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 CONGENITAL
AND ACQUIRED
BONE MARROW
FAILURE
Edited by

M.D. Aljurf
Adult Hematology and Bone Marrow Transplantation
Oncology Center, King Faisal Specialist Hospital
and Research Center, Riyadh, Saudi Arabia

E. Gluckman
Eurocord, Saint Louis Hospital, Paris, France

C. Dufour
Hematology Unit
G. Gaslini Children’s Hospital, Genova, Italy

 
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 List of Contributors

S.O. Ahmed Adult Hematology and Bone Marrow S. Elmahdi Department of Pediatrics, Graduate
Transplantation, Oncology Center, King Faisal School of Medicine, Nagoya University, Nagoya,
Specialist Hospital and Research Center, Riyadh, Japan
Saudi Arabia
P. Farruggia Pediatric Hematology and Oncology
G. Aldawsari Adult Hematology and Bone Marrow Unit, A.R.N.A.S. Ospedale Civico, Palermo, Italy
Transplantation, Oncology Center, King Faisal
F. Fioredda Hematology Unit, G. Gaslini Children’s
Specialist Hospital and Research Center, Riyadh,
Hospital; Unità di Ematologia Istituto Giannina
Saudi Arabia
Gaslini, Genova, Italy
M.D. Aljurf Adult Hematology and Bone Marrow
S. Gandhi Department of Haematological Medicine,
Transplantation, Oncology Center, King Faisal
King’s College Hospital/King’s College London,
Specialist Hospital and Research Center, Riyadh,
London, United Kingdom
Saudi Arabia
S. Giraudier Hematology Laboratory, Henri–
H. Alzahrani Adult Hematology and Bone Marrow
Mondor Hospital, Paris–Est–Creteil University,
Transplantation, Oncology Center, King Faisal
Paris, France
Specialist Hospital and Research Center, Riyadh,
Saudi Arabia E. Gluckman Eurocord, Hospital Saint-Louis, Paris,
France
M. Ayas Pediatric Hematology–Oncology and Stem
Cell Transplantation, King Faisal Specialist Hospital F. Grimaldi Hematology, Department of Clinical
and Research Center, Riyadh, Saudi Arabia Medicine and Surgery, Federico II University,
Naples, Italy
A. Bacigalupo Istituto di Ematologia, Policlinico
Universitario A. Gemelli, Universita’ Cattolica del B. Höchsmann Institute of Transfusion Medicine,
Sacro Cuore, Roma, Italy University of Ulm; Institute of Clinical Transfusion
Medicine and Immunogenetics, German Red Cross
F. Ciceri Hematology and BMT Unit, IRCCS San
Blood Transfusion Service Baden–Württemberg–
Raffaele Scientific Institute; University Vita-
Hessia, and University Hospital Ulm, Ulm,
Salute San Raffaele, IRCCS San Raffaele Scientific
Germany
Institute, Milano, Italy
K. Hosokawa National Institutes of Health, National
J.N. Cooper National Institutes of Health, National
Heart, Lung, and Blood Institute, Bethesda, MD,
Heart, Lung, and Blood Institute, Bethesda, MD,
United States
United States
S. Kojima Department of Pediatrics, Graduate
J.H. Dalle Hematology–Immunology Pediatric
School of Medicine, Nagoya University, Nagoya,
Department, Robert–Debre Hospital, Paris,
Japan
France
T. Leblanc Hematology–Immunology Pediatric
C. Dufour Hematology Unit, G. Gaslini Children’s
Department, Robert–Debre Hospital, Paris, France
Hospital; Unità di Ematologia Istituto Giannina
Gaslini, Genova, Italy

ix
x List of Contributors
J.C.W. Marsh Department of Haematological
Medicine, King’s College Hospital/King’s College
London, London, United Kingdom
D. Meyran Hematology–Immunology Pediatric
Department, Robert–Debre Hospital, Paris, France
M. Miano Hematology Unit, G. Gaslini Children’s
Hospital; Unità di Ematologia Istituto Giannina
Gaslini, Genova, Italy
G.J. Mufti Department of Haematological
Medicine, King’s College Hospital/King’s College
London, London, United Kingdom
J.R. Passweg Division of Hematology, University
Hospital Basel, Basel, Switzerland
R. Peffault de Latour BMT Unit, French Reference
Center for Aplastic Anemia and PNH, Saint-Louis
Hospital, Paris, France
A.M. Risitano Hematology, Department of Clinical
Medicine and Surgery, Federico II University,
Naples, Italy
A. Rovó Hematology, University Hospital of Bern,
Bern, Switzerland
A. Ruggeri Eurocord, Hospital Saint-Louis;
Hematology Department, Hospital Saint Antoine,
Paris, France
S. Samarasinghe Department of Haematology,
Great Hormond Street Hospital, London, United
Kingdom
 
P. Scheinberg Oncology Center, Hospital São José
National Institutes of Health, National Heart, Lung,
and Blood Institute, Bethesda, MD, United States
H. Schrezenmeier Institute of Transfusion
Medicine, University of Ulm; Institute of Clinical
Transfusion Medicine and Immunogenetics,
German Red Cross Blood Transfusion Service
Baden–Württemberg–Hessia, and University
Hospital Ulm, Ulm, Germany
S. Sica Istituto di Ematologia, Policlinico
Universitario A. Gemelli, Universita’ Cattolica del
Sacro Cuore, Roma, Italy
M.T.L. Stanghellini Hematology and BMT Unit,
IRCCS San Raffaele Scientific Institute, Milano,
Italy
A. Tichelli Hematology, University Hospital of
Basel, Basel, Switzerland
M.T. Van Lint Divisione di Ematologia e Trapianto
di Midollo Osseo, IRCCS AOU San Martino IST,
Genova, Italy
A.J. Warren Cambridge Institute for Medical
Research; The Department of Haematology,
University of Cambridge; Wellcome Trust–Medical
Research Council Stem Cell Institute, University of
Cambridge, Cambridge, United Kingdom
N.S. Young National Institutes of Health, National
Heart, Lung, and Blood Institute, Bethesda, MD,
United States
 Introduction
From the first descriptions by Ehrlich over a
century ago to where we are today, the under-
standing of the pathogenesis and biology and
of the diseases that are encompassed under
the umbrella of the “bone marrow failure syn-
dromes” have witnessed tremendous progress.
This has been coupled with significant improve-
ments in the clinical care and outcomes of both
congenital and acquired forms of bone marrow
failure.
When considering acquired bone marrow
failure, in the last 4 decades, aplastic anemia
has progressed from a disease that was almost
universally fatal to one in which the majority
of patients can now expect to be cured and lead
normal lives. We have gained noteworthy in-
sights in understanding the immune mechanism
of hematopoietic stem cell destruction, stem cell
niche, and T-cell dysregulation. This knowledge
has placed immunosuppressive therapy at the
center stage in the treatment of aplastic anemia,
and has facilitated the initiation of clinical trials
for the use of new potential therapies to treat ac-
quired aplastic anemia.
Substantial progress in the knowledge about
the role of somatic mutations and their relation
to clonal hematopoiesis in acquired bone mar-
row failure has been facilitated by the use of the
next generation sequencing technologies, and
has allowed us to understand their relationship
with myelodysplastic syndromes, paroxysmal
nocturnal hemoglobinuria, and the risk of dis-
ease progression.
Advances in HLA-typing technology, prog-
ress in the field of alternate donor availability,
xi
haploidentical and cord blood transplants, and
in supportive care of hematopoietic stem cell
transplantation have lead not only to the expan-
sion of the potential donor pool, but also to re-
markable improvements in the outcome of he-
matopoietic stem cell transplantation for bone
marrow failure from related and unrelated stem
cell sources with excellent rates of cure, par-
ticularly in the younger patients, when a fully
matched unrelated donor is used.
Telomere shortening and telomeropathies
have been increasingly recognized as contrib-
uting factors for bone marrow failure and stem
cell exhaustion in acquired states and causative
factors for the increasing number of entities of
congenital bone marrow failure.
Several new treatment modalities have
emerged during the last decade, most notable
of which is the introduction of thrombopoietin
mimetic agents. Possible interventions to rescue
telomere length are being actively investigated.
Given the exciting progress in the field, this
book is a timely educational initiative produced
jointly by the Working Party of Severe Aplas-
tic Anemia of the European Society for Blood
and Marrow Transplantation and the European
School of Haematology.
The contents are a collection of up-to-date
contributions from world-renowned experts in
the field of congenital and acquired bone mar-
row failure. The chapters in this book provide
extensive coverage for all aspects of congenital
and acquired bone marrow failure, including bi-
ology, pathology, and treatments involving he-
matopoietic stem cell transplantation.
xii Introduction

We hope this book will be an important re-
source for scientists, clinicians, nurses, and all
other health-related professionals involved in
research and patient care with the bone marrow
failure syndromes.
With the endorsement of the European Soci-
ety for Blood and Marrow Transplantation and
the European School of Haematology
Mahmoud Aljurf, Eliane Gluckman, Carlo Dufour

 
 C H A P T E R

1
Epidemiology of Acquired Bone
Marrow Failure
F. Grimaldi*, S. Gandhi**, A.M. Risitano*
*Hematology, Department of Clinical Medicine and Surgery, Federico II University,
Naples, Italy; **Department of Haematological Medicine, King’s College Hospital/
King’s College London, London, United Kingdom

INTRODUCTION studies to gather data on the epidemiology of

Paul Ehrlich in 1888 gave the first seminal
description of aplastic anemia (AA) in a preg-
nant woman, where the normal hemopoietic
tissue was replaced by a fatty marrow and
empty spaces, the “hypocellular” marrow that
resulted in pancytopenia. Idiopathic AA is
a rare form of acquired bone marrow failure,
where improved supportive care, early insti-
tution of immunosuppressive treatment, and
hematopoietic stem cell transplantation have
led to better treatment outcomes [1]. Several
retrospective studies from Europe, United
States, South America, and Asia suggest that
the incidence is 0.6–6.1 cases per million popu-
lation. In addition, the incidence of AA shows
geographical variability, with lower rates re-
ported in Europe, North America, and Brazil
and higher rates in Asia. However, the rarity of
disease means there have been few prospective
AA. Based on the two epidemiological studies
carried out in Europe and Asia that used the
same methodology, the incidence of the disease
is two- to threefold higher in Asia than in the
West [2–12]. This variability in incidence rates
may reflect differences in exposure to environ-
mental factors including viruses, drugs and
chemicals, genetic background, diagnostic cri-
teria, and study designs.
In the following sections, a short review of
studies performed and available in literature, in-
cluding case series and reports to determine the
epidemiology and demographics of AA across
different centers of the world is presented. Dis-
cussion is restricted to acquired cases of AA, and
hence the inherited bone marrow failure syn-
dromes, the inevitable cases of marrow aplasia
that follow intentional chemoirradiation treat-
ments and cytopenias of nutritional deficiencies
or other causes have been excluded.

Congenital and Acquired Bone Marrow Failure

http://dx.doi.org/10.1016/B978-0-12-804152-9.00001-4
1 Copyright © 2017 Elsevier Inc. All rights reserved.
2 1. Epidemiology of Acquired Bone Marrow Failure
INCIDENCE OF AA IN DIFFERENT
GEOGRAPHICAL REGIONS
AND RACE
The annual incidence of AA varies from 0.6
to 6 per million populations per annum across
centers in different continents. Most findings
are from retrospective studies, and even retro-
spective reviews of death registries. However,
this incidence masks the variability that is seen
across continents and different ethnic groups;
for example, reports from the Barcelona group
(2008), which was a detailed prospective study
by Montané et al. [2] had an incidence of 2.34 per
million population. This incidence rate is simi-
lar to the 2.0 per million reported by the Inter-
national Agranulocytosis and Aplastic Anemia
Study (IAAAS) [3], which was conducted in Eu-
rope and Israel from 1980 to 1984, and to rates re-
ported in smaller national studies in Europe that
included United Kingdom [4], France [5], Scan-
dinavia [6], and in South Americas and Brazil [7].
The incidence was accurately determined to be 4
cases per million population in Bangkok [8], but
based on prospective studies, it may actually be
closer to 5.6 cases per million population in the
rural areas of Thailand (Khonkaen region) [9].
In the prospective Chinese Epidemiologic Study
Group of Leukemia and Aplastic Anemia survey,
7.4 per million was reported as a national inci-
dence, which clearly is much on the higher side,
but may have been overestimated, as stringent
criteria for the diagnosis of AA, as bone marrow
study, were not strictly applied [10]. Increased
incidence in Eastern countries may be related to
environmental factors, such as increased expo-
sure to toxic chemicals and pesticides on agricul-
tural farms, practiced in the Far East and South
Asia. However, the incidence of AA in children
of immigrants from the East Asia in a pediat-
ric population from the ages 0 to 14 years, in a
study from British Columbia (Canada) was sig-
nificantly higher at 6.9 per million, as compared
to children of white/mixed ethnic descent at 1.7
per million [11]. Children of immigrants from
 
South Asia, in this study were found to have an
incidence even higher than their counterparts
from East Asia, at 7.3 per million [13]. This study
suggested that Asian children have an increased
incidence of AA, possibly as a result of a genetic
predisposition. Indeed, in a hospital based case
control study from Lucknow (India), the annual
incidence of childhood AA was determined to be
6.8 per million [14].
Benzene has been found to be toxic to the
hemopoietic progenitor cells. In large collab-
orative studies between the National Cancer
Institute and American and Chinese institutions
[15], hematologic susceptibility to benzene has
been correlated to nucleotide polymorphism
in key drug metabolic patways [16]. Thus, he-
matotoxicity from exposure to benzene may be
particularly evident among genetically suscep-
tible populations, and it is plausible that the
increased incidence of AA seen in Asia may be
related not only to increased exposure but also
to key polymorphism in genes regulating the
metabolism and cytokine expression.
Similarly, although AA incidence reported
in a multicenter Latin American study remains
very low at 1.6 per million; this study corrobo-
rated the association between risk of exposure to
benzene, chloramphenicol, and also azithromy-
cin and predisposition to AA in this area [17,18].
AGE AND GENDER RELATED
DEMOGRAPHICS OF AA
In nearly all modern studies of AA, the sex
ratio has been close to 1:1, which is unusual for
immune-mediated diseases [2,19]. An exception
to this has been a study from the Sabah prov-
ince in Malaysia [12], where an unusually high
male to female ratio was noted at 3:4. Similarly
a male preponderance was also noted in stud-
ies from Thailand [9], India [20], and Pakistan
[21]. This may reflect the underreporting of cases
of AA among females and access to adequate
healthcare services in Asia. However, it remains
 AA and association with toxins/drugs
unclear why a female preponderance is not seen
in a quintessential autoimmune disorder, such as
AA among studies in Europe and United States.
In all the largest studies available, including a
series of 300 patients reported by Clinical Center
at NIH by Young et al. [22], the Barcelona report
[2] and epidemiologic study from Thailand [9],
2 patient age peaks of incidence are constantly
observed, one among young adults and the sec-
ond in the elderly. This characteristic biphasic
distribution shows two peaks, one from 10 to
25 years and the second above 60 years. Within
the younger age group, a small peak in the in-
cidence is observed in childhood, probably due
to overlap with inherited marrow-failure syn-
dromes featured by a less penetrating pheno-
type, where classical physicalanomalies of the
inherited marrow-failure syndromes are not ob-
vious. On the other hand, the second incidence
peak of AA seen above 60 years may reflect the
smaller pool of hematopoietic stem cell reserve
left, with age-related telomeric attrition and its
capacity to maintain normal hemopoiesis, in the
face of an immune insult against the hematopoi-
etic precursor cells [23].
POSTHEPATITIS AA AND AA
OCCURRING AFTER VIRAL
INFECTIONS
Posthepatitis AA is a stereotypical syndrome,
where pancytopenia often presents 2–3 months
after an acute attack of seronegative severe but
self-limited liver inflammation. This distinct
variant has been commonly seen in 5–10% of
“classical” AA cases, typically occurring in ado-
lescent boys and young men [24]. Severe imbal-
ance of the T-cell immune system as seen with
“classical” AA, human leukocyte antigen (HLA)
association, and effective response to immuno-
suppressive therapy strongly suggest an im-
mune-mediated mechanism. As for other form
of AA, higher incidence is noted in East Asia
(4–10%), when compared to the Western coun-
 
3
tries and Europe, where recently an incidence of
5.4%, stable across the years, has been reported
in a large registry study from EBMT [25].
Cases of AA associated with HAV, HBV, HGV,
parvovirus B19 [26–29], Epstein–Barr virus
(EBV) [30], transfusion-transmitted virus (TTV)
[31] or echovirus [32] infections have been re-
ported. In a German–Austrian study of 213 pe-
diatric cases aged 17 years or less of AA, 80% of
cases were idiopathic, 9% followed posthepatitis
AA, 7% were following viral infections, and 4%
were associated with drugs/toxins [33].
Parvovirus B19 is the causative agent for fifth
disease, usually in the immunocompetent host.
However, transient aplastic crises have been re-
ported in chronic hemolytic anemias, such as
sickle cell disease owing to reticulocytopenia,
and cases of severe AA have also been reported
in normal individuals during an acute episode
of infection [34]. The actual incidence of acute
parvovirus B19 infection at presentation in AA
is not known, but in single case series of 27 pa-
tients with AA from India, parvovirus B19 IgM
and viral DNA was detected in nearly 40% of the
cases [35]. This maybe an important etiological
factor, especially in immunocompromised host
or patients with chronic hemolytic anemias.
Very recently retrospective observations
about eight AA cases occurring during HIV in-
fection have been reported [36]. Even if AA ap-
pears to be a late rare complication in HIV pa-
tients, report from Pagliuca et al. [36] highlights
that immunosuppressive therapy is a feasible
strategy in AA patients and that better outcome
is observed in patients eligible to transplant,
while death for infection remain the principle
cause of mortality in undertreated patients.
AA AND ASSOCIATION WITH
TOXINS/DRUGS
There is no discernible difference in the de-
mographics or clinical behavior, including re-
sponse to immunosuppressive therapy, between
4 1. Epidemiology of Acquired Bone Marrow Failure

patients classified as having “drug or toxin in- clined to the point that it has not been reported
duced” versus “idiopathic” AA [37]. as significant risk factor in any recent systematic
Benzene is the most widely studied and im- epidemiologic study of AA in Western countries.
plicated amongst toxins causing AA. The rela- Even in Thailand where the need for such effec-
tionship was initially brought to light by a case tive and inexpensive antibiotic is substantial, and
where a series of workers exposed through their usage is reported 100 times greater than in the
specific occupations [15] and has since been West, association with AA is infrequent, prob-
detected in some, but not all population-based ably due to lower-doses prescription [9].
case-control studies. An association has been In the IAAAS study [3] approximately 25%
seen in some case-control studies but even when of the identified AA cases were related to
present, the proportion of cases that can be at- drug use. Major drug associations were with
tributed to this chemical has been small. Studies gold salt (relative risk, RR of 29), antithyroid
on American workers earlier in this century sug- drugs (RR of 11), and nonsteroidal antiinflam-
gested that the risk of AA was about 3% in men matory agents (RR of 8.2 for Indomethacin).
exposed to concentration higher than 300 ppm, Similarly in 235 patients with AA prospec-
and in the more recent IAAAS study [3], benzene tively followed by the Barcelona group [2],
was accounted for about 1–3% of AA recorded 67 cases (28.5%) had a history of exposure to
cases. Similarly in Thailand population, benzene drugs or toxic agents that have been associated
carried a relative risk of 3.5 but accounted for an with AA, sometime in the preceding 6 months.
etiologic fraction of only 1% [9]. Forty nine (20.8%) cases had been exposed to
Pesticides have been associated with AA in a the following drugs (Table 1.1). In addition, 21
large number of medical records. In the Indian (8.9%) cases had been exposed to toxic agents:
cohort of pediatric AA, although significantly insecticides (n = 8), benzene (n = 6), and other
higher blood levels of organochlorine com- solvents (n = 10).
pounds were detected suggesting an associa-
tion, they were not entirely supported by statis- TABLE 1.1 Exposures to Drugs Reported to be
tical methods [14]. Anecdotal case reports of AA Associated With Aplastic Anemia in the
following use and pesticides, such as dichloro- 2–6 Months Prior to Hospital Admission
Among 235 Cases (Montané et al. [2])
diethyly-trichlorthane (DDT), chlordane or lin-
dane, or following exposure to organic solvents, Drug N (%)
such as toluene and other molecules resembling
Allopurinol 9 (3.8)
benzene, or containing benzene ring, again point
merely to an association. Unfortunately, system- Indomethacin 9 (3.8)
atic population case-control studies correlating Gold salts 9 (3.8)
level and duration of exposure of these identi- Sulfonamides 9 (3.8)
fied toxins and AA onset are lacking. Carbamazepine 5 (2.1)
Initially suggested by accumulation of case re- Ticlopidine 4 (1.7)
ports, specific drug associations have been estab-
Chloramphenicol 3 (1.2)
lished in different population based study and
have changed across time, mainly due to chang- Oxyphenbutazone 3 (1.2)
es in drugs diffusion and utilization. Chloram- Phenylbutazone 3 (1.2)
phenicol, for example, that gained notoriety for Penicillamine 3 (1.2)
its prominent association with AA in the 1950s Clopidogrel 2 (0.8)
and for decades was considered the common-
Methimazole 2 (0.8)
est cause of the disease, has progressively de-

 
 AA and association with HLA genes
Finally, incidence of drug-associated AA ap-
pears to be lower in East Asia [8,9].
AA AND ASSOCIATION
WITH HLA GENES
The (HLA) system is a crucial group of genes
responsible for starting and regulating immune
response. Since antigen presentation and T-cell
activation through HLA may represent the early
step that precede global hematopoietic stem cell
destruction in AA, HLA polymorphism may
contribute to pathogenesis of the disease by: (1)
increasing or decreasing susceptibility to AA,
particularly for specific ethnic or age groups,
(2) facilitating activity of drugs or viral antigen
to break immune tolerance and starting the dis-
ease, (3) influencing response to immunosup-
pressive therapy.
As for other autoimmune disease, a large
number of studies demonstrated an association
between polymorphism of HLA class II genes
and AA susceptibility (Table 1.2, a).
An increased frequency of HLA-DR2 was
first described in several studies for European
and American Caucasian patients [38], and
finally confirmed in a multiethnic cohort by
5
Nimer et al. [39]. Subsequently, positive asso-
ciation between HLA-DR2 (precisely DRB1*15
allele) and AA was confirmed in Chinese [40],
Japanese [41], Turkish [42], Pakistani [43], and
Malaysian [44] series. These data depict a clear
role for HLA-DR2 gene as risk factor for AA,
and different distribution of this gene across
human population may probably account for
different incidence seen for AA inspecific geo-
graphical areas and ethnic groups. Interestingly,
when Maciejewski et al. [45] analyzed distribu-
tion of HLA-DR2 (mainly DRB1*15 allele) across
disease subgroups (i.e., AA, hemolytic PNH
and AA/PNH), they found an increased fre-
quency in the ones where bone marrow failure
was associated with a PNH clone. Other DR2 al-
leles have been correlated with AA; in a single
case report, Nakao et al. [46] showed a specific
T-cell cytotoxic response associated with the
DRB1*0405 allele. The DRB1*07 allele has been
reported in a single cohort of Iranian subjects
[47], and DRB1*0901 in Chinese children [48].
Finally, evidences available correlate AA even
with other HLA-II class genes, such as Dpw3
[49] and DR4 [22].
Less data are available for HLA class I genes.
Early reports suggested a correlation with HLA-
A2 gene [50,51] and with HLA-B7 and HLA-B14

TABLE 1.2 Summary of AA and Incidence of Specific HLA Genes or Alleles

a. HLA and b. HLA and
increased risk increased risk c. HLA and d. HLA and e. HLA and drug/ f. HLA and
of AA (Class II) of AA (Class I) reduced risk of AA onset age of AA viral related AA AA outcome

HLA-DRB1*1501 HLA-A2 HLA-DRB1*13 HLA-DRB*09 Haplotype: -B38, HLA-DR2

-DR4, -DQ3
HLA-DRB1*0405 HLA-A*0206 HLA-DRB1*03:01 HLA-A26 Haplotype: HLA-DRB1*1501
-DRB1*0402,
-DQB1*0302
HLA-DRB1*07 HLA-B7 HLA-DRB1*11:01 HLA-B14 Haplotype: HLA-DR4-Ala74
-DRB1*1601,
-DQB1*0502
HLA-DRB1*0901 HLA-B14 HLA-DRB1*51:01 HLA-B48 HLA-DRB1*08
HLA-Dpw3 HLA-B*4002 HLA-DRB1*03
HLA-DR4 HLA-DRB1*13:02

 
6 1. Epidemiology of Acquired Bone Marrow Failure
genes at least in European patients [52,53]. More-
over, association between HLA-B14 alleles, HLA-
Cw7, and AA has been confirmed by Maciejewski
et al. [45] in a multiethnic cohort of 212 American
individuals. Finally Shichishima et al. [54] report-
ed higher incidence of HLA-B*4002 and HLA-
A*0206 in 78 Japanese AA patients, suggesting
a potential role of HLA class I genes even in Far
East countries.
HLA genes revealing a protective role in devel-
oping AA have been identified too (Table 1.2, b).
Even if data refer mainly to small series of pa-
tients, and may reflect natural polymorphism
in HLA system, again a key role for HLA class
II genes and its alleles is suggested. HLA-
DRB1*13 appeared to be protective in a cohort
of patients of Turkish origin [55], as well as
HLA-DRB1*03:01, HLA-DRB1*11:01, and HLA-
B1*51:01 alleles appear to be protective in co-
hort of Chinese children [48]. In a small cohort
of Pakistani patients [43], HLA-DRB1*03 had an
higher frequency in healthy control, suggesting
a putative protective role, and a similar observa-
tion is available for allele DRB1*1302 in Korean
population [56].
Even if AA has a typical bimodal age of inci-
dence, majority of studies did not look specifi-
cally into HLA frequency and age differences,
mostly due to their retrospective nature and
rarity of disease. Therefore, a good assump-
tion could be that data on HLA allele frequency
could be inferred to the pediatric setting. How-
ever Fuhrer et al. [57] in a recent study involv-
ing 181 Caucasian children observed a positive
association between HLA-A26 and HLA-B14
alleles, but not a higher incidence of HLA-DR2.
Similarly Chen et al. [48] in a retrospective sur-
vey conducted on 80 Chinese children showed
an higher than expected incidence of class I
HLA-B48 alleles and class II HLA-DRB*09 al-
lele. Finally, a frequency of HLA-DR2 B15 allele
not different from normal population has been
reported by Kook et al. [58] in North Korean AA
children and by Yoshida et al. [59] in Japanese
AA children. These limited data suggest a po-
 
tentially different HLA landscape in children
with AA, even if further investigation involving
a higher number of patient are needed to specifi-
cally address this question (Table 1.2, c).
Association between agranulocytosis and
HLA genes has been reported for drugs expo-
sure in specific ethnic groups, suggesting that
certain alleles may facilitate the initiation of AA
through direct presentation of drug-derived an-
tigens to T-cells [37]. HLA-class II haplotypes
have been reported to be associated with clozap-
ine-induced agranulocytosis in Askenazi Jewish
[60,61] individuals, and association between
HLA-DRB1*08 alleles and thionamide-induced
AA has been described for Japanese patients
[62]. A similar mechanism of disease can be sug-
gested for posthepatitis AA too, where associa-
tion between HLA class I, specifically HLA-B8,
and hematological disease have been document-
ed [24] (Table 1.2, d).
Finally, some groups have shown that re-
sponse to immunosuppressive therapy can be
related to specific HLA genes. HLA-DRB1*1501
is the most clearly allele associated with a better
response to Cyclosporine [41], and the presence
of HLA-DR2 and a PNH clone independently
predict response to therapy in patients under
immunosuppression [45]. On the other hand
HLA-DRB1*1502 allele [63], that represents a dif-
ferent allele variant of HLA-DR2, doesn’t seem
to have same influence on treatment, even if its
incidence is increased among older Japanese pa-
tients with AA. High-resolution genotyping of
HLA-DRB1 showed that the HLA-DRB1*04 al-
lele coding for alanine position 74 (HLA-DR4-
Ala74) [64] predispose to AA independently
from HLA-DRB1*15 and that HLA-DRB1*04 al-
leles are associated with worse response to cy-
closporine and poorest prognosis (Table 1.2, e).
Association between AA and HLA remains
an intriguing field of interest. However studies
with larger patients populations from different
ethnic backgrounds are needed to better address
complex relations between HLA, environmental
factors, ethnicity, and AA incidence.
 AA during pregnancy
AA AND AUTOIMMUNE
DISORDERS
Although AA is idiopathic in most cases, as-
sociations with other autoimmune disease (AID)
have been shown in numerous single-case re-
ports. In rheumatic diseases, such as systemic
lupus erythematosus (SLE) and rheumatoid ar-
thritis (RA), there is a recognized associations
with AA [65], with a true incidence not known,
but presumed to be very low.
Peripheral autoimmune cytopenias are com-
monly seen in SLE, and they are listed among
diagnostic criteria for the disease in the revised
American College of Rheumatology classifica-
tion. Similarly, anemia of chronic disease, and
cytopenias in relation to the use of cytotoxic
drugs are commonly seen in SLE patients [66].
Less frequently, case reports and small series
documented bone marrow abnormalities consis-
tent with AA, suggesting that in rare cases bone
marrow may also be a target organ of the disease,
showing a full picture of acquired bone marrow
failure [67]. Very recently Chalayer et al. [68] re-
ported a MEDLINE methanalysis of 25 patients
with SLE and AA. In 12 of these 25 patients, di-
agnosis of AA was associated with long story of
SLE, extensive disease, and drug exposure, sug-
gesting that drug-induced AA may represent a
consistent type of AA in these patients.
Similarly the association of RA with AA is
better recognized because of the use of thera-
peutic agents in RA, such as Methotrexate, gold
salts, penicillamine, and Eternacept [69] causing
AA, likely drug induced.
Correlation with immune disorders is also
highlighted by the strong link observed with
eosinophilic fasciitis (Shulman disease), a rare
sclerodermiform syndrome that, in most cases,
resolves spontaneously or after corticosteroid
therapy, and that is frequently reported in asso-
ciation with hematological diseases, especially
AA [70].
Two large different studies have specifically
looked into incidence of autoimmune conditions
 
7
among AA patients. Stalder et al. in a single cen-
ter series [71] of 253 individuals showed that
5.3% of patients with AA had a previous diagno-
sis of AIDS, and 4.5% developed an AIDS after
AA was diagnosed. Similarly 4% of patients re-
corded in EBMT database [72] for AA have been
found diagnosed with a previous AIDS in a ret-
rospective analysis. Most frequently diagnosed
AIDS were autoimmune gastritis and thyroid-
itis in Stalder series, and RA in EBMT analysis,
respectively. Interestingly, in both studies pa-
tient’s age at diagnosis of AA seems to be higher
(>50 years) than normal. Impact of immunosup-
pressive treatment for AA on concomitant AIDS,
and effects on its natural history, remains at the
moment a controversial topic.
AA DURING PREGNANCY
There are no prospective studies about the
incidence of AA during pregnancy. Curiously
AA was first described in a pregnant women
by Ehrlich in 1888. Since then, there have been a
few published reports of AA during pregnancy.
Tichelli et al. [73] described a case series of 36
pregnancies in women with AA. Their study
showed that successful pregnancy with normal
outcome is possible in women with AA who
have been previously treated with immuno-
suppression. Nineteen percent of women were
found to have relapse of AA and a further 14%
needed transfusion support at the time of de-
livery. Complications appear to be more likely
in patients with low platelet counts and par-
oxysmal nocturnal hemoglobinuria-associated
AA. Similarly, Choudhry et al. [74] described
10 cases of AA and concomitant pregnancies,
reporting successful delivery in 10 of 11 cases,
with adverse outcome related to fatal bleeding
in only 2 patients.
Although pregnancy remains an immuno-
modulatory state, with an higher incidence of
autoimmune disease reported, causative rela-
tionship with AA remains controversial.
8 1. Epidemiology of Acquired Bone Marrow Failure
AA POSTVACCINATION
There have been three case reports of AA,
following hepatitis B vaccination [75]. System-
atic case control studies for the incidence of AA
following vaccination are not known. Patients
with AA who have been treated with immu-
nosuppressive treatment, should better avoid
vaccinations, if possible, including influenza,
as there remains a theoretical risk of disease re-
lapse [1].
PROBLEMS WITH
EPIDEMIOLOGICAL STUDIES IN
AA AND FUTURE STRATEGIES
AA remains a rare disease with an annual inci-
dence between 0.6 and 6 per million per annum. It
is innately difficult to conduct a population based
study in a rare disease, such as AA. Reporting of
cases with AA is likely to be only from areas and
centers that have a high coverage of health servic-
es. It’s likely that there had been underreporting
of cases with AA in regions with poor access to
tertiary health care services or facilities for diag-
nostic tests, including special diagnostic tests for
genomic and molecular analysis.
Drug recording and reporting to the medi-
cines regulatory body for association studies
is not uniformly practiced, leading to under
or over estimation of association and causality
(Chloramphenicol remains a case in point for an
example of the latter).
The distinction between acquired and inher-
ited disease may present a clinical challenge, es-
pecially among pediatric cases.
Multicenter clinical trials for newer thera-
peutic agents or treatment strategies in AA may
provide on different countries a uniform panel
of recording data, including family history for
inherited bone marrow failure syndromes, and
special tests, including T-cell subset repertoire
analysis and next-generation technique molecu-
lar analysis.
 
Ready availability of nucleotide variants
from the human genome project have defined
new polymorphisms that are definitely patho-
geneic and disease causing as opposed to vari-
ants that are disease predisposing and require
the interplay of other external factors for disease
causation. Furthermore, genetic tests have also
defined how environmental influences, such as
benzene play a role in the pathogenesis of AA
because of nucleotide polymorphisms that affect
key drug metabolism pathways or cytokine sig-
naling molecules.
Following this theme, future epidemiological
studies for AA, are likely to better explain the
association to causality in AA, precise diagno-
sis and staging prognostic information and also
unravel key molecular pathways for therapeutic
exploitation.
References
[1] Killick S, Brown N, Cavenagh J, et al. Guidelines for the
diagnosis and management of adult aplastic anemia. Br
J Haematol 2016;172:187–207.
[2] Montané E, Ibanez L, Vidal X, et al. Epidemiology of
aplastic anaemia: a prospective multicenter study. Hae-
matologica 2008;93:518–23.
[3] Kaufman DW, Kelly JP, Levy M, et al. The drug etiol-
ogy of agranulocytosis and aplastic anemia. New York:
Oxford University Press; 1991.
[4] Cartwright RA, McKinney PA, Williams L, et al. Aplas-
tic anaemia incidence in parts of the United Kingdom
in 1985. Leuk Res 1988;12:459–63.
[5] Mary JY, Baumelou M, Guiguet M. The French Coop-
erative Group for Epidemiological Study of Aplastic
Anemia. Epidemiology of aplastic anemia in France: a
prospective multi-centric study. Blood 1990;75:1646–53.
[6] Clausen N, Kreuger A, Salmi T, et al. Severe aplastic
anaemia in the Nordic countries: a population based
study of incidence, presentation, course, and outcome.
Arch Dis Child 1996;74:319–22.
[7] Maluf EM, Pasquini R, Eluf JN, et al. Aplastic anemia
in Brazil: incidence and risk factors. Am J Hematol
2002;71:268–74.
[8] Issaragrisil S, Sriratanasatavorn C, Piankijagum A, et al.
Incidence of aplastic anemia in Bangkok. The Aplastic
Anemia Study Group. Blood 1991;77(10):2166–8.
[9] Issaragrisil S, Kaufman DW, Anderson T, et al. The
epidemiology of aplastic anemia in Thailand. Blood
2006;107:1299–307.
 REFERENCES
[10] Yang C, Zhang X. Incidence survey of aplastic anemia
in China. Chin Med Sci J 1991;6:203–7.
[11] Szklo M, Sesenbrenner L, Markowitz J, et al. Incidence
of aplastic anemia in Metropolitan Baltimore. A popu-
lation based study. Blood 1985;66:115–9.
[12] Yong AS, Goh M, Rahman J, et al. Epidemiology of
aplastic anemia in the state of Sabah, Malaysia. Cell Im-
munol 1996;1284:S75.
[13] McCahon E, Tang K, Rogers PC, McBride ML, et al. The
impact of Asian descent on the incidence of acquired
severe aplastic anaemia in children. Br J Haematol
2003;121(1):170–2.
[14] Ahamed M, Anand M, Kumar A, Siddiqui MK. Child-
hood aplastic anaemia in Lucknow, India: incidence,
organochlorines in the blood and review of case re-
ports following exposure to pesticides. Clin Biochem
2006;39(7):762–6.
[15] Qing L, Luoping Z, Guilan L, et al. Hematotoxicity
in workers exposed to low levels of benzene. Science
2004;306(5702):1774–6.
[16] Qing L, Luoping Z, Min S, et al. Polymorphisms in cy-
tokine and cellular adhesion molecule genes and sus-
ceptibility to hematotoxicity among workers exposed
to benzene. Cancer Res 2005;65:9574–81.
[17] Maluf E, Hamerschlak N, Cavalcanti AB, et al. In-
cidence and risk factors of aplastic anemia in Latin
American countries: the LATIN case-control study.
Haematologica 2009;94(9):1220–6.
[18] Young N, Kaufman D. The epidemiology Of acquired
aplastic anemia. Haematologica 2008;93:489–92.
[19] Heimpel H. Epidemiology and aetiology of aplastic
anaemia. In: Schrezenmeier H, Bacigalupo A, editors.
Aplastic anaemia: pathophysiology and treatment.
Cambridge, UK: Cambridge University Press; 2000.
p. 97–116.
[20] Mahapatra M, Singh PK, Agarwal M, et al. Epidemiol-
ogy, clinico-haematological profile and management of
aplastic anaemia: AIIMS experience. J Assoc Physicians
India 2015;63(3 Suppl):30–5.
[21] Adil SN, Kakepoto GN, Khurshi M. Epidemiological
features of aplastic anaemia in Pakistan. J Pak Med As-
soc 2001;51:443.
[22] Young NS. Bone marrow failure syndromes. Philadel-
phia: W.B. Saunders; 2000.
[23] Hao LY, Armanios M, Strong MA, et al. Short telomeres,
even in the presence of telomerase, limit tissue renewal
capacity. Cell 2005;123:1121–31.
[24] Brown KE, Tisdale J, Barrett AJ, et al. Hepatitis-associ-
ated aplastic anemia. N Engl J Med 1997;336:1059–64.
[25] Locasciulli A, Bacigalupo A, Bruno B. Hepatitis-as-
sociated aplastic anaemia: epidemiology and treat-
ment results obtained in Europe. A report of The
EBMT aplastic anaemia working party. Br J Haematol
2010;6:890–5.
 
9
[26] Gonzalez-Casas R, Garcia-Buey L, Jones EA, et al. Sys-
tematic review: hepatitis-associated aplastic anaemia—
a syndrome associated with abnormal immunological
function. Aliment Pharmacol Ther 2009;30:436–43.
[27] Adachi Y, Yasui H, Yuasa H, Ishi Y, Imai K, Kato Y. Hep-
atitis B virus-associated aplastic anemia followed by
myelodysplastic syndrome. Am J Med 2002;112:330–2.
[28] Byrnes JJ, Banks AT, Piatack M Jr, Kim JP. Hepatitis G-
associated aplastic anaemia. Lancet 1996;348:472.
[29] Pardi DS, Romero Y, Mertz LE, Douglas DD. Hepatitis-
associated aplastic anemia and acute parvovirus B19
infection: a report of two cases and a review of the lit-
erature. Am J Gastroenterol 1998;93:468–70.
[30] Lau YL, Srivastava G, Lee CW, et al. Epstein–Barr virus
associated aplastic anaemia and hepatitis. J Paediatr
Child Health 1994;30:74–6.
[31] Poovorawan Y, Tangkijvanich P, Theamboonlers A,
et al. Transfusion transmissible virus (TTV) and its pu-
tative role in the etiology of liver disease. Hepatogas-
troenterology 2001;48:256–60.
[32] Imai T, Itoh S, Okada H, et al. Aplastic anemia follow-
ing hepatitis associated with echovirus 3. Pediatr Int
2002;44:522–4.
[33] Führer M, Rampf U, Baumann I, et al. Immunosup-
pressive therapy for aplastic anemia in children: a
more severe disease predicts better survival. Blood
2005;106:2102–4.
[34] Young NS, Brown KE. Mechanisms of disease: parvovi-
rus B19. N Engl J Med 2004;350:586–97.
[35] Mishra B, Malhotra P, Ratho RK, et al. Human parvovi-
rus B19 in patients with aplastic anemia. Am J Hematol
2005;79:166–7.
[36] Pagliuca S, Gérard L, Kulasekararaj A, et al. Character-
istics and outcomes of aplastic anemia in HIV patients:
a brief report from the severe aplastic anemia work-
ing party of the European Society of Blood and Bone
Marrow Transplantation. Bone Marrow Transplant
2016;51:313–5.
[37] Young NS, Alter BP, Young NS. . In: Young NS, Alter BP,
editors. Aplastic anemia, acquired and inherited, drugs
and chemicals. Philadelphia: W.B. Saunders; 1994.
p. 100–32.
[38] Chapuis B, Von Fliedner VE, Jeannet M, et al. Increased
frequency of DR2 in patients with aplastic anaemia and
increased DR sharing in their parents. Br J Haematol.
1986;63:51–7.
[39] Nimer SD, Ireland P, Meshkinpour A, et al. An in-
creased HLA DR2 frequency is seen in aplastic anemia
patients. Blood 1994;84:923–7.
[40] Shao W, Tian D, Congyan L, et al. Aplastic anemia is
associated with HLA-DRB1*1501 in northern Han Chi-
nese. Int J Hematol 2000;71:350–2.
[41] Nakao S, Takamatsu H, Chuhjo T, et al. Identification
of a specific HLA class II haplotype strongly associated
10 1. Epidemiology of Acquired Bone Marrow Failure
with susceptibility to cyclosporine-dependent aplastic
anemia. Blood 1995;84:4257–61.
[42] Ilhan O, Beksac M, Arslan O, Koc H, et al. HLA-DR
frequency in Turkish aplastic anemia patients and the
impact of HLA-DR2 positivity in response rate in pa-
tients receiving immunosuppressive therapy. Blood
1995;86:2055.
[43] Rehman S, Saba N, Khalilullah, et al. The frequency
of HLA class I and II alleles in Pakistani patients with
aplastic anemia. Immunol Investig 2009;38:251–4.
[44] Dhaliwal JS, Wong L, Kamaluddin MA. Susceptibility
to aplastic anemia is associated with HLA-DRB1* 1501
in an aboriginalpopulation in Sabah, Malaysia. Hum
Immunol 2011;72:889–92.
[45] Maciejewski JP, Follmann D, Nakamura R. Increased
frequency of HLA-DR2 in patients with paroxysmal
nocturnal hemoglobinuria and the PNH/aplastic ane-
mia syndrome. Blood 2001;98:3513–9.
[46] Nakao S, Takami A, Takamatsu H. Isolation of a T-cell
clone showing HLA-DRB1*0405-restricted cytotoxicity
for hematopoietic cells in a patient with aplastic ane-
mia. Blood 1997;89:3691.
[47] Yari F, Sobhani M, Vaziri MZ, et al. Association of aplas-
tic anemia and Fanconi’s disease with HLA-DRB1 al-
leles. Int J Immunogenet 2008;35:453–6.
[48] Chen C, Lu S, Luo M, et al. Correlations between HLA-
A, HLA-B and HLA-DRB1 allele polymorphism to ac-
quired aplastic anemia. Acta Haematol 2012;128:23–7.
[49] Odum N, Platz P, Morling N, et al. Increased frequency
of HLA-DPw3 in severe aplastic anemia. Tissue Anti-
gens 1987;29:184–5.
[50] Albert E, et al. HLA antigens and haplotypes in
200 patients with aplastic anemia. Transplantation
1976;22:528–31.
[51] Dausset J, Gluckman E, et al. Excess of HLA-A2 and
HLA-A2 homozygotes in patients with aplastic anemia
Fanconi’s anemias. Nouv Rev Fr Hematol Blood Cells
1977;18:315–24.
[52] Gluckman E. HLA markers in patients suffering from
aplastic anaemia. Haematologia 1981;14:165–72.
[53] D’Amaro J, et al. HLA associations in Italian and non-
Italian Caucasoid aplastic anemia patients. Tissue Anti-
gens 1983;21:184–91.
[54] Shichishima T, Noji H, Ikeda K, et al. The frequency of
HLA class I alleles in Japanese patients with bone mar-
row failure. Haematologica 2006;91:857.
[55] Oguz FS, Yalman N, Diler S, et al. HLA-DR15 and
pediatric aplastic anemia patients. Haematologica
2002;87:772–4.
[56] Song EY, Park S, Lee DS, et al. Association of human
leukocyte antigen-DRB1 alleles with disease suscep-
tibility and severity of aplastic anemia in Korean pa-
tients. Hum Immunol 2008;69:354–9.
 
[57] Fuhrer M, Durner J, Brunnler G, et al. HLA association
is different in children and adults with severe acquired
aplastic anemia. Pediatr Blood Cancer 2007;48:186–91.
[58] Kook H, Hwang TJ, Seo JJ, et al. The frequency of
HLA alleles in Korean children with aplastic anemia
and the correlation with the response to immunosup-
pressive treatment. Korean J Pediatr Haematol Oncol
2003;10:177–88.
[59] Yoshida N, Yagasaki H, Takahashi Y, et al. Clinical im-
pact of HLA-DR15, a minor population of paroxysmal
nocturnal haemoglobinuria-type cells, and an aplastic
anaemia-associated autoantibody in children with ac-
quired aplastic anemia. Br J Haematol 2008;142:427–35.
[60] Yunis JJ, Corzo D, Salazar M, et al. HLA associa-
tions with clozapine-induced agranulocytosis. Blood
1995;86:1777.
[61] Corzo D, Yunis JJ, Salazar M, et al. The major histo-
compatibility complex region marked by HSP70-1 and
HSP70-2 varisnts is associated with clozapine induced
agranulocytosis in two different ethnic groups. Blood
1995;86:3835–40.
[62] Tamai H, Sudo T, Kimura A, et al. Association be-
tween the DRB1*08032 histocompatibility antigen
and methimazole-induced agranulocytosis in Japa-
nese patients with Graves disease. Ann Intern Med
1996;124:490–4.
[63] Sugimori C, Yamazaki H, Feng X, et al. Roles of
DRB1*1501 and DRB1*1502 in the pathogenesis of
aplastic anemia. Exp Hematol 2007;35:13–20.
[64] Kapustin SI, Popova TI, Lyshchov AA, et al. HLA-
DR4-Ala74 beta is associated with high risk and poor
outcome of severe aplastic anemia. Ann Haematol
2001;80:66–71.
[65] Bacigalupo A. Aetiology of severe aplastic anaemia and
outcome after allogeneic bone marrow transplantation
or immunosuppression. Eur J Haematol 1996;57(Sup-
pl):16–9.
[66] Bhatt AS, Berliner N. Hematologic Manifestations of
SLE. In: Schur P, Massarotti E, editors. Lupus erythe-
matosus: clinical evaluation and treatment. New York:
Springer; 2012. p. 127–40.
[67] Alishiri GH, Saburi A, Bayat N, et al. The initial pre-
sentation of systemic lupus erythematosis with aplastic
anemia successfully treated with rituximab. Clin Rheu-
matol 2012;31(2):381.
[68] Chalayer É, Ffrench M, Cathébras P. Aplastic anemia as
a feature of systemic lupus erythematosus: a case report
and literature review. Rheumatol Int 2015;35(6):1073–
82.
[69] Kozak N, Friedman J, Schattner A. Etanercept-asso-
ciated transient bone marrow aplasia: a review of
the literature and pathogenetic mechanisms. Drugs
2014;14(2):155–8.
 REFERENCES
[70] De Masson. Severe aplastic anemia associated with eo-
sinophilic fasciitis: report of 4 cases and review of the
literature. Medicine (Baltimore) 2013;2:69–81.
[71] Stalder MP, Rovó A, Halter J, et al. Aplastic anemia
and concomitant autoimmune disease. Ann Hematol
2009;88:659–65.
[72] Cesaro S, Marsh JC, Tridelli G, et al. Retrospective
survey on the prevalence and outcome of prior au-
toimmune diseases in patients with aplastic anemia
reported to the registry of the European group for
blood and marrow transplantation. Acta Haematol
2010;124:19–22.
 
11
[73] Tichelli A, Socié G, Marsh J, et al. Outcome of preg-
nancy and disease course among women with aplastic
anemia treated with immunosuppression. Ann Intern
Med 2002;137(3):164.
[74] Choudhry VP, Gupta S, Gupta M, et al. Pregnancy asso-
ciated aplastic anemia—a series of 10 cases with review
of the literature. Haematology 2002;7:233–8.
[75] Shah C, Lemke S, Singh V, et al. Case reports of aplas-
tic anemia after vaccine administration. Am J Hematol
2004;77(2):204.
 C H A P T E R

2
Pathophysiology of Acquired Bone
Marrow Failure
K. Hosokawa*, P. Scheinberg**, N.S. Young*
*National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda,
MD, United States; **Oncology Center, Hospital São José National Institutes of
Health, National Heart, Lung, and Blood Institute, Bethesda, MD, United States

INTRODUCTION: EVIDENCE AND therapy (IST) alone is strong evidence of an im-

INFERENCES FROM THE CLINIC
Acquired aplastic anemia (AA) is the proto-
typical bone marrow (BM) failure syndrome.
AA is characterized by pancytopenia of pe-
ripheral blood and BM hypoplasia. Low blood
counts and “empty” marrow pathology implies
the absence of stem and progenitor cells, which
is consistent with, the success of BM transplan-
tation (BMT), in which replacement of hemato-
poietic stem cells (HSCs) (and immune cells) is
adequate to cure disease. There is little evidence
that AA is mediated by BM stromal cells. If stem
cell absence were the only defect, twin donor or
syngeneic transplants should be successful with
infusion of BM, but a large proportion suffer
graft failure; that conditioning eliminates graft
failure suggests an immune pathophysiology
[1]. Immunosuppressive regimens were devel-
oped in the context of graft failure and now are
widely employed when stem- cell transplant is
not feasible. The efficacy of immunosuppressive
mune mechanism in most patients with AA: 60–
70% respond to one course of horse hATG/cyclo-
sporine (CsA) and an additional 30% of primary
nonresponders will respond to a second course
of IST. Similarly, patients’ blood counts often are
dependent on continued administration of CsA,
as would be expected of a T-cell driven disease.
Eltrombopag, a thrombopoietin (TPO) mimetic,
has activity in refractory SAA as single agent
and in increasing the response rate and com-
pleteness of the response when combined with
IST as first therapy. These results suggest that
there are residual HSCs that can repopulate BM,
even if they are not detectable. Recent genomic
data applying whole exome sequencing in AA
show that hematopoiesis can be sustained from
a single or very few HSC clones. Clonal hemato-
poiesis has also been inferred from the frequent
and unique association of paroxysmal nocturnal
hemoglobinuria (PNH), the origin of which is a
somatic mutation in an X-linked gene, with ac-
quired AA.

Congenital and Acquired Bone Marrow Failure

http://dx.doi.org/10.1016/B978-0-12-804152-9.00002-6
13 Copyright © 2017 Elsevier Inc. All rights reserved.
14 2. Pathophysiology of Acquired Bone Marrow Failure
In vitro experiments with patients’ cells are
consistent with clinical observations in support-
ing an immune mechanism of AA. The presence
of PNH or acquired copy number-neutral loss of
heterozygosity of the 6p arms (6pLOH) clones
support clonal escape from immune-mediated
BM destruction. Immune-mediated destruction
of BM can be modeled in animals and animal ex-
periments employing myelotoxic drugs or with
myeloablative transplants show that very limit-
ed numbers of HSCs can support hematopoiesis
for very prolonged time periods.
Clonal evolution, the development of myelo-
dysplastic syndrome (MDS) and acute myeloid
leukemia (AML) in a patient with typical AA, of-
ten after successful IST, demonstrates genomic
instability in the setting of immune or inflamma-
tory disease environment (and occurs in other
immune diseases, such as inflammatory bowel
disease and chronic hepatitis). Short telomeres
appear to predispose to genomic instability,
with tissue culture and animal model experi-
ments providing a mechanism of chromosome
derangement. In some cases of clonal evolution,
there is evidence of origin from a tiny clone of
cells harboring a recurrent mutation in an MDS/
AML candidate gene.
PATHOPHYSIOLOGY
Hematopoiesis in AA
AA is a BM failure syndrome characterized
by pancytopenia of the peripheral blood and
BM hypoplasia [2–4]. Profound reduction in he-
matopoietic stem and progenitor cells (HSPCs)
is a consistent finding [5–9]. Stem cells/early
progenitor cells can be assayed by long-term
culture-initiating cell assays (LTC-ICs) [7,9], or
cobblestone area-forming cells [10], these cells
are also markedly deficient in AA. The scant
numbers of LTC-ICs per mononuclear cell sug-
gest that only a small percentage of residual
early hematopoietic cells remain in severely af-
 
fected patients at presentation. There are few or
no CD34+ cells on flow cytometry [8].
Recent HSC fate-mapping analyses in mice
have suggested that progenitors and not HSCs
are fundamental for hematopoiesis under ho-
meostatic conditions [11,12]. Physiological
studies to experimentally test this hypothesis
are not possible in normal human subjects.
However, certain disease states may indicate
the consequences of HSC loss on progenitors
and the role of HSCs in human blood produc-
tion under nontransplant conditions. Using a
flow cytometric gating scheme to define MPPs
(CD34+CD38–Thy1–CD45RA–CD49f–), CMPs
(CD34+CD38+CD10–FLT3+CD45RA–), and MEPs
(CD34+CD38+CD10–FLT3- CD45RA–), the pro-
genitor hierarchy was examined in a few cases
of AA [13]. Consistent with previous reports,
the proportion of CD34+ cells within the over-
all mononuclear cell pool was much lower
in AA compared with normal BM [6,9]. The
CD34+CD38– stem-cell compartment in AA was
more significantly depleted compared with the
CD34+CD38+ progenitor compartment. HSCs
and MPPs were virtually undetectable in the
residual CD34+CD38– compartment, confirming
that HSCs are lost in AA, as determined by phe-
notype. Despite the loss of phenotypic HSCs,
the CD34+CD38+ compartment was detectable
in all cases. The percentage of myeloid progeni-
tors was equivalent compared with normal BM.
In contrast, erythroid progenitors were low, like
HSCs, in all patients. These results suggest that
ongoing erythropoiesis is more reliant on HSC
input compared with myelopoiesis. Consistent
with these findings, clinical data suggested that
the baseline absolute reticulocyte count (ARC)
and absolute lymphocyte count (ALC) together
serve as a simple predictor of response to IST
and greater rate of 5-year survival [14].
In AA, BM is not truly empty but replaced by
fat cells [15]. BM adipocytes were reported to
be possible negative regulators in the hemato-
poietic microenvironment [16]. To examine the
role of adipocytes in BM failure, recent study
 Pathophysiology
investigated peroxisomal proliferator-activated
receptor gamma (PPARγ), a key transcription
factor in adipogenesis, utilizing an antagonist of
this factor [17]. While PPARγ antagonists inhib-
ited adipogenesis as expected, it also suppressed
T-cell infiltration of BM, reduced plasma in-
flammatory cytokines, decreased expression of
multiple inflammasome genes, and ameliorated
marrow failure. These results suggested that
PPARγ antagonists acted as negative regulators
of T cells in addition to their inhibition of BM
adipogenesis.
AA is strongly associated with PNH [18].
PNH is a rare acquired disorder of HSCs, char-
acterized by hemolytic anemia, BM failure, and
venous thrombosis. The etiology of PNH is a
somatic mutation in the X-linked phosphati-
dylinositol glycan class A gene (PIG-A), result-
ing in global deficiency of glycosyl phosphati-
dylinositol–anchored proteins (GPI–APs) [19].
Clinically, AA may coexist or appear to evolve
to other hematologic diseases that are character-
ized by proliferation of distinctive cell clones, as
in PNH or MDS [2]. Nearly half of AA patients
have clonal populations of cells lacking GPI–APs
because of somatic mutations in the PIG-A gene;
these are called PNH clones [20,21]. Most clones
are small and do not lead to clinical manifesta-
tions of hemolysis or thrombosis [22], but classic
PNH can be dominated by marrow failure (the
“AA/PNH syndrome”). PIG-A mutant cells can
support hematopoiesis for long term, despite
accumulation of somatic mutations associated
with clonal evolution to MDS/AML [23–25].
Recent studies have demonstrated clonal he-
matopoiesis in the majority of AA [26,27]. To
clarify the origin, importance, and dynamics
over time of clonal hematopoiesis in AA, and its
relationship to the development of MDS, AML,
or both, targeted deep-sequencing, SNP array
karyotyping, and whole-exome sequencing,
were performed to identify genetic alterations in
AA and described their dynamics over long clin-
ical courses [26]. Somatic mutations in myeloid
cancer candidate genes were present in one-third
 
15
of the AA patients, in a limited number of genes
and at low initial variant allele frequency [26].
Clonal hematopoiesis was detected in 47% of the
AA, most frequently as acquired mutations. The
prevalence of the mutations increased with age.
DNMT3A-mutated and ASXL1-mutated clones
tended to increase in size over time; the size of
BCOR- and BCORL1-mutated and PIGA-mutat-
ed clones decreased or remained stable. How-
ever, clonal dynamics were highly variable and
did not determine the response to therapy and
long-term survival among individual patients.
These results were consistent with those of re-
cent studies in which candidate-gene targeted
sequencing also showed recurrent mutations in
a similar spectrum of genes [28,29]. Two hun-
dred and nineteen genes were screened in 39 pa-
tients, and found somatic mutations in 9 (23%),
comprising ASXL1, DNMT3A, and BCOR. The
median allele burden was <10% in 7 patients
[28]. In 2 of 38 patients (SLIT1, and SETBP1 with
ASXL1) using a smaller panel of 42 genes, 3 mu-
tations were found. However, the patient with
SETBP1 and ASXL1 was tested at time of pro-
gression to MDS.
These results show parallels between BM
failure and normal aging of the hematopoietic
compartment. The characteristic mutation sig-
nature and correlation of mutations with patient
age suggested age-related, spontaneous conver-
sion of methylated cytosine to thymidine at CpG
sites as major source of nucleotide alternations
in AA [30]. Similar C-to-T conversion muta-
tions accumulate in hematopoietic progenitors
in healthy persons [31–33]. Mutations generally
appeared at a low variant allele frequency and
involved common mutational targets in my-
eloid cancers, which suggests that the origin and
clonal selections of these mutations are similar
to those in AA.
However, the exact mechanism of selection
of mutated cells in AA is unclear. DNMT3A is
essential for hematopoietic stem-cell differen-
tiation [34]. DNMT3A loss predisposes murine
HSCs to malignant transformation [35]. Deletion
16 2. Pathophysiology of Acquired Bone Marrow Failure
of ASXL1 results in myelodysplasia in vivo
[36,37]. Cells containing DNMT3A or ASXL1
mutations may preferentially self-renew rather
than differentiate in response to extrinsic sig-
nals. In contrast, striking overrepresentation of
BCOR and BCORL1 and PIGA mutations as well
as frequent 6pUPD involving the specific HLA
classes suggest a mechanism of protection of
mutated cells from immune-mediated destruc-
tion by pathogenic T cells [38,39].
Immune Mechanisms in AA
Clinical Data
An immune mechanism was inferred de-
cades ago from the recovery of hematopoiesis
in patients who failed to engraft after stem-cell
transplantation, when renewal of autologous
blood-cell production was credited to the con-
ditioning regimen. Also, the majority of synge-
neic transplantations in which BM was infused
without conditioning failed due to rejection im-
plying a disease immune mechanism [40]. The
responsiveness of AA to IST in most patients
is the best evidence of an underlying immune
pathophysiology: the majority of patients show
hematologic improvement after only transient
T-cell depletion by ATGs; relapse also usually
responds to ATG; and dependence of adequate
blood counts on administration of very low dos-
es of CsA is not infrequent [2].
T Cells and Cytokines
In early laboratory experiments, removal of
lymphocytes from aplastic BMs improved colony
numbers in tissue culture, and their addition to
normal marrow inhibited hematopoiesis in vitro
[41]. Immunity to HSCs by activated T cells has
been considered to be responsible for the patho-
genesis of AA [42,43]. Laboratory in vitro data
has further reinforced the immune pathogenesis
in AA with the principal findings including:
1. An increased cytokine (IFN-γ) of activated
T cells identified both in the blood and
 
BM [44–50]; CD8+ CTLs are expanded
in AA, leading to the production of
proinflammatory cytokines (e.g., IFN-γ) that
induces apoptosis of CD34+ cells [47,50].
2. Oligoclonal skewing of the T-cell repertoire
indicating expansion of pathogenic CD8+
T cells [51–53]. In general, patients at
presentation demonstrate oligoclonal
expansions of a few Vβ subfamilies, which
diminish or disappear with successful
IST; original clones reemerge with relapse,
sometimes accompanied by new clones,
consistent with spreading of the immune
response. Very occasionally, a large clone
persists in remission, perhaps evidence of
T-cell tolerance.
3. A reduction of regulatory T cells (Treg) and
an increase in Th17 related T cells resulting
in a high Th17/Treg ratio at diagnosis which
tends to normalize in responding patients
to IST [54,55]; reduction in Treg numbers
correlates with disease severity, and the
defect is most prominent in severe and very
severe AA [56].
4. Increased transcription of Th1-related genes
in activated T cells of AA patients [57,58];
recent study in BM failure mouse models
identified NOTCH signaling as a primary
driver of Th1-mediated pathogenesis in
AA and may represent a novel target for
therapeutic intervention.
5. Confirmation in murine models on the role
of Th1 and Th17 cells and related cytokines
to producing destruction of marrow
progenitor cells and the positive effects of
Th17 blocking antibodies and infusion of
regulatory T cells in reversing BM failure in
these models [55,59–63].
The impact of T-cell attack on BM can be mod-
eled in vitro and in vivo. IFN-γ (and tumor necro-
sis factor-α) in increasing doses reduce numbers
of human hematopoietic progenitors assayed in
vitro; the cytokines efficiently induce apoptosis
in CD34+ target cells, at least partially through
 Pathophysiology
the Fas-dependent pathway of cell death [43,64].
In long-term culture of human BM, in which
stromal cells were engineered to constitutively
express IFN-γ, the output of long-term-culture-
initiating cells (LTCI-ICs) was markedly dimin-
ished, despite low concentrations of the cytokine
in the media, consistent with local amplification
of toxicity in the marrow milieu [49].
Measurements of soluble circulating mediat-
ing factors in BM failure were limited largely to
one or two cytokines in AA [65–68]. High TPO
levels have been observed in patients with AA,
and these abnormal levels correlate with disease
severity [66,68]. Comprehensive analysis of 31
cytokines by an immuno-bead-based multiplex
assay (Luminex) identified that high levels of
TPO and granulocyte colony-stimulating fac-
tor, with low levels of CD40 ligand, CXCL5,
CCL5, CXCL11, epidermal growth factor, vascu-
lar endothelial growth factor, and CCL11 were
a signature profile for AA [69]. An increase in
IL-17-producing Th17 cells in the peripheral
blood and BM of patients with AA has also been
reported [55,70,71]. Recent study showed that
TPO and IL-17 levels are useful for differentiat-
ing hypocellular refractory cytopenia of child-
hood (RCC) from pediatric AA [72].
HLA and Cytokine Gene Polymorphisms
There have been a number of studies on the
human leukocyte antigens (HLA) and their as-
sociation with AA. HLA-DR2 is overrepresent-
ed among patients [73], suggesting a role for
antigen recognition, and its presence is predic-
tive of a better response to CsA [74]. Further re-
search showed HLA-DRB1*1501 was associated
with a good response to IST in Japanese cohorts
[75,76].
Polymorphisms in cytokine genes, associated
with an increased immune response, also may
be more prevalent: a nucleotide polymorphism
in the TNF-α (TNF2) promoter at −308 [77], ho-
mozygosity for a variable number of dinucleo-
tide repeats in the gene encoding IFN-γ [78], and
polymorphisms in the CTLA4 [79].
 
17
Immune Escape Clones (PNH, 6pLOH)
Certain clones may escape the immune attack
within the BM environment and proliferate and
attain a survival advantage over normal HSCs.
The global absence of a large number of cell-sur-
face proteins in PNH has been hypothesized to
allow escape and survival of a preexisting mutant
clone. Association of present PNH clone with a
predictor of responsiveness to IST suggests that
the escape is from immune attack [20,80–83].
Small PNH clones present at diagnosis usually
remain stable over time, but may expand suffi-
ciently to produce symptomatic hemolysis [84].
Comparison by microarray shows that residual
cells of normal phenotype in the PNH BM upreg-
ulate the same apoptosis and cell-death genes as
do CD34+ cells in aplastic marrow, while the PIG-
A mutant clone appears transcriptionally similar
to CD34+ cells from healthy donors [85]. Alter-
natively, NK cell mediated cytotoxicity may play
a role; immunoglobulin-like receptors (KIR) may
be differentially expressed in PNH compared to
normal, resulting in cytotoxicity of normal HSCs
[86]. Recent work has suggested expansion of au-
toreactive, CD1d-restricted, GPI-specific T cells
in PNH [38]. These data suggested important
roles for cell-extrinsic factors in clonal expansion
of PNH cells.
It was recently reported that AA patients po­
ssessing clonal/oligoclonal hematopoiesis who
had specifically lost either HLA haplotype con-
taining the HLA-B*40:02, HLA-A*31:01, HLA-
A*02:01, and HLA-A*02:06 [87]. Approximately
10% of AA have acquired copy number neutral
loss of heterozygosity (CN-LOH) in chromo-
some arm 6p (6pLOH), postulated to emerge by
immune selection against specific HLA alleles
[87–89]. This clonal hematopoiesis may repre-
sent a signature of an escape from cytotoxic T-
cells autoimmunity targeting autoantigens and
strengthen the hypothesis of the immune-me-
diated pathogenesis of AA, although the exact
mechanism is still unclear. Recent report showed
the PNH patient that had acquired CN-6pLOH
in GPI–AP+ granulocytes, but not in GPI–AP−
18 2. Pathophysiology of Acquired Bone Marrow Failure
granulocytes, supporting the hypothesis that a
hostile immune environment drives selection
of resistant hematopoietic cell clones [90]. Re-
cent study reported successful isolation of HLA-
B*40:02-restricted CTLs specific for HSCs that
were present in AA patient peripheral blood or
BM [91].
STAT3 Mutant Clones
Large granular lymphocyte leukemia (LGL)
is often associated with immune cytopenias and
can occur in BM failure, such as AA and MDS
[92,93]. STAT3 mutations in LGL clonal expan-
sions are detected [94,95]. STAT3 clones can be
not only in known LGL concomitant cases, but
in a small population of other BM failure cases
(7% AA and 2.5% MDS) [72]. In STAT3-mutat-
ed AA patients, trend toward better responses
of IST and an association with the presence of
HLA-DR 15 were found. STAT3-mutant clones
may facilitate a persistently dysregulated auto-
immune activation, responsible for the primary
induction of BM failure in a subset of AA and
MDS.
Innate Immunity
Transcriptional analysis of T cells from AA
has implicated some components of innate im-
munity in AA, including toll-like receptors and
natural killer cells [96].
There are some experimental results that sup-
port the natural killer cells involvement in AA
[97,98]. KIR and KIR ligand (KIR-L) genotype
study showed that AA and PNH showed de-
creased frequency of KIR-2DS1 and KIR-2DS5
genes [98]. The reduced frequency of these KIRs
in AA and PNH may indicate an immunogenetic
relationship between these diseases.
microRNAs
There is emerging evidence that microRNA
(miRNA) play crucial roles in controlling and
modulating immunity. Dysregulation of miRNA
can lead to autoimmune diseases, such as rheu-
matoid arthritis, multiple sclerosis, and inflam-
 
matory bowel disease. Recent work described
previously unknown potential regulatory roles
of the miR-145-5p and miR-126-3p in T-cell ac-
tivation in AA, in which MYC and PIK3R2 are
the respective targets of these miRNA [99]. Dys-
regulated miR-145-5p and miR-126-3p promote
T-cell proliferation and increase GZMB and IFN-
γ production. Targeting or employing miRNA
mimics might be novel molecular therapeutic
approaches in AA.
Autoantibodies
Autoantibodies are frequently detected in
patients with AA [100–103]. Antimoesin [100],
diazepam-binding inhibitor-related protein 1
[101], kinectin [102], postmeiotic segregation in-
creased 1 [102], and HNRNPK antibodies [103]
were reported to be expressed in AA. Recent
study using SEREX identified autoantibodies
that are expressed in AA accompanied by im-
mune abnormality [104]. Eight candidates were
identified: CLIC1, SLIRP, HSPB11, NHP2L1,
SLC50A1, RPL41, RPS27, and SNRPF.
Immune-Mediated BM Failure
Mouse Models
Mouse models of AA, produced by the de-
struction of BM cells using radiation, cytotoxic
drugs, and immune cells, have been useful in
defining the hematopoietic stem cell and illus-
trating the potency of small numbers of lympho-
cytes in specifically inducing apoptosis of BM
targets and their cytokines (e.g., IFN-γ-) as nega-
tive effector molecules [105–108]. Murine mod-
els mimicking AA have used exposure to agents
that result in marrow destruction through a
direct toxic effect, but models that explore anti-
genic disparities between strains have resulted
in immune-mediated destruction of the marrow,
more closely modeling human AA [109]. Infu-
sion of parental lymph node cells into F1 hybrid
donors caused pancytopenia, profound mar-
row aplasia, and death [63]. Not only a murine
version of ATG and CsA but also monoclonal
antibodies to IFN-γ and tumor necrosis factor
 Pathophysiology
abrogated hematologic disease, rescuing ani-
mals. A powerful “innocent bystander” effect,
in which activated cytotoxic T cells kill geneti-
cally identical targets, was present in second-
ary transplantation experiments [62]. In a minor
histocompatibility antigen-discordant model,
marrow destruction resulted from activity of an
expanded H60 antigen-specific T-cell clone [61].
Treatment with the CsA abolished H60-specific
T-cell expansion and rescued animals from fatal
pancytopenia. The development of BM failure
was associated with a significant increase in ac-
tivated CD4+CD25+ T cells that did not express
intracellular FoxP3, whereas inclusion of normal
CD4+CD25+ regulatory T cells in combination
with C57BL/6 LN cells aborted H60-specific T-
cell expansion and prevented BM destruction.
Trafficking of T cells to the marrow has also been
shown to be important in AA pathogenesis in
murine models [110].
Mouse Models of Chemical and Drug
Hematopoietic Toxicity
In a few instances, mouse models have been
utilized to examine chemical and drug toxicity
for hematopoiesis. Industrial exposure to ben-
zene has numerous deleterious hematologic
effects in human workers. When benzene was
subcutaneously injected into CD1 mouse, they
showed lethargy, irritability, and weight loss,
with decreased hemoglobin, erythrocytes, leu-
kocytes, and BM cells indicative of BM failure
[111].
Chronic, delayed hematotoxicity of the che-
motherapy drug busulfan was recapitulated in
a mouse model: following a course of therapy,
animals maintained normal blood and BM cell
counts for 1 year before developing pancytope-
nia and frank marrow aplasia, with significant
decline in splenic colony-forming units (CFU)
[112]. BALB/c mice were treated 8 times with
busulfan over 23 days and found reductions
in nucleated marrow cells, granulocyte-macro-
phage (CFU-GM), CFU-erythroid, erythrocytes,
leukocytes, platelets, and reticulocytes on day 1
 
19
and continued until days 91 and 112 posttreat-
ment [113].
Genetic Risk Factors in AA
Telomeres are DNA sequences with a struc-
ture that protects chromosomes from erosion and
that a specific enzyme, telomerase, is involved
in their repair after mitosis [114,115]. Telomeres
are repeated nucleotide sequences that cap the
ends of chromosomes and protect them from
damage. Acquired and congenital AA have been
linked molecularly and pathophysiologically
by abnormal telomere maintenance [116,117].
Telomeres are eroded with cell division, but in
HSCs, maintenance of their length is mediated
by telomerase. Accelerated telomere shorten-
ing is virtually universal in dyskeratosis con-
genita, caused by mutations in genes encoding
components of telomerase or telomere-binding
protein (TERT, TERC, DKC1, NOP10, or TINF2)
[118–122]. Short telomeres were found in leuko-
cytes from approximately one-third of patients
with AA, especially those who do not have a re-
sponse to IST [123,124]. Systematic screening of
patients with apparently AA showed a few pa-
tients with TERT or TERC mutations [125,126].
Mutation of SBDS underlie Shwachman–
Diamond syndrome (SDS), inherited syndrome
featuring BM failure [127]. Heterozygosis for
258 + 2 T > C SBDS gene was associated with
AA (4 of 91 AA) and telomere shortening of
leukocytes [128]. These mutations cause low
telomerase activity, accelerated telomere short-
ening, and diminished proliferative capacity of
hematopoietic progenitors. Sex hormones in-
crease telomerase activity by upregulating the
TERT gene [129]. Blood count improvement can
be obtained with androgen therapy in patients
with mutation in telomere repair complex genes
[130]. For more information about telomeres,
please refer Chapter 15.
Germ-line GATA2 gene mutations, lead-
ing to haploinsufficiency, have been identi-
fied in patients with familial MDS/AML [131],
20 2. Pathophysiology of Acquired Bone Marrow Failure
monocytopenia and mycobacterial infections
[132,133], Emberger syndrome [134], and den-
dritic cell, monocyte, B-, and NK-cell deficien-
cy [135,136]. GATA2 mutations have also been
identified in a subset of patients presenting with
chronic neutropenia [137], and young adults
with AA [138,139], highlighting the clinical
heterogeneity and variable hematologic phe-
notypes associated with a single genetic defect.
The BM from patients with GATA2 deficiency
is typically hypocellular, with varying degrees
of dysplasia. The marrow had severely reduced
monocytes, B cells, and NK cells; absent hema-
togones; and inverted CD4:CD8 ratios. Atypi-
cal megakaryocytes and abnormal cytogenetics
were more common in GATA2 marrows. Routine
BM flow cytometry, morphology, and cytogenet-
ics in patients who present with cytopenias can
identify patients for whom GATA2 sequencing
is indicated [139]. If GATA2 mutations are iden-
tified, it is important to screen family members
who may be potential donors, as BM transplan-
tation is the only definitive therapy for GATA2
deficiency [140,141].
Familial AA is an extremely rare inherited
subtype affecting multiple individuals in a fam-
ily. Patients typically only have features of AA;
the absence of any somatic features making it
distinct from other inherited AA. By exome se-
quencing, the causative homozygous MPL mu-
tation in a family with familial AA is reported
[142]. Biallelic constitutional mutations in MPL
have been described in congenital amegakaryo-
cytic thrombocytopenia (CAMT) [143]. MPL
mutations can be found in children with famil-
ial AA in whom CAMT was not diagnosed or
suspected. Additional studies will be needed to
further clarify the relationship between CAMT,
AA, and MPL.
For screening, genomic panels of large num-
bers of genes are now available and routinely
used in the clinic to molecularly characterize
patients with suspected inherited bone marrow
failure syndromes (IBMFS); multiple genes from
pathways involved in, Fanconi anemia (FA),
 
dyskeratosis congenita (DC), and Diamond–
Blackfan anemia (DBA) are sequenced by this
method [144].
Clonal Evolution in AA
With improved survival, the late develop-
ment of MDS, AML, or both has been noted in
about 15% of AA patients and termed “clonal
evolution” [145]. AA patients with clonal cy-
togenetic patterns are heterogenous; unlike in
primary MDS, aberrancies of chromosome 5
and 20 were infrequent [146]. The clinical course
depended on the specific abnormal cytogenetic
pattern. Most deaths related to leukemic trans-
formation occur in patients with abnormalities
of chromosome 7 or complex cytogenetic altera-
tions or both [146]. In contrast, +8 and del13q,
may appear in AA that is responsive to IST and
associated with good prognosis [146–149]. In AA
patients with PNH clone, cytogenetic abnormal-
ities usually occur in hematopoietic cells that are
normal phenotype (GPI–AP positive), suggest-
ing these cells have different origin [25,148].
Telomere dynamics play a role in the devel-
opment of myeloid cancers in patients with AA
not associated with a telomeropathy. In adult
patients with severe AA undergoing IST (with-
out a known genetic telomeropathy), pretreat-
ment telomere length in the bottom quartile for
age was a significant risk factor for evolution to
MDS [150]. Patients with the shortest telomeres
had more uncapped telomere-free chromosome
ends as compared to the patients with the lon-
gest telomeres [151]. Analysis of patients, with-
out telomeropathies and with normal telomere
length at the time of diagnosis, who developed
to monosomy 7 found these patients had dra-
matically accelerated telomere attrition before
developing MDS [152]. Rapid telomere loss
led to an accumulation of individual chromo-
somes bearing extremely short telomeres prior
to the development of monosomy 7 as detected
by STELA. Dependence on a limited stem-cell
pool to support hematopoiesis would require
 Treatments for AA
an increased rate of cell division and accelerate
telomere attrition.
In recent years, a number of studies have
reported the presence of acquired somatic mu-
tations in AA, often associated with low level
clones [28,29,153,154]. These mutations were
recurrent somatic mutations found in MDS/
AML. In a small cohort of predominantly pedi-
atric patients, somatic mutations were detected
in 72%, most frequently involved in immune
escape (PIGA, 6pLOH) and signal transduction
(STAT5B, CAMK2G), and MDS-associated SM
were found in only 9% of patients [27]. A large
cohort of 150 AA patients with no morphologi-
cal evidence of MDS identified a subgroup (19%)
with relevant somatic mutations in a small num-
ber of genes (ASXL1 in 12 patients, DNMT3A in
8, BCOR in 6, and
1 each for SRSF2, U2AF1, TET2, MPL, IKZF1,
and ERBB2) [155]. Somatic mutations, when ex-
amined together, predicted for risk of later evo-
lution to MDS; the risk was 38% compared to 6%
in the absence of a somatic mutation, and if the
disease duration of the AA was >6 months, the
risk of MDS was even more significant at 40%
compared to 4% without a somatic mutation.
ASXL1 and DNMT3A mutations were associated
with evolution to monosomy 7 in 4 AA patients.
They also showed that presence of a somatic
mutation was associated with shorter telomere
length compared to patients who lacked a somat-
ic mutation. In a combined USA and Japanese
study targeted sequencing of 106 genes in 439
AA patients [26], various sets of mutations show
distinct behavior and clinical effect; BCOR-mu-
tant and BCORL1-mutant clones and PIGA-mu-
tant clones tended to disappear or remain small,
were associated with a better response to IST,
and predicted favorable outcomes. These data
are compatible with previous studies focusing
on the significance of PIG-A mutant clones. The
vast majority of patients tended to equilibrate at
a clone size, even after IST [23,84]. Recent study
reported that 6p CN-LOH clones were present
in 11.3% of AA, remained stable over time, and
 
21
were not associated with the development of
MDS-defining cytogenetic abnormalities [156].
In contrast, clones carrying mutations in DN-
MT3A, ASXL1, and a few other genes were more
likely to increase in size over time, and these mu-
tations (dominated by DNMT3A and ASXL1) as
a group were associated with a poorer response
to IST, inferior overall survival, and progression
to MDS, AML, or both. Computational strategy
identified patients with better overall survival
(those with PIGA, BCOR, and BCORL1) and pa-
tients with worse overall survival (those with
ASXL1, DNMT3A, TP53, RUNX1, and CSMD1)
than overall survival in the unmutated group,
and patients with better progression-free surviv-
al (those with PIGA, BCOR, and BCORL1) and
patients with worse progression-free survival
(those with ASXL1, DNMT3A, RUNX1, JAK2,
and JAK3) than progression-free survival in the
unmutated group.
A more detailed analysis of clonal evolution
was obtained by the sequencing of serial samples
from 35 AA patients that spanned years [26]. In
most patients, clonal hematopoiesis originated
from a minor clone that was already present at
the time of diagnosis. However, the subsequent
temporal course of these clones was highly vari-
able. Close monitoring of clonal hematopoiesis
by means of both deep sequencing and SNP ar-
ray karyotyping will need to be combined with
clinical evaluation to estimate prognosis and to
guide treatment of patients with AA.
TREATMENTS FOR AA
BMT With Matched Sibling Donors
HSCT is the treatment of choice in newly di-
agnosed patients up to 40 years of age eligible
for HSCT with a histocompatible donor [157].
For all other patients IST with horse ATG/CsA
is the preferred treatment modality. The long-
term survival for either therapy is about 80% for
patients of all ages, with younger patients (<20)
22 2. Pathophysiology of Acquired Bone Marrow Failure
faring better in general [158]. Standard treat-
ment for patients who have a matched sibling
donor is HSCT which provides a cure in about
80–90% of patients [159]. Cyclophosphamide
(CY) with ATG as a conditioning regimen and
the CsA plus methotrexate (MTX) as GVHD pro-
phylaxis represent an effective treatment, with a
rate of engraftment of 90–95% and overall sur-
vival near 80–90% [159]. These rates tend to be
worst in older patients (>40 years of age) ap-
proximating 50–60% [160].
BM source, conditioning with CY + ATG, and
GVHD prophylaxis by CsA + MTX represent the
gold standard in transplantation for AA in pa-
tients receiving transplantations from an HLA-
identical sibling donors. Given these excellent
results, survival is thus no more the sole concern
then prevention and early detection of late com-
plications after BMT is the main objective [161].
After transplantation from an HLA-identical sib-
ling donor or from an unrelated donor, the use
of peripheral blood stem cells must be strongly
discouraged because they have been systemati-
cally associated with an increased incidence of
chronic GVHD compared with the use of BM as
a stem cell source, leading to an unacceptably
higher risk of treatment-related mortality in this
setting.
BMT From Alternative Donors
For patients who lack an HLA identical sib-
ling donor, IST remains the first treatment of
choice. However, 30–40% of the patients will
be refractory or relapse to IST and will thus be
considered for transplantation using an alterna-
tive donor. HSCT is indicated if refractory AA
patients are fit and have a suitably matched
donor. Transplantation from an unrelated do-
nor (UD) is usually considered after failure of
at least one course of IST [162]. This strategy is
based on a relatively high risk of complications
for UD transplant recipients, such as graft rejec-
tion, GvHD, and infections [163,164]. However,
the outcome of unrelated donor transplants has
 
significantly improved [165,166]. Recent study
reported that the outcome of UD transplants for
AA is currently not statistically inferior when
compared to sibling transplants, although pa-
tients are at greater risk of acute and chronic
GVHD [167]. The risk of death of UD grafts was
higher, but not significantly higher, compared to
a sibling donor. The strongest negative predic-
tor of survival was the use of peripheral blood
as a stem cell source, followed by an interval of
diagnosis to transplant of 180 days or more, pa-
tient age 20 years or over, no ATG n in the con-
ditioning, and donor/recipient cytomegalovirus
serostatus, other than negative/negative.
Experimental HSCT
Other alternative source of stem cells in-
cludes umbilical cord blood and a haploiden-
tical family donor [168]. The difficult situation
encountered is when a patient with refractory
AA has no suitably matched UD, and this is not
uncommon. The options for these individuals
include a second course of IST, an alternative
immunosuppressive drug or novel agent, or an
experimental form of transplantation using an
alternative donor source, namely cord blood or
a haploidentical family donor. HSCT offers pos-
sibilities of cure, but risks of alternative donor
HSCT remain graft rejection and GVHD, espe-
cially chronic GVHD, which affects mortality
and quality of life.
The key features of haploidentical graft are
availability for most patients, the time to pro-
cure the graft is short, and the cost is low. This
is not a new approach to HSCT for SAA patients
lacking a matched sibling donor or a suitably
matched UD. Historically, haploidentical HSCT
was invariably unsuccessful, with high rates of
graft rejection and GVHD. A recent review on
73 patients receiving HSCT between 1976 and
2011 and mostly using nonmyeloablative regi-
mens showed a 3-year OS of only 37% [169]. A
novel approach is nonmyeloablative condition-
ing with high-dose CY given on days +3 and +4
 Treatments for AA
after transplantation (PTCy) to prevent GVHD
by depleting dividing donor-alloreactive T cells
but sparing quiescent, nonalloreactive T cells.
Such an approach has been reported anecdotally
in PNH and is under study in protocols in AA
[170]. Recent studies from Johns Hopkins and
others showed that nonmyeloablative allo-BMT
with PTCy from haploidentical donor appears
promising in patients with refractory acquired
and inherited AA with acceptable rates of en-
graftment, eradication of preexisting clonal dis-
eases, low risk of GVHD, and expansion of the
donor pool [171,172].
The largest retrospective study of unrelated
cord blood transplantation comprised 71 AA
patients (9 with PNH) [173]. The main problem
was engraftment failure, with a cumulative in-
cidence of neutrophil recovery of only 51% at
2 months and a 3-year OS of 38%. All those pa-
tients receiving total body irradiation 12 Gy as
part of the conditioning regimen died, indicat-
ing that a RIC rather than myeloablative regi-
men is preferable. Significantly improved OS
was seen in recipients of >3.9 × 107 TNCs/kg
prefreezing. Recent study showed that haplo-
cord HSCT is an effective treatment option for
severe AA patients who lack an HLA-matched
donor [174].
IST
The possibility that the pathophysiology of
AA could be immune mediated was initially
proposed by Barnes and Mole and later rein-
forced by autologous hematologic recovery af-
ter ATG exposure [109,175]. The combination of
ATG + CsA was shown superior to ATG alone
and became the standard IST option in patients
not eligible for HSCT [176]. Extensive experi-
ence with this regimen showed that 60–70% of
patients responded to the combination of horse
ATG/CsA becoming the standard IST regimen.
Across these studies hematologic response
correlated with excellent long-term survival
[157,176–179].
 
23
Amounting evidence that AA had an immune
mediated pathogenesis led to the exploration
of more immunosuppressive agents in clinical
protocols. This development was conducted in
two manners: (1) adding a third immunosup-
pressive agent to horse ATG/CsA and (2) using
more potent lymphocyte depleting agents than
horse ATG. Neither strategy improved the out-
comes. Adding mycophenolate mofetil or siro-
limus to horse ATG/CsA did not improve out-
comes in SAA and the use of more lymphocyte
depleting agents (cyclophosphamide, alemtu-
zumab, rabbit ATG) was equally disappointing
[180,181]. Cyclophosphamide, despite being an
active agent in SAA, is associated with prohibi-
tive toxicity impeding its use [182,183]. Toxic-
ity was considerable, mainly due to prolonged
absolute neutropenia, that occurred regardless
of pretherapy blood counts, and persisted an
average of 2 months [183]. Alemtuzumab as-
sociated with a low response rate (about 20%)
when given as first therapy [184]. Noteworthy
are the disappointing results with rabbit ATG/
CsA when compared directly to horse ATG/
CsA in a randomized study [185]. The anticipa-
tion was for a higher response rate with rabbit
ATG/CsA given its more lymphocyte depleting
properties, Treg inducing property, activity in
horse ATG/CsA refractory cases and superior-
ity to horse ATG in solid organ transplant [186–
189]. However, results showed a lower response
rate of about 35–40% compared to the expected
60–70% seen with horse ATG/CsA [185]. This
difference resulted in superior survival out-
comes with horse ATG/CsA compared to rab-
bit ATG/CsA [185]. Other observations from
prospective studies confirmed this observation
[190]. Therefore, horse ATG/CsA remains the
optimal immunosuppressive regimen as first
line therapy in SAA. The options for patients
who fail initial horse ATG/CsA include HSCT
from a related (in older patients) or unrelated
(in younger patients) histocompatible donor or
a repeat course of IST [191,192]. Rabbit ATG/
CsA or alemtuzumab in this refractory setting
24 2. Pathophysiology of Acquired Bone Marrow Failure
can salvage about 30–40% of patients who can
achieve a hematologic response [184,188]. The
ability to salvage a proportion of patients with
transplant and nontransplant modalities along
with advances in supportive care have resulted
in improved survival outcomes in IST refractory
patients over the years [193]. Even among very
refractory patients to IST who do not undergo
HSCT long-term survival can be achieved with
supportive care measure, such as transfusions,
antimicrobials, growth factor, androgens and
iron chelation. Neutrophil count in this setting
are a principal determinant of survival [194].
When neutrophils are adequate in numbers
that prevent recurrent life-threatening infec-
tions long-term survival with supportive care
measures can be achieved [194]. A longer, taper-
ing course of CsA following horse ATG up to
24 months as initial therapy delayed but did not
ultimately prevent relapses [195]. Therefore, ef-
forts to improve beyond the outcomes achieved
with horse ATG plus CsA were ineffective until
recently.
Eltrombopag
TPO mimetics, such as romiplostim and el-
trombopag, were developed to treat patients with
refractory immune thrombocytopenia but have
been investigated for the treatment of BM failure
syndromes [196]. TPO is the main regulator for
platelet production and its receptor (c-Mpl) is
present on megakaryocytes and HSCs [197,198].
Historically the use of G-CSF and erythropoietin
have not been effective in systematic AA studies
and did not change the natural history of the dis-
ease [199]. The use of a TPO agonist was of par-
ticular interest given the expression of the TPO
agonist receptor in marrow progenitor cells and
the reduced numbers of HSCs in murine TPO
receptor knockout models [200]. However, the
very high endogenous TPO levels in SAA could
render this approach ineffective [201].
In a pilot study (n = 26) eltrombopag was
investigated at an initial dose of 50 mg/day
 
titrated up to 150 mg in a IST refractory SAA
cohort [202]. The overall response rate was 44%
with some bi- and trilineage hematologic im-
provements observed. The degree and quality of
improvement in blood counts with eltrombopag
of patients with refractory AA was unanticipat-
ed. Responses were striking in several respects:
they were not restricted to platelets and were
robust, resulting in transfusion independence.
In an extended experience (n = 43) the response
rate was confirmed at 40% and multilineage in-
crement in blood counts were continued to be
observed [203]. Discontinuation of eltrombopag
was possible in a few patients who had achieved
a robust hematologic recovery without worsen-
ing of the counts. Eight of 43 patients developed
new cytogenetic abnormalities. The most com-
mon chromosomal changes were chromosome
7 abnormalities, which developed in five of the
eight evolvers. This clonal transformation is as-
sociated with a poor outcome, but all patients
who developed chromosome 7 changes were
successfully transplanted. Increase in bone mar-
row cellularity was observed in some respond-
ing patients suggesting that eltrombopag was
stimulating a more primitive progenitor popu-
lation leading to improvement in marrow func-
tion and increase in blood counts. The protection
and/or stimulation of residual HSCs by eltrom-
bopag is a strategy with many applications.
Multiple clinical trials of thrombopoietin mi-
metics, eltrombopag, and romiplostim are in
progress. Eltrombopag is being combined with
standard horse ATG and CsA in treatment-naive
severe AA [204]. In these previously untreated
patients, the combination of eltrombopag with
horse ATG and CsA yielded overall response
rate at 3 and 6 months of 80 and 85%, respec-
tively, which are 20–30% higher than histori-
cal rates with the same regimen without Tpo
agonist in AA. Clonal cytogenetic evolution oc-
curred in 7 of 88 patients, similar to prior rates
observed with standard IST. Longer and more
mature data regarding this novel combination
is awaited to better define the durability of
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joignaient, se traversaient pour se séparer ensuite, lentement ou en
hâte. Le trafic de la grande ville continuait au milieu de la nuit qui
s’approfondissait sur le fleuve sans sommeil. Nous regardions et
attendions patiemment, — il n’y avait rien d’autre à faire jusqu’à la fin
de la marée. Ce ne fut qu’après un long silence quand il nous dit
d’une voix hésitante : « Je suppose que vous vous souvenez, vous
autres, qu’une fois je me suis fait marin d’eau douce, pour quelque
temps », que nous comprîmes que nous étions destinés, avant que
le reflux ne se fît sentir, à entendre le récit d’une des inconcluantes
expériences de Marlow.
« Je n’ai pas l’intention de vous infliger le détail de ce qui m’est
arrivé personnellement, commença-t-il, — non sans trahir par cette
remarque l’erreur commune à tant de conteurs qui semblent si
souvent ne point se douter de ce que leur auditoire préférerait
entendre. — Pourtant pour apprécier l’effet produit sur moi, il faut
bien que vous sachiez comment je fus amené là-bas, ce que j’y vis
et comment je remontai ce fleuve jusqu’à l’endroit où pour la
première fois je me trouvai en présence du pauvre diable. C’était le
point extrême accessible à la navigation : ce fut aussi le point
culminant de mon aventure. Il me parut répandre une sorte de
lumière sur toutes choses autour de moi et dans mes pensées. Il
était sombre à souhait, cependant — et lamentable — point
extraordinaire en quoi que ce fût — pas très clair non plus… Non,
pas très clair… — Et néanmoins, il semblait répandre une espèce de
lumière…
« Je venais tout juste à ce moment, vous vous en souvenez, de
rentrer à Londres, après force service dans l’Océan Indien, le
Pacifique, les mers de Chine — une dose régulière d’Extrême-
Orient, quoi !… Six ans ou peu s’en faut — et je flânais de-ci de-là,
vous empêchant de travailler et envahissant vos foyers, tout comme
si j’avais reçu mission du Ciel de vous civiliser. Ce fut charmant pour
un temps, mais j’en eus bientôt assez de me reposer. Je commençai
alors à chercher un navire — la plus dure corvée, je crois bien, qui
soit au monde. Mais les navires ne daignaient même pas
s’apercevoir de mon existence. Et de ce jeu-là aussi, je finis par me
lasser.
« Or quand j’étais gamin, j’avais la passion des cartes. Je restais
des heures à considérer l’Amérique du Sud, ou l’Afrique ou
l’Australie — perdu dans toutes les gloires de l’exploration. A cette
époque, il y avait pas mal d’espaces blancs sur la terre et quand j’en
apercevais un sur la carte qui avait l’air particulièrement attrayant
(mais ils ont tous cet air-là !) je posais le doigt dessus et disais :
« Quand je serai grand, j’irai là ». Le Pôle Nord fut l’un de ces blancs,
je me rappelle. Je n’y suis pas encore allé et à présent je n’essaierai
pas… Le prestige a disparu… D’autres blancs étaient dispersés
autour de l’Équateur et par toutes sortes de latitudes sur les deux
hémisphères… Je suis allé voir certains d’entre eux, et…, — mais ce
n’est pas de cela qu’il s’agit. Il y en avait un cependant, le plus
grand, le plus « blanc » si j’ose dire qui entre tous m’attirait.
« Il est vrai qu’au moment dont je vous parle, ce n’était plus un
vrai blanc. Depuis mon enfance, il s’était garni de rivières, de lacs,
de noms. Il avait cessé d’être un vide espace de mystérieuses
délices, l’endroit vierge à faire glorieusement rêver un enfant. C’était
devenu une région de ténèbres. Il y avait là notamment un fleuve, un
énorme fleuve qu’on distinguait sur la carte, pareil à un immense
serpent déroulé, la tête dans la mer, son corps au repos s’étendant
au loin au travers d’une vaste contrée, la queue perdue dans les
profondeurs de l’intérieur. Et tandis que j’en contemplais la carte à
une devanture, il me fascinait comme un serpent le ferait d’un
oiseau, un pauvre petit oiseau sans cervelle. Ensuite je me souvins
qu’il existait alors une grosse entreprise, une Compagnie pour le
commerce sur ce fleuve. Que diable, pensai-je, ils ne peuvent faire
du commerce sans utiliser une espèce quelconque de bâtiment sur
tout ce flot d’eau douce, — des vapeurs ! Pourquoi ne pas essayer
de m’en faire confier un ? Je continuai à arpenter Fleet Street, mais
l’idée demeurait attachée à moi. Le serpent m’avait fasciné.
« Il s’agissait à vrai dire d’une affaire continentale ; mais j’ai
quantité de relations sur le continent ; la vie y est bon marché et
point si déplaisante qu’elle en a l’air, assurent-elles.
 « Je rougis d’avouer qu’incontinent je me mis à les relancer.
Cela, déjà, était pour moi une nouveauté ! Je n’avais pas coutume
d’arriver à mes fins de cette manière-là… D’ordinaire, j’allais droit
mon chemin, sans emprunter les jambes d’autrui pour marcher. De
fait, je ne m’en serais pas cru capable, mais à ce moment, voyez-
vous, j’étais sous l’impression qu’il me fallait aller là-bas coûte que
coûte. Je relançai donc mes gens. Les hommes me répondirent :
« Comment donc, cher ami ! » et ne bougèrent pas. Alors — le
croirez-vous ! — je me rabattis sur les femmes… Oui, moi —
Charles Marlow, je mis les femmes en mouvement pour me
décrocher une situation. Bon sang ! — Mais l’idée fixe me tenait… —
J’avais une tante, une tendre âme enthousiaste. Elle m’écrivit :
« Que ce sera charmant ! Je suis prête à faire n’importe quoi pour
vous. C’est une idée admirable. Je connais la femme d’un
personnage très important dans l’Administration et aussi un homme
qui a beaucoup d’influence parmi eux, etc., etc. ». Bref elle était
résolue à remuer ciel et terre pour arriver à me faire nommer
capitaine sur un vapeur d’eau douce, si telle était ma fantaisie.
« J’obtins la place — comme de juste, et cela ne traîna même
pas. Il paraît que la Société venait d’apprendre qu’un de ses
capitaines avait été tué au cours d’une échauffourée avec les
indigènes. Ce fut l’occasion pour moi et je n’en fus que plus chaud
pour partir. Ce n’est que, bien des mois plus tard, lorsque je tentai de
recueillir ce qui restait du corps, que j’appris que toute la querelle
était due à un malentendu à propos de poules. Oui, à propos de
deux poules noires ! Fresleven, — ainsi s’appelait l’homme, un
Danois — s’était cru lésé de quelque manière dans le marché, c’est
pour quoi il descendit à terre, et se mit à travailler le chef du village
avec un gourdin. Je ne fus pas surpris le moins du monde
d’apprendre tout cela et de m’entendre dire, en même temps, que
Fresleven était l’être le plus doux et le plus pacifique qui se soit
jamais promené sur deux pattes. Incontestablement il l’était, mais il y
avait deux ans déjà qu’il était engagé là-bas au service de la noble
cause et sans doute avait-il éprouvé enfin le besoin de manifester sa
dignité d’une manière ou d’une autre. Il se mit donc à rosser
impitoyablement le vieux nègre sous les yeux des indigènes
terrorisés, jusqu’au moment où quelqu’un — le fils du chef, me dit-
on, — poussé au désespoir par les hurlements du vieillard, fit le
geste de pousser vers l’homme blanc la pointe d’une lance, qui, bien
entendu, pénétra sans la moindre difficulté entre les deux
omoplates. Sur quoi la population tout entière se dispersa dans la
forêt, persuadée que les pires calamités allaient se produire,
cependant que d’un autre côté le vapeur que commandait Fresleven
fuyait dans un coup de panique, sous les ordres, je crois, du
mécanicien. Ensuite, nul ne parut se soucier beaucoup des restes
de Fresleven jusqu’au jour où j’arrivai là-bas pour chausser ses
pantoufles. Je ne pouvais laisser les choses en l’état, mais quand
une occasion enfin se présenta pour moi de rencontrer mon
prédécesseur, l’herbe qui lui croissait entre les côtes était assez
haute pour dissimuler ses os. Ils y étaient tous. On n’avait point
touché à l’être surnaturel, après sa chute. Et le village était
abandonné, les cases béaient, noires, pourrissantes, toutes
disloquées entre les enclos renversés. Les calamités effectivement
s’étaient abattues sur lui. Quant aux gens ils s’étaient évanouis. Une
terreur aveugle avait tout dispersé, hommes, femmes, enfants, dans
la brousse : et ils n’étaient jamais revenus. J’ignore ce qu’il advint
des poules. J’incline à penser cependant qu’elles demeurèrent
acquises à la cause du progrès. Quoiqu’il en soit, ce fut à cette
glorieuse affaire que je dus ma nomination avant même d’avoir
commencé à l’espérer.
« Je courus comme un fou pour être prêt à temps, et quarante-
huit heures ne s’étaient pas écoulées que je traversais la Manche
pour me présenter à mes patrons et signer le contrat d’engagement.
En quelques heures je gagnai cette ville qui me fait songer toujours
à un sépulcre blanchi. — Parti-pris, sans doute ! Je n’eus guère de
peine à trouver les bureaux de la Société. C’était ce qu’il y avait de
plus considérable dans toute la ville, et personne qu’on rencontrât
qui n’en eût plein la bouche. Pensez donc ! Ils allaient exploiter un
empire d’outre-mer et en tirer un argent fou par le négoce !
 « Une rue étroite et déserte, dans une ombre profonde de hautes
maisons aux fenêtres innombrables, garnies de jalousies, un silence
de mort, l’herbe poussant entre les pavés, d’imposantes entrées
cochères à droite et à gauche, d’immenses portes à double battant
mornement entrebâillées. Je m’insinuai dans l’une de ces fissures,
gravis un escalier nu et soigneusement balayé, aussi aride que le
désert et poussais la première porte que j’avisai. Deux femmes,
l’une grasse et l’autre maigre, étaient assises sur des chaises de
paille et tricotaient de la laine noire. La femme maigre se leva et
s’avança droit sur moi en continuant de tricoter, les yeux baissés et
déjà je songeais à m’écarter devant elle, comme on ferait pour une
somnambule, quand elle s’arrêta et redressa la tête. Sa robe était
aussi unie qu’un fourreau de parapluie. Elle fit demi-tour sans ouvrir
la bouche et entra devant moi dans une antichambre. Je donnai mon
nom, et jetai les yeux autour de moi. Il y avait une table de bois
blanc au milieu, des chaises toutes simples au long des murailles, et
au bout de la pièce, une grande carte brillante, bariolée de toutes les
couleurs de l’arc-en-ciel. Beaucoup de rouge, qui fait toujours plaisir
à voir, parce qu’on sait que là, du moins, on travaille effectivement ;
une quantité de bleu, un peu de vert, quelques taches orange et sur
la côte Est, une bande pourpre pour indiquer l’endroit où les joyeux
pionniers du progrès dégustent le joyeux lager !… Mais il n’y avait là
rien pour moi : j’étais destiné au jaune ; tout juste au centre ! Et le
fleuve était là aussi, fascinant, terriblement comme un serpent.
Brr !… Une porte s’ouvrit ; une tête de secrétaire à cheveux blancs,
avec une expression pleine de compassion, apparut, et un index
osseux en même temps me fit signe de pénétrer dans le sanctuaire.
La lumière y était avare et une lourde table à écrire s’étalait au
milieu. Derrière ce monument se distinguait quelque chose de
corpulent et de blême, dans une redingote. C’était le grand homme
en personne ! Il était haut de cinq pieds six pouces, me parut-il, et
tenait dans son poing les ficelles de combien de millions !… Il me
serra la main, je crois, murmura quelque chose vaguement, se
déclara satisfait de mon français. Bon voyage.
 « Au bout de quarante-cinq secondes, je me retrouvai dans
l’antichambre auprès du secrétaire compatissant qui, plein de
désolation et de sympathie, me fit signer un document. Je crois bien
que je m’y engageais entre autres choses à ne révéler aucun secret
commercial. — Vrai, ce n’était pas mon intention…
« Je commençais à me sentir mal à l’aise. Vous savez que je n’ai
pas l’habitude de ces sortes de cérémonies, et il y avait quelque
chose de sinistre dans l’atmosphère. C’était tout juste comme si je
venais d’être admis dans une espèce de conspiration, je ne sais quoi
de pas tout à fait honnête et je fus enchanté de m’échapper. Dans
l’autre pièce, les deux femmes tricotaient leur laine noire
fiévreusement. Des gens arrivaient et la plus jeune allait et venait en
les introduisant. La vieille demeurait assise sur sa chaise. Ses
pantoufles plates en étoffe étaient appuyées sur une chaufferette, et
un chat reposait dans son giron. Elle portait une chose blanche
empesée sur la tête, elle avait une verrue sur la joue et des lunettes
d’argent pendaient au bout de son nez. Elle me jeta un coup d’œil
par-dessus ses verres. L’indifférente et fuyante placidité de ce
regard me troubla. Deux jeunes hommes, l’air joyeux et insouciant,
étaient introduits à ce moment et elle leur lança le même preste
coup d’œil de sagesse impassible. Elle semblait ne rien ignorer de
moi-même ni de ceux-là. Une impression inquiétante m’envahit. Elle
avait l’air fatal et au-dessus de toutes choses. Souvent, quand je fus
là-bas, je revis ces deux créatures, gardiennes de la porte des
Ténèbres, tricotant leur laine noire comme pour en faire un chaud
linceul, l’une introduisant, introduisant sans trêve dans l’inconnu,
l’autre scrutant les visages joyeux et insouciants de ses vieux yeux
impassibles. Ave ! Vieille tricoteuse de laine noire. Morituri te
salutant ! De tous ceux qu’elle regarda ainsi, il n’en est pas
beaucoup qui la revirent, moins de la moitié, il s’en faut !…
« Restait la visite au médecin. « Simple formalité », m’assura le
secrétaire avec, l’air de prendre une part immense à mes malheurs.
En conséquence, un jeune gaillard qui portait son chapeau incliné
sur le sourcil gauche — un commis, je pense, car il devait bien y
avoir des commis dans cette affaire, encore que la maison fût aussi
silencieuse qu’une maison de la cité des morts ! — s’amena de
l’étage au-dessus et se chargea de me conduire. Il était râpé et
négligé, avec des taches d’encre sur les manches de son veston, et
une ample cravate bouffante sous un menton en galoche. Comme il
était un peu tôt pour trouver le médecin, je proposai d’aller boire
quelque chose, ce qui du coup le mit en verve. Tandis que nous
étions attablés devant des vermouths, il se mit à exalter les affaires
de la Société, si bien que je finis par m’étonner qu’il ne partît pas lui
aussi. Il devint froid et réservé sur-le-champ : « Je ne suis pas aussi
bête que j’en ai l’air, disait Platon à ses disciples », déclara-t-il
sentencieusement en vidant son verre avec résolution, et nous nous
levâmes.
« Le vieux docteur me tâta le pouls, tout en pensant évidemment
à autre chose. « Bon, bon, pour là-bas », marmotta-t-il et ensuite,
avec un certain intérêt, il me demanda si je l’autorisais à prendre la
mesure de mon crâne. Un peu surpris, j’y consentis, sur quoi il sortit
une espèce d’instrument pareil à un calibre, et releva mes
dimensions, par-devant, par derrière et de tous les côtés, en prenant
soigneusement des notes. C’était un petit homme mal rasé, en
veston élimé d’étoffe sèche comme de la gabardine, les pieds dans
des pantoufles et qui me fit l’effet d’un fou inoffensif. « Je demande
toujours la permission, dans l’intérêt de la science, de mesurer le
crâne de ceux qui s’en vont là-bas. — Le faites-vous aussi quand ils
reviennent ? demandai-je. — Oh, répondit-il, je ne les vois jamais et
de plus, c’est à l’intérieur que les modifications se produisent. » Il
sourit, comme à une douce plaisanterie. « Ainsi, vous allez là-bas !…
Fameux… Intéressant aussi… » Il me jeta un coup d’œil pénétrant,
prit encore une note : « Aucun cas de folie dans votre famille ? »
demanda-t-il d’un ton tout naturel. Je me sentis plutôt froissé —
« Cette question est-elle dans l’intérêt de la science également ? — Il
serait intéressant pour la science de suivre sur place les
modifications mentales de l’individu, mais… » Je lui coupai la
parole : « Etes-vous aliéniste ?… — Tout médecin devrait l’être tant
soit peu », me répondit cet original imperturbablement. « J’ai une
petite théorie qu’il vous appartient, à vous autres, Messieurs, qui
allez là-bas, de justifier. Tel est mon lot parmi les avantages que mon
pays est appelé à recueillir de la possession d’une si magnifique
dépendance. La vulgaire richesse, je la laisse aux autres…
Pardonnez-moi ces questions, mais vous êtes le premier Anglais
que j’aie l’occasion d’observer… » Je me hâtai de l’assurer que je ne
devais en aucune façon être considéré comme représentant mon
espèce. « Si je l’étais, ajoutai-je, je ne bavarderais pas ainsi avec
vous… — Ce que vous dites est plutôt profond et probablement
erroné, me dit-il en riant. Évitez toute irritation plus que l’exposition
au soleil… Adieu. Comment dites-vous cela en Angleterre ? Good
Bye. Eh bien, Good Bye. Adieu. Avant tout, sous les tropiques il faut
conserver son calme… » Il éleva un index significatif : Du calme du
calme. Adieu…
Il ne restait plus qu’à prendre congé de mon excellente tante. Je
la trouvai triomphante. Elle m’offrit une tasse de thé — la dernière
tasse de thé convenable pour combien de jours ! — et dans une
pièce qui répondait de la manière la plus flatteuse à l’idée qu’on se
fait du salon d’une dame, nous eûmes une longue causerie tranquille
au coin du feu. Au cours de ces confidences, il m’apparut clairement
que j’avais été représenté à la femme du haut dignitaire — et Dieu
sait à combien d’autres encore ? comme un être exceptionnellement
doué, — une chance pour la Compagnie ! — un des hommes dont
on ne s’attache pas le pareil tous les jours… N’empêche qu’avec
tout cela, c’était d’un méchant rafiau de quatre sous que j’allais
prendre charge, sans parler du sifflet d’un sou qui le complétait ! Du
moins j’allais être désormais l’un des Pionniers avec un grand P, s’il
vous plaît !… Quelque chose comme un émissaire de lumière, une
espèce d’apôtre au petit-pied… Un flot de sornettes de ce genre
avait été lâché à cette époque, en paroles et en écrits, et la brave
femme qui vivait au cœur même de cette plaisanterie en avait tout
simplement perdu la tête. Elle ne parlait que d’« arracher ces millions
de créatures ignorantes à leurs affreuses coutumes », si bien que je
finis par me sentir gêné. Je me risquai à suggérer qu’après tout la
Compagnie avait pour but de réaliser des bénéfices.
 — « Vous oubliez, cher Charlie, que toute peine mérite salaire »,
fit-elle, rayonnante. Extraordinaire, la façon dont les femmes vivent
en dehors de la réalité. Elles vivent dans un monde qu’elles se font
elles-mêmes, à quoi rien n’a jamais été ni ne sera pareil. Trop parfait
d’un bout à l’autre et tel que si elles avaient à le réaliser, il
s’écroulerait avant le premier coucher de soleil. Quelqu’un de ces
misérables faits, avec qui, nous autres hommes, n’avons cessé
d’être en difficultés depuis le jour de la création, surgirait
brusquement et jetterait tout l’édifice par terre…
« Après cela, ma tante m’embrassa, me recommanda de porter
de la flanelle, de ne pas manquer d’écrire souvent, que sais-je
encore ! et je m’en fus… Dans la rue, je ne sais pourquoi, je me fis
l’effet singulier d’être un imposteur. Étrange que moi qui étais
habitué, en vingt-quatre heures de temps, à partir pour n’importe
quel endroit du monde, sans plus de réflexion que la plupart des
hommes n’en mettent à traverser la rue, — j’ai eu un instant, je ne
dirai pas d’hésitation, mais tout au moins d’effarement devant cette
banale entreprise. Je ne saurais mieux le faire entendre qu’en vous
disant que, pendant une ou deux secondes, il me parut qu’au lieu de
partir pour le cœur d’un continent, j’étais sur le point de m’enfoncer
au centre de la terre.
« Je pris passage sur un bateau français qui fit escale à chacun
de ces sacrés ports qu’ils ont là-bas, à seule fin, autant que je pus
en juger, d’y débarquer des soldats et des douaniers. Je considérais
la côte. Considérer une côte tandis qu’elle défile au long du navire,
c’est comme se pencher sur une énigme. Elle est là devant vous,
souriante ou hostile, tentante, splendide ou médiocre, insipide ou
sauvage, et muette toujours, non sans un air de murmurer :
Approche et devine. Cette côte-ci était presque sans traits, comme
encore inachevée, avec un aspect de monotone sévérité. La lisière
d’une jungle colossale d’un vert si foncé qu’il en était presque noir,
bordée d’une barre d’écume blanche, courait toute droite, comme
tracée au cordeau, au long d’une mer bleue dont l’éclat était voilé
par une brume traînante. Le soleil était terrible ; la terre semblait luire
et ruisseler dans la vapeur. De-ci de-là, quelques taches d’un gris
blanchâtre apparaissaient, groupées derrière la barre, avec parfois
un drapeau hissé. C’était des établissements vieux de plusieurs
siècles, pas plus importants cependant qu’une tête d’épingle au
regard de l’étendue inviolée de l’intérieur. Nous nous traînions
lentement, nous arrêtions, débarquions des soldats ; nous repartions
ensuite, débarquions des commis de douane, appelés à percevoir
leurs taxes dans ce qui avait l’air d’une sauvagerie oubliée de Dieu,
avec, perdus là-dedans, un hangar de zinc et un mât de pavillon ;
nous débarquions encore des soldats, pour veiller à la sécurité des
commis de douane, apparemment. Quelques-uns, à ce que j’appris,
se noyaient en franchissant la barre, mais qu’il en fût ainsi ou non,
personne ne paraissait y attacher la moindre importance. Les
pauvres diables étaient simplement jetés à terre et nous repartions.
La côte chaque jour était pareille, à croire que nous n’avions pas
bougé ; mais nous touchâmes à divers ports de commerce ! dont les
noms, comme Grand-Bassam ou Petit-Popo semblaient appartenir à
quelque farce misérable jouée devant une sinistre toile de fond. Mon
désœuvrement de passager, l’isolement parmi tous ces hommes
avec qui je n’avais pas de point de contact, la mer huileuse et
indolente, la sombre uniformité de cette côte, semblaient me tenir à
l’écart de la réalité des choses, dans l’oppression d’une sorte de
lamentable et absurde fantasmagorie. Le bruit de la barre que je
percevais de temps en temps me causait un plaisir réel, comme la
parole d’un frère. C’était quelque chose de naturel, qui avait sa
raison et sa signification. Parfois, un canot qui se détachait de la
côte créait un contact momentané avec la réalité ! Il était monté par
des pagayeurs noirs. On pouvait voir de loin le blanc de leurs yeux
qui luisait. Ils criaient ou ils chantaient ; leurs corps ruisselaient de
sueur ; ils avaient des visages pareils à des masques grotesques,
ces gaillards, mais ils avaient des os, des muscles, une vitalité
sauvage, une intense énergie de mouvements qui était aussi
naturelle et authentique que la barre au long de leur côte. Ils
n’avaient pas besoin d’excuse pour justifier leur présence. C’était un
grand soulagement de les considérer. Pour un temps, je sentais que
j’appartenais toujours à un monde de faits positifs, mais cette
impression ne durait guère. Quelque chose ne tardait pas à survenir
qui avait tôt fait de la dissiper. Un jour, je me souviens, nous
rencontrâmes un navire de guerre, mouillé au large du rivage. Il n’y
avait même pas de hangar là, et cependant il canonnait la brousse. Il
paraît que les Français avaient une guerre en cours dans ces
parages. Le pavillon pendait flasque comme une loque ; la gueule
des longs canons de huit pouces hérissait de toute part la coque
basse, que la houle grasse et boueuse soulevait paresseusement
pour la laisser ensuite retomber, en faisant osciller les mâts effilés.
Dans la vide immensité du ciel, de l’eau et de la terre, il restait là,
incompréhensible, à canonner un continent. Boum ! faisait l’une des
pièces de huit pouces ; une courte flamme jaillissait, et
s’évanouissait ; un peu de fumée s’évaporait, un pauvre petit
projectile passait en sifflant, et rien ne se produisait. Qu’eût-il pu se
produire ? Il y avait je ne sais quelle touche de folie dans toute cette
affaire, une impression de drôlerie macabre dans ce spectacle et elle
ne fut pas pour la dissiper, l’assurance que me donna sérieusement
quelqu’un à bord qu’il y avait un camp d’indigènes — il disait
d’ennemis ! — caché hors de vue, quelque part.
« Nous remîmes ses lettres à ce navire solitaire (dont j’appris que
les hommes étaient emportés par la fièvre à raison de trois par jour)
et nous repartîmes. Nous fîmes escale à quelques autres endroits
aux noms bouffons, où la joyeuse danse du Commerce et de la Mort
va son train dans une immobile et terreuse atmosphère de
catacombe surchauffée, au long d’une côte sans forme bordée par
une barre dangereuse, comme si la nature elle-même eût voulu en
écarter les intrus ; dans les eaux ou en vue de fleuves, vivants
courants de mort, dont les berges pourrissaient parmi la vase, dont
le flot, épaissi par la boue, inondait des palétuviers convulsés qui
semblaient se tordre vers nous, comme dans l’excès d’un désespoir
impuissant. Nulle part l’arrêt ne fut assez long pour permettre une
impression particulière, mais d’une manière générale, je sentais
s’accentuer en moi un sentiment d’étonnement, confus et déprimant.
C’était comme une sorte de morne pèlerinage parmi des éléments
de cauchemar.
 « Il se passa plus de trente jours avant qu’on n’aperçût
l’embouchure du grand fleuve. Nous jetâmes l’ancre en face du
siège du Gouvernement. Mais mon rôle ne devait commencer qu’à
quelque trois cents kilomètres plus loin. C’est pourquoi, aussitôt qu’il
fut possible, je gagnai un endroit à trente milles en amont.
« Je fis le voyage sur un petit vapeur de haute mer. Le capitaine,
un Suédois, en apprenant que j’étais marin, m’invita à monter sur la
passerelle. C’était un jeune homme, maigre, blond, morose, avec
des cheveux raides et une allure traînarde. Comme nous quittions le
misérable petit wharf il désigna la rive d’un hochement méprisant :
« Vous êtes descendu là ?… » Je lui dis que oui. « Fameux, ces
types du Gouvernement, pas vrai ? » continua-t-il. Il parlait anglais
avec une grande précision et une remarquable amertume :
« Étrange ce que certaines gens consentent à faire pour quelques
francs par mois… je me demande ce qu’il advient à ces gens-là
lorsqu’ils s’avancent dans l’intérieur !… » Je répondis que je
comptais bien être fixé là-dessus avant longtemps : « Avant
longtemps ! » s’écria-t-il. Il traversa le pont en traînant la semelle,
sans quitter la route des yeux. « Ne soyez pas si sûr de votre
affaire… L’autre jour, j’en ai chargé un qui s’est pendu en route. Et
c’était un Suédois !… — Pendu ! m’écriai-je. Et pourquoi, grands
dieux ! » Il ne détourna pas son regard vigilant. « Que sais-je !…
Sans doute en avait-il assez du soleil ou du pays peut-être… »
« A la fin, le fleuve s’élargit. Une falaise rocheuse apparut, des
monticules de terre retournée sur la rive, des maisons sur une
colline, d’autres, avec des toits de fer, perdues dans un chaos
d’excavations ou accrochées au versant. Un bruit incessant de
rapides, en amont, planait au-dessus de ce paysage de dévastation
habitée. Des hommes, en général noirs et nus, allaient et venaient
comme des fourmis. Une jetée s’avançait dans le fleuve. Et un soleil
aveuglant noyait parfois l’ensemble dans une recrudescence subite
d’éclat. « Voilà le poste de votre Compagnie », fit le Suédois, en
désignant du doigt trois édifices de bois, pareils à des
baraquements, sur la pente rocheuse. « Je vous fais monter vos
affaires. Quatre caisses, dites-vous… Parfait. Au revoir… »
 « Je donnai sur une chaudière vautrée dans l’herbe, et trouvai un
sentier qui gravissait la colline. Il faisait un coude de temps en temps
pour éviter les blocs de rocher, voire un wagonnet échoué sur le dos,
les roues en l’air. Une d’elles manquait. La chose avait l’air aussi
morte qu’une carcasse d’animal. Je tombai sur d’autres pièces de
machine, un tas de rails rouillés. A ma gauche, un bouquet d’arbres
faisait un îlot d’ombre où des choses obscures semblaient remuer
faiblement. Je bronchai : la côte était roide. Une trompe sonna sur
ma droite et je vis les noirs courir. Une détonation puissante et
sourde secoua le sol, une bouffée de fumée s’éleva de la falaise, et
ce fut tout. Aucun changement n’apparut sur l’aspect du roc. Ils
construisaient un chemin de fer. Sans doute la colline n’était-elle pas
à l’alignement ! A ces coups de mine sans objet se bornaient du
reste les travaux.
« Un léger tintement derrière moi me fit tourner la tête. Six nègres
à la file gravissaient péniblement le sentier. Ils marchaient, raides et
lents, balançant de petites corbeilles de terre sur la tête, et le
tintement marquait la mesure de leurs pas. Des haillons noirs étaient
noués autour de leurs reins et les bouts leur pendillaient derrière le
dos comme des queues. On distinguait chacune de leurs côtes, les
articulations de leurs membres étaient pareilles à des nœuds dans
un câble ; chacun avait un collier de fer autour du cou et ils étaient
tous attachés par une chaîne dont les maillons se balançaient avec
un tintement rythmé. Une nouvelle détonation qui s’éleva de la
falaise me fit ressouvenir de ce navire de guerre que j’avais aperçu,
canonnant un continent. C’était la même voix sinistre, mais ces
hommes-ci, par quel effort d’imagination, voir en eux des ennemis ?
Aussi bien ils n’étaient appelés que criminels et la loi outragée,
pareille aux obus explosifs, s’était abattue sur eux, insoluble mystère
surgi de la mer… Les maigres poitrines haletaient toutes ensemble :
les narines, violemment dilatées, frémissaient, leurs regards étaient
tendus en l’air fixement. Ils passèrent à moins d’un pas de moi, sans
un coup d’œil, avec cette totale, cette mortelle indifférence du
sauvage malheureux. Derrière cette matière première, l’un des
Régénérés, le produit des forces nouvelles à l’œuvre, flânait d’un air
déprimé, tenant un fusil par le milieu. Il avait une vareuse d’uniforme
à laquelle un bouton manquait et en apercevant un blanc sur le
sentier, il porta vivement l’arme à l’épaule. C’était là simple
précaution ; à distance, les hommes blancs se ressemblent à ce
point qu’il ne pouvait deviner qui j’étais. Il fut bientôt rassuré et avec
une large grimace de coquin, qui lui découvrait les dents, il cligna de
l’œil vers son convoi, comme pour m’associer à la haute mission
qu’il remplissait. Après tout, moi aussi, je faisais partie de la grande
cause d’où procédaient ces nobles et justes mesures !…
« Au lieu de continuer à monter, j’obliquai et descendis vers la
gauche. Je tenais à laisser à l’équipe enchaînée le temps de
disparaître avant de reprendre mon ascension. Je ne suis pas
particulièrement tendre, vous le savez ; j’ai eu dans la vie à cogner
et à me défendre ; j’ai eu à résister et parfois à attaquer (ce qui n’est
qu’une façon de résister), sans trop penser à la casse et selon ce
qu’exigeait le genre d’existence où je m’étais fourvoyé. J’ai vu le
démon de la violence, et le démon de la cupidité et celui du désert
brûlant ; bon sang ! C’était là de vigoureux démons bien en chair,
l’œil hardi — et c’était des hommes, des hommes, entendez-vous,
que ces démons-là commandaient et possédaient. Mais, debout sur
le flanc de la colline, j’eus le pressentiment que sous l’aveuglant
soleil de ce pays, j’allais apprendre à connaître le démon, flasque,
hypocrite, aux regards évasifs, le démon d’une folie rapace et sans
merci. Ce qu’il pouvait être insidieux aussi, je ne devais le découvrir
que plusieurs mois plus tard et à quelques milliers de kilomètres de
là ! Un moment je demeurai épouvanté, comme par un
avertissement. Enfin je me mis à descendre la colline, obliquement,
dans la direction des arbres que j’avais aperçus.
« J’évitai un vaste trou artificiel que l’on avait creusé dans la
pente et dont il me fut impossible de deviner l’objet. Ce n’était
assurément ni une carrière ni une sablière. C’était un trou sans plus.
Peut-être avait-il quelque rapport avec le philanthropique désir de
fournir quelque occupation aux criminels, qui sait ? Ensuite je faillis
dégringoler dans une tranchée très étroite, à peine plus marquée
qu’une coupure dans le flanc de la colline. Je constatai qu’une
quantité de tuyaux de drainage importés y avait été jetée pêle-mêle.
Pas un qui ne fût brisé. C’était un massacre sauvage. Enfin je me
trouvai sous les arbres, je me proposais simplement de flâner un
instant à l’ombre, mais à peine fus-je entré, il me parut que je venais
de pénétrer dans le cercle sinistre de je ne sais quel Enfer… Les
rapides étaient tout proches, et leur voix ininterrompue, uniforme,
précipitée et jaillissante, remplissait la tranquillité désolée de ce petit
bois, — où pas un souffle, pas une feuille ne bougeait, — d’un bruit
mystérieux, comme si le mouvement éperdu de la terre dans
l’espace y fût subitement devenu perceptible.
« Des formes noires, parmi les arbres, étaient accroupies,
gisantes ou assises, appuyées contre les troncs, collées à la terre,
moins indiquées qu’effacées par la lumière trouble, dans toutes les
postures de la douleur, de l’accablement et du désespoir. Un
nouveau coup de mine éclata sur la falaise suivi par un léger
frémissement du sol sous mes pieds. L’œuvre se poursuivait.
L’œuvre !… Et ceci était l’endroit où certains de ses serviteurs
s’étaient retirés pour mourir.
« Ils mouraient lentement ; aucun doute là-dessus. Ce n’était pas
des ennemis, ce n’était pas des criminels ; ils n’étaient plus quoi que
ce fût dans ce monde désormais, rien que les ombres noires de la
maladie et de l’épuisement, répandues confusément dans la
pénombre verdâtre. Amenés de tous les points de la côte, en vertu
de ce qu’il y a de plus régulier dans les contrats d’engagement à
terme, dépaysés dans un milieu contraire, soumis à un régime
inaccoutumé, ils ne tardaient pas à dépérir, cessaient d’être utiles et
dès lors étaient autorisés à se traîner jusqu’ici et à reposer. Ces
formes moribondes étaient libres comme l’air et presque aussi
diaphanes. Je commençai à distinguer la lueur de leurs yeux sous
les arbres. Ensuite en regardant à mes pieds, j’aperçus un visage
tout près de ma main. La noire ossature était étendue de toute sa
longueur, l’épaule contre un arbre ; avec lenteur, les paupières se
soulevèrent ; les yeux creux me considérèrent, énormes et vides : il
y eut une sorte de clignotement aveuglé dans la profondeur des
orbites, elle s’éteignit peu à peu. L’homme ne semblait pas âgé,
presque un jeune homme, — mais avec ces gens-là sait-on
jamais !… Je ne trouvai rien de mieux à faire que de lui tendre un de
ces excellents biscuits de mer suédois que j’avais dans ma poche.
Les doigts se fermèrent lentement sur lui et le retinrent. Il n’y eut ni
un autre mouvement ni un autre regard. Il avait un bout de laine
noué autour du cou. — Pourquoi ? — Et d’où le tenait-il ?… Était-ce
un insigne, un ornement, un fétiche, une façon d’acte propitiatoire ?
Y avait-il là une intention quelconque ? Il avait l’air saisissant sur ce
cou noir, ce bout de cordon blanc venu de par-delà les mers.
« Près du même arbre, deux autres paquets d’angles aigus
étaient tapis, les jambes remontées L’un d’eux, le menton étayé sur
les genoux, regardait dans le vide d’une manière intolérable et
effrayante : son frère fantôme se soutenait le front comme accablé
d’un intense ennui, et à l’entour, d’autres encore étaient dispersés,
dans toutes les attitudes de l’effondrement et de la contorsion, ainsi
qu’on en voit dans certains tableaux de massacre ou de peste.
Tandis que je demeurais saisi d’horreur, l’un de ces êtres se dressa
sur les mains et les genoux, et se dirigea vers le fleuve à quatre
pattes, pour y boire. Il lapait l’eau dans le creux de sa paume.
Ensuite, il s’assit au soleil, les tibias croisés devant lui et au bout
d’un instant laissa tomber sa tête laineuse sur sa poitrine.
« J’avais perdu toute envie de flâner à l’ombre et je repris
vivement le chemin de la station. Près des bâtiments, je rencontrai
un homme blanc d’une élégance apprêtée si inattendue que tout
d’abord je le pris pour une vision. J’apercevais un col droit empesé,
des manchettes blanches, un veston d’alpaga léger, un pantalon
immaculé, une cravate claire et des chaussures cirées. Pas de
chapeau, mais sous le parasol doublé de vert qu’élevait une forte
main blanche, des cheveux bien brossés, huilés, avec une raie au
milieu. Il était déconcertant et il avait un porte-plume derrière l’oreille.
« J’échangeai une poignée de main avec ce miracle et j’appris
qu’il était le chef comptable de la Compagnie et que toute la
comptabilité était tenue dans ce poste. Il était sorti un instant, me dit-
il, « pour respirer une bouffée d’air frais ». L’expression me paraissait
singulièrement surprenante par ce qu’elle suggérait de vie
sédentaire dans un bureau. Je ne vous aurais du reste pas parlé du
personnage si ce n’était par lui que pour la première fois j’entendis
prononcer le nom de l’homme qui reste indissolublement lié à tous
mes souvenirs de cette époque. Et puis, je me sentis du respect
pour ce gaillard. Oui, j’éprouvai du respect pour ses faux-cols, ses
amples manchettes, ses cheveux bien brossés. Son aspect était
certainement celui d’un mannequin de coiffeur, mais au milieu de la
démoralisation de ce pays, il gardait le souci des apparences. Et
cela c’est de la force de caractère. Ses cols amidonnés, ses devants
de chemise apprêtés n’étaient ni plus ni moins que des preuves de
caractère. Il y avait près de trois ans qu’il était là, et par la suite, je
ne pus m’empêcher de lui demander comment il s’y prenait pour
arriver à exhiber ce linge-là. Il eut une imperceptible rougeur et
répondit modestement : « J’ai dressé une des femmes indigènes du
Poste. Cela n’a pas été sans peine. Elle n’avait aucun goût pour ce
travail… » Ainsi cet homme avait réellement réalisé quelque chose.
De plus il était appliqué à ses livres qui étaient dans un ordre
exemplaire.
« Tout le reste du Poste n’était que confusion, — têtes, choses et
bâtiments. Des files de nègres poussiéreux, aux pieds plats,
arrivaient et repartaient. Un flot de produits manufacturés, cotons de
pacotille, verroteries et fil de laiton, était dirigé vers les profondeurs
des ténèbres d’où découlait en revanche un mince filet d’ivoire
précieux.
« Il me fallut attendre dix jours au Poste, — une éternité ! J’étais
logé dans une baraque au milieu de la cour, mais pour échapper au
chaos, j’allais me réfugier parfois chez le comptable. Son bureau
était construit de planches posées de champ et si mal jointes que
lorsqu’il se penchait sur sa haute table, il était zébré du cou aux
talons d’étroites raies de lumière. Il n’était pas besoin de pousser le
lourd volet pour y voir clair. Et quelle chaleur là-dedans ! De grosses
mouches bourdonnaient férocement ; elles ne piquaient pas, elles
poignardaient. Je m’asseyais généralement sur le plancher
cependant que perché sur un tabouret, irréprochable et même
légèrement parfumé, il écrivait, écrivait… De temps en temps, il se
tenait debout pour se dégourdir. Lorsqu’un malade — un agent de
l’intérieur qu’on rapatriait — fut installé chez lui dans un lit-tiroir, il ne
laissa pas de témoigner une certaine contrariété : « Les
gémissements de ce malade, disait-il, distraient mon attention. Et à
moins d’attention, il est extrêmement difficile d’éviter les erreurs
matérielles sous ce climat… »
« Un jour, il remarqua, sans lever la tête : « Dans l’intérieur, vous
rencontrerez certainement M. Kurtz. » Comme je lui demandais qui
était M. Kurtz, il me dit que c’était un agent de premier ordre et
constatant mon désappointement à cette information sommaire, il
déposa son porte-plume et ajouta lentement : « C’est un homme très
remarquable… » Après force questions je finis par apprendre que M.
Kurtz dirigeait un poste de traite, très important ; dans le vrai pays de
l’ivoire, « au fin fond là-bas. » « Il nous envoie autant d’ivoire que
tous les autres réunis. » Il se remit à écrire. L’homme malade était
trop accablé pour gémir. Les mouches bourdonnaient dans une
grande paix.
« Soudain, il y eut un murmure grossissant de voix et un grand
bruit de piétinement. Une caravane venait d’arriver. Un jacassement
violent, aux sonorités barbares, éclata de l’autre côté des planches.
Tous les porteurs parlaient à la fois, et au milieu du vacarme, on
distinguait la voix lamentable de l’agent principal qui « y renonçait »
pour la vingtième fois ce jour-là. — Il se leva avec lenteur : « Quel
terrible vacarme !… » Il traversa la pièce avec précaution pour jeter
un coup d’œil sur le malade et revenant vers moi : « Il n’entend plus,
fit-il. — Quoi, est-il mort ! m’exclamai-je, saisi. — Non, pas encore,
répondit-il » avec un grand calme. Ensuite faisant d’un signe de tête
allusion au tumulte de la cour : « Quand on a à passer des écritures
correctement, on en arrive à détester ces sauvages, à les détester à
mort… » Il demeura un instant pensif. « Lorsque vous verrez M.
Kurtz, reprit-il, dites-lui de ma part que tout ici (et il jeta un coup d’œil
sur sa grande table) va très bien. Je n’aime guère lui écrire : avec
les courriers que nous avons, on ne sait jamais entre quelles mains
une lettre peut tomber au Poste Central. » Il me considéra un instant
de ses gros yeux placides ; « Oh ! il ira loin, très loin, reprit-il. Il sera
quelqu’un dans l’Administration avant peu… C’est leur intention
arrêtée à ces Messieurs là-bas. — Je veux dire au Conseil en
Europe… »
« Il se remit au travail. Le bruit au dehors avait cessé. Près de
franchir la porte pour sortir je m’arrêtai. Parmi l’incessant
bourdonnement des mouches, l’agent qu’on rapatriait gisait inerte et
congestionné ; l’autre, penché sur ses livres, passait en écriture le
plus correctement possible des opérations parfaitement correctes, et
à cinquante pieds en contrebas, j’apercevais les cimes immobiles du
bosquet de la mort.
« Le jour suivant, je quittai le Poste enfin, avec une caravane de
soixante hommes, pour une ballade à pied de trois cents kilomètres.
« Inutile de vous en dire long là-dessus. Des pistes, des pistes
partout, un réseau de pistes foulées, étendu sur un pays vide, au
travers d’herbes hautes, d’herbes brûlées, de broussailles,
descendant des ravines fraîches, remontant des collines embrasées
de chaleur — et parmi quelle solitude !… personne, pas une hutte.
Les populations s’étaient enfuies depuis longtemps. Ma foi, à
supposer qu’une bande de nègres mystérieux, porteurs de toutes
sortes d’armes terribles, prît fantaisie de circuler sur la route de Deal
à Gravesend, en mettant la main au collet de tous les ruraux à droite
et à gauche pour leur faire porter des fardeaux, j’imagine volontiers
qu’il ne faudrait pas longtemps pour vider proprement fermes et
cottages dans ces parages. Seulement, ici, les habitations elles-
mêmes avaient disparu. Pourtant je traversai quelques villages
abandonnés. Il y a je ne sais quoi de puérilement pathétique dans
les ruines de murailles d’herbes !… — Les jours suivaient les jours
parmi le traînement derrière moi de soixante paires de pieds nus
supportant chacune une charge de trente livres. Camper, cuisiner,
dormir, décamper et puis marcher. Parfois un porteur mort sous le
harnais, gisait dans les hautes herbes près de la piste, avec une
gourde vide et son long bâton à côté de lui. Un grand silence autour
et au-dessus de nous. A peine par certaines nuits tranquilles le
frémissement d’un tam-tam lointain, tour à tour s’effaçant et
s’enflant, tremblement indistinct et vaste, rumeur étrange, attirante,
évocatrice et barbare, dont le sens peut-être était aussi profond que
le son des cloches en terre chrétienne. Un jour, un blanc, en
uniforme déboutonné, campé au travers de la piste, avec une
escorte en armes de maigres Zanzibaristes, fort hospitaliers et
joviaux du reste, pour ne pas dire gris. Il s’occupait de l’entretien de
la route, à ce qu’il disait. Je n’oserais affirmer qu’on s’aperçût de la
présence d’une route ni d’un entretien quelconque, à moins que le
corps d’un nègre d’âge mûr, le front troué d’une balle, et sur lequel je
buttai littéralement à une lieue de là, ne dût être considéré comme
une amélioration d’ordre permanent. J’avais pour compagnon un
autre blanc, pas mauvais garçon, mais trop bien en chair et doué de
l’exaspérante habitude de tourner de l’œil chaque fois qu’il fallait
gravir une côte un peu chaude, à des kilomètres du plus petit coin
d’ombre, et de l’eau. Plutôt énervant, je vous prie de croire, d’avoir à
déployer son veston comme un parasol au-dessus de la tête de
quelqu’un en attendant qu’il veuille bien revenir à soi. Je ne pus
m’empêcher de lui demander un jour ce que diable il venait faire
dans ce pays. — « Drôle de question ! Faire de l’argent, parbleu ! »
me répondit-il d’un air de mépris. Ensuite il prit les fièvres et il fallut
le porter dans un hamac suspendu à une perche. Comme il pesait
plus de deux cents livres ce furent avec plusieurs porteurs des
histoires sans fin !… Ils se rebiffaient, prenaient le large, désertaient
la nuit furtivement avec leurs charges : une mutinerie, quoi ! Aussi
bien, un soir, je leur tins un discours en anglais, avec gestes dont
pas un ne fut perdu pour les soixante paires d’yeux qui me
regardaient, et le matin qui suivit, le hamac prit les devants à
souhait. Une heure plus tard, je découvrais tout le chargement
chaviré dans la brousse. La lourde perche avait écorché son pauvre
nez et il tenait à toute force à me faire tuer quelqu’un ; mais il n’y
avait pas l’ombre d’un porteur à proximité. Je me souvins du vieux
médecin : « Il serait intéressant pour la science de suivre sur place
les modifications mentales de l’individu… » Je constatai que je
commençais à devenir scientifiquement intéressant. Du reste tout
cela est hors de propos. Le quinzième jour, je me retrouvai en vue
du grand fleuve et fis mon entrée, clopin-clopant, au Poste Central. Il
se trouvait au fond d’une crique, entouré de broussailles et de forêt,