung) show a greater tendency than others to produce this phenomenon. The reason for this is not clear.
- Another cause of erythroblastemia is hemopoiesis within the intravascular space-a phenomenon that bypasses the sinus sieve. This is seen in the myeloproliferative disorders, notably myeloid metaplasia, polycythemia vera, and chronic granulocytic leukemia. In these disorders, particularly myeloid metaplasia, with or without myelofibrosis, poikilocytosis is often profound as deformed cells proliferate directly within the blood stream in teardrop and other abnormal forms. The appearance of bizarre platelets and immature granulocytes in the circulation (leukoerythroblastosis) is also explicable on the basis of intravascular hemopoiesis. As may be expected, nucleated red cells in all stages of development (basophilic, polychromatophilic, orthochromatic) are seen in the blood. Mild reticulocytosis (2 to 5 percent) is usually present as well.
- Persistent fatigue, pale or yellowish skin, and frequent headaches.
- Diarrhea, nausea, and a loss of appetite.
- Physical weakness with minimal exertion, an enlargement of the liver, shortness of breath, and the expulsion of bile through urine and fecal matter.
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