Two Cases of Acute Idiopathic Circumscribed Gangrene.

not found. The serum bilirubin was 0.7 mg./iOO ml., the alkaline phosphatase x6 K.A. units/ioo ml. and the flocculation tests were normal. In the xylose absorption test, 5 g. xylose were excreted in the urine in five hours. A three day test of fat excretion in the stools showed an average of 2.8 g./24 hours. Progress Nine days after admission the h2emoglobin had fallen to 7.2 g./ioo ml., the white cells numbered 4,I00 and the reticulocytes were 6%. The direct Coombs' and Schumm's tests were now negative, but serum haptoglobins were absent. Eighteen days after admission, the hmoglobin was 9.5 g./ioo ml., and the reticulocytes 12%. The bone marrow contained fewer megaloblasts and a greater number of polymorphs, the differential count being: Blast cells 5%, myelocytes and metamyelocytes i8%, polymorphs and band cells 33%, proerythroblasts 6%, normoblasts 27%, megaloblasts 8%. There was still a large amount of FIGLU in the urine. Six weeks later the hemoglobin was I2.4 g.Io00 ml., and the reticulocytes I %. Autohemolysis was normal. FIGLU was still present in the urine, but the amount was much less than previously. The serum vitamin B12 level had risen to 220 ,ug./ml. The spleen was not palpable, and he had gained 12 lbs in weight. In January I963, the hwmoglobin was I2.8 g./ioo ml. The stained blood film showed a normal appearance of the red cells, but there were a large number of polymorphs with hypersegmented nuclei, 35% having 5 lobes, I3% 6 lobes and 3% 7 lobes. A slight trace of FIGLU was detected in the urine, and the serum haptoglobins were absent. He was then given I5 mg. folic'acid by mouth daily for four weeks. Following this treatment, the hamo-globin rose to 14.8 g./iooml., I4% of the polymorphs had s-lobed nuclei and none had 6-or 7-lobed nuclei. There was no FIGLU in the urine. The Coombs, and Schumm's tests remained negative, but hapto-globins were still absent in the serum. Discussion At the time of this patient's admission to hospital the evidence for hzmolysis was not particularly obvious, there being no reticulocytosis, poly-chromasia or raised serum bilirubin, and the initial diagnostic problem was that of a young man with a megaloblastic anemia. Hemolysis was confirmed by a positive Schumm's test, and the transiently positive direct Coombs' test suggests an auto-immune mechanism. Hasty treatment with folic acid or vitamin B12 could have obscured the correct interpretation of the situation, …