Postgraduate Medical Journal (July 1971) 47, 504-510.

CLINICAL REVIEW

Haemocytic periodicity and periodic disorders:Periodic neutropenia, thrombocytopenia, lymphocytosis and anaemia

HOBART A. REImANNM.D.

The Department of Medicine, Hahnemann Medical College and Hospital,Philadelphia, Pennsylvania 19102

SummaryEvidence has accumulated of rhythmic numericaloscillation of each of the blood cells either indepen-dently or in combinations.The cyclic changes originate in the marrow of some

normal persons and animals without causing illness,and can be induced experimentally.

In more than 100 reported instances, periodic oscilla-tions of various cells were accompanied by respectiveepisodes of the disorders named in the title. The dis-orders may be transitory but usually recur throughoutlife and occasionally are fatal. All resist therapy.Features in common suggest an interrelationship of thehaemal disorders and other disparate heritable periodicdiseases.

Theoretically, the rhythms are regulated byubiquitous, inherent, intracellular bioclocks controlledhypothalamically or neurohumorally in relation to afeedback mechanism. Reactions to long cycles are ofgreater clinical importance than disturbances arisingfrom the circadian rhythm.

IntroductionAfter the establishment of periodic (cyclic)

neutropenia as an entity in 1949 (Reimann & DeBerardinis, 1949) nearly fifty cases were added to theforty-two cited in 1963 (Reimann, 1963). Because thetrouble originates in the marrow, the term periodicmyelodysplasia was proposed. The broad termapplies if the numbers of more than one kind ofhaemocyte oscillate synchronously or independentlyas they often do. When neutrophils, platelets, mono-cytes, lymphocytes and erythrocytes alone oscillate,specific designation is appropriate. By includingperiodic disorders related to the numeric fluctuationof various haemocytes, the total number of reportedcases involving the blood exceeds 100. Many un-recognized ones, no doubt, exist.

Periodic haemocytic changes are either primary orare associated with mensis, lymphomas and immuno-suppressive therapy. In both circumstances, the

involvement is either overt or clinically inapparentexcept for the numeric cellular oscillation. Periodicityescapes detection unless cells are counted at shortintervals in patients, n healthy genetic relatives orothers. Serial counts have disclosed periodicity insome patients regarded as cases of continuous, con-genital or hereditary neutropenia (Morley, Carew &Baikie, 1967).

Periodic neutropenia is heritable. Probably throm-bocytopenia, lymphocytopenia and anaemia also aregenetically transmissible. The disorders are notalways benign. Concurrent infection or bleedingoccasionally is fatal. Therapy generally is ineffectual;the symptoms alone are meliorated, cellular cyclesusually persist. This review stresses the periodicity ofvarious haemocytes, their interrelated disorders andfrequent heritability as described in published casesand personally observed ones. Articles cited inreferences recount detailed clinical features.

Periodic neutropeniaHeredity

Morley's studies, particularly his opportunity tostudy five afflicted families, provided much informa-tion. Twenty members had had overt disease, usuallysince infancy. Neutrophils also fluctuated rhythmi-cally in several symptomless members. Some ofthem had continuous neutropenia with cycles offurther depression. The tempo ranged from 15 to 35days, averaging 20. Synchronous monocytosis andfever occurred often. Anaemia, eosinophilia andthrombocytopenia concurred episodically in threerelatives. An autosomal dominant trait of highpenetrance and variable manifestations character-ized the afflicted families (Morley et al., 1967).

Table 1 portrays thirty-seven primary casesaccruing after forty-two previously recorded onesand includes a few I omitted in 1963. Table 2 showsten cases regarded as secondary neutropenia, makinga total of eighty-nine in all. Of the seventy-nineprimary ones, forty-two were in females, thirty-seven

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TABLE 1. Periodic neutropenia

Age at Perio- Thrombo-Author Sex Age onset dicity Mono- Lympho- cyto- Eosino- Familial Unusual

(years) (years) (days) cytosis cytosis penia philia features

Lorre & Denys F 8 3/12 23 + + + Rapid ESR(1960)

Toro et al. (1960)

Bray (1960)

Gorlin &Chaudry (1960)

Malooly (byletter)

M 2 4/12 19 (21 days +after

cortisone)F 9 ? 21

Thrombo-cytosis

F 8 4 21

M 54 33 28 Mono-cyto-penia

Alestig (1961) F 58 54 14

Telsey et al.(1962)

Videbaek (1962)

Wade & Stafford(1963)

Coutel, Morel &Thomet (1963)

Smith (1964)

Journal of theAmerican Medi-cal Association(1965)

Simonsen (1966)

Morley (1967)Twenty cases

Felitti (by letter)Waldron-Shah

(by letter)

F

MMM

M

M

14

29218

38

4/12 ±21

210/12

1

32

2121

21; later14

21-28

+

6 1 ±21 +

M 20 6 14-20

F 22 16 ?

F 21

7M13F

FF

17 ±21

Usuallychild-hood

6 ?35 8

15-35 Often

21

Sialorrhoea,diarrhoea, seizures

Serious infections,steroids ineffective

+

Prednisonemelioratedsymptoms onlyPrednisonemelioratedsymptoms only.Spontaneousremission 1 yearfever 40° CSplenectomy andsteroids ineffective

+ Fever 39 'CFever 38 'C

Splenectomy, pred-nisone relievedsymptoms onlyPulm. abscess

Hypergamma-globulinaemiaFive episodes ofpancreatitis

Lympho-cyto-penia

+ +

Abdominalgia,arthralgia

7 familial Periodic arthralgiain three

Died, peritonitis+ Doubtful Stethalgia, abdomi-

in several nalgia, arthralgia,relatives erythema, xero-

stomia, diaphoresis,diarrhoea, oedema,somnolence, pallor

in males. They began in infancy in twenty-seven andafter age 60 in three. Periodicity generally rangedfrom 14 to 28 days, mostly 20 or 21. Monocytosis ormonocytopenia, lymphocytosis or lymphocytopenia,eosinophilia and thrombocytopenia or thrombo-cytosis characterized some instances. The recordednumbers depended upon whether cells were countedduring episodies or in the intervals. Publishedreports do not always specify the timing. Seriousinfections occasionally ensued and seven endedfatally. Familial involvement was evident in eleveninstances. In several groups, symptomless relatives

were neutropenic or had recurrent oral ulcers with-out detected rhythm. Pregnancy suppressed,worsened or had no effect on episodes. Cortico-steroids meliorated the symptoms in a few, but hadslight or no effect on the cellular cycles. Splenectomyseldom was justified. As found in common withother disparate periodic disorders, synchronousfever, sialorrhea, xerostomia, exanthems, arthrosis,abdominalgia and diarrhoea occasionally occurred.

Similar to human disease, six grey Collie dogs hadheritable periodic neutropenia. Three had con-current gingival and dermal ulcers, arthralgia and

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fever. Neutropenic episodes recurred every 8-13days averaging 10 with compensatory monocytosis(Lund, Padgett & Ott, 1967).

Complement anomaly in periodic neutropeniaStudy of my patient E.C. disclosed the inhibitor

of C1 esterase reduced from a normal 5 6 units to 3-6u and 4 u in two respective episodes, and to 4 u in aninterval. His whole serum complement activity duringthe two episodes measured 34 u and 58 u, and in thesymptomless interval 44 u (normal 62 ± 19 u)(Reimann, Coppola & Villegas, 1970). Splenectomyfailed to help the patient. Testosterone melioratedthe symptoms for a time by preventing extremeneutropenia. It induced concurrent monocytosis,and lymphocytosis and increased the granulocyticreserve as demonstrated by the pyrogen stimulationtest (Brodsky, Reimann & Dennis, 1965).

Aysmptomatic and secondary periodic neutropeniaMorley demonstrated symptomless neutropenia

at intervals of 14-23 days in eight of eleven normalmen from unaffected families. Similar oscillationaccompanied mensis in two normal women (Morley,1966). The behavior indicates the existence of anunderlying inherent biorhythm and a feedbackmechanism affecting the formation of cells. Thisaction in genetically susceptible persons provokesdisease (Reimann, 1948). In one of my patients withperiodic polyserositis (Case 1, Reimann, 1948),periods of symptomless neutropenia, monocytosisand lymphocytosis occasionally recurred separatelyfrom episodes of her disease.

After the deliberate impairment of immunity,Alexander demonstrated fluctuation of antibacterialactivity of neutrophils in cycles usually of 14-24days in patients and monthly in dogs. The activitywas independent of the number of neutrophils.Injury and immunosuppressive therapy adverselyaffected phagocytosis but did not abolish the basiccycle. As in periodic neutropenia, infection occasion-

ally concurred (Alexander. Dionigi & Meakins,1971). Morley & Stohlman using cyclophosphamidereduced the number of neutrophils in dogs andlowered neutropenia every 11-17 days (Morley &Stohlman, 1970). A hypothetic feedback control wasdiscussed in detail (Morley, 1970).

Patients with polycythemia or leukaemia andsecondary periodic neutropenia listed in Table 2 allwere adults. The rhythm of neutropenia ranged from30 to 120 days. Its amplitude probably was extendedto that length by the gravity of the underlyingdiseases or by therapy thereof. Thrombocytopeniaconcurred in four. Episodes of neutropenia affectedaganunaglobulinemic children (Telsey, et al., 1962).

Neutropenia andpancreatic disturbanceNeutropenia and pancreatic dysfunction affected a

child at 21-day intervals (Colebatch et al., 1965).In six other patients, a 'new' entity, in one instancefamilial, consisted of pancreatic insufficiency,anaemia, neutropenia and occasional thrombo-cytopenia and purpura. The tabulated data suggestunnoticed recurrent episodes of neutropenia(Shwachman et al., 1964). Bodian also commentedon the combination of congenital pancreatic hypo-plasia, neutropenia and thrombocytopenia (Bodian,Sheldon & Lightwood, 1964). Fluctuation of thethree factors appears in the tables of two of hispatients, but cell counts were too widely spaced todetect regular periodicity. Elsewhere I describedperiodic pancreatosis without attention to neutro-philic changes (Reimann, 1962).

Periodicity during haemal diseasesIn a polycythemic patient, the number of neutro-

phils fluctuated every 15 days, the platelets every 27days, both within the normal range. A reticulocytecycle of another patient lasted 17 days (Morley,1969a). As noted by Morley and others, periodicneutropenia occasionally accompanies lymphoma-toses (Morley, Baikie & Galton, 1967) (Table 2). In

TABLE 2. Secondary periodic neutropenia

Perio- Thrombo-Disease Sex Age Age at dicity Mono- cyto-

(years) onset (days) cytosis penia

Morley (1969a) Polycythemia M 68 8 15 + + Another patient had peri-27-day odic reticulocytopenia atcycles 17-day intervals

Morley, Baikie & Galton Myelogenous F 42 ? 50-55 + Modified by therapy(1967) leukaemia

Leukaemia M 45 ? 30-35 + Modified by therapyLeukaemia F 60 57? 30 Modified by therapyLeukaemia M 37 35? 100-120 Modified by therapy

Kennedy (1970) 5 patients 30-50 +Myelogenousleukaemia

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Kennedy's five patients with myelogenous leukaemiatreated with hydroxyurea, leucocytes and plateletsfluctuated in 30-50-day cycles (Kennedy, 1970).Rhythm may be obscured by therapy or by thegravity of the primary disease. On the other hand,either therapy or the disease induces oscillation.

Secondary lymphocytosisLymphocytosis occasionally accompanies normal

mensis (Minot, 1936). During lymphocytic leukaemiain a patient, spells of fever, polyuria and facialoedema appeared at 5-10 day intervals. Fourmonths of observation disclosed a lymphocyte-lymphoblast number of about 280,000 which dimin-ished to normal during episodes. The 2%Y of seg-mented cells diminished slightly in unison. Anattack of herpes zoster temporarily lengthened therhythm to 15 and 17 days. On one occasion, with-drawal of spinal fluid promptly increased the numberof lymphocytes and averted an expected febrileepisode. The event suggested central neural or neuro-humoral regulation (Stacher & Bohnel, 1958). Theidea was based on the experimental demonstration ofprompt leucocytosis after mechanical disturbance ofthe hypothalamic area. Although governed centrally,the effect presumably is mediated humorally on themarrow (Rosenow, 1951).

Periodic thrombocytopeniaSince Demmer's report, at least six primary cases

have been described (Demmer, 1920). In one instance,a man had episodes of bleeding for 42 years. Hisplatelets diminished monthly to fewer than 50,000/mm3 after reduction of megakaryocytes in themarrow. The numbers of leucocytes and erythrocytesremained normal. Prednisone was ineffective(Engstrom, Lundquist & Soderstrom, 1966). A man,aged 37, had five episodes of thrombocytopenia and

bleeding, each one worse until death from cerebralhaemorrhage. Episodes came at predicted 21-dayintervals. Platelet counts ranged from 0 to 500,000/mm3. Splenectomy and prednisone had failed tohelp (Wasastjerna, 1967).

Table 3 lists the six patients. The disorder beganin middle age. Periodicity ranged from 21 to 39days. One patient had haemolytic anaemia. Onedied during an episode. Spenectomy and cortico-steroid therapy had no effect.

Asymptomatic and secondary periodic thrombo-cytopeniaMorley discovered a 21-35-day rhythmic oscilla-

tion in the number of platelets in normal persons. Inoccasional susceptible persons like these, bleedingmay occur regardless of the degree of thrombo-cytopenia (Morley, 1969b). Rhythm may be over-looked unless serial counts are made. If these aremade on patients with essential thrombocytopenicpurpura, rhythmic fluctuation of platelets maybecome evident in some of them. Correct diagnosisobviates splenectomy which is ineffective forperiodic thrombocytopenia.Thrombocytopenia and purpura also occur in

rhythm with mensis (Pohle, 1939). In a woman aged46, episodes of epistaxis, menorrhagia and purpurarecurred every 28 days for 8 years. Episodes usuallycoincided with mensis and also happened in the mid-period. Platelets varied in number from 10,000 to300,000. The marrow contained nonfunctioningmegakaryocytes fluctuating in rhythm. Normalhormonal amounts remained constant. Becauseepisodes recurred regularly after oophorectomy(Skoog, Lawrence & Adams, 1957), prior relation tomensis may have been coincidental. In anotherwoman, thrombocytopenic purpura happened atevery other menstrual flow (Pepper, Liebowitz &

TABLE 3. Periodic thrombocytopenia

Age Age at PeriodicitySex (years) onset (days) Symptoms Comment

Demmer (1920) M 61 55 28 Purpura Irregular synchronous lympho-cytosis. Death from nephritis

Skoog et al. (1957) F 46 38 28 Epistaxis, menorrhagia, With and between mensis.purpura, mucosal lesions Persisted after oophorectomy

Dameshek (by letter) F 42 27 Episodes of haemolytic Had prior splenectomy foranaemia, thrombocytopenic haemolytic anaemiapurpura

Wasastjerna (1967) M 37 33 21 Severe bleeding Died in predicted episode fromcerebral haemorrhage. Sple-nectomy and steroids no help

Engstrom et al. (1966) M 61 59 39 Purpura 'Absolutely regular sequence'Bernard & Caen M 54 12 Monthly Buccal ulcers, subcutaneous Corticosteroid and splenec-

haemorrhages tomy, no effectCandura (1960)

Fourteen cases re-lated to mensis

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Lindsay, 1956). In the published case record, lowerplatelet counts appear without comment at about 20-day intervals suggesting a circa 21-day periodicity.Candura described two cases related to mensis andcited reports of at least twelve others chiefly inItalian and German journals (Candura, 1960).These are regarded here as secondary but if includedin Table 3 would make a total number exceedingtwenty. More cases, no doubt, will be diagnosedwhen serial counts are made.

Regardless of known platelet participation, bleed-ing and purpura can be induced periodically inreligious stigmatists presumably by wilful excite-ment ofthe autonomic neurovascular system (Agle&Ratnoff, 1962).

Periodic erythrocytic oscillationA 7-year-old boy had 'congenital hypoplastic

anaemia and periodic erythrocytopenia' sinceinfancy. At first, episodes came at 2-3-monthintervals, later about twice yearly. The marrowduring episodes showed erythrocytic aplasia. Thechild was well between episodes and developednormally otherwise. An infant brother died fromanaemia (Gordon & Varadi, 1962).A man who died at age 21 from Hodgkin's disease

had had numerous episodes of anaemia with in-creased sedimentation-rate, lymphocytopenia andfever. Two-week-long episodes alternated withabout 3 weeks of relative good health. Five episodeswere observed during 5 months in a hospital.Because of brisk erytnropoiesis in the marrow, hisphysicians regarded the periodic anaemia as ofhaemolytic origin (Ranl0v & Videbaeck, 1963).Ashby observed 8-16-day cycles of haematopoesis

in animals and changes in human erythrocytenumbers every 14 days (Ashby, 1948). In Morley'spolycythemic patient, independent reticulocyte,neutrophil and platelet cycles indicated that normalhomeostatic controls still were functional (Morley1969a). A 14-day oscillatory rhythm of reticulocytesappeared in dogs. Bleeding and transfusion shiftedthe oscillatory phases (Morley & Stohlman, 1969).

DiscussionIn the past 20 years, clinical interest in life-long

recurrent disorders in otherwise healthy persons hasincreased. Many examples have been delineated andadded to those described previously. They are in-cluded in a proposed group of disparate noso-logically related entities. Common to all are herit-ability, precise or irregular periodicity, overlappingfeatures, menstrual suppression of episodes, resis-tance to therapy and similar serum-complementaldefects (Reimann, 1963).

Considering the interrelation of periodic dis-orders, the case described to me as one of possible

periodic neutropenia by Waldron-Shah (Table 1) ispertinent. The patient has constant leucopenia withperiods of neutropenia every 21 days 'predictable tothe day'. Other leucocytes increase reciprocally.During episodes, the usual oral ulcers appear. But inaddition, there occur fever, severe abdominalgia andstethalgia, arthralgia of elbows and knees, andoedema of the eyelids, face, palate and hands. Thesefeatures respectively characterize periodic poly-serositis, periodic arthrosis and periodic oedema.Myalgia, sialorrhea, xerostomia, erythema, somno-lence, blurred vision, diaphoresis, tachypnea, vomit-ing and diarrhoea common to all periodic disordersalso concur at times in the episodes as autonomicreactions. An electroencephalogram was normal.Because none of the symptoms predominate con-sistently, a basic diagnosis of periodic neutropeniawith composite symptoms is appropriate.

It may be recalled that a patient with periodicpolyserositis (Case 1, Reimann, 1948), cited abovehad occasional separate periods of neutropenia. Asindicated in Table 1, Simonsen's neutropenicpatient had abdominalgia and arthralgia. Somefamily members of Morley's group had arthralgia,and Lorre's patient had synchronous sialorrhoea,diarrhoea and seizures. Periodic neutropenia withpancreatic disturbance was mentioned above.Systemic disturbance is obvious.Regarding periodic haemal disorders, several

entities have emerged. According to the tables,primary periodic haemal disorders begin at anytime of life, occasionally are familial, have overlap-ping features, resist therapy and occasionally arefatal. Evidence of similar periodicity emerges duringunrelated diseases. Periodicity can also be inducedexperimentally in man and animals. Various haemalcells oscillate in number independently or in com-binations. When independent, specific names may beapplied; for combinations, the term myelodysplasiaseems apropos. Synchronous increases in numbersof certain cells may be compensatory or specific.The immediate site of disturbance is in the marrow.

Why the oscillatory rhythm varies in days, weeks ormonths, often precisely, in different patients and fordifferent cells is unknown. Occasional temporalassociation with mensis may indicate either hor-monal incitement or the synchronous effects of twoseparate biorhythms. Morley's discovery of similarhaemocytic cycles in asymptomatic members ofafflicted families, in normal persons, and in animalsindicates the ubiquity of the rhythm. Exaggerationof oscillation or oscillation in susceptible personsevokes periodic disease.Alexander demonstrated depressed antibacterial

action of neutrophils in the usual 14-24-day rhythmin normal persons. At the nadir of action, infectionoccurred in one person. Infections also occurred at

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the time in burned patients and in others treated withimmunosuppressive drugs. The behavior may beone variable factor favoring unexpected recurrentinfections. Long biorhythms as principles of life andreactions to them are of much more clinical im-portance than disturbances incident to the circadianrhythm.

Concerning the ultimate cause, no demonstrableinborn-error of metabolism or endocrinal influenceparticipates. The circadian rhythm, extraneous geo-physical or cosmic influences have no bearing.Whether a complement disturbance observed in thesingle case of periodic neutropenia is a characteristicand relevant to the cause cannot be said withoutfurther evidence.

Theoretically, an inherent biorhythm excites thehypothalamic area, the effects of which are mediatedneurally. Pertinent to the blood, Richter postulatedthe existence of local bioclocks or Zeitgebers in cellsof the marrow (Richter, 1960). An action-phase inthe stem cells of each of the haematopoetic com-ponents may synchronize independently to causeneutropenia, lymphocytopenia, thrombocytopenia,reticulocytopenia or anaemia, or these in variouscombinations. The bearing of the theories on thefeed-back proposal (Morley, 1970) is conjectural.Does feedback control the rhythm or the reverse?Morley, King-Smith & Stohlman (1970) discussedthe matter of haemal periodicity in detail concludingthat 'if many systems do show the same principles ofcontrol as does haemopoiesis, many periodicdiseases may arise in similar fashion'.

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