Pure Smooth Endoplasmic Reticulum (SER) Inclusions in Granulocytes of MYH9-Related Disorder Patients
Authors: Pujol-Moix Núria , Muñiz-Diaz Eduardo , Español Ignacio 
Published: November 2021

Abstract
MYH9-related disorders are a group of disorders (May-Hegglin anomaly, Fechtner syndrome, Sebastian syndrome) characterized by macrothrombocytopenia and ribosome inclusions in granulocytes. They are caused by mutations in the MYH9 gene and, depending on the location of the mutation, are associated with extrahematological pathologies (sensorineural hearing loss, progressive nephropathy, presenile cataracts) of variable intensity.
The inclusions are formed by single and clustered ribosomes and are partially surrounded by segments of rough endoplasmic reticulum (RER). Typical inclusions in May-Hegglin anomaly are spindle-shaped, well-defined, and contain longitudinal filaments. Those found in Sebastian and Fechter syndromes are round or oval, have no filaments and, sometimes, show cross-striated arrangement of the ribosome aggregates.
When reviewing the electron micrographs of the granulocyte inclusions of 10 patients with MYH9-related disorders previously published (Pujol-Moix et al. Haematologica 2004;89:330-337) we observed a special type of inclusion not described in the article. This inclusion has the typical appearance of smooth endoplasmic reticulum (SER) clusters, that is, a meshwork of branching tubules of SER without limiting membranes and no other structures such as ribosomes or RER. In 3 of the patients reviewed, in addition to the typical inclusions of MYH9-related disorder, some granulocytes with SER clusters were observed. These clusters were rounded or oval in shape and, when present, were 1 or 2 per cell (Fig. 1).
The patients who presented granulocyte SER clusters are those identified as B4, C6 and D8 in the Haematologica article and are briefly described in Table 1. The patients presenting with SER clusters showed different characteristics such as age, bleeding, platelet counts, and proportion of giant platelets. Therefore, we cannot relate the presence of SER clusters to any clinical or biological characteristic of patients. It should be noticed that we did not find SER clusters in any patient with May-Hegglin anomaly. However, the small number of cases studied does not allow any conclusions to be drawn.
SER clusters have been described in different types of cells such as hepatocytes or kidney tubular epitelial cells (Ghadially FN. Ultrastructural Pathology of the Cell and Matrix. Butterwords. London, 1988, pp 422-427). Normal granulocytes (neutrophils, eosinophils, and basophils) besides their own specific granules, also contain other general subcellular structures, including dispersed SER membranes. However, SER membranes forming clusters in these cells have not been previously described. In addition, SER clusters do not seem to correspond to evolved forms of typical MYH9 inclusions, for example by degranulation of the RER, based on the observations that typical inclusions show abundant ribosomes but few RER segments, no appreciable ribosomes are observed in the SER clusters, and the morphology of the tubules forming the SER and RER is different.
We suggest that SER clusters could be considered a new type of inclusion in MYH9-related disorders.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.