Indian J Hematol Blood Transfus DOI 10.1007/s12288-015-0608-0
ABSTRACT
Abstracts of the Oral and Poster Presentations During Haematocon 2015 (56th Annual Conference of Indian Society of Haematology & Blood Transfusion)
Indian Society of Haematology & Transfusion Medicine 2015
Topic: Acute Leukemias
OR 2
OR 1
Role of Mid-Induction Peripheral Blood Minimal Residual Disease Assessment in a Resource Limited Country
Haematological & Molecular Profile of Acute Myelogenous Leukaemia in North East India—A Hospital Based Study
Dr. B. K. Karthik Bommannan, Dr. Man Updesh Singh Sachdeva, Dr. Neelam Varma, Mrs. Parveen Bose, Dr. R. K. Marwaha
Jina Bhattacharyya, Smita Das, Damodar Das, Sukanta Nath, Nita Patwary
Postgraduate Institute of Medical Education and Research, Chandigarh
Gauhati Medical College and Hospital
Introduction: Minimal residual disease (MRD) is an independent risk assessment tool in acute leukemia management. In a country not privileged with good socio-economic conditions, followup during chemotherapy is a major concern. Our aim was to study the role of midinduction (day15) peripheral blood MRD (PB-MRD) in pediatric B-lineage acute lymphoblastic leukemia (pB-ALL). Methods: Prospectively, day15 MRD was analysed by six colour flow cytometry in concurrent PB and BM samples. Results: Among 40 B-ALLs under UKALL2003 protocol, 25 were day15 BM-MRD positive with 16 showing concurrent PBMRD positivity. With positive and negative predictive values of 100 % and 62.5 %, respectively, day 15 PB-MRD was 64 % sensitive and 100 % specific in identifying concurrent BM-MRD positivity. On a median follow up of 101 (range, 21 to 134) weeks, 6 BM-MRD positive patients relapsed (3 isolated CNS, 1 isolated medullary, 1 CNS with medullary and 1 testicular with CNS) at a median of 77 weeks (range, 48 to 117 weeks). Among relapsed patients, 67 % were PB-MRD positive. None of BMMRD negative patients relapsed. Conclusion: BM-MRD is an independent prognostic factor in B-ALL. Wesuggest, day15 PB-MRD could be considered as an early, easily accessible, minimally invasive and low cost MRD option in low resource countries. Keywords MRD, Pediatric, Peripheral blood
Introduction: AML accounts for approximately 20 % of acute leukemia in children and 80 % of acute leukemia in adults. Its heterogenity with respect to morphologic, immunophenotypic, cytogenetic and molecular characteristics is responsible for the varying clinical profile and therapy response. Need for Presenting Study: To discuss the scenario in North East India. Materials and Methods: Patients suspected of acute leukemia attended by the Dept of Clinical Hematology, GMCH during past two and half years were analysed for cell morphology on peripheral blood and bone marrow, immunophenotyping and karyotyping. Those with AML were further taken up for molecular studies (PML-RARA, AML ETO, FLT3 ITD translocations; NPM1 mutation). Chemotherapy was planned and correlation between response and genetic/molecular profile was tried to establish. Results and Conclusion: Of the total 211 AML patients (Total 427 cases of Acute Leukemia) 50 % were males. Majority (56 %) were between 20–60 yrs of age. Commonest FAB subtype was AML-M2. Karyotyping could be done for 184 cases of which 5 had complex karyotype. Molecular analysis for the mentioned translocations was done in 138cases and revealed PML-RARA to be the most common mutation (20 %). NPM1 positivity found in 47 % cases. 36 %of patients either left for higher centre or discontinued chemotherapy at various stages of induction phase and were lost to follow up. 40 %expired during or soon after the chemotherapy. 6 cases relapsed. 21 % are either on treatment or maintenance. Complex karyotype and FLT3 ITD positive cases were associated with worst prognosis. Keywords Acute Myeloid Leukemia, Molecular profile, Response to therapy
OR 3 Carbapenem Resistant MDR Gram Negative Sepsis During Induction Chemotherapy in AML—Single Institution Experience Prasanth Ganesan, V. Varalakshmi, Krishnarathinam Kannan, Ts Ganesan, Venkatraman Radhakrishnan Cancer Institute (Wia)
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Indian J Hematol Blood Transfus Introduction: Increasing incidence of multi-drug resistant (MDRGNB) gram negative bacterial sepsis during induction therapy of acute leukemia is a major challenge with limited published literature and guidelines on management. Methods: Adult (C18 years) patients with Acute Myeloid Leukemia who underwent induction chemotherapy between September 2014 and August 2015 were analysed. Results: Twenty-one patients analysed [13 (57 %) males] underwent induction (Daunorubicin and cytarabine (3 + 7), N = 19; Decitabine, N = 2). All (100 %) developed febrile neutropenia of which 13 (61 %) had positive cultures for MDR-GNB (Blood, N = 10; sputum N = 2 and stool N = 1). Organism: Kleibsiella pneumonia:7, Kleibsiella oxytoca:3, Escherichia coli:1. All cultures were resistant to quinolones, aminoglycosides, carbapenems and sensitive to colistin. Six patients (28 %) died during induction chemotherapy. Among the 10 patients with blood culture positive for MDR-GNB, 5 died due to sepsis (attributable mortality, 50 %). High dose Colistin was used in all patients with positive cultures. Among patients with MDR gram negative sepsis, 7 patients (53 %) developed liver function test derangements, 9 (69 %) required inotropic support and 6 (46 %) required ventilator support. When the stools of patients presenting for AML induction was cultured at the time of presentation, 50 % of the patients were found to colonize MDR bacteria in the stools. Conclusion: Incidence of MDR gram negative sepsis is increasing with high attributable mortality. The infection appears to be community acquired with half the patients found to harbour the bacteria in the gut. Revising empiric antibiotic policies with earlier initiation of colistin in high risk patients may help to reduce mortality.
OR 4 Childhood Relapsed Acute Lymphoblastic Leukaemia—Outcome Analysis Froma Single Centre M. Deenadayalan, V. Lakhsmanan, R. Sreejith, U. Ramya, Revathi Raj
30 25 20 15 10 5 0 very early relapsers
early relapsers our centre
late relapsers other centre
OR 5 Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia: 8 Years’ Experience from a Tertiary Care Centre in India Nizams’ Institute of Medical Sciences Introduction: The Philadelphia chromosome (Ph) is the most common cytogenetic abnormality associated with adult acute lymphoblastic leukemia (ALL), occurring in 20 % to 40 % of patients. The advent of tyrosine kinase inhibitors (TKIs) has revolutionized therapy of Phpositive ALL. Materials and Methods: Patients This retrospective and descriptive single centre study was carried out based on data retrieved of 508 patients treated for ALL from 2007 to 2014. Of these 30 patients were Philadelphia-chromosome positive ALL were included in the study. Statistics Data were analysed using SPSS 16 for Windows. Results: The choice of first line TKI was Imatinib in 25 (83.3 %) patients and Dasatinib in 1 (3.3 %) patient. Fourteen patients (46.6 %) had a complete response, 3 (10 %) had a partial response, 8 (26.6 %) had persistence of disease at the end of induction therapy. The overall survival in those who received sequential chemotherapy followed by TKI (n = 4) was 28.5 months (95 % CI 10.78 to 46.21 months) compared with 13.98 months (95 % CI 6.04 to 21.97 months) for patients who received concurrent chemotherapy and TKI (n = 20), log rank (Mantel Cox) X2 = 8.33, p = 0.040). Conclusion: The results of our study showed that treatment employing an integrative chemotherapeutic regimen using concurrent or sequential strategies appears to elicit improved response rates, and better long term outcomes.
Apollo Hospital Recent advances in the management of childhood Acute lymphoblastic leukaemia (ALL) has resulted in survival rates of over 80 %. However, outcomes in children with relapsed ALL is abysmal in our country. We performed a retrospective analysis of children diagnosed with relapsed ALL at our centre from 2002 to 2015. Data regarding the duration of primary remission, site of relapse, remission status at end of reinduction, outcome in terms of event free survival 12 months after the diagnosis of relapse were analysed. Results: A total of 61 children were treated for relapsed ALL of which 41 % of them had received primary therapy at a different centre. Bone marrow was the primary site of relapse at 67.21 % and 14.75 % had isolated central nervous system (CNS) relapse. 24 % of children had refractory disease and thirty of the 46 children who had responded were in molecular remission at end of reinduction. However, 75 % of the children who continued chemotherapy post reinduction as per UKALLR3 protocol had relapsed. The event free survival in the children who underwent haematopoiectic stem cell transplant (HSCT) was 61 %. Conclusion: This is the first outcome study of relapsed childhood ALL from India. The children at our centre received risk stratified, aggressive UK ALL based chemotherapy at primary diagnosis had very early relapse, resulting in high failure rates during reinduction. HSCT provides a definite survival advantage over chemotherapy for children with relapsed ALL and should be offered upfront in these children. Keywords Relapsed ALL, Reinduction chemotherapy, HSCT
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OR 6 Fungal Brain Abscess in Haematological Malignancy: Is Good Outcome Possible? Amita Trehan, M. R. Shivaprakash, Arunaloke Chakrabarti, Kanchan Mukharjee, Deepak Bansal Postgraduate Institute of Medical Education and Research Introduction: Incidence of invasive fungal infections in children with hematological malignancies is increasing. We present clinical features and outcome of children with fungal brain abscess in acute lymphoblastic leukemia (ALL), an entity which traditionally has dismal outcomes. Methods: Eighteen months data is presented. Total 160 new ALL patients were recruited. Thirteen developed proven fungal infection. Details of children with fungal CNS infection were analyzed. Results: Five children had fungal brain abscesses. B cell ALL:T-cell was 4:1. Three children were standard risk, 2 intermediate risk. All were on intense chemotherapy including steroids; 4 induction, 1 intensification. Clinical presentation: Prolonged neutropenia: 100 %; fever: 100 %; altered sensorium/seizures in 80 % (4/5). Duration of neutropenia: 16 days (14–23). Primary focus-lung:4, ear: 1. Brain abscess was single in 2, multiple in 3 children. Meningitis was present in 2. All children underwent surgery (burr-hole drainage:4, excision:1). Culture/ PCR proven fungus was seen in all: Aspergillus in 4; Mucor:1. Elevated
Indian J Hematol Blood Transfus serum galactomannan seen in 66 %. Combination antifungals were given for aspergillus: Amptotericin (plain/liposomal)& voriconazole for 10 days, followed by voriconazole alone for 6 months. Single mucor patient received amphotericin for 12 months. Overall survival at 10 months: 80 %; event free survival: 40 % (events-death:1, defaulter:1, cortical blindness:1). Three children are continuing chemotherapy. Conclusion: Mortality rate in fungal brain infections in children is reported to be 65 %. Better outcomes in our patients can be attributed to multimodality therapy and early initiation of antifungal therapy along with judicious management of chemotherapy. Keywords Aspergillus, Acute lymphoblastic leukemia, Brain abscess, Invasive aspergillosis
OR 7 Effect of Cytogenetics and Molecular Mutations on Induction Outcome in Acute Myeloid Leukemia: A Single Center Study from North India Prof. Soniya Nityanand Sanjay Gandhi Postgraduate Institute of Medical Science To evaluate the effect of cytogenetics study & molecular mutations on induction outcome in Indian acute myeloid leukemia patients, during July 2012 to June 2014, we undertook a two year prospective study to evaluate the clinical characteristics, pathological features, cytogenetics study, molecular mutations and Induction outcome of patients with a diagnosis of AML referred to our tertiary care center. A total of 231 patients were diagnosed with AML during this period. Of the newly diagnosed patients only 90 (38.96 %) opted for induction chemotherapy. Cytogenetic data was available in 64 (71.11 %) patients. Risk stratification was possible in 84 (93.33 %) patients of these 21 (23.33 %), 33 (36.67 %) and 30 (33.33 %) were in the good, intermediate and adverse risk groups respectively. FLT3 mutation status was available in all patients. 24 (26.67 %) patients were positive for FLT3ITD mutation. Out of the 90 patients, 3 patients opted for LAMA for various reasons before induction chemotherapy, 5 patients died before induction therapy. 82 patients undergone induction chemotherapy. 54 (65.85 %) patients achieved remission after induction chemotherapy. There was 15 (18.29 %) induction failures. There were 6 (07.32 %) induction deaths. The overall survival at one year was 41.1 % for all patients. The survival among FLT3-ITD mutation positive (25.0 %) and negative (48.4 %) cases was statistically significant (log rankp = 0.04). FLT3-TKD (D835Y) mutation was also associated with poor overall survival (25.0 %). The survival among favorable, intermediate & unfavorable risk groups were 85.7 %, 35.3 % & 24.1 % respectively. None of the variable was statistically significant as a predictor for induction outcome in Cox regression analysis. To conclude, Induction outcome & overall survival is dependent on cytogenetics risk group & mutational status. FLT3-ITD mutation is associated with poor induction outcome & long term survival.
OR 8 Outcomes for Adult Philadelphia Positive Acute Lymphoblastic Leukemia—Experience from a Tertiary Cancer Centre Manju Sengar, Hasmukh Jain, Bhausaheb Bagal, Pratibha Amare, P. Subramaniam Tata Memorial Hospital
Introduction: Philadelphia chromosome (Ph) positivity in acute lymphoblastc leukemia (ALL) has been associated with poor outcomes. Tyrosine kinase inhibitors (TKIs) have improved complete remission (CR) rates and survival. We analyzed the outcomes of patients treated at our centre. Methodology: All patients 15 years and above who were diagnosed with Ph positive ALL and treated at our centre between January 2009 and December 2014 were included in this retrospective study. CR rates and toxicities were recorded. Overall survival (OS) and event free survival (EFS) were analyzed by Kaplan–Meier method. Patients lost to follow up in CR (5) were excluded from survival analysis. Results: Eight hundred fifty ALL patients were registered and 171 (20 %) were Ph positive of which 122 were treated at our centre. Demographic and treatment details are given in Table 1. Morphological CR was seen in 84 patients (68.9 %). Cytogenetic remission was assessed in 70 patients and 64 achieved CR. Median follow up of the cohort was 33 months with OS of 34 % and EFS of 33 % at 3 years. For the nine patients who underwent allogeneic transplant OS was 65 % at 3 years. Grade 3/4 hepatotoxicity was seen in 54.9 %, hyperglycemia in 16.4 %, pancreatitis in 12.3 % and CNS toxicity (sinus thrombosis and/or bleed) was noted in 9 % of the patients. Thirty-four (27.8 %) patients died due to complications in induction. Conclusion: The Ph positive ALL outcomes remain poor probably due to high induction mortality. Decreasing intensity of induction in the era of TKI should be explored.
Table 1 Demographic data Demographic variable
Median (range/%)
Age (years)
28 (15–58)
Gender (M:F)
2.7:1 9
Total leukocyte count (9 10 /L)
36.5 (0.62–481)
Splenomegaly
67 (54.9 %)
CNS positivity
28 (23 %)
CD 13 and/or CD 33 co-expression (n = 117)
48 (41 %)
Aneuploidy
61 (50 %)
Additional abnormality
25 (20 %)
Ph duplication
32 (26 %)
Treatment MCP-841 + Imatinib BFM 90 + Imatinib
70 33
BFM 90 + Dasatinib
1
MCP-841 + Dasatinib
1
Steroids + Dasatinib
1
Steroids + Imatinib
7
HyperCVAD + Imatinib
1
MCP-841 without TKI
8
*In 12 patients the TKI was changed from Imatinib to Dasatinib in view of poor tolerance or inadequate cytogentic response. Nine patients underwent allogeneic stem cell transplant
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Indian J Hematol Blood Transfus OR 9 Prognostic Significance of Early Lymphocyte Recovery in Children with Standard and High Risk Precursor B Acute Lymphoblastic Leukemia Muhammad Asim, Mohammad Abdelhaleem, Angela Punnett Max Hospital Objectives: The primary aim of this study was to determine if absolute lymphocyte count (ALC) at end of induction is an independent prognostic marker of event free survival (EFS). Methods: Retrospective analysis of children (aged 1–18 years) diagnosed with standard and high risk precursor B ALL. At day 29 of induction ALC (ALC29)—1.5 9 109/l was considered high and \1.5 9 109/l was considered low. Minimal residual disease (MRD) (flowcytometry) value [0.1 % was considered positive. Result: Total 260 children (183 standard risk and 77 high risk) with Precursor B ALL were included. The mean age of the study cohort was 5.2–4.0 years. Eight patients (of 131 tested) were MRD positive. Fourteen patients had an event (12 relapse, four deaths). Mean follow-up duration was 41–20 months (median 41 months). Overall survival (OS) and EFS of the entire study cohort were 98.5 % and 94.6 % respectively. Actuarial survival at 4 years was 100 % for children with high ALC29 versus 94 % for those with ALC \ 1.5 9 109/l (p = 0.001). ALC as continuous variable at days 8 (p = 0.002), day 15 (p = 0.002) and as dichotomized variable at day 29 (p = 0.001) of induction was associated with superior event free survival for entire cohort. MRD at day 29 was the strongest predictor of both death (p = 0.00) and relapse (0.034). ALC29 did not differentiate EFS among MRD negative patients. Conclusion: Early Lymphocyte recovery does not refine MRD based risk stratification.
OR 10 Acute Lymphoblastic Leukemia (All-L 1) Presenting as Autoimmune Hemolytic Anaemia Narendra Nath Soren, Sunil Kumar Agarwalla, Samir Kumar Behera Mkcg Medical College Brahmapur, Odisha Introduction: Autommune hemolysis is common with lymph-proliferative disorders like CLL, Hodgkins lymphoma but it is very rare with Acute Lymphoblastic Leukemia. Autoimmune hemolytic anemia may be warm antibdy type, cold antibody type or mixed type. Here we report a 4 year old female child with autoimmune hemolytic anemia as the presenting feature of ALL-L 1. Case Report: A 4 year old female child presented with progressive pallor, yellowish discolouration of eyes and abdominal distension of three months duration. Physical examination showed severe pallor and icterus. There were no bleeding tendencies or any lymphadenopathy or sternal tenderness. Hepatosplenomegaly +. Cardiovascular examination showed features of haemic murmur. Other systems were normal. Hb 3.8 g/dl, TLC 8 9 109 cells/L, DLC P30 L70 E1 M4, Platelet count 278 9 109 cell/L, MCV 101fL, Reticulocyte count 8 %. Peripheral smear s/o hemolytic anaemia. Sickling negative, HPLC & Enzyme assay WNL. But DCT positive and ANA positive. HbsAg and Anti
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HCV IgM negative. Patient managed in the line of autoimmune hemolytic anaemia and discharged. But patient again admitted with severe pallor. Bone marrow study and flow cytometry suggested ALL-L 1. Patient was started on chemotherapy and now in remission. Discussion: Lymphoproliferative disorders such as CLL, Hodgkin lymphoma, NHL, and Waldenstrom macroglobulinemia are the leading secondary causes of AIHA. Other secondary causes include autoimmune disorders, nonlymphoid neoplasms, immunodeficiency disorders and childhood viral illnesses. But ALL as such is very rarely associated with AIHA. Summary: Acute Lymphoblastic leukemia presenting as autoimmune haemolytic anemia is very rare. Here a 4 yrs old child presenting with AIHA as the presenting manifestation of ALL is described.
OR 11 Outcome and Long Term Follow Up Study of Acute Promyelocytic Leukemia Patients Treated with Arsenic Trioxide and Atra Based Regimen—A Single Centre Experience Dr. Apte Shashikant, Dr. Kannan Subramaniam, Dr. Dudhatra Abhishek, Dr. Kamat Girish, Dr. Raiyani Ankit Sahyadri Speciality Hospital Introduction: Acute promyelocytic leukemia (APL) is a distinct variant of acute myeloid leukemia (AML). It is classified as AML M3 by the old French-American-British (FAB) system and as APL with translocation between chromosomes 15 and 17—that is, t(15;17)—by the World Health Organization (WHO) classification system. Arsenic trioxide had revolutionized treatment of APL. Material and method: All patients at diagnosis classified into low risk, intermediate risk and high risk according to white cell count and platelet count. Low risk and intermediate risk patients treated with single agent Arsenic trioxide (As2O3) in induction, consolidation and maintenance. High risk patients treated with combination of As2O3, ATRA with anthracycline in induction and consolidation followed by maintenance therapy with As2o3 and ATRA. MRD was monitored by PCR technique for PML-RARalpha gene. Results: In this retrospective study we analyze 48 patients of newly diagnosed APL admitted from 2008 to 2014. Out of 48 patients 8(17 %) were low risk, 23(48 %) were intermediate risk and 17(35 %) were high risk. 8(17 %) patients were expired, of them 7 had IC bleed. Majority of patients are high risk (75 %). Only 2 patients (4 %) had MRD positive after consolidation phase. Only 2 patients had relapsed within 3 years of treatment. They belongs to low risk category. DFS was 79 % and OS was 83 %. Conclusion: The CR rate and long-term survival are high and the relapse rate is low in APL patients treated with As2O3. Keywords Acute promyelocytic leukemia, Arsenic trioxide, ATRA Table 1 MRD status of patient after consolidation therapy MRD status after consolidation
High risk No (%)
Intermediate risk No (%)
Low risk No (%)
Total No (%)
MRD negative
5 (10 %)
9 (19 %)
4 (8 %)
18 (45 %)
MRD positive
6 (13 %)
11 (23 %)
4 (8 %)
21 (53 %)
Indian J Hematol Blood Transfus OR 12
Keywords Acute Lymphoblastic Leukemia, BCR-ABL, Incidence
Incidence of Bcr-Abl Positivity in Acute Lymphoblastic Leukemia Akhilesh Kumar, Ashish Kumar, Manish Kumar Singh, Ruchi Gupta, Akanksha Garg
OR 13
Sgpgims, Lucknow Background: BCR-ABL positivity in Acute Lymphoblastic Leukemia (ALL) confers a poor prognosis in these patients. Though limited, the available data from Indian subcontinent suggest a higher frequency of BCR-ABL positivity as compared to western available data. Aim: To evaluate the incidence of BCR-ABL positivity in newly diagnosed cases of ALL. Material and Methods: This study evaluated consecutive ALL patients diagnosed over a period of 14 months (June 2014–July 2015). Age group less than 18 years was labeled as pediatric cases and more than 18 years were labeled as adults. Diagnosis of ALL was established based on morphological evaluation of peripheral blood and bone marrow along with immunophenotyping using six color flow cytometry. Molecular examination for BCR-ABL transcript analysis was done by Q-PCR as well as nested PCR. Data analysis was done to see the correlation of positivity with type of leukemia and age group. Results: A total of 190 patients were diagnosed of ALL over this period of which 109 were subjected to BCR-ABL transcript analysis. Of these 62 were pediatric and 47 were adult patients. There were 87(80 %) cases of B ALL and 22(20 %) cases of T ALL. BCR-ABL positivity was seen in 12.9 % (8/62) pediatric and 42.55 % (20/47) of adult ALL patients. All the positive cases were B ALL, while none of the T ALL cases (n = 22) tested positive. The positivity rate for pediatric B ALL (n = 46) and adult B ALL (n = 41) cases were 17.39 % and 48.78 % respectively. Maximum positivity was seen in 4th and 5th decade of life, where 12 out of 18 patients (66.66 %) tested positive. It was observed that after an age of 35 years, the positivity rates increased three fold from 20.6 % to 58.8 % for the patient. There was no significance difference in the positivity rates between the two genders. Conclusion: The Incidence of BCR-ABL positivity was found to be higher as compared to several reported western literature. This may be a probable reason for the inferior treatment outcome of these patients in this geographic region.
Unusual Presentation in an Unusual Malignancy. Blastic Plasmacytoid Dendritic Cell Neoplasm—A Case Report and Literature Review Abhishek Purohit, Venkatesan Somasundaram, Dinesh Chandra, Mukul Aggrawal, Seema Tyagi All India Institute of Medical Sciences (Aiims), New Delhi Introduction: Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and aggressive hematological malignancy derived from precursors of plasmacytoid dendritic cells. This disease typically presents in elderly patients with cutaneous and bone marrow involvement. Case Presentation: A 21-year-old male presented with weakness, intermittent fever, skin and gum bleeding for three months. Liver and spleen were palpable two and three cm below costal margins respectively. No cutaneous involvement by tumour. Rest of the systemic examination was normal. Peripheral blood revealed pancytopenia and bone marrow aspirate sample showed atypical cells which on flowcytometric immunophenotyping revealed CD45dim, Lin-, CD4+, CD56+, CD123+ and HLA-DR+; hence a diagnosis of BPDCN was made. He succumbed to the disease before starting any therapy secondary to febrile neutropenia. Need for presenting the case: BPDCN is categorized as a newer entity under ‘‘acute myeloid leukemia and related precursor neoplasms’’ in the 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. Few cases may present in younger age with fulminant leukemia without cutaneous manifestations which may pose a diagnostic challenge. Discussion: BPDCN is a clinically aggressive tumour. BPDCN without cutaneous involvement at presentation is extremely rare, and most cases eventually develop cutaneous lesions during the course of disease progression. Literature review showed only 46 cases without cutaneous manifestations (Table). No consensus on the optimal treatment, because of its rarity. BPDCN has a dismal prognosis and median survival ranging from 12 to 27 months.
Table 1 Blastic plasmacytoid dendritic cell neoplasm (BPDCN) with no cutaneous involvement cases Reference
Cases
Mean age (years)
Mean Hb (g/dl)
Mean total WBC count (109/L)
Mean platelet count (109/L)
Aberrant IPT features
Cytogenetics
Survival (months)
Feuillard et al. (2002)
3
60
9.8
6.9
91
CD2-, CD7-, TdT- (2 cases); CD2-, CD7+ (1 case)
Loss (5q,14,15) & i9q; gain (Xq, 1q) & loss (1p, 12p, 13q, Y); Gain (8q,12p), loss (5q, 13q) & der (9q)
28.3
Reimer et al. (2003)
1
53
NA
NA
NA
NA
NA
53
Reichard et al. (2005)
4
63
NA
NA
NA
CD2-, CD7-, TdT- (2 cases); CD2-, CD7+, TdT- (1 case), CD2-, CD7-, TdT+ (1 case)
Loss (12p), inv5q
5.5
Herling et al. (2007)
2
NA
NA
NA
NA
TdT+ (1 case), TdT- (1 case)
Gain (12p), loss (5q, 13, 15)
NA
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Indian J Hematol Blood Transfus Table 1 cotninued Reference
Cases
Mean age (years)
Mean Hb (g/dl)
Mean total WBC count (109/L)
Mean platelet count (109/L)
Aberrant IPT features
Cytogenetics
Survival (months)
Reineks et al. (2009)
2
76
8.3
5.3
44.5
CD2+ (1 case)
NA
6
Jeglian et al. (2009)
9
68
NA
NA
NA
NA
NA
NA
Tsagarakis et al. (2010)
3
76.3
9.3
22.2
72
CD2+, CD7+, TdT+ (2 cases); CD2-, CD7+ (1 case)
NA
8.7
Rauh et al. (2012)
3
81.6
9.3
124.4
55
CD2+, CD7+, TdT(1 case); CD2-, CD7+ (2 cases)
NA
4
Wang et al. (2012)
1
21
NA
NA
NA
NA
NA
3
Takiuchi et al. (2012)
1
74
11.7
33.6
224
Nil
47, XY, t(6:8), +r
\1
Pagano et al. (2013)
9
NA
NA
NA
NA
NA
NA
NA
An et al. (2013)
3
48
12.5
8.6
252
TdT- (3 cases)
Normal karyotype (2 cases)
9
Endo et al. (2013)
1
82
8.5
3.5
122
CD38+
Normal karyotype
3
Park et al. (2014)
1
49
14.7
6.4
78
NA
44, XY, loss (4p, 5q, 6q, 9p), gain (8q), der(12;14), t(3;15)
4+
Yu et al. (2014)
1
41
12.7
6.1
329
CD2-, TdT-
45XY, der(3:7), t(6:19), t(8:18)
NA
Gao et al. (2015)
1
48
12.8
2.8
129
CD38-, TdT-
NA
7
Present case (2015)
1
21
4.4
1.9
21
CD38+, TdT+, CD7-
Normal karyotype
3
Total cases in the literature
46
57.1
10.18
21.18
124.6
CD2+ (26.6 %), CD7+ (53.3 %), TdT+ (31.2 %), CD38+ (66.6 %)
5q (41.6 %), 9q (25 %), 12p (41.6 %), 13q (25 %), 15 (25 %)
10
Total M/F = 26/9 (2.9:1), in 2 cases, sex was not mentioned Hb Hemoglobin, IPT immunophenotype, NA not available
Keywords Plasmacytoid dendritic cell, Cutaneous manifestations, CD 4, CD 56, CD 123.
OR 14 Serum Levels of Vascular Endothelial Growth Factor and Its Receptor in Newly Diagnosed Paediatric Acute Lymphoblastic Leukemia Anita Nangia, Sunita Sharma, Jagdish Chandra Lady Hardinge Medical College Introduction: Angiogenesis is an important event in growth, dissemination and metastasis of solid tumors. Vascular endothelial growth factor (VEGF) along with its receptors (VEGFR-1, VEGFR-2 and VEGFR-3) is an important mediator of angiogenesis. Autocrine and paracrine loop involving VEGF and its receptors have been described in haematological malignancies. However, scarce literature
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is present on angiogenesis in paediatric ALL with studies showing controversial results. Matetrial and Method: Serum VEGF, VEGFR1 and VEGFR-2 levels were measured by enzyme-linked immunoabsorbant assay at diagnosis (day 0) and at the end of induction phase (day 35) in 30 newly diagnosed paediatric ALL patients. Results: Median s-VEGF was significantly lower at day 0 as compared to day 35 (196.15 vs 606.75 pg/ml: p \ 0.001). s-VEGFR1 levels were detectable only in 7 patients at day 0 and were below detection level at day 35 in all patients. Median s-VEGFR-2 at day 0 was significantly lower as compared to day 35 (17577.5 vs 20507.5 pg/ml; p = 0.005). Median VEGF-R1 showed an inverse relationship with VEGF-R2 but was statistically insignificant. All patients were in remission at the end of induction. Conclusion: Thus, leukemic infiltration of bone marrow affects angiogenesis and reduces pro-angiogenic markers VEGF and VEGFR-2 in serum possibly due to increased local consumption by blasts. A successful induction leads to clearing of blasts causing restoration of normal hematopoiesis with normalization of VEGF and VEGFR-2 levels. Keywords Angiogenesis, VEGF, Paediatric ALL
Indian J Hematol Blood Transfus OR 15 A Study of Serum and Csf Methotrexate Levels Following High Dose Methotrexate Infusion in Acute Lymphoblastic Leukemia and Its Correlation to Relapse Nita Radhakrishnan, Veronique Dinand, Tanvi Khanna, Seema Bhargava, Anupam Sachdeva Sir Ganga Ram Hospital Background/Objectives: High dose methotrexate is a major component of most contemporary acute lymphoblastic leukemia (ALL) treatment protocols as a CNS-directed therapy. Design/Methods A retrospective analysis of ALL cases diagnosed between January 2007 to December 2013. 114 children (378 cycles) received high dose methotrexate infusion using two ALL protocols (BFM-95 protocol (5 gm/m2/cycle 9 4), UK ALL XI (6 gm/m2/cycle 9 3). Serum and CSF methotrexate levels were measured at the end of 24 h, with additional serum levels at 48 and 72 h. Data analyzed for the correlation of serum and CSF methotrexate levels to relapse. Results: Median age at diagnosis 4 years. 12 patients had T cell, rest had B ALL. Median 24-hour and 48-hour levels achieved were comparable between both protocols. Significant variability noted in the 24-hour values. 48-hour serum and CSF level remained homogenous. Good correlation observed between 24-hour serum and CSF level. [90 % patients achieved protective level of Mtx in the CSF in all cycles. Total of 7 relapses occurred during a median follow up of 3.7 years. No statistically significant difference seen in any serum or CSF drug level between patients who relapsed and who did not. In patients who relapsed, CSF and serum levels were significantly less than average. Conclusion: HDMtx is feasible in India. Although our follow up is short, it has definitely helped us in reducing the incidence of CNS relapse. 48 h Methotrexate values were homogenous and close to statistical significance in preventing relapse. Keywords Methotrexate relapse ALL
OR 16 Aberrant Myeloid Antigen Expression in Acute Lymphoblastic Leukemia—A Study of 95 Cases Vishal Singh, Richa Gupta, Naresh Gupta, A. P. Dubey, Tejinder Singh
associated with CD 34 expression by blast cells (p value = 0.009). Conclusion: LAIP is a well known fact about leukemic cells. The detection of aberrant myeloid antigen expression helps in differentiating the blast cells from the normal hematogones and also in evaluation of minimal residual disease at a later date. Also ALL blasts expressing myeloid antigens are more likely to be CD 34 positive.
OR 17 Profile and Clinical Outcome of Patients with Cd10 Negative Acute Lymphoblastic Leukemia Punit Jain, Anu Korula, Poonkuzhali Balasubramanian, Biju George, Vikram Mathews Christian Medical College Vellore Introduction: CD10 negative acute lymphoblastic leukaemia (CD10veALL) is a subset of ALL historically known as pro-B cell ALL. Mixed lineage leukemia gene (MLL) rearrangements are specific for this subset with 11q23 translocations present in 82 %. Currently, CD10–ve ALL with absent MLL rearrangement is not considered high risk by conventional risk stratification. Materials and Methods: This is a retrospective study of 67 patients in a tertiary care centre in India between 2004 and 2014 with confirmed diagnosis of CD10–ve ALL based on decreased CD10 positivity of less than 20 % by flow cytometry (FCM). The aim was to describe the clinical, laboratory profile and the clinical outcomes of the patients with CD10-veALL. MLL rearrangements were documented by cytogenetics and RT-PCR. Results and Discussion: The median age was 20 years (range: 1–65). MLL rearrangement was documented in 14 of 67 (21 %). Comparing MLL positive (n = 13) and MLL negative (n = 43), all the baseline parameters were comparable. There was a significant inferior overall survival and a trend for inferior event free survival and relapse free survival among MLL positive (log rank p = 0.042, 0.112, 0.731) respectively. In adults (C15 years), there was no significant survival difference based on MLL rearrangement. Conclusions: 1. In the pediatric population, MLL positivity is associated with a significant inferior survival. 2. In adult patients (data not shown), CD10 negativity was associated with an inferior clinical outcomes irrespective of MLL rearrangements. 3. Prevalence of MLL positivity in CD10 negative ALL in our setting is less than previously reported.
Maulana Azad Medical College Introduction: Acute Lymphoblastic Leukemia (ALL) is the most common childhood malignancy. These tumors like other leukemias may show leukemia associated aberrant phenotype (LAIP), i.e. asynchronous or discordant expression of markers, deviating from the normal stages of corresponding normal cell development. An example of such asynchrony is the expression of myeloid associated antigens by the blasts of ALL. Objective: To assess the prevalence of aberrant myeloid antigen expression in ALL and to correlate with other clinical, morphological parameters and flowcytometry findings. Methods: 95 cases of ALL were included in the study. The diagnosis was made on the basis of morphology (Geimsa), cytochemistry (MPO, PAS) and flowcytometric analysis on peripheral blood and/or bone marrow aspirate. Aberrant myeloid antigen expression was also studied. Results: Of the 95 patients of ALL 83 were B-ALL and 12 were T-ALL. 12.6 % (12/95) cases expressed myeloid antigens. The most common myeloid antigen expressed was CD13 seen in a total of 6 cases (4 B-ALL and 2 T-ALL). Four cases (3 B-ALL and T-ALL) showed CD 33 expression while 2 cases of B ALL expressed both CD13 and CD33. Myeloid antigen expression was significantly
Fig. 1 Overall survival of entire cohort (adult+pediatric) MLL positive (n = 13) and MLL negative (n = 43)
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Indian J Hematol Blood Transfus OR 18 Acute Myeloid Leukemia: Treatment Related Mortality is a Bane in a Developing Country Amita Trehan, Deepak Bansal, Richa Jain, Neelam Varma, Shanoo Naseem Pgimer, Chandigarh Background/Objectives: To determine the outcome of children treated for Acute Myeloid Leukemia (AML). Design/Methods: Hundred children were treated for AML (Non M3) from January 2004 to December 2013. Results: The mean age was 7.3 ± 3.6 years: 76 boys and 24 girls. FAB subtype: M0: 2; M1: 12; M2: 46; M4: 17; M5: 14; M6: 3; M7: 6. Cytogenetics were not available. Seven patients had gum hypertrophy and 14 granulocytic sarcoma. Median TLC: 26,500/ mcL (8,200–67,000); Platelets 30,000/mcL (13,500–69,700). Eight patients had central nervous system (CNS) involvement. Remission: 75 patients after course 1: 64 % in remission (M1), 76 %: \15 % blasts. Five children had refractory AML. Three defaulted therapy. Treatment related mortality (TRM): Forty-eight children died. Twenty-five (53 %)—during course 1, with 8, 7 & 8 deaths after course 2, 3 & 4. Cause of death: 25 (52.1 %) severe sepsis; 13 (27.1 %) bacterial culture positive sepsis, 6 (12.5 %) probable fungal infection, 3 (6.3 %) proven fungal infection, 1 (2.3 %) leukostasis related. Relapses: Twenty relapsed; 3/4 early relapses. Survival: The overall survival—27.2 % (665.47 ± 130.24). Disease free survival (DFS)—34.7 % (845 ± 160.62). There was no difference in DFS between those who had [15 %/\15 % blasts after course 1 (31.6 % vs. 35.5 %; p = 0.916). Age, gender, FAB subtype & CNS positivity had no association with outcome. Conclusion: High TRM precludes satisfactory outcomes in AML. Infections are responsible for the majority of TRM. One-fourth of the cohort died during the first induction.
OR 19 An Institutional Experience on Acute Leukemias—A Detailed Retrospective Study Dr. M. K. Kalpana Kumari, Dr. Vijaya V. Mysorekar, Dr. Nalini Kilara Ms Ramaiah Medical College Background: Acute leukaemias comprise a large number of leukaemias which differ in etiology, morphology, course and prognosis and it is insufficient to merely make a diagnosis of acute leukaemia. Further classification is essential in order to determine the prognosis. Bone marrow studies, immunophenotyping and cytogenetics together have significant role in subtyping, to assess prognosis. Objective: To study morphology and cytogenetics in acute leukaemias. Methods: A retrospective study was conducted on blood and bone marrow aspirate samples of leukemia cases in our institute between July 2014 and 2015. The bonemarrow study, cytogenetic analysis by conventional karyotyping (GTG Banding) and whenever possible, immunophenotyping was done to diagnose and subtype leukemias. Results: Out of the 30 cases (50 %) were AML and (50 %) were ALL. The age range among the AML cases was 25 to 65 years, whereas the age range of the ALL cases was 2 to 18 years and male predominance (66.7 %) was present. Out of 15 AML cases, subtypes from AML M1 to AML M5 were typed of which, CALLA positive AML M2, HLADR-ve
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AMLM3, AML NonM3 (1 case each) and 8 cases as only AML were diagnosed. Among the 15 cases of ALL, 4 cases were B-ALL, 2 were T-ALL,1 was ALL L3 and 7 were not subtyped. Cytogenetics analysis among AML cases showed t(8;16), del 7q, and t(15:17) and many cases had normal karytype. Majority ALL had normal karyotype. Conclusion: Hence cytogenetics and immunophenotyping help in arriving at an accurate diagnosis especially in cases of leukemias with ambiguous morphology. Keywords AcuteLeukemias, Morphology, Cytogenetics, Immunophenotyping
OR 20 Long Term Follow up Data of Acute Promyelocytic Leukemia Treated with a Triple Drug Regimen-Real World Data from a Tertiary Care Center Uma Dangi, Navin Khattry, Pratibha Amre, P.G. Subramaniam, Hari Menon Tata Memorial Hospital Introduction: Acute promyelocytic leukemia (APL) remains the most curable myeloid leukemia made feasible through effective use of two differentiating agents, All Trans Retinoic acid (ATRA) and Arsenic trioxide (ATO) with or without chemotherapy (CT). However, early morbidity and mortality remains a problem. With the objective of reducing early death a strategy of sequential induction ATO followed by consolidation ATRA in combination with CT was adopted. We present our long term outcomes of patient of APL treated on this sequential approach at our center. Materials and Methods: This was a retrospective analysis of prospectively maintained database. Consecutive adult patients with APL irrespective of their Sanz risk group were treated using a protocol of ATO (10 mg IV infusion over 3 h daily for 45 days) in the first phase followed by ATRA (45 mg/m2 for 60 days) in combination with Daunorubicin (60 mg/m2 for 3 days 9 3 cycles) in second phase. All patients received maintenance ATRA (45 m/m2 for 15 days every 3 months) for a period of 18 months in phase 3. Patients were monitored for cytogenetic and molecular responses after phase 1 and 2. All patients were followed up for toxicity, event free and overall survival. Results: 131 consecutive patients between Jan 2008 to Dec 2012 were included. The median age was 30 years. Sanz class I risk constituted 15.3 % while 33.6 % and 48.1 % were in class II and III, respectively. Cytogenetic remission was achieved in 78.8 % (data available in 115/131 patients) while molecular remission was seen in 65 % (data available in 96/131 patients) following phase 1. Molecular remission improved to 85 % (data available 112/131) following phase II. Relapse was encountered in 6.1 % while 7.63 % died within 7 days of initiating therapy. At a median follow up of 39 months, 77 % are alive with an overall event free survival (EFS) of 71 %. Class I fared better (86 %) versus class II and III patients who had a 71 % EFS. Median survival was not reached at the time of analysis. The regimen was well tolerated with differentiation syndrome occurring in 20 % of treated patients and transient QTc prolongation occurring in 18 %. Only 5 % of patients developed peripheral neuropathy (grade II). Conclusion: The sequential schedule has shown excellent tolerance and toxicity profile when treating newly diagnosed APL. The long term follow up data shows comparable if not better survival compared with the published real world data and this has been consistent across all risk groups.
Indian J Hematol Blood Transfus OR 21 Clinicopathological Analysis of 25 Cases of Acute Erythroleukemia Diagnosed in a Tertiary Care Hospital in Southern India Srinivas Bh, Rakhee Kar, Sajini Elizabeth Jacob, Debdatta Basu, Bhawana Badhe Jipmer Introduction: Acute Erythroleukemia (AML-M6) is a rare subtype of acute myeloid leukemia, and is associated with poor prognosis. Need for Study: AML-M6, although rare, has varied clinical presentation and needs to be differentiated from other entities ranging from marrow failure syndromes, megalobalstic anemia and Myelodysplastic Syndrome. Materials and Methods: This is a retrospective study of AML-M6 diagnosed between January 2006 to June 2015 with a detailed analysis of clinical and hematological parameters. Results: There were 25 cases (6.2 % of all AML) of AML-M6 of which 22 were AML6a and three AML 6b. Seven cases had associated MDS. The age of the patients ranged from 14 to 75 years. Fever and constitutional symptoms were common clinical presentation. Hepatomegaly and/or splenomegaly were seen in 40 % cases. One patient presented with features of autoimmune haemolytic anemia. Pancytopenia was present in 36 %. Peripheral smear showed macrocytosis in 60 %with nRBCs ranging from 0–500/100WBCs. Marrow was hypercellular with prominent dyserythropoiesis, erythroid cells ranged from 52 to 84 % (AML-M6a) and 88 to 91 % (AML-M6b) with megaloblastic maturation in 76 %. Myeloblasts in marrow ranged from 6 to 38 % (AML-M6a) and around 1 % (AMLM6b). In three cases, the non-erythroid blast was of monoblastic lineage. PAS positivity was seen in 87.5 %. CD34, MPO, CD117, done in 11 cases, highlighted the blasts. Flowcytometry, done in three patients showed positivity for glycophorinA, CD34, CD117, MPO. Cytogenetics, done in three patients, showed normal karyotype. Follow up was available for six cases, five (83 %) of whom were associated with poor outcome. Conclusion: Acute Erythroleukemia has a varied clinical presentation and hematological findings and needs to be differentiated from other mimics. Keywords Acute leukemia, Erythroleukemia, AML-M6a, AML-M6b
OR 22 The Leukemogenic Translocation (8,21) Fusion Protein Aml1-Eto in Acute Myeloid Leukemia Cases: A Tertiary Care Center Experience Faiq Ahmed, Rachna Khera, Sudha Murthy, Senthil Rajappa
new cases of AML were diagnosed. Prognostic panel by FISH was ordered in 114 cases, in which t (8,21) was positive in 25 cases. The incidence was higher in adults (24/101). Immunophenotyping data is available in 23 cases. All thcases showed pan Myeloid marker expression with aberrant expression of CD19/56 seen in few cases. The details will be discussed later. Conclusions: Frequency of t(8,21) was 21.9 % (25/114) which was higher than described in literature. Morphology and immunophenotypic data can be tailored to order FISH for the translocation. Keywords Acute Myeloid Leukemia, FISH, t(8,21), Immunophenotyping
OR 23 Do Responses of Generic Imatinib Compare with the Innovator in Chronic Myeloid Leukemia in Chronic Phase? Arvind Sahu, Nikhil Patkar, Sumeet Gujral, Pratibha Amre, Manju Sengar Tata Memorial Hospital Introduction: Imatinib mesylate (IM) use in Chronic Myeloid Leukemia (CML) has yielded early, transformation free and durable responses. The availability of generics and access programs has allowed most patients to benefit from IM. There are concerns about efficacy of the generics in comparison to the innovator molecule. We present our data on responses to generic IM and innovator brand in CML-CP patients treated at our center over a 42-month period. Materials and Methods: This was a retrospective analysis which included patients between January 2011 and June 2013. Patients received either generic or innovator IM. Cytogenetic responses at 6 and 12 months and the molecular response at one year and anytime from start of therapy was recorded. The data analysis was censored as of 30th June 2014. Results: Four hundred forty-three patients were enrolled. The median age was 39 years (18–77) with 74 % being male. Sokal score was available in 202 patients of which 43.5, 32.6 and 23.7 % constituted high, intermediate and low risk group respectively. 69.3 % received generic IM. Overall 60.5 % attained CCgR at 6 months, which improved to 83.8 % at 12 months. The major molecular response (MMR) at 12 months was 43.6 % and overall MMR was 65.1 % on censor date. The comparison of responses between the innovator and generic IM is described in the table. Conclusions: This analysis suggested higher responses favoring the innovator over the generic across all time points. The responses for the generic IM were however comparable to the published literature. Table 1 Response to innovator versus generic Responses
Innovator IM (n = 136)
Generic IM (n = 307)
P value
Complete CgR at 6 months
70.9 %
55.8 %
0.007
Complete CgR at 12 months
92.9 %
79.7 %
0.001
Conversion of pCgR to CCgR at 12 months
14/19 (73.7 %)
29/62 (46.8 %)
NS
Major Molecular Response at 12 months
33/55 (60 %)
46/126 (66.9 %)
0.003
Major Molecular response at 18 months
85/105 (81 %)
119/126 (66.9 %)
0.011
Major Molecular response at 24 months
92/110 (76.2 %)
164/273 (60.1 %)
0.05
Major molecular response at censor date
93/122 (76.2 %)
164/273 (60.1 %)
0.02
Biach&Ri Introduction: Acute Myeloid leukemia (AML) are heterogenous group of disorders. WHO 2008, subclassifies this entity on the basis of the recurrent genetic abnormalities with comparisons drawn with FAB classification based on morphology and immunophenotypic findings. Molecular classification is included as a part of prognostication too. Aims and Objectives: To study the incidence of t(8,21)in Indian population and understand its epidemiology. To study the morphological and immunophenotypic attributes. Materials and Methods: the study was performed in the time frame of Jan 2009 to July 2015. The study is retrospective observational type, cases were retrieved from the archives. The bone marrow leishman stained smears were studied for the blast morphology and FAB subtype. Immunophenotyping was performed on FACS Calibur with a comprehensive panel of all lineage markers. FISH was performed by Vysis dual colour dual tanslocation probe. Cytogenetics was performed. Results: In the study period 423
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Indian J Hematol Blood Transfus OR 24 Clinical and Hematological Spectrum of Infantile Leukemia from a Tertiary Care Center Shano Naseem, Neelam Varma, Narender Kumar, Reena Das, Jasmina Ahluwalia Pgimer, Chandigarh Introduction: In infants, leukemias comprise approximately 16 % of all malignancies. Acute lymphoblastic leukemia (ALL) is commoner than acute myeloid leukemias (AML), observed in 56 % and 43 % cases respectively. Only 1 % cases show mixed phenotypic acute leukemia (MPAL). Here, we present the clinical and hematological spectrum of infantile leukemia cases diagnosed at our center over 2 years period. Materials and Methods: All cases in children aged from 1 day to 1 year with diagnosis of acute leukemia from August 2013 to June 2015, were enrolled in the study. Details regarding the presenting complaints, physical examination, peripheral blood, bone marrow examination, immunophenotyping and molecular findings were noted in a pre-designed performa. Results: A total of 20 infants were diagnosed with leukemia during the study period, with age range of 2 months to 1 year. Male predominance was noted with M:F ratio of 1.5:1. Most common presenting complaint was fever (45 %) followed by progressive pallor, hemorrhagic manifestations and joint pain. All cases showed hepatomegaly, splenomegaly was seen in 95 % and lymphadenopathy in 40 % cases respectively. Cytopenias were common with thrombocytopenia in 85 % and anemia in 75 % of cases. High Total leucocyte count ([50 9 109/L) was observed in 35 % cases. ALL was diagnosed in 60 % cases and AML in 40 %. All ALL cases were of B-lineage and amongst AML, megakaryoblastic lineage was observed in 50 % cases. Molecular analysis [for AML = t(15;17), t(8;21) and inv(16)] and ALL = t(9;22), t(12;21), t(9;11) and t(1;19)] was performed in 12 cases. Of these, only 1 case of ALL showed t(9;22); BCR-ABL fusion transcript, rest were negative for all the transcripts tested. Conclusion: In present study males were commonly affected which is in contrast to previously reported female predominance. ALL was more common than AML, which is similar to what have been reported earlier. Among AML, acute megakaryoblastic leukemia were most common. No case of MPAL was seen. None of the case showed MLL gene rearrangement, which may be seen in infants with leukemia. Keywords Infant, Leukemia
OR 25 Clinicopathological Study of Acute Lymphoblastic Leukaemia: A Study from a Tertiary Centre in Northeast India Jina Bhattacharyya, Sewali Deka Talukdar, Smita Das, Damodar Das, Aishwarya Raj Guwahati Medical College and Hospital Introduction: Acute Lymphoblastic Leukaemia (ALL) though can present in any age group, is the most common hematological malignancy in children and the clinipathological profile of the patients at presentation is necessary for their risk stratification. Need for Study: In this study, we present the clinicopathogical profile including the cytogenetic study of the patients of ALL from northeast India and its correlation with the prognosis. Methods and Materials: This retrospective study included all newly diagnosed cases of ALL (171 cases) from January 2013 to July 2015 in the department of clinical hematology, Guwahati Medical College and Hospital.
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Results: ALL constituted 23 % of all hematological malignancies. 54 % cases were in the age group of 2 to 12 years. Male to female ratio was 1.7:1. Fever and generalized weakness were the commonest presenting features. Splenomegaly (46 %), lymphadenopathy (30 %), hepatomegaly (20 %) were common finding on physical examination. Initial high white cell count ([50,000) in 30 % patients. Haemoglobin \7 g/dl in 34 %, platelet count less than 20,000 in 8 %, pancytopenia in 16 % and CNS disease was present in 8 % cases. B-ALL was found in 75 % patients and 84 % patients had normal karyotype and 6 % were Philadelphia positive. Conclusion: Age group\2 years and [20 years, high WBC count, CNS disease and complex karyotype were associated with a poor prognosis. Keywords Lymphoblastic Leukaemia, Clinicopathogical profile, Hematological malignancies
OR 26 Evaluation of Post Chemotherapy Bone Marrow Changes in Acute Myeloid Leukemia Debdatta Basu, Rakhee Kar, Biswajit Dubashi Jipmer, Puducherry Introduction: In Acute Myeloid Leukemia (AML), post-induction bone marrow gives valuable information regarding the response to chemotherapy and adequacy of hematopoietic regeneration. Need for Study: To analyze remission, residual disease status and the histomorphological changes in post-induction bone marrow in AML. Materials and Methods: All AML patients, diagnosed from January 2014 to June 2015 and treated with 7 + 3 regimen - Cytarabine + Daunorubicin, with a follow up post induction marrow were included in this study. Detailed histomorphological features and identification of residual disease by relevant immunohistochemistry (IHC) was done. NCCN (2014) criteria for complete remission was used while evaluating the marrow. Results: 81 cases of AML were diagnosed in this period. Post-induction marrow was available in 49 cases of whom 29 cases were in remission. Of the remaining 20 not in remission cases, 12 cases succumbed during re-induction, seven cases went into remission and one case showed persistence of disease. Cases not in remission had more of AML-M4 subtype (34 %) and higher mean bone marrow blasts (average 69 %) at diagnosis. Stromal changes noted were edema (14.2 %), serous atrophy (10.2 %) and increased fibrosis (4 %). These stromal changes were also seen in nine cases in remission, of whom eight showed delayed recovery of counts. IHC with CD 34 was helpful to highlight scattered and small clusters of blasts in as many as seven cases which were not in remission. Conclusion: Post chemotherapy response assessment in bone marrow in AML can be augmented by staining with CD 34. Delayed recovery of counts may be attributable to marrow stromal changes. Keywords Acute myeloid leukemia, Bone marrow, Chemotherapy, Remission
OR 27 Correlation of Immunophenotypic Expression and Prognosis in Acute Lymphoblastic Leukemia Shyamali Dutta, Tk Dolai, Rajib De, P. K. Mandal, B. Bagchi Nrs Medical College & Hospital, Kolkata
Indian J Hematol Blood Transfus Introduction: Acute lymphoblastic leukemia (ALL) displays characteristic patterns of antigen expression, which facilitate their identification and proper classification. The mean fluorescence intensity (MFI) used for the quantification of immunophenotypic expression has been used to study its correlation with known prognostic variables in patients of ALL and can be used to predict poor treatment outcome. Materials and Methods: A prospective study was conducted on 50 cases of newly diagnosed ALL from September 2013 till June 2015. Immunophenotypic expression was characterized using multiparameter 10-colour flowcytometry at diagnosis. Treatment with ALL-BFM90 was initiated and all patients were followed up till CR1. Results: Among the cases analyzed, B-lineage ALL constituted 38 cases, T-ALL: 9 cases and 3 cases were of MPAL (B/Myeloid), with median age: 12 years (age range: 10 months–18 years). Male to female ratio was 2:1. All patients had median TLC: 17,500/cumm (range: 2500–80,000/cumm). Most common cytogenetic abnormality was hyperdiploidy. On flowcytometry, the lymphoblasts had a MFI of 7.81 in comparison to lymphocytes having MFI of 44.15. Low MFI was seen in 88 % and high MFI in 12 % ALL cases, of which majority were T-ALL, and in children of 10 years and above. The most common aberrant expression was of CD33 with MFI of 4.78. Prednisolone good response was seen in 96 % patients, 80 % of whom had low MFI. Day 33 bone marrow was in remission in 92 % cases, with 78 % having low MFI. Conclusions: Quantification of CD45 expression appears to be predictive of treatment outcome and can be a part of additional stratification tool in ALL. Keywords Acute leukemia, Immunophenotype, MFI
OR 28 Clinical and Biological Significance of DNA Index Values and S-Phase Fraction in Paediatric B-Cell Acute Lymphoblastic Leukemia Cases: A Tertiary Care Centre Experience Banothu Kiran Kumar, Amita Trehan, Ajit Kumar, Deepak Kaul, Deepak Bansal Pgimer, Chandigarh Introduction: DNA ploidy categorizes B-ALL into favorable or unfavorable risk groups based on DNA index values. Aims & Objectives: To note the frequency of DNA ploidy abnormalities in pediatric B-ALL and to correlate with early response to chemotherapy. Materials and Methods: DNA ploidy assessment was done in 40 pediatric B-ALL cases before chemotherapy. 40 non-leukemic controls were run with each sample. Samples were processed using DNA ploidy kit reagents and analysis was done on a LSR-II cytometer. The DI (DNA index) was calculated using the Modfit software. The results were compared with standard risk criteria and chemotherapy outcome. Results: Aneuploidy was noted in 26/40 (65 %) cases. A DI 1.10–1.6 (hyperdiploidy B) was noted in 20/40 (50 %) and 6/40 (15 %) had a DI [ 1.60 (triploid and tetraploid range). None of the cases had a DI \ 0.90 or 1.06–1.09 range. The S-phase fraction of cells ranged from 0.00 to 17.59 % with a mean of 2.6 % and median of 2.3 %. Taking median of 2.3 % as cut-off, 24 (60 %) had S-phase fraction \2.3 % and 16 (40 %) [2.3 %. DI values and S-phase fraction had no correlation with ALL risk and treatment response parameters, except for a positive correlation of low S-phase with high NCI risk category (p = 0.032). Discussion & Conclusion: Overall frequency of hyperdiploidy in our cohort of B-ALL patients was high (65 %), in contrast to earlier studies from our region. No correlation between hyperdiploidy B and low TLC or common B-phenotype was observed. Moreover, S-phase fraction analysis does not yield any significant prognostic information in pediatric ALL.
Fig. 1 (a & b): DI values 1.27 (Hyperdiploidy B) and 1.84 (Triploidy) in two cases of B-ALL
OR 29 Flt3 Internal Tandem Duplication (Itd) Mutation in Acute Myeloid Leukemia and Its Clincopathological Correlation— Study from a Tertiary Care Centre in Southern India N. G. Rajesh, Debdatta Basu, Suresh Chandra Pradhan, Smita Kayal Jipmer Introduction: Acute Myeloid Leukemia (AML), has a heterogeneous clinical as well as molecular profile. Molecular markers like FLT3, NPM1, and CEBPA have a prognostic impact in AML, particularly in those with normal cytogenetics. Need for the study. FLT3 ITD has been extensively studied in western population but surprising lack of data in South Indian population urged us to pursue with the study. Materials and Methods: All newly diagnosed and relapsed cases of AML from January 2014 to June 2015 were included in this study. PCR amplification was done to detect the presence of FLT3 ITD mutation in peripheral blood samples. Results: 74 patients of AML were included in this study with a mean follow up of 112 days. Normal karyotype was found in 67.6 % of patients in whom karyotyping was performed. FLT3 ITD mutation was found positive in 11(14.8 %) of 74 patients. Both the relapsed cases included in this study were positive. AML M1 was most commonly associated with FLT3 ITD mutations in this study. The peripheral blood total leukocyte count (p-0.02) and percentage of blasts in bone marrow (p0.04) were significantly higher in patients with FLT3 ITD mutation when compared with patients without the mutation. There was no significant association with other haematological parameters, remission status at first and second induction marrow. However, there was a significantly low overall survival (55 days vs 185 days) in FLT3 ITD positive patients. Conclusion: FLT3 ITD mutation, detected in 14.8 % of AML cases confers a worse prognosis in terms of survival and is associated with higher peripheral leukocyte count and bone marrow blasts.
OR 30 ‘Mixed Phenotypic Acute Leukaemia (Mpal)’ Case Series from Tertiary Care Centre in Eastern India Dr. D. K. Mishra, Dr. Neeraj Arora, Dr. Mayur Parihar, Dr. Mammen Chandy, Dr. Reena Nair Tata Medical Center, Kolkata Introduction: Mixed phenotypic acute leukaemias (MPALs) are rare and are characterised by presence of antigens of more than one lineage or by dual population of tumor cells belonging to different lineages.
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Indian J Hematol Blood Transfus They constitute 2–5 % of all acute leukaemias. We present the clinicpathological, immunophenotypic, cytogenetic and molecular genetic data of 14 patients of MPAL. Materials and Methods: Clinical details, morphology, immunophenotyping and cytogenetic data of all the MPALS received from 2012 till date. The diagnosis was based mainly on the WHO classification 2008. Results: There were 14 patients with a median age of 41 yrs (2–80 yrs) and a male:female ratio of 1.3:1. Most common MPAL were B + myloid (9 cases) followed by T + myloid (4 cases). Cytogenetic analysis of these cases reveal 3 cases with normal karyotype, 3 cases of t(9;22) and 2 complex karyotypes. We also came across a rare case of B + T lymphoid with MLL gene rearrangement. Conclusion: MPAL are rare subset of stem cell disorder with poor prognosis. It is important to diagnose them with the help of multiparametric flowcytometry by using comprehensive antibody panels, subsequent cytogenetics and molecular analysis for further prognostic stratification and treatment modalities. Keywords MPAL, Immunophenotype, Cytogenetics
OR 31
India on MRD analysis particularly using 8 color flow cytometer. In this study we discuss the MRD detection methodology, the importance of some of the new MRD markers and implications of the same in the resource restricted settings like ours. Methods: We analysed 29 cases of B ALL for MRD using BD FACS Canto II, 3 laser, 8 color instrument. The analysis was done using 4 tube assay comprising of 2 tubes with leukemia markers along with the backbone markers, one tube of isotype control and one for viablility and nucleated cell correction. Results: Out of 29 samples from 28 patients, 12 samples (41.28 %) were positive for MRD at a level of more than 0.01 %. 1st tube alone showed abnormal expression of leukemia markers in 11/12 (91.7 %) samples. 2nd tube alone showed abnormalities in 6/12 (50 %) samples. One sample showed abnormality only in the second MRD tube. The frequency of individual leukemia markers in decreasing frequency was CD38 (61.54 %), CD73 (46.15 %), CD86 (38.56 %), CD123 (30.77 %), CD58 (23.08 %) and CD66c (7.69 %). Conclusion: The implications of analyzing and reporting MRD accurately are rapidly increasing. In resource restricted settings like ours, customizing MRD assay and using only the most informative markers is extremely important to make it more cost effective, so that the assay is more widely used for treatment decisions.
Impact of Cytogenetics in Acute Lymphoblastic Leukaemia: Results from a Tertiary Care Centre Dr. U. K. Nath, Dr. Maitreyi Bhattacharya Institute of Haematology and Transfusion Medicine, Medical College, Kolkata Introduction: Limited data is available on the incidence and significance of cytogenetic anomalies in ALL patients in India. Materials and Methods: Retrospective analysis of 75 ALL patients treated in our institute with a minimum follow up of 2 years post completion of maintenance therapy. Results: 22.7 % patients were adults and 77.3 % were children. 8 %-T ALL and 92 %-B ALL. Median age at diagnosis-8.1 years in children and 34.11 in adults. Normal karyotype seen in 31 % children and 41.2 % adults. In children, hyperdiploidy and high hyperdiploidy seen in 10.3 % and 8.6 % respectively. With hyperdiploidy, trisomy most commonly involved chromosomes 21, 4 and 6. Other cytogenetic anomalies seen in children were trisomy 21, del 9p, complex karyotype, hypodiploidy and MLL rearrangement. t(12,21) was surprisingly not seen in any patient. In adults, the rarer cytogenetic anomalies included del7p and trisomy 12. t(9,22) was found in 4 adults (23.5 %), all of whom achieved a CR after induction therapy, but relapsed later. Hyperdiploidy with trisomy 8 and i7q and i9 was associated with poor prognosis. OS was 78.8 % in children and 58.8 % in adults, with OS in children with hyperdiploidy being 50 %, high hyperdiploidy 60 % and normal cytogenetics being 81.2 %. Conclusion: The frequency and distribution of cytogenetic anomalies in Indian patients is different from that reported in literature. Normal karyotype was associated with good prognosis. Hyperdiploidy was not associated with a favourable outcome, contrary to what has been previously reported. Keywords ALL, Cytogenetics, Hyperdiploidy
OR 32 Minimal Residual Disease Analysis in Precursor B Lymphoblastic Leukemia Using 8 Color Flow Cytometer Anurag Mehta, Gauri Kapoor, Dinesh Bhurani, Sandeep Jain, Rayaz Ahmed Rgci & Rc, New Delhi Introduction: Minimal Residual Disease is an established prognostic marker in B lymphoblastic leukemia. There is limited literature from
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OR 33 Serum and CSF Levels of Methotrexate in Pediatric all Patients: A Comparative Analysis of Pharmaceutical Brands Used at a Tertiary Care Center in North India Dr. Nita Radhakrishnan, Dr. Veronique Dinand, Dr. H. V. Smitha, Dr. Anupam Sachdeva Sir Gangaram Hospital Introduction: Managing cancers in resource-constrained settings is challenging in many aspects. The balance of providing optimal care is offset against the increased risk of infections and cost of supportive care. As majority of patients fund for their own treatment, chemotherapeutic medicines provided by local pharmaceutical companies are often sought in order to reduce the cost of therapy. The drug regulatory environment in our country is not geared to ensure good quality of all the chemotherapeutics that are marketed. As therapeutic drug level monitoring is often difficult, this goes unnoticed and may be one reason that compromises quality of cancer care in India. We analyzed the serum and CSF drug level of methotrexate following administration of high dose methotrexate in pediatric acute lymphoblastic leukemia (ALL) patients and compared the levels achieved from different brands of drugs to the efficacy of therapy. Methods Retrospective analysis of pediatric ALL who received high dose methotrexate as part of cranial prophylaxis between 2007–2013 was done. 84 patients who had evaluable drug levels, follow up data and information on the brand issued from the hospital pharmacy were included in the study. Patients received HDMtx as per the standard protocols followed at our center. Serum and CSF methotrexate levels were measured at the end of 24 h, with additional serum levels at 48 and 72 h following infusion. The data was analyzed for the correlation of serum and CSF methotrexate levels achieved to the brand of methotrexate used for the infusion. Results: Median age at diagnosis was 4 years (1.4–18), M: F ratio of 2.1:1. 87.7 % children was B ALL (10 %) T ALL, MPO negative ALL (2.2 %). Nearly 90 % of patients achieved CSF methotrexate [1 micromoles/l in all cycles. Renal function was normal in all patients prior to the infusion. 5 brands of methotrexate were used. 2 brands used in 5 and 2 patients respectively were excluded from the comparative analysis. Significantly different levels of serum methotrexate were obtained at 24 h (p = 0.008) and 48 h (p = 0.024) with the 3 different brands used. No significant difference was observed with the CSF levels (0.33). There were a
Indian J Hematol Blood Transfus total of 3 deaths, 6 LFU, 5 relapses (6.6 %). Conclusions: Significant differences were observed in the drug levels achieved following infusion between the various brands used. Bioequivalence studies should be mandatory before marketing approval and an active surveillance system should be instituted to improve the quality of drugs available for cancer care.
OR 34 Role of Combination Therapy with ATO and ATRA in APML Irrespective of Risk Stratification: Experience of 100 Cases Over 10 Years Parathan Karunakaran, Alka Khadwal, Gaurav Prakash, Shano Naseem, Reena Das Pgimer Background: APML is amongst highly curable haematological malignancies. The discovery of all-trans-retinoic-acid (ATRA) in 1980’s and Arsenic Trioxide (ATO) in 1990’s led to excellent remission rates in APML. Combination of ATRA and ATO has proved its superiority for treatment of low risk APML, but unanswered questions include role in high risk APML, the optimal duration and necessity of consolidation. Methodology: It is a single centre retrospective observational study. All APML patients from January 2005 till July 2015, irrespective of risk category were managed with combination therapy based on risk stratified dosing after obtaining informed consent. Induction was followed by 3 cycles of consolidation and 2 years maintenance. Events were defined as death due to any cause/disease relapse. Results: Data of 100 APML patients (59 males, 41 females) was analysed, of whom 43, 46 and 11 patients were in high intermediate and low risk respectively. Differentiation syndrome was present in 37 % of patients. All-cause mortality was 14 %. The cumulative overall survival (OS) was 86 % at a median follow up of 3701 days. The OS in high, intermediate and low risk were 73.8, 93.3 and 100 % (log rank p-0.004) (Fig. 1). The EFS was 85 % with only one patient in intermediate risk relapsed at 1 year. The cumulative OS on exclusion of early deaths (B7 days of diagnosis) secondary to disease severity was 93 %. Conclusion: Combination therapy is a good alternative in our country where patients present at a late stage with a very good survival benefit irrespective of risk category.
OR 35 Cytogenetic and Molecular Profile of Acute Myeloid Leukemia (AML) from a Tertiary Care Centre In Eastern India Sr Arun, A Yadav, Dk Mishra, N Arora, A Bhattacharya Department of Cytogenetics, Tata Medical Center
Introduction: Cytogenetic profile is the most important prognostic factor in the risk stratification of AMLs. Patients are classified into favourable, intermediate and unfavourable groups. There is little published data on the various cytogenetic abnormalities in AML from India. We present clinicopathological and cytogenetic features of 257 AML patients. Method and Material: G banded karyotypes and FISH analysis results of patients with AML (n = 259) between July 2011 and December 2014 were correlated with blood, and bone marrow findings. Results: Successful karyotypes were seen in 254 (98.8 %) patients of which 180 (71 %) were abnormal. There were 56 paediatric and 198 adult patients with 143 males and 111 females. Favourable (FR), intermediate (IR) and high risk (HR) cytogenetics were seen in 40 (18 %), 123 (56 %) and 57 (26 %) respectively. AML with t(15;17) was seen in 34 (13 %), t(8;21) in 32 (14.5 %) and inv (16) in 8 (4 %) patients. In the Paediatric patients 43 % were IR and 24 % were HR. Adult patients had 59 % IR and 26 % HR. Monosomal and Complex karyotypes were seen in 26 (12 %) and 29 (13 %) patients respectively. MLL gene rearrangement was seen in 16 (7 %) patients of whom 3 had MLL amplification. We also reported rare translocation like t(6;11), t(8;16). FLT3 ITD, NPM1, NPM1/FLT3 and FLT3TKD mutations were seen in 13, 15, 9 and 1 patients respectively out of total 64 cases analyzed. Conclusion: The cytogenetic and molecular profile of AML in our series is similar to the western literature. This is one of the largest series from India demonstrating the cytogenetic distribution in AML.
OR 36 To Study Abberant Expression of Lymphoid Markers in Acute Myeloid Leukemia Vijaya Devi, Richa Gupta, Naresh Gupta, A. P. Dubey, Tejinder Singh Mamc Delhi Introduction: Aberrant expression of antigens in acute myeloid leukemia has been reported in literature with varying frequency with some of them associated with prognostic impact. The present study was undertaken to evaluate the occurrence of aberrant lymphoid phenotypes and to correlate their presence with French American British classification. Materials and Methods: 41 cases of freshly diagnosed AML were included in the study. Smears from Whole blood and/or Bone marrow aspirates were examined with Giemsa stain and cytochemistry (MPO, PAS and NSE) and immunophenotyping was performed in all the cases using flow cytometry. Aberrant expression of CD2, 7 and 19 was noted alongwith the routine flow cytometry done for diagnosis. Results: 43.9 % cases (18/41) demonstrated aberrant antigen expression. CD7 was the most frequent lymphoid marker expressed in total 17 Cases. CD7 alone was seen in 11 cases out of 41 cases (including 3 cases each of AML-M1 and AML-M2, 2 cases of AML-M5 and 1 case each of AML-M3, AML-M4 and B/Myeloid), co-expression of CD2 & 7 was seen in 5 cases (including 2 cases each of AML-M2 and AMLM3 and 1 case of AML-M5), 1 case of AML-M2 was expressing CD19 and there was co-expression of CD7 & 19 in 1 case of AMLM1. Conclusion: Expression of lymphoid antigens was more common in adult cases of acute myeloid leukemia (AML). we found CD7 to be the most frequently expressed lymphoid antigen (41.4 %). This markers could be used to carry out MRD detection in AML cases.
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Indian J Hematol Blood Transfus
Topic: Coagulation Disorders
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Clinico-Hematological Profile of Rare Inherited Coagulation Disorders in Tertiary Centre
Coagulation Profile in Snake Bite Victims Susheela J. Innah Jubilee Mission Medical College & Research Institute Background and Objectives: Snake bite is a common and serious problem in a tropical country like India. Hematotoxic snake bites are very much common in this part of the country but there are only a few reliable data available regarding the coagulation profile of snake bite victims. AIM: 1. To assess the coagulation abnormalities in snake bite patients 2. To note the difference in coagulation profile in different species of snakes 3. To ascertain any selective coagulation factor defect (if any). Methods: Patients who had come to our hospital with a history of snake bite during the period of January 2013 to June 2014 and where admitted in medical ICU satisfying inclusion and exclusion criteria were selected. Detailed clinical examination and investigations were done to assess the status of envenomation. 20 min WBCT was used as the screening test to say that the patient has a hematotoxic snake bite. It is repeated every 30 min for 4 times and if any one value is prolonged the patient is taken as having received a hemotoxic snake bite. If the 20 min WBCT is prolonged, other tests are also done which includes blood routine, platelet count, BT, PT, INR, aPTT, fibrinogen and blood grouping. A citrated sample is collected at the time of deranged 20 min WBCT, the plasma is separated and frozen as fast as possible for later tests on coagulation assay. Results: A total of 595 snake bite patients had come to our hospital during the time period of January 1st 2013 to June 30th 2014. There were 445 adult patients and the rest were pediatric patients. 282 snake bites were considered non venomous as they did not show any signs of envenomation.163 snake bite patients showed some sign of envenomation and was given ASV. Of the venomous bites 50 % of the snakes could not be identified as they had not brought the snake here nor could any of the bystanders give adequate information regarding the snake to identify it.66 patients were bitten by Russell’s viper. 9 patients were bitten by Pit viper snakes. Local manifestations and systemic manifestations were more severe in patients who received treatment later. Hematological manifestations were seen in patients with bite from Russell’s viper, Pit viper bite and unidentified group. Acute renal failure due to DIC & capillary leak syndrome was found only in patients with Russell’s viper bite. Among the patients who developed ARF, dialysis was required for patients with Russell’s viper bite. Coagulation screen was deranged for most of the Russell viper and Pit viper patients. The usual tests that were requested included the 20 min WBCT, PT and INR. The aPTT and Fibrinogen were rarely requested. Coagulation Factor assays were done on all the Russell viper and Pit viper patients, who showed severe factor V and factor X deficiency in all the Russell Viper patients. Even though the coagulation screen was abnormal for Pit viper the clotting factors were normal in them. Factor XIII qualitative test was done and it was found to be deficient in cases of Russell Viper bites only. Conclusion: Guidelines have to be formulated and followed. There is an important requirement for a protocol for lab investigations and hemotherapy in snake bite patients which has to be formulated in the institution. To improve the patient outcome, evidence based transfusion can be implemented. Cryoprecipitate can be used as many of the patients had factor XIII and fibrinogen deficiency after snake bite. As prevention is always better than cure, public awareness and population based programs have to be conducted so as to spread the message of snake bite prevention, first aid and early treatment which are the main pillars of adequate snake bite management.
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Venkatesan Somasundram, Prabhu Manivannan, Neha Singh, Pravas Mishra, Seema Tyagi Aiims Introduction: The rare coagulation disorders are inherited abnormalities of hemostasis may present significant difficulties in diagnosis and management. Aim: To analyze the clinico-hematological profile of the rare inherited coagulation factor disorders diagnosed and followed up in a tertiary care hematology centre of North India. Methods: This was a retrospective study conducted in Department of Hematology, All India Institute of Medical Sciences, New Delhi, from 2012 to 2015. The cases were diagnosed based on the following tests, which include platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), relevant factors assays and clot solubility test in 5 M urea. Factor V, VII and X assays were PT based and factor XI assay was aPTT based. Results: The cases include sixteen males and nine females. The median age of patient was 7 yrs (range; 4 months–45 years). The age at presentation ranged from since to 24 years (median—04 years). The commonest manifestation include skin bleeds (52 %) followed by soft tissue bleeding, gum bleeding, umbilical bleed, and menorrhagia (16 % each). Commonest among the rare coagulation deficiency disorder include factor X (56 %), followed by afibrinogenemia (16 %), factor XIII (12 %), factor V (08 %), factor VII (04 %), and dysfibrinogenemia (04 %). Conclusion: Factor X deficiency is the most common among these rare coagulation disorders in our population. A high index of suspicion and an algorithm based diagnostic approach would aid in diagnosis of these rare coagulation disorders. Keywords Clinico-hematological profile, Factor deficiency
OR 39 Antithrombin Iii Deficiency in North-Indian Population: An Underestimated Risk Factor for Thrombosis? Amit Sharma, Dr. M. Mahapatra, Dr. Renu Saxena, Dr. Mohamad Aman Jairajpuri Jamia Millia Islamia Introduction: Thrombosis is a common cause of mortality and morbidity in the world affecting 0.1 % of persons per year worldwide. Deficiencies of endogenous anticoagulant Antithrombin III (AT) is one of the well studied factor responsible for thrombosis in western population. However, studies of AT deficiency and subsequent genetic analysis in Indian population remain obscure. Objectives: Analysis of Indian deep vein thrombosis (DVT) population with low AT levels for type I and II deficiency. Materials and Methods: AT activity and antigen levels were determined using commercially available kits for screening 2010 Doppler proven DVT patients. Direct DNA based sequencing was used to identify underlying genetic defects. Results: Out of 60 patients with low AT levels (2.98 %), type II AT deficiency was more frequent (63.33 %) as compared to type I AT deficiency (36.66 %). Two novel (T280A, A427T) and one previously reported (R47C) point mutations were observed in patients with type II AT deficiency. Polymorphisms like rs2227589, rs3138521 and DdeI were associated with type I AT deficiency. In addition, two patients with type I AT deficiency were found to be carrying C-4X point mutation. Conclusion: Frequency of AT deficiency in Indian DVT population is similar to that reported in western
Indian J Hematol Blood Transfus population. Identification of genetic variations in AT gene (SERPINC1) warrants similar studies in a larger sample size. Keywords Antithrombin, Mutation, Polymorphisms, Thrombosis
OR 40 Recurrent Pelvic Pseudotumor in Hemophilia B: A Case Report Tanu, Jasprit K. Singh, Amrith Mathew, Chepsy C. Philip, M. Joseph John Christian Medical College & Hospital Introduction: Hemophilia B is an inherited X-linked bleeding disorder with deficiency of factor IX. Those with inadequately treated muscle bleeds develop pseudotumour. Management of pseudo-tumors is a challenge. We report a course of a patient with recurrent pseudotumour and its successful multidisciplinary surgical management. Case Presentation: 37 year old Severe Hemophilia B presented with a large, heterogeneous, well-encapsulated mass approx. 12 x8.2x10.4 cm involving right iliac bone with osteodestruction, and extensive extension. He had been unsuccessfully managed elsewhere with radiotherapy. Patient underwent excision of Pseudotumour under standard Factor IX support. The capsule remnants were left in situ with the intent to cover up the dead space with granulation tissue. However he developed a recurrence. The excision was repeated; the course complicated by a non-healing sinus and repeat recurrence. A revised surgery was then undertaken. An iliac crest excision and curettage of unhealthy tissue and sinus; excision of the pseudotumour and closure of sinus and dead space with a pedicled latissimus-dorsi flap was done. At last follow up, the patient had rejoined work and there was no recurrence. Discussion Pseudotumour is seen in 1–2 % of severe cases of hemophilia. Our patient developed recurrent pseudotumor which was managed with surgical excisions. Approaches include radiotherapy, excision and amputation. Radical excision appears the treatment of choice. However as noted in our patient the surgery carries significant risks-notably bleeding, recurrence and chronic fistulae. The dead space following resection leads to many of the complications. We emphasize the importance of obliteration of dead space. Attempts at closing the dead space have included the fibrin seal, bone cement, omentum, rectus-abdominus muscle and other free tissue flaps.1 We report the first case to the best of our knowledge of successfully using a pedicled latissimus dorsi flap. References 1. Pennekamp, P. H., Strauss, A. C., Klein, C., Marx, A., Goldmann, G., Friedrich, M., Marquardt, N. and Oldenburg, J. (2015), Giant haemophilic pseudotumour of the pelvis: case report and literature review. Haemophilia.
OR 41 Haemostatic Alterations in Patients with Alcoholic Cirrhosis Dr. Pratibha Dhiman, Dr. Chhagan Bihari, M/S Roshni Mirza, Dr. Ajeet Singh Bhadoria, Dr. S. K. Sarin Institute of Liver and Biliary Sciences Introduction: Progressive liver injury leads to fibrosis and ultimately cirrhosis. As liver is the major site of synthesis of several coagulation factors and natural anticoagulant proteins, cirrhosis of liver may lead to serious impairment of haemostasis causing subsequent hemorrhagic and/or thrombotic complications. This study was conducted to detect the coagulation profile (conventional and viscoelastic) derangements and their correlations with disease activity (using MELD scores) in patients with alcoholic cirrhosis and to study the usefulness of these parameters in assessing the bleeding/thrombotic
risk. Methods: A prospective study comprising 67 patients of biopsy proven compensated alcoholic cirrhosis was undertaken. Blood samples were analyzed for prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT), proteinC (PRC), proteinS (PRS), antithrombin (AT), factor VIII (F8), von Willebrand factor (vWF Ag) (coagulometric assays), tissue factor (TF) (ELISA assay), platelet count (PC) (using cell counter) and activated clotting time (ACT), clot rate (CR) and platelet function (PF) (viscoelastic method, sonoclot analyser). The bleeders and non bleeders were grouped separately. The abovementioned tests were correlated with MELD scores using student T test. P value considered significant if B0.05. Results: Mean age was 50.9 ± 10.0 years, 94 % of which were males. While an increase from normal range was seen in PT, INR, APTT, F8, vWF Ag there was a definite decrease in levels of PRC, PRS, AT and PC. A significant negative correlation between MELD and PRC (r = -0.535, p = .000), AT (r = -0.49, p = .000) and significant positive correlation with F8 (r = 0.23, p = 0.05) was noted. None of the parameters could predict bleeding/thrombosis. Conclusion: Low levels of proteinC, antithrombin and high levels of factorVIII correlate significantly with disease activity in alcoholic cirrhotics. Keywords Cirrhosis, Hemostasis, Bleeding, Thrombosis
OR 42 Spectrum of Hemostatic Disorders in Women with Unexplained Menorrhagia—A Hospital Based Analysis Prof. Ashutosh Kumar, Dr. Kusum Lata Mishra, Prof. Pushplata Sankhwar, Prof. Renu Singh K.G.M.U Introduction: Menorrhagia is a common problem in women of reproductive age group. Menorrhagia in adolescent and perimenopausal women is usually due to anovulatory cycles but can also be due to organic causes such as leiomyomas. Hemostatic disorders are also known to contribute to a significant proportion of these cases. The present study was conducted to study the type and frequency of hemostatic disorders in women presenting with unexplained menorrhagia. Need for the Study: This was a pilot study conducted in K.G.M.U, Lucknow with the aim to diagnose a wide range of hemostatic disorders which can give rise to menorrhagia in women. Materials and Methods: All women attending Gynaecology emergency with complaints of menorrhagia underwent complete evaluation. Those patients having local pelvic pathology and hormonal disorders as a cause of menorrhagia were excluded and remaining patients underwent Screening investigations including BT, PT, APTT, Platelet count and morphology. The following diagnostic investigations were carried out as and when required: Platelet Aggregation Tests using ADP and Ristocetin, Platelets function tests (e.g. PF 3 Release), Specific Factor analysis as and when required, as for factor VIIIc, IX. Results: Age of patients ranged from 13 years to 46 years. Eighteen patients had menorrhagia since menarche. Seven patients had family history of abnormal bleeding. 23 patients were found to have systemic hemostatic disorder (10 patients of vWD, 7of Glanzmanns, 1 of Bernard Souliers and 5 of Immune Thrombocytopenic Purpura). Conclusion: This study was an effort to characterize systemic hemostatic disorders in menorrhagic females presenting to gynaecological emergencies in tertiary care centre in North India. From this study it is concluded that systemic hemostatic disorders are found in substantial number of women presenting with menorrhagia. Hence, after excluding organic/hormonal cause, hemostatic disorders should be considered before taking patient for invasive surgical procedures.
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Indian J Hematol Blood Transfus OR 43 Efficacy of Once Weekly Factor VIII Prophylaxis in the Prevention of Clinically Significant Bleeds in Patients with Severe Hemophilia A T. K. Dutta, P. Nalini, S. Mahadevan, Niranjan Biswal, Debdatta Basu
between the non-overt DIC and the non-DIC patients (p = 0.0001). At ROC generated cut-off values, FM had higher specificity, sensitivity and negative predictive value for distinguishing between overt and non-DIC groups as well as non-overt and non-DIC groups in comparison to DD. Conclusion: FM is a better indicator than DD in distinguishing non-overt-DIC from non-DIC patients, raising possibility about its diagnostic utility as a marker for both overt and nonovert DIC.
Jipmer Introduction: The optimal regime for prophylaxis remains to be defined. In a previous study done in our centre, prophylaxis with Factor VIII at 10u/kg twice weekly was found to be effective in preventing joint bleeds. To reduce the inconvenience of twice weekly administration, this study was designed to give prophylaxis once a week. Here we are reporting the outcome after one year of low dose prophylaxis. Materials and Methods: Children 1–12 years of age with severe hemophiliaA were divided into prophylaxis (n = 12) and on-demand groups (n = 8). Prophylaxis group received Factor VIII 20U/kg once a week. Results: The mean age in years was 5.83 ± 2.75 in the prophylaxis group and 9.62 ± 2.13 in the ondemand group (p = 0.004). The total units of FactorVIII/kg/month was 88.92 ± 17.59 in prophylaxis group and 35.65 ± 17.66 in on demand group (p = 0.000). The total number of bleeds were 4 (2–8) in the prophylaxis group and 5.5 (2–12) in the on-demand group (p = 0.09). The total number of joint bleeds was 1.5 (0–7) in prophylaxis group and 4.5 (1–8) in the on-demand group (p = 0.03). The mean clinical score (HJHS) was 1(0–8) in prophylaxis group and 5.5 (2–8) in the on demand group (p = 0.1) at the end of study period. The Petterson radiological score at the end of study was 0 (0–3) and 3 (0–4) in the prophylaxis and on demand groups respectively (p = 0.03). Conclusion: Once weekly low dose factor VIII prophylaxis is effective in reducing the number of joint bleeds and preserving the index joint structure in patients with severe Hemophilia A. Keywords Factor prophylaxis, Joint bleed, Joint score
OR 44 Evaluation of the Diagnostic Performance of Soluble Fibrin Monomer Complexes in Comparison to D-Dimer in Patients with Overt and Non-Overt Disseminated Intravascular Coagulation Hp Pati, Seema Tyagi, Renu Saxena
OR 45 Study of the Coagulation Profile in Children with HIV Infection Sunita Sharma, Jagdish Chandra, Anita Nangia Lady Hardinge Medical College New Delhi Introduction: The introduction of Highly Active Antiretroviral Therapy (HAART) has increased the life expectancy of HIV infected patients. Newer non-AIDS related complications like arterial and venous thrombosis had increased in these patients. This study was conducted to know the impact of HIV infection on coagulation in children and the effect of treatment on the deranged coagulation parameters. Materials and Methods: Study group: 42 newly diagnosed HIV positive children (age: 1.5–18 years). Following investigations were done: CBC, PT, aPTT, fibrinogen, D-Dimer, protein C (PC), protein S (PS), antithrombin (AT), lupus anticoagulant (LA) and antiphospholipid antibody (APLA). Thirty patients received ART & were followed up for 6 months (all the above investigations were repeated and observed for clinical evidence of thrombosis). Results: Prolonged PT and aPTT were observed in 30.9 % and 23 % of the cases respectively. Raised fibrinogen and D-Dimer levels were seen in 11.9 % and83.3 % of the patients. PS, PC & AT activity was reduced in 90.4 %, 42.8 % & 11.9 % of cases respectively. LA was negative. Antiphospholipid IgM & IgG antibody were observed in 6.6 % & 10 % of the patients respectively. At 6 month statistically significant improvement was seen in the protein S activity. Conclusion: The study suggests that there exists a hypercoagulable state in HIV positive children which improves after giving ART.
OR 46 Spectrum of Inherited Bleeding Disorders from a Single Tertiary Care Centre Over 6 Years and Their Diagnostic Approach
All India Institute of Medical Sciences, New Delhi Introduction: Disseminated Intravascular Coagulation (DIC) is a thrombo-hemorrhagic disorder characterized by hyper-activation of coagulation and secondary fibrinolysis. Few studies have demonstrated that elevations in soluble fibrin monomer complexes (FM) and D-Dimer (DD) often precede overt-DIC by several days and identification of such patients before they develop overt-DIC would allow prompt intervention. AIM: The primary aim of this prospective study was to evaluate and compare the diagnostic performance of FM and DD for the preemptive diagnosis of DIC in early stages. Materials and Methods: The patients were categorized into three groups: overtDIC, non-overt DIC and non-DIC based on the ISTH scoring for overt-DIC and the modified non-overt-DIC criteria. Quantitative determination of FM and DD was done by immuno-turbidimetric assay. Results: Median DD and FM levels in overt DIC patients were significantly higher in comparison with the other two groups. However, the difference in DD levels was not statistically significant between the non-overt DIC and the non-DIC patients. Interestingly, the difference in FM levels was found to be statistically significant
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Debdatta Basu, Bhawana Ashok Badhe, Pl Ambika, S. Sushya, R. Sundharamurthi Jipmer, Puducherry Introduction: Inherited bleeding disorders are a heterogenous group of disorders of primary and secondary hemostasis. These vary in prevalence and their diagnosis requires an algorithmic approach. Need for this Study: This was undertaken to analyse the spectrum of these disorders from a single tertiary care centre. Materials and Methods: This was a record-based descriptive study over six years. All the inherited bleeding disorders were included. The diagnoses were based on screening coagulogram followed by mixing studies and factor assays for secondary hemostatic defects and platelet aggregation studies and RiCoF for primary hemostatic defects. Results: There were 148 patients in total with mean age at diagnosis 14.4 years (SD 13.98) with 87.8 % males and 12.2 % females. Primary hemostatic defects accounted for 19 (12.8 %) cases which included 10 (6.8 %) von Willebrand disease, 7 (4.7 %) Glanzmann thrombasthenia and 2 (1.4 %) Bernard-Soulier syndrome. The defects of secondary
Indian J Hematol Blood Transfus hemostasis comprised 129 (87.2 %) cases. Intrinsic pathway defects constituted the majority with deficiencies of factor VIII in 103 (69.6 %), factor IX in 12 (8.1 %) and factor XI in 1 (0.7 %). Extrinsic pathway defect was rare with 1 (0.7 %) case of factor VII deficiency. Common pathway defects included deficiencies of factor I in 3 (2 %), factor II in 2 (1.4 %), factor V in 4 (2.7 %) and factor X in 1 (0.7 %). Factor XIII deficiency and combined deficiency of factors VIII & IX were seen in 1 (0.7 %) case each. Conclusion: Hemophilia A was the single commonest inherited coagulopathy accounting for 69 % cases. A number of rare bleeding disorders were also encountered, the diagnosis of which was arrived at by a systematic approach. Keywords Inherited bleeding disorders, Primary hemostasis, Secondary hemostasis, Haemophilia A
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hypertension, hyperlipidemia, diabetes mellitus and family history were elicited. The initial tests included CBC, PT, APTT, LFT, blood sugar and lipid profile. Functional assay on thrombophilia markers was performed using clotting based method. Results: In total 121 patients (63 males 58 females) were studied. No abnormality was detected in 75 (61.9 %) patients. 46 (38.0 %) were positive for one or more thrombophilia markers. The commonest abnormality was deficiency of single factor (86.9 %), mainly protein C (55 %). Protein S and factor V were deficient in 32.5 % and 12.5 % respectively. Most were in age group 15–40 years with history of thrombotic event at a young age. Antithrombin-III was normal in all samples. Conclusion: An association was found between low levels of protein C, protein S, factor V and thrombotic event. Attempt was made to group patients according to severity of deficiency. Since high end molecular/mutational studies are not available in most set-ups, screening the patients for basic thrombophilia markers can help in diagnosing primary thrombophilia.
Study of Presence of Factor VIII Inhibitor in Haemophilia A Patients S. K. Behera, D. P. Mishra Mkcg Medical College, Berhampur Study of presence of Factor VIII Inhibitor in Haemophilia A Patients Joyshree Panda, S.K. Behera, D.P. Mishra (Department of Pathology, M.K.C.G Medical college, Brahmapur) Background: Factor VIII administration to hemophilia A patients results in an immune response (inhibitor formation) which significantly complicates the therapy. Aim: To determine the prevalence of inhibitors in hemophilia A patients receiving factor VIII therapy. Materials and Methods: This was a prospective study done in pathology department of M.K.C.G Medical college, Brahmapur during 2014–2015. The venous blood samples were mixed in a proportion of 9 to 1 with 3.2 g/dl citrate sodium. Clotting factor inhibitor screening was performed by activated partial thromboplastin time mixing studies using normal pool plasma collected from twenty healthy donors. Bethesda assay for quantitation of factor VIII inhibitors was performed on samples which were positive with screening tests. Results: All known haemophilia patients taking factors were screened for inhibitors. Total 52 patients were screened. 5 (10 %) patients were inhibitor positive; out of them 4 (8 %) were low responders and 1 (2 %) was high responder. Conclusion: Regarding to high prevalence of the factor VIII inhibitor in patients of haemophilia A, screening all hemophilia A patients every 6 months and doing Bethesda test for new identified cases with this inhibitor is highly recommended. Keywords Hemophilia A, Factor VIII inhibitor, Bethesda assay
OR 48 Prevalence of Common Thrombophilia Markers in Young Patients with Primary Arterial and Venous Thrombosis Dr. Monika Gupta, Dr. Nisha Marwah, Dr. Rajeev Sen
OR 49 Antiphospholipid Antibodies and Bleeding Manifestation: An Institutional Experience Jasmina Ahluwalia, Sunil Bose, Varun Uppal, Vikas Suri, Subhash Varma Postgraduate Institute of Medical Education & Research Introduction: Antiphospholipid antibodies (aPL) comprise of lupus anticoagulant [LA], anticardiolipin antibody [aCL] and anti-b2-glycoprotein-I antibody [anti-b2GPI]. These are the essential component of antiphospholipid syndrome (APS). Although thrombosis is the main clinical phenotype in aPL-positive patients, major bleeding occurs in approximately 10 % of patients. Need for Study: The data related to bleeding manifestations in patients having aPL is sparse in the world literature and especially from India. The main objective was to highlight such association and its frequencies in patients with bleeding manifestations. Materials and Methods: This was a retrospective study. The laboratory details of patients who presented with a bleeding history in the last 15 years were searched out for the presence of aPL. Results in Brief: Antiphospholipid antibodies were detected in 16 cases presenting with following bleeding manifestations: ecchymosis (6), intramuscular hematoma (3), Hematuria (3) and others (4). A female preponderance was noted. The mean age of testing was 37 years. PT and APTT prolongation was seen in 31 % (5/16) and 81 % (13/16) cases respectively. Inhibitors were detected by correction studies in 83 % (10/12) cases. Thirteen, 4 and 4 cases were positive for LA, aCL and anti-b2GPI respectively. Multiple positivity akin to APS was seen in 4/7 cases. Seven cases had underlying clinical conditions—haematological malignancies (3), ITP (2), and chronic kidney disease (2). Conclusions: aPL-positivity can be seen in patients with bleeding. LA is the most commonly detected antibody. The site of bleeding, antibody positivity and underlying clinical conditions show a wide and varied spectrum.
Pt. B. D. Sharma Pgims Rohtak Introduction: A vascular thrombotic event involves interaction of genetic and environmental factors. The genetic factors include activated protein C resistance, deficiency of natural anticoagulants protein C, protein S, factor V and antithrombin-III. Acquired cause include presence of antiphospholipid antibody. Need for Study: This study was carried out to establish the role of thrombophilia markers APC-R, antithrombin-III, factor V, protein C and protein S in diagnosing patients with primary thrombophilia. Materials and Methods: Samples were collected from 121 patients of arterial/venous thrombosis after 10–12 weeks of acute episode. History of smoking,
OR 50 Hemostatic Abnormalities in Patients with Head Injury Meera Sikka, Gurubachan Singh, Mrinalini Kotru Ucms and Gtb Hospital, Delhi Introduction: Patients with head injury, a leading cause of morbidity and mortality worldwide are susceptible to the early development of coagulopathy which further contributes to an adverse outcome. It’s
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Indian J Hematol Blood Transfus early identification is hence important. Need for study : To study the prevalence and nature of hemostatic abnormalities in patients with isolated head trauma and correlate with outcome. Materials and Methods: Complete blood counts, platelet count, tests of hemostasis:PT, APTT, TT and plasma fibrinogen were performed on 100 patients admitted within 12 h of isolated head trauma. Results: Seventy-four (74 %) patients sustained injury due to Road traffic accident. Based on the GCS, head injury was classified as mild (GCS 13–15, n = 45), moderate (GCS 9–12, n = 28) and severe (GCS 3–8, n = 27). Thrombocytopenia was seen in 48 % patients. Coagulopathy as defined by prolonged PT ([14 s) and/or APTT ([34 s) was present in 39 % patients and hypofibrinogenemia in 48 % patients. Twenty-six patients died. Mortality was significantly (p \ 0.001) higher in patients with coagulopathy and/or thrombocytopenia. Platelet count and plasma fibrinogen were significantly lower and PT, APTT, TT significantly (p \ 0.001) higher in non survivors as compared to survivors. Platelet count significantly (p \ 0.05) decreased while PT, APTT and TT increased with increasing severity of injury. Seven (17.9 %) patients with mild injury also had coagulopathy. Conclusion: As coagulopathy was associated with a significantly higher mortality, measurement of hemostatic parameters in patients with head injury irrespective of it’s severity will help in identification of patients at poor risk thus aiding better management and improved survival of these patients. Keywords Traumatic brain injury, Prothrombin time, Activated partial thromboplastin time, Plasma fibrinogen
OR 51 D-Dimer A Predictor for Lymph Node Metastases in Breast Cancer Dr. Gaurav Chhabra, Dr. Subhadra Sharma, Dr. N.K Shukla, Dr. S.V.S Deo, Dr. J Arulselvi Aiims Summary Raised levels of D-dimer can be used as cut off for Axillary lymph node dissection (ALND) along with primary tumor resection. D-dimer values were found to be significantly raised in patients with operable breast cancer and more so in those with lymph node metastasis. Introduction: Coagulation and fibrinolytic pathways have been documented for being involved in the process of carcinogenesis and its metastases. So the hypotheses made for this case study was to study the correlation of D-dimer, Prothrombin Time (PT), Partial Thromboplastin time (aPTT), Platelet count and Mean Platelet Volume (MPV) to the lymph node status of the patient diagnosed with operable breast cancer. Establishment of a cut-off value for raised D-dimer levels shall be a very useful and specific test for making the decision of ALND even in absence of radiological or clinical evidence of lymph node metastases. Materials and Methods: 50 cases of operable breast cancer were recruited from the Onco-surgery department, BRAIRCH, AIIMS and 50 healthy controls of comparable age were recruited from the volunteers. From each cases and control a citrated sample was obtained for analyses of PT, aPTT, D-dimer in Sysmex CA 1500 and an EDTA sample for measurement of Platelet count and MPV in a Beckmann Coulter LH750. The data obtained from the clinical pro forma and the laboratory results were tabulated in excel sheet and analyzed by SPSS 20 using Student T test, Mann–Whitney U test (non-parametric). The intergroup comparisons were done using the Chi Square and ANOVA. ROC was plotted for determining the cut-off for D-dimer. Results: D-dimer and MPV were significantly higher in breast cancer cases as compared to healthy controls. No significant difference was found between different subgroups of cases based on histological types and hormone
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status. But D-dimer levels were significantly increased in cases with age C 45 years and those with BIRADS B4 (p value = 0.045 & 0.038 respectively). Those cases with lymph node metastases (irrespective of no. of lymph nodes involved) were found to have comparatively higher levels of D-dimer (p value = 0.048) than those without lymph node involvement. From the ROC the cut-off for D-dimer as an indicator for lymph node metastases was 0.765 lg/dl with a specificity of 91 % and sensitivity of 56 %. Conclusion: Increased levels of D-dimer could be a very specific and early indicator of lymph node metastases at the time of diagnosis hence enabling to go for ALND along with primary tumor resection even in absence of any clinical or radiological suspicion.
Topic: Experimental Therapies and Protocols OR 52 Role of Hematological Profile in Early Diagnosis of Neonatal Sepsis—One Year Cross Sectional Study in a Tertiary Care Centre Dr. Anil Prasad, Dr. Priyanka Arora, Dr. Ramesh Chavan Jnmc, Belagavi, Karnataka Introduction: Neonatal sepsis is major cause of morbidity and mortality in developing countries. Neonates are easily prone for bacterial infection. Early signs of sepsis may be subtle and different at different ages. Need for study—It is life threatening condition but curable if treated early The present study was undertaken to assess the significance of the hematological scoring system (HSS) for early detection of neonatal sepsis. Objective: To evaluate the utility of the hematological parameters for early detection of neonatal sepsis. Materials and Methods: A septic work up was carried out in all these infants which includes complete blood counts, C-reactive protein and blood culture with antibiotic sensitivity. The analysis of the peripheral smear was done by the pathologist blinded to the diagnosis of the baby. The parameters includes total leucocyte count, absolute neutrophil counts, I:T & I:M ratio, degnerative changes in neutrophils, thrombocytopenia and C-reactive proteins. Results: A total of 100 babies were evaluated for suspected sepsis. Commonest age group was 4–10 days (58 %). 70 % had positive blood cultures. The sensitivity of hematological scoring system with cut-off score of 5 in predicting sepsis was 67.14 % and specificity was 96.6 %. Among hematological parameters I:T ratio was most sensitive and specific which is 90 % and 93.33 % respectively. Conclusion: HSS is a simple, quick, cost effective tool. It can be used as a screening test for early diagnosis of neonatal sepsis and aid the clinicians in identifying sepsis, institute proper anti-biotic therapy, hence decrease morbidity and mortality. Keywords Neonatal sepsis, Hematological scoring system (HSS), I;T ratio
OR 53 Red Cell Exchange Our Experience in a Tertiary Care Centre in Tamilnadu H. M. Prakash, Dr. Chezhian Subash Mahatma Gandhi Medical College and Research Institute ‘‘Red cell exchange’’ our experience in a tertiary care hospital of Tamil Nadu, India. Red cell exchange (RCE) is removal of patient’s
Indian J Hematol Blood Transfus red blood cells and replacing with donor red blood cells. RCE using automated cell separator is useful sickle cell disease (SCD) during sickling crisis and to bring down the sickle cell percentage prior to major surgical procedure to avoid sickling complications during prolonged anesthesia. RCE is effective in patients infested with malaria and babesiosis whose parasitic index remain high despite medical management. RCE is tried as an adjuvant therapy in certain poisons like nitrobenzene and carbon monoxide when first line management fails. This procedure is safe, effective, easy and quick to use with less complications. This retro prospective study analyzed 21 cases of RCE performed on 18 cases of sickle cell disease, 2 case of severe falciparum malaria and 1 case of nitrobenzene poisoning. All these procedures were performed with through Spectra Optia Apheresis System—Terumo BCT. Almost all of those RCE done on SCD were for avascular necrosis of head of femur and admitted for hip replacement surgery. Two RCE were performed on patients infested with Falciparum malaria with high parasitemic index ([10 %), and one on nitrobenzene poisoning. Red cell exchange transfusions remain an effective but possibly underutilized therapy in developing world. Only very few centers are practicing red cell exchange in India due to inadequate awareness, technical expertise, lack of equipments and facilities to identify the clinical conditions.
OR 54 Gcn5 Mediated Hyperactivation of Atm Kinase Is Responsible For The Early Onset of Acquired Drug Resistance in Leukemic Minimal Residual Cells (MRD)
OR 55 Excellent Remission Rates with Limited Toxicity in Relapsed Langerhan Cell Histiocytosis with Pulse Dexamethasone and Lenalidomide in Children Dr. S. Divya, Dr. U. Ramya, Dr. Hemalatha Doss, Dr. Atish Bakane, Dr. Revathi Raj Apollo Speciality Hospital Backgroud Lenalidomide has been licensed for use in adults with multiple myeloma and myelodysplastic syndromes is a drug with immunomodulatory potential with antiangiogenic, proapoptotic, and anti-inflammatory activities. We present a series of four children with refractory/relapsing Langerhan Cell Histiocytosis (LCH) who have achieved durable remission with a lenalidomide based chemotherapeutic regimen with minimal toxicity. Patients and methods The study was conducted between June 2012 and December 2014 and the children aged between 3 to 5 years had a biopsy proven diagnosis of LCH treated with steroids and vinblastine followed by second line therapy with cytarabine and cladribine upon relapse. Results: All 4 children managed to complete the regimen without compliance issues as it was outpatient based and well tolerated. One child had a fracture of both bones of forearm after a trivial fall. There were no documented grade IV cytopenias. Three out of four children showed PET negative lesion and one has resolution of lesion on MRI. Conclusion: Refractory LCH can be used with good efficacy and safety profile in children with refractory/relapsing disease. The pilot regimen needs to be validated with more number of patients and long term safety studies and is particularly suited for resource poor countries.
Sanket Shah, Devanand, Ashwin Ramaswami, Jyothi Nair, Smita Patkar Actrec Tata Hospital Introduction: Elimination of Minimal Residual Disease (MRD) cells of leukemia is a major problem due to our limited knowledge of molecular events that render them resistant to chemotherapy. Therefore, this study aims to identify early changes during the development of resistant unique to MRD cells. Materials and Method: We have used early drug (doxorubicin) resistant leukemic cell line (K562) developed in our lab and leukemic patient samples (n = 20). Molecular changes were analyzed by electron microscopy, quantitative PCR, western blotting, immunofluorescence, flow cytometry. Results: We show that despite equal drug uptake, by 2 rounds of doxorubicin treatment K-562 cells (referred to as DTEP-2) start to acquire higher survival and clonogenic potential as compared to parent population. We demonstrate that there is over expression of GCN5, a histone acetyl transferase in DTEP-2 cells that lead to higher modification of H3K16ac. This modification increase the recruitment of ATM, regulating double strand break repair pathway to the chromatin and consequently hyperactivating its downstream targetsBRCA1, p-Chk-2 and anti-apoptotic protein MCL-1 thereby enhancing DNA repair in the DTEP-2 population. Importantly q-PCR analysis show significant overexpression of GCN5 also in MRD positive (n = 20) patient sample as compared to MRD negative (n = 20) samples. Conclusion: Taken together we have identified molecular mechanism that leads to enhanced DNA repair of MRD cells during early stages of acquired resistance. Accordingly we show that GCN5, ATM and Chk-2 kinase specific inhibitors along with doxorubicin efficiently eliminate leukemia MRD cells. Keywords Leukemia, Minimal residual disease, Chemoresistance, DNA repair, Chromatin modification
Topic: Lymphomas OR 56 Comparison of the Efficacy of Rituximab (Mabthera) and Its Biosimilars in Diffuse Large B-Cell Lymphoma Patients: A Retrospective Analysis A. Korula, B. George, A. Srivastava, V. Mathews, A. Abraham Christian Medical College, Vellore Introduction: The addition of the Anti-CD20 monoclonal antibody Rituximab to standard chemotherapy (CHOP) has resulted in improved response rates and overall survival in diffuse large B-cell lymphoma. However, due to high costs, this drug is beyond the reach of a large proportion of the Indian population. The introduction of biosimilar drugs has made anti-CD20 antibody more accessible, but there is limited data on the efficacy of these drugs. Methods: We conducted a retrospective, observational study on all Diffuse Large B Cell Lymphoma (DLBCL) patients who had received R-CHOP between January 2011 and December 2014. All adult patients with DLBCL of any stage who had received either original rituximab molecule or biosimilar version along with CHOP chemotherapy were included. Both brands of rituximab were administered at a standard dose of 375 mg/m2 along with standard CHOP regimen every 3 weeks. Results: A total of 152 patients with DLCBL were treated with R-CHOP during the study period. There were 111 males (73 %) and the median age of all patients was 50 years (Range 15 to 78 years). Response was assessed by PET scan (n = 94), CT scan (n = 32) and Ultrasonogram/Chest X-Ray (n = 26) based on the
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Indian J Hematol Blood Transfus patients financial status. Out of 152 patients, 60 patients (39.4 %) received Mabthera and 92 patients (60 %) received generic rituximab. The median follow-up of all patients was 13 months. In the Mabthera group, overall response rate (ORR) (CR + PR) was documented in 88 % patients (CR in 76 % (n = 46) and PR in 11.6 % (n = 7) with progressive, relapse or refractory disease in 8.3 % (n = 5). In generic group, overall response rate was 82 % (CR in 64 % (n = 59) and PR in 18.4 % (n = 17) while stable/progressive disease was seen in 13 % (n = 12). Six patients died during the course of treatment, 2 in the Mabthera group and 4 in the Generic group. The 3 year EFS and OS in Mabthera group and Generic groups were 86 % ± 5.3 % vs 68 % ± 10.1 % and 93 % ± 3.8 % vs 79 % ± 10.4 %. These differences were not statistically significant (p = 0.4). Conclusion: The development and introduction of biosimilar rituximab has increased the number of patients who are able the access the drug for treatment of DLBCL. This small, retrospective study did not show a statistically significant difference between original drug Mabthera, and the biosimilar alternatives available in the market. These findings need to be validated in a prospective study, with comparable patient groups.
OR 57 Peek-A-Boo Lymphomas Kumudini Devi, Rajashree Tripathy, Debahuti Mohapatra, Pranita Mohanty, Seema Chauhan Ims and Sum Hospital Introduction: Neophytes usually believe lymphomas to be a disease primarily affecting lymph nodes only. But frequently these can affect solid organs and present with morphologies that resemble other neoplasms instead of lymphoma. Such morphologies can confuse a histopathologist and can be diagnosed only after immunohistochemistry. Results: can surprise even the best of the minds as what was believed to be carcinoma or some other malignancy, is unveiled as a lymphoma. Materials and Methods: We wish to report three such cases; a Signet Ring Cell Lymphoma of stomach, a primary testicular lymphoma and a primary CNS lymphoma without AIDS. The Signet Ring Cell Lymphoma of stomach was initially reported as infiltrative adenocarcinoma on the endoscopic biopsy. The primary testicular lymphoma was confused with seminoma and primary CNS lymphoma was confused with PNET. In all the three cases IHC was performed. Results: In all the three entities, the results of Immunohistochemistry were completely unanticipated and changed the final diagnosis. Discussion: Final diagnosis of malignancies should only be given after Immunohistochemistry as a diagnosis given only on the basis of morphology can be erroneous. Chemotherapy is the primary line of treatment for lymphomas. On the other hand carcinomas or other tumors are mostly treated by surgery along with chemotherapy/radiotherapy. As pathologists we should keep this in mind while reporting so that appropriate treatment is given to the patient. Keywords Lymphoma, Immunohistochemistry, Carcinoma, Seminoma
OR 58 Long Term Outcome of Hodgkin Lymphoma from Cancer Institute and Application of a Mathematical Model to Predict Outcome M. Tanmay, R. Swaminathan, S. Rama, Rejiv Rajendranath, Prashanth Ganesan Cancer Institute
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Introduction: The long term outcome of Hodgkin Lymphoma (HL) is poorly documented from developing countries including India. The International prognostic score (IPS) for advanced HL has not been validated in patients from India. The application of alternative approaches such as Mathematical Modeling would be beneficial in deriving a predictive model for outcome. Material & Methods: Five hundred and thirty-one consecutive previously untreated HL patients who received treatment at Cancer Institute, Chennai from 2001 to 2010 were analysed. Results: The median age was 27 years (range 2–70 years). Males constituted 70 % and 30 % were females. B symptoms were present in 50 % of patients. Stage I, II, III and IV constituted 16, 36.9, 35 and 12.1 % respectively. The most common chemotherapy administered was ABVD followed by COPP-ABV regimen. Consolidation radiotherapy was delivered to 23 % of patients. The median follow up was 6.5 years. Complete remission was achieved in 83.1 % and partial remission in 8.7 %. Patients with primary progressive disease were 3.8 % and 11.9 % have relapsed of their disease. 5 yr DFS (Disease free survival) and OS (Overall Survival) was 75 % and 84 % respectively. The 10 yr DFS & OS was 69 % & 80 % respectively. In the multivariate analysis (Model 1) Age, Stage and Lymphocyte count was predictive of DFS and OS. In another model (Model 2) B symptoms, cervical node and inguinal node were predictive of OS. IPS for advanced Hodgkin Lymphoma was not validated in our patients as in the multivariate analysis only Stage and Lymphocyte count were significant. IPS was also not validated in children (age \ 14 years). With alternative models like Mathematical Modeling by using correlation matrix, lymphocyte count and albumin levels were positively correlated with DFS and OS. In the Principle Component Analysis Stage, B symptoms & ESR were grouped together. Conclusion: Our analysis confirms the excellent outcome of HL similar to the developed countries. IPS for advanced HL is not validated in our patients. Alternative models with mathematical modelling can be used for prognostication in HL. Keywords Hodgkin Lymphoma, Prognostic factors, IPS validation, Mathematical modeling
OR 59 Extramedullary Plasmablastic Plasma Cell Myeloma Presenting as Plasmablastic Lymphoma Raja Pramanik, Pranay Tanwar Dr. Brai-Rch, Aiims, New Delhi Introduction: Multiple myeloma (MM) is a clonal plasma cell proliferative disorder. Plasmablastic MM is a subset of myeloma, in which the bone marrow (BM) aspirate smear shows C2 % of plasmablasts. Short clinical history: 31 year old male presented with Painful rapidly growing swelling in oral cavity (right) & face for one month. Clinical examination showed ulceroproliferative growth covering 40 % of oral cavity & cervical lymphadenopathy. Mass lesion noted in right maxilla on CECT. Skeletal survey was normal. M-band (serum), B symptom & Viral markers were negative. FNAC showed atypical cells with CD45 + ve & HMB 45-ve (excludes malignant melanoma), suggested NHL. Biopsy showed cells positive for CD79a, CD138, MUM1 & negative for CD20, CD3, CD56, CK & HMB45, suggestive of plasmablastic lymphoma (PL). Peripheral blood smear was normal. BMA smear showed 50 % Plasma cells predominantly plasmablasts, was supported by BM biopsy. After 6 cycles of CHOP, repeat BMA showed 20 % plasma cells, SEP showed no M-band, Serum free light chain (SFLC) ratio kappa/ lambda429/15.84 = 27.09 (0.26 to 1.65), B2 microglobulin 3.263 (1.21–2.70 mcg/mL) & creatinine 1.8 mg/dl. Therapy for Plasmablastic myeloma (PBM)/Multiple myeloma (MM) started. After 4 cycles of thalidomide +dexamethasone plan was switched to
Indian J Hematol Blood Transfus Bortezomib + dexamethasone. Symptomatic improvement seen with normal hemogram/biochemistry. Discussion: This case presented with PL, later turned out to be PBM, initially showed no feature of myeloma. With passage of time on SFLC ratio & B2 microglobulin gave the clue in this case. A careful differentiation is must.
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was 5.3:1. Patients less than 18yrs were 24.4 % (11/45), while majority were adults 75.6 % (34/45). Nodal presentation was seen in 77.7 % (35/45) & extranodal involvement was noted in 22.3 % (10/ 45). ALK + expression was seen in 68.9 % (31/45), while 31.1 % (14/45) were ALK-. The phenotype in majority was Null type 52.7 % (19/37). Conclusion: ALCL is a distinct entity. Morphologically it can mimic as carcinomas/lymphomas & vice versa. Identification of ALK + &ALK—has clinical & prognostic significance. Keywords ALCL, ALK expression, Immunohistochemistry
A Rare Case Report of Childhood Burkitt Lymphoma Presenting with Paraplegia Nisha S. Iyer, Kasi Viswanathan
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Meenakshi Mission Hospital and Research Center
Quite Indolent Follicular Lymphoma Since 20 Years in 40 Years Old Male—A Case Report
Introduction: Paravertebral malignant tumors at presentation is seen in less than five percent of childhood cancer and mostly constitutes neuroblastoma and soft tissue sarcomas. The paraspinal mass with cord compression is one of the neurological emergencies in oncology. Immediate interventions will include emergency surgical decompression, systemic corticosteroids and radiation. Case presentation: Six years old boy, born of nonconsanguinous parents, presented with fever for 20 days, leg pain and constipation for 1 week. He had Lower limb weakness and urinary incontinence for 2 days. He had received antibiotics and systemic steroids in a hospital and then he was afebrile. He had moderate hepatosplenomegaly and right renal mass, bilateral lower limb hypotonia, absent DTR and extensor plantar. Neuroimaging revealed Epidural soft tissue mass from D3–D9 vertebral level significantly compressing the spinal cord with leukemic infiltration in vertebrae and ribs. Bone marrow biopsy and flowcytometry were suggestive of burkitt lymphoma (stage IV). We started on FAB/LMB 96 protocol and he had dramatic complete recovery within 2 weeks of chemotherapy. Need of presentation and discussion: Paravertebral mass presenting with spinal cord compression and neurological deficit is rare in childhood cancer. Early appropriate intervention with corticosteroids and chemotherapy can avoid long term morbidities. The event free survival for Burkitt Lymphoma has improved from 45 % to above 80 % with short course mulitagent chemotherapy.
Dr. Parth Patel Cims Hospital Follicular lymphoma comprises about 20–25 % of cases of nonHodgkin lymphomas. Patients with follicular lymphoma typically present withsuperficial lymphadenopathy as well as rarely extra nodal involvement. We are presenting a case of 40 years old male patient with generalized lymphadenopathy and massive splenomegaly. Patient was also having leukocytosis with lymphocytosis and bone marrow infiltration by lymphoma cells. As follicular lymphoma is rare to find in a 40 year old as well as here we are able to find and document the typical features of follicular lymphoma.
OR 63 Concordance and Discordance Between FDG PET/CT and Bone Marrow Biopsy in Lymphoma Patients: A Single Center Retrospective Study Dr. M. Lakshmi Srinivas, Dr. G. Sadashivudu, Dr. K. Krishnamani, Dr. Ravi Shankar, Dr. Ranga Raman Nims
OR 61 Clinicopathologic Analysis and Immunoprofile of Anaplastic Large Cell Lymphoma: An Institutional Experience Faiq Ahmed, Manasi S. Mundada, Rachna Khera, Sudha Murthy S., Suseela K. Basavatarakam Indo-American Cancer Hospital and Research Institute Introduction: Anaplastic large cell lymphoma is a type of mature T cell lymphoma characterized by presence of hallmark cells which are CD30 positive. Subtypes include ALK positive and ALK negative, and recognition of this lymphoma is important as it has various clinical and morphologic mimics. Need for study: Anaplastic large cell lymphoma (ALCL) is a rare aggressive non-Hodgkin’s lymphoma. Our objective was to analyze clinical presentation, morphology & immunohistochemical features. Material and Methods: Cases diagnosed as ALCL from January 2009 to July 2015 were analyzed from files of lab medicine BIACH&RI. H&E and IHC profile of the cases where reviewed. The antibody panel included LCA, CD3, CD5, CD20, CD30, CD15, PAX5, ALK-1, EMA, PCK. Results: They were 45 cases of ALCL. The age range was from 5 yrs–65 yrs. Mean age of presentation was 35 yrs. Male to female ratio
Introduction: Bone marrow biopsy (BMB) forms an important part in the staging work up of lymphoma. With the advent of (18F) flourodeoxyglucose (FDG)—positron emission tomography (PET)/computed tomography (CT) scan bone marrow involvement has been increasingly seen, thus questioning the role of an invasive procedure like BMB in staging. Need for Study: The main aim is to study the concordance and discordance between BMB and FDG PET/CT in lymphoma patients. Materials and Methods: This is a retrospective study. Patients who underwent both BMB and FDG PET/CT between January 2011 to June 2015 were selected. Results: Total 110 patients were analysed. 34 were Hodgkin’s lymphoma and 76 were Non Hodgkin’s lymphoma. The median age is 46 years. In 93/110 patients (84.54 %) there is concordance between PET CT and BMB. In 17/110 patients (15.46 %) there is discordance between PET CT and BMB. The sensitivity, specificity, PPV, NPV of FDG PET/CT for the detection of BMI in High grade NHL is 50 %, 93.10 %, 60 %, 90 % respectively. The sensitivity, specificity, PPV, NPV of FDG PET/CT for the detection of BMI in HL is 100 %, 96.77 %, 75 %, 100 % respectively. Conclusion: FDG PET/CT can replace BMB in Hodgkin’s lymphoma patients. But for Non-Hodgkin’s lymphomas FDG PET/CT can’t obviate the need for BMB for proper staging work up. Keywords (18F) flourodeoxyglucose (FDG)—positron emission tomography (PET)/computed tomography (CT) scan, Bone marrow biopsy (BMB), Non-Hodgkin’s lymphoma, Hodgkin’s lymphoma
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Indian J Hematol Blood Transfus OR 64 Dose-Adjusted R-Epoch Chemotherapy in High Grade B Cell Non-Hodgkin’S Lymphomas-Experience from India Harsh Vardhan Atreya, Prasanth Ganesan, Tg Sagar, Ts Ganesan, Venkatraman Radhakrishnan, Rejiv R. Cancer Institute, Wia, Adyar Introduction: Recent reports suggest very high survival with the combination of rituximab infusional chemotherapy (DA-REPOCH). We report on our experience with this regimen in high grade B cell lymphomas in immunocompetent patients. Methods: Till date, 23 patients have received chemotherapy consisting of etoposide (50 mg/m2), vincristine (0.4 mg/m2), and doxorubicin (10 mg/m2), all given in a continuous infusion on days 1–4. Cyclophosphamide (750 mg/m2) on day 6 as i.v. bolus, prednisone given orally 60 mg/m2 on days 1–6; G-CSF from day 6. Courses repeated every three weeks. Dose escalation in each cycle depending on the toxicities in the previous cycle. Results: Out of the 23 patients, males: 13; median age 48 (24–61) years. Histology: burkitt’s lymphoma 14 (61 %); burkitts-like: 4 (17 %); mediastinal B cell: 4 (17 %) and plasmablastic: 1 (4 %). Fourteen patients have completed therapy and their data is shown here-updated data of all 23 patients will be presented later. Out of 14, 13 achieved complete remission and 1 had progression at the end of therapy. Toxicity: Febrile neutropenia (grade 3 and 4): 8 (57.1 %); peripheral neuropathy (grade 1/2): 6 (42.9 %), mucositis: 4 (28.6 %) (grade 3 mucositis in 1 patient). There are no relapses among the 13 patients who achieved complete remission after a median follow up of 1 year (1 year OS: 92 %). Conclusion: DAR-EPOCH yields excellent results in high grade B cell lymphomas at the cost of increased toxicity. It is feasible to deliver this regimen in Indian patients.
OR 65 Hairy Cell Leukemia YH-A-L Hairy Cell Leukemia, Dr. V. Dinu Satheesh, Dr. J. Latha Fathima, Dr. S. Sitalakshmi
Pancytopenia was the most common hematological finding (70 %). The presence of lymphadenopathy, absence of palpable splenomegaly and association with autoimmune hemolytic anaemia were a few uncommon findings. Keywords Hairy cell, Leukemia, Splenomegaly, Pancytopenia
OR 66 Plasmablastic Lymphoma of the Gastrointestinal Tract: A Rare Entity with a Dismal Prognosis Rudresh Ah, Kc Lakshmaiah, Rekha V. Kumar, Loknatha D., Govind Babu Kidwai Memorial Institute of Oncology Introduction: Plasmablastic lymphoma (PBL) is a rare and aggressive type of mature B-cell lymphoma, which is usually associated with HIV infection. The most common site of PBL is the oral cavity. Involvement of the gastrointestinal tract is rare and literature is limited to few case reports and case series. Aims: To retrospectively analyze the presentation, clinical findings and outcome of patients presenting to our institute with a diagnosis of plasmablastic lymphoma involving the GI tract. Materials and Methods: A retrospective observational study was conducted at our institute from February 2008 to January 2015 on consecutive patients presenting with plasmablastic lymphoma involving the GI tract. The data was compared to various case reports and series published in peer-reviewed journals. Results: There were four patients diagnosed with plasmablastic lymphoma of the GI tract; three male and one female. The location of involvement were in the stomach, ileo-caecal junction, ascending colon and rectum. Only one patient was HIV positive and was on combination anti-retroviral therapy since 2 years. Among the three immunocompetent patients, only one survived with therapy; however, the patient relapsed within 6 months of completion of treatment. Conclusion: Plasmablastic lymphoma was seen to have a uniformly aggressive clinical course with poor outcomes even with optimal treatment. The prognosis of immunocompetent patients appears to be worse than that of HIV-AIDS patients. Although the most common histologies seen with GI lymphomas are MALT lymphomas or DLBCL, rarer and more aggressive histologies like plasmablastic lymphoma need to be kept in mind.
St Johns Academy of Health Sciences Introduction: Hairy cell leukemia (HCL) is a rare, low grade, B-cell neoplasm with a distictive morphologic, cytochemical and immunophenotypical characteristics. The identification of the characteristic hairy cell remains the hallmark feature. It needs to be differentiated from other chronic lymphoproliferative disorders because of the different treatment protocol and clinical course. Aims: 1. To study the hematological features of HCL cases. 2. To evaluate the clinical profile of HCL cases. Materials and Methods: The study included 10 cases diagnosed over eight years (2007–2015). Clinical presentation, examination findings and complete blood counts were obtained. Review of the bone marrow aspirates, imprint smears, trephine biopsies and flow cytometry was done. Treatment and followup details were noted. Results: This study showed 10 cases, age ranging from 42 years to 59 years, with a male predominance (M:F = 7:3). Splenomegaly (8/10) was a consistent clinical examination finding. The most common hematological finding was pancytopenia (7/10). 3 patients showed bicytopenia.2 patients developed pleural effusions and one had a co-existent autoimmune hemolytic anaemia. Dry tap was observed in 3 cases. Hairy cells were picked up in the peripheral smear in 2 cases and in the marrow aspirates in 3 cases. In the remaining 5 cases, trephine biopsy clinched the diagnosis. Conclusions: Splenomegaly was present in 80 % cases.
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OR 67 Impact of Generic Rituximab on Outcomes of Diffuse Large B Cell Lymphoma: Experience from Cancer Institute Rejiv Rajendranath, Trivadi S. Ganesan, Venkatraman Radhakrishnan, Sumant Gupta, Shirley Sundersingh Cancer Institute (Wia) Introduction: Rituximab (R)-CHOP improves survival over CHOP in diffuse large B cell lymphoma (DLBCL). Use of R-CHOP was initially limited due high cost of innovator R. However, since 2007, generic rituximab (REDITUX , Dr Reddy’s Laboratories) is available in India which has reduced the costand increased accessibility. Methods: We retrospectively analysed the outcomes of adult (age 15–60 years) DLBCL treated at our center with CHOP/RCHOP chemotherapy. Baseline features, type of chemotherapy and monoclonal antibody and survival outcomes were analysed. The use of rituximab was predominantly dictated by cost issues. Results: In the period 2000–2013, 444 patients [median age 47 years: 15–60; males:
Indian J Hematol Blood Transfus 288 (65 %); stage III/IV: 224 (50 %)] received either CHOP (N = 325,73 %) or RCHOP (N = 119, 27 %) therapy. The innovator brand and generic brand were used in 95 (80 %) and 24 (20 %) patients respectively. After a median follow up of 46 (0.2–126) months, the 5 year event free and overall survival of the entire cohort was 59 % and 68 % respectively. Age [ 40 years, higher stage, lower hemoglobin, high LDH, higher aaIPI score, non-use of rituximab and non-use of radiation were the factors which predicted poorer outcomes in univariate analysis. Use of rituximab, use of radiation, and aaIPI were prognostic in multivariate analysis. Subgroup analysis showed that addition of rituximab benefited all aaIPI risk categrories. Conclusion: Availability of generic rituximab has greatly improved the accessibility and has subsequently improved the survival in DLBCL in Indian patients.
OR 68 Flowcytometric Immunophenotyping of B-Cell Lymphoproliferative Disorders and Their Correlation with Clinico-Hematological Profile Vijay Kumar, Gurdeep Buxi, Sadhna Marwah, As Nigam
steadily increasing and several parameters predictive of outcome are being evaluated. Materials and Methods: A retrospective and prospective analysis was conducted on all patients diagnosed and managed as Non-Hodgkin Lymphoma in the Department of Haematology, NRS Medical College & Hospital, Kolkata, from 2010–2015. Patient records were reviewed for staging investigations and therapy provided. All patients underwent initial staging according to Ann Arbor staging and IPI was applied. CR, OS and PFS were calculated. Results: Out of 85 patients diagnosed as Lymphoma, 67 (77.9 %) were of NHL with median age-43 years (age range: 4–84 yr). Among the NHL, most common was diffuse large B-cell lymphoma (85.8 %). Male to female ratio was 3:1. According to IPI, 22.5 % patients had low grade lymphomas, while 78 % had intermediate and high grade lymphomas. B-symptoms were present in 51.4 %, 3 patients had extra-nodal involvement and 40 % had bone marrow involvement. Majority patients had ECOG 2–3. The most common chemotherapy regimen used was R-CHOP, with a minimum of 6 cycles given. Sixty patients were evaluable for response, of which 32.5 % achieved CR after 4 cycles and 38 % after 6 cycles. Partial response was achieved in 25.5 % patients. Response was maintained at a median follow-up of 2 years. Conclusion: DLBCL was the commonest NHL diagnosed in our setting and after 6 cycles R-CHOP chemotherapy overall response of 55.8 % was achieved and maintained till 2 years. Keywords Non hodgkin lymphoma, DLBCL, R-CHOP
Pgimer, Dr. Rml Hospital, New Delhi Introduction: Multiparameter flow cytometric immunophenotyping has become a powerful tool for ascertaining the ontogeny in B-cell lymphoproliferative disorders by virtue of its high throughput, low turnaround time and feasible logistics. A diagnosis often poses numerous challenges. Materials and Methods: This retrospective analysis was carried out in the Department of Pathology, PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi over a period of approximately one and a half years (Jan 2014 to June 2015) and included 50 cases. Clinical presentation, peripheral blood counts and picture and flowcytometric analysis was carried out for every case and correlated with bone marrow examination. FNAC and histopathology correlation was made along with a panel of IHC wherever available. Results: Of the 50 cases that were analysed, 84 % (42 patients) with CLL/SLL. Other diagnostic categories include prolymphocytic leukemia (2 cases), mantle cell lymphoma (2 cases), diffuse large B-cell lymphoma (2 cases) and hairy cell leukemia (2 cases). CD 22, FMC 7 and CD79b were most important prognostic markers. Discussion: Flowcytometry scoring and pattern recognition recommendations have been developed to diagnose CLL and distinguish it from other lymphoproliferative disorders. Immunophenotyping of lymph node aspirates further aides in characterising patients with exclusive nodal disease or spill over in peripheral blood. Conclusion: A careful analysis of basic panel on flowcytometry in conjunction with clinical picture and ancillary investigations provides rapid and accurate diagnosis, prognosis of CLPDs.
OR 69 Clinicopathological Profile and Outcome of Non-Hodgkin Lymphoma Patients: Data from a Tertiary Care Hospital Tk Dolai, Pk Mandal, Rajib De, B. Bagchi, S. Dutta Nrs Medical College & Hospital, Kolkata Introduction: Non-Hodgkins lymphoma is one of the most common haematological malignancies in India. Incidence rates have been
OR 70 Hairy Cell Leukemia—Clinical Profile and Treatment Outcome from a Tertiary Regional Cancer Institute in South India Dr. Linu Jacob Abraham, Dr. K C Lakshmaiah, Dr. K Govind Babu, Dr. D Lokanatha, Dr Shankaranand S Bharatnur Kidwai Memorial Institute of Oncology Hairy cell leukemia (HCL) is an indolent neoplasm of small mature B lymphoid cells. It is characterized by pancytopenia, splenomegaly, bone marrow fibrosis and presence of atypical lymphoid cells with hairy projections in peripheral blood, bone marrow and spleen. HCL is potentially curable and treatment with purine analog cladribine induces complete remission (85 %). This is a retrospective analysis of HCL cases diagnosed in the Department of Medical Oncology at a tertiary regional cancer institute, South India, over 7 years. The clinical features, laboratory parameters, bone marrow findings, cytochemistry, immunophenotyping with treatment were studied. A total of 10 cases diagnosed as HCL and treated with cladribine achieved remission. Median follow-up was 61 months. In Conclusion: HCL is a chronic lymphoproliferative neoplasm with potentially curative treatment. Cladribine is treatment of choice and majority of patients achieve long-lasting complete remission. Upon relapse, these patients can be successfully salvaged with cladribine retreatment.
OR 71 Primary Diagnosis of Hodgkin Lymphoma on Bone Marrow Biopsies-A Case Series from a Tertiary Care Hospital in South India T. Roshni Paul, Shantveer G. Uppin, Megha S. Uppin, Amvr Narender, Y. S. Raju, G. Sadashivudu Nims
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Indian J Hematol Blood Transfus Introduction: Bone marrow involvement occurs in stage IV Hodgkin lymphoma (HL). Occasionally, the primary diagnosis of HL has to be made on trephine sections, when there is no lymph node available for biopsy. Need for Study: To study the clinico-pathologic profile of patients diagnosed on trephine sections and difficulties encountered in diagnosis. Materials and Methods: This was a retrospective study of 4 years duration. Cases where the primary diagnosis of HL was made on marrow morphology, followed by IHC, were included in the study. The clinical details were obtained from the patient’s records. Peripheral smears, marrow cytology and trephine sections stained with routine stains and IHC panel were reviewed. Results: There were 20 patients of HL, diagnosed first on trephine biopsies. The ages ranged from 17–75 years (median age-39). M: F ratio was 3:1. Three patients were HIV positive. Common presentations were fever, loss of weight, appetite and anemia. All 20 patients had some form of cytopenia. Nine patients had palpable lymphadenopathy and 6 others were found to have abdominal or mediastinal lymphadenopathy. Marrow studies were done for cytopenias Biopsies revealed mononucleate/binucleate RS cells in the appropriate milieu. IHC with CD 30 was positive in 4/15 biopsies. Seven patients had lymph node biopsies diagnosed as HL later. Two cases were negative for CD 30 in trephine but positive in lymph nodes. Conclusion: The diagnosis of HL on trephine sections, without a nodal biopsy, is challenging. A thorough search for lymphadenopathy and organomegaly is required. Most of the patients presented with fever, loss of weight and cytopenias. Keywords Hodgkin lymphoma, Trephine biopsy, IHC with CD 30
Keywords MF, TCR gene rearrangements
Topic: Miscellaneous OR 73 Pancytopenia-Clinicohematological Evaluation, A Tertiary Centre Study
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Dr. Sunita Singh, Dr. Rajnish Kalra, Dr. Veena Gupta, Dr. Monika Gupta, Dr. Promil Jain
Mycosis Fungoides: Histopathologic Features and T-Cell Receptor Gene Rearrangements in Patients from South India
Pt. B.D. Sharma Pgims Rohtak
Rajalakshmi Tirumalae, Jyothi S. Prabhu, Radhika Aiyappa St John’S Medical College, Bangalore Introduction: Mycosis Fungoides (MF) is the commonest cutaneous T-cell lymphoma. MF presents in three stages i.e. the patch, plaque and tumor. The distinction of patch-stage MF from inflammatory dermatoses is a diagnostic challenge. Need for the Study: MF shows T-cell receptor gene rearrangements (TCRG and TCRB), detectable by polymerase chain reaction. Data about the clonality of infiltrates in our population and their utility in diagnosis is lacking. Materials and Methods: Skin biopsies from 50 patients with Mycosis Fungoides from Jan 2007 to July 2015 were studied for microscopic features. TCR Gamma and Beta gene rearrangement assays were performed on 14 patients where FFPE was available. DNA was extracted using phenol chloroform method. PCR was performed using primers from Invivoscribe Identiclone assay. Clonality was analysed using agarose gel electrophoresis. Results: Of the 50 cases, 37 were patch, 9 were plaque and 4 were tumor stage. All cases showed disproportionate lymphocyte epidermotropism, 38 showed lymphocyte atypia, 33 showed adnexotropism (11 eccrotropism and 22 folliculotropism). Clonality was assessed in 14 cases. Of these, 3/9 patch stage were monoclonal (1/3 monoclonal for beta, and 2/3 monoclonal for gamma and beta). 3/3 plaque stage MF were monoclonal (1/3 for gamma, 2/3 for both), 1/2 tumor stage MF was monoclonal for gamma and beta receptors. Conclusion: Patch stage was the most common presentation. TCR gene rearrangements were noted in 50 % of MF, with TCR gamma rearrangements being more common. Plaque and tumor stages yielded higher positive rates.
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Introduction: Pancytopenia is characterized by reduction in all the three cellular elements of blood leading to anaemia, leucopenia and thrombocytopenia. It exists when Hb \ 10gm/dl, TLC \ 3500/ mm3 and platelet \ 1lakh/mm3. It is a clinicopathological entity with wide spectrum of etiology resulting from numerous disease processes affecting bone marrow primarily or secondarily. Need for Study 1. To evaluate spectrum of pancytopenia and its correlation with hematological and bone marrow findings. 2. Etiological analysis of various biochemical parameters. 3. Incidence of pancytopenia in defined population. Materials and Methods: It was a retrospective study conducted in the Department of Pathology of PGIMS, Rohtak, a tertiary care hospital, over a period of one year (January 2014-December 2014). Total 175 cases of both the sexes having pancytopenia were included. Correlation of hematological investigations, including bone marrow and relevant biochemical investigations wherever available was performed. Results: Out of total 175 cases, most common age of presentation was 15–45 years. Most of the patients presented with generalized weakness and fever. Male:female ratio was 1.4:1. Pallor, hepatosplenomegaly followed by bleeding was the most common clinical presentation. The most common bone marrow finding in patients of pancytopenia was hypercellular marrow with megaloblastic change seen in 47 % of cases. Vitamin B12 and folate level were found to be low in more than 50 % cases of megaloblastic anaemia whereas normal in cases of leukemia/lymphoma. Conclusion: Detailed clinical history, physical examination along with basic hematological investigations followed by bone marrow aspiration, are important for diagnosis and treatment of pancytopenia.
Indian J Hematol Blood Transfus OR 74 Bone Marrow Changes in Bicytopenia: A Clinically Relevant Insight
features such as the increased no. of plasma cells, histiocytes and hemophagocytosis in bone marrow. To the best of our knowledge, increased no. of plasma cells up to 31 % has not been reported in literature till date.
Dr. Bhagyashree Hungund Jawaharlal Nehru Medical College, Belgavi, Karnataka Introduction: Bicytopenia is the reduction of any of the two cell lines of blood i.e. red blood cells, platelets or white blood cells. The etiology can range from transient marrow viral suppression to lifethreatening malignancies. Bicytopenia can be an early indicator for many diseases. Need for study Many studies have been done on pancytopenias but there are very few on bicytopenias. This study was carried out to evaluate the bone marrow changes in patients of different age groups, presenting with bicytopenia. Materials and Methods: Around 400 bone marrow trephines and aspirations are performed at our centre every year out of which all the cases of bicytopenia (89) were selected and studied. The aspiration and trephine were performed using the standard protocol from the posterior superior iliac spine. Clinical correlation was done. Results: The Male:Female ratio was 1.2:1. The average age of presentation was 31.7 yrs. The most common bicytopenia was anemia with thrombocytopenia (79.7 %). Most predominant bone marrow picture was megaloblastic hypercellular marrow (22.4 %), followed by normoblastic hypercellular marrow (7.8 %), micronormoblastic hypercellular marrow (6.7 %), hypoplastic marrow (4.4 %) and bone marrow fibrosis (1.1 %). The specific diagnoses were Acute lymphoid leukemia (10.1 %), Acute Myeloid Leukemia (15.7 %), Chronic lymphoid leukemia (1.1 %), Multiple Myeloma (2.2 %), ITP (6.7 %) and bone marrow tuberculosis (1.1 %). Conclusions: Evaluating bicytopenia as an early indicator for specific diseases can have an impact on the mortality and morbidity in vulnerable patients. Bone marrow studies can help in early detection and prompt treatment. Keywords Bone marrow study, Bicytopenia, Leukemia
OR 75 Morphological Spectrum of Bone Marrow Findings in Aplastic Anemia in a Tertiary Care Hospital
OR 76 Left Ventricular Dysfunction by Strain Echocardiography in Thalassemia Patients Dr. P. G. Kerkar, Dr. Dhiraj Kumar, Dr. C. P. Langewar, Dr. Hetan Shah, Dr. Milind Phadke Seth G.S Medical College, K.E.M Hospital Mumbai Introduction: Thalassemia or Mediterranean anemia being the most common single gene disorder which needs repeated transfusions leading to iron deposition in various tissues of bodies most notably myocardium leading to progressive left ventricular systolic dysfunction and later on death. Therefore newer sensitive echo modalities like strain imaging can detect LV dysfunction much earlier than conventional methods and lead to more intense chelation therapy. Inclusion Criteria: Children and adults suffering from Thalassemia more than 8 years of age with normal LV function who have received more than 10–20 units of blood transfusion Exclusion Criteria: Patients with Rheumatic heart disease, Congenital Heart disease, primary cardiomyopathy, pregnant population Sample Size = 45 Machine Used: GE Vivid T8 Methods: 45 patients satisfying the inclusion criteria will be recruited in the cross sectional observational study. Their echos will be done taking both conventional parameters and tissue Doppler and LV strain using speckle tracking. Results: Conventional echocardiographic examinations revealed that betathalassemia patients had larger left ventricular end-systolic diameter, end-diastolic and end-systolic volume, left ventricular mass index, and mitral early/late diastolic flow velocity ratio (p \ 0.05). Strain and strain rate imaging study of the basal lateral wall of the left ventricle was higher in patients who received more than 80 transfusions than those who received lesser transfusions at p = 0.035 and p = 0.008, respectively Conclusions: We found that systolic strain index and strain rate imaging of the left ventricle indicated the presence of early LV systolic dysfunction in those with more number of transfusions ([80).
Simranjeet Kaur, Anita Tahlan, Manveen Kaur, Monica Gupta Government Medical Colloge and Hospital, Sector 32, Chandigarh Introduction: Aplastic anaemia (AA) is a life threatening bone marrow failure disorder. However, there is a paucity of studies in the literature discussing its clinico-morphologic spectrum. Materials and Methods: This is a retrospective study of clinico-morphologic spectrum in 119 patients diagnosed as aplastic anemia in GMCH, Chandigarh over 11 year period (2004–2015). Results: The mean age at presentation was 26.4 years, with maximum number (35.29 %) being in the second decade of life. Inherited bone marrow failure syndromes constituted 0.008 % of all AA patients. Pancytopenia was present in 117 patients and bicytopenia in 2. All the cases had a reticulocyte count less than 1 %. Bone marrow was hypocellular in all the patients, with NE:E ratio ranging from 3.5–50:1. No. of cases in the very severe, severe and non severe categories were 36 (30.25 %), 27 (22.69 %), 56 (47.06 %) respectively. Features of dyserythropoeisis were seen in 53 cases. Lymphocyte count ranged from 42 to 86 %. Increased plasma cells ([4 %) were found in 44 cases, with maximum no. being 31 %. Additional findings included increase in no. of mast cells and histiocytes in 34 and 44 cases respectively. Haemophagocytosis was reported in 10 cases (8-Grade 1, 2-Grade 2). 80 (67.2 %) patients had increased iron stores. Lymphoid aggregates were present in 15 patients. Conclusion: This study highlights
OR 77 Morphological Spectrum of Bone Marrow Aspirates in Infections Dr. Mrinalini Kotru, Dr. Meera Sikka University College of Medical Sciences Introduction: Various infectious diseases can result in morphologic changes in bone marrow. Careful examination of bone marrow aspirates for such indicators is necessary to suspect an infectious disease process. Materials and Methods: Retrospective analysis of all bone marrow aspirates from August 2011 to August 2015 was done. Morphologic details of the 52 cases with infections were further analysed. Results: Parasites like Leishmania donovani, microfilaria, plasmodium falciparum and vivax were reported in 14/52 (27 %) cases. Associated findings were plasmacytosis, eosinophilia, reactive lymphocytosis or leucoerythroblastic picture on peripheral smear. Viral infections (12/52) were suspected in cases which showed reactive lymphocytes in peripheral smear, presence of nuclear inclusions in proerythroblasts or increased lymphocytes (4–60 %) in bone marrow. Tuberculosis (6/52) was associated with presence of epithelioid cell granulomas, 3–20 % plasma cells, reactive
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Indian J Hematol Blood Transfus lymphocytes, monocytosis or trilineage dysplasia. In 38 % (20/52) cases, no specific cause of infection was found in bone marrow. These patients showed increased number of histiocytes, hemophagocytosis, maturation arrest in myeloid lineage, relative myeloid hyperplasia, dysmyelopoiesis, toxic granulation or vacuolation in myeloid cells, lymphocytosis, increased plasma cells or monocytosis in marrow. Conclusion: Increased histiocytes, hemophagocytosis, dysplastic changes, maturation arrest, relative myeloid hyperplasia or reactive plasmacytosis, lymphocytosis, monocytosis, are bone marrow aspirate features which must alert the pathologist towards an infectious disease process. A knowledge of these changes and careful examination of each smear can help extend the scope of marrow examination beyond hematolymphoid malignancies.
Low Cost Innovations in Supportive Care in Children Undergoing High Dose Chemotherapy
Severe AA vs. very severe AA was 10:19. Chromosomal breakage studies were negative in all. Flowcytometry for PNH was positive in 4/13 evaluated. One child each was positive for CMV, HAV and Varicella. Patients received equine ATG (40 mg/kg/day, 4 days) and cyclosporine to maintain serum levels: 150–300 ng/ml. Results: Median symptom to therapy interval (STI) was 79 days (30–280); follow up duration: 29 months. Outcomes: 7 (24 %) in complete remission[CR], 12 (42 %) in partial response[PR], 7 (24 %): no response[NR] and 3 (10 %) died within 6 months of therapy PR was noted in at 6 months in; Ten of SAA & 10/19 of VSAA had response. Five year OS was 70 % and EFS was 56 %. Conclusion: OS & EFS was higher in children with SAA vs. vSAA: OS of 100 % vs. 56.33 % (P = 0.0399); EFS of 66.7 % vs. 41.35 % (P = 0.026). There was no correlation of STI with poor response. One child relapsed & 1 developed AML at 5 & 6.5 years post-therapy. Literature has shown response to vary between 40–88 %. A collaborative study would give a comprehensive overview of childhood acquired AA in our country. Keywords Aplastic anemia, Antithymocyte Globulin, Children, Cyclosporine
Dr. R Sreejith, Dr. Atish Bakane, Dr. Ramya Uppuluri, Dr. Hemalatha Doss, Dr. Revathi Raj
OR 80
OR 78
Apollo Hospital Background: Low cost innovations in supportive care result in improved outcomes in children undergoing cancer chemotherapy. Methods: Our study included children from 0 to 18 years of age treated for malignancy at our centre from 2002 to 2014. Their outcomes in terms of rates of sepsis, mortality and durable remission rates were analyzed. Results: The first intervention was with respect to neutropenic diet based on the fact that translocation of gut bacteria resulted in systemic sepsis. Neutropenic children were put on a strict diet program including double boiled rice, vegetables, pulses, yogurt and lactose free milk supplements. This intervention has decreased the infection rates from 22 % to 8 %. The second intervention was related to central line associated blood stream infections (CLASBI). Biopatch placed over central line entry site has decreased rates of CLASBI by 32 %. The cost of the biopatch is 500 Indian rupees, while the cost incurred on average for treatment of CLASBI amounts to over 12,000 Indian rupees a day. The third intervention was related to the universal use of Peg Asparaginase for all children with acute lymphoblastic leukaemia. Two or three children shared the cost of each vial (Rs 120,000), ensuring availability of this expensive yet highly efficacious chemotherapeutic drug to all children irrespective of their economic condition. Conclusion: Effective use of simple low cost innovations in supportive care of our children helped reduce rates of hospital acquired infections and ensured equitable treatment for all children with improved survival.
OR 79 Acquired Aplastic Anemia: Outcome with Immunosuppressive Therapy in Children
Hemophagocytic Lymphohistiocytosis in Chediak Higashi Syndrome Annapoorani Annamalai, Nisha S Iyer, Kasi Viswanathan, Somasundaram Jayabose Meenakshi Mission Hospital and Research Center Introduction: Chediak-Higashi syndrome (CHS) is a rare autosomal recessive disorder with immunodeficiency, partial oculocutaneous albinism and bleeding diathesis. Approximately 85 % of affected individuals develop life threatening accelerated phase, Hemophagocytic lymphohistiocytosis (HLH). Allogenic hematopoietic stem cell transplantation (HSCT) is the curative treatment option. Case Presentation: Ten year old identical female twin siblings born of consanguineous parents with albinism and hypergranular neutrophils which were clinically suggestive of CHS presented with prolonged fever and hepatosplenomegaly in varying time periods. Second child also had focal neurological deficit at presentation. Laboratory investigations were suggestive of HLH. They are currently in remission with HLH 2004 protocol, with the first child three years off chemotherapy. They are not HLA matched with parents and planned for matched unrelated donor search. Need of Presentation and Discussion: Encountering CHS in clinical practice is rare. We have described CHS with HLH surviving without HSCT. No patient with familial HLH is alive without HSCT. The relatively benign nature of the disease in our case could explain a mutation with partially functioning protein in the family. This might initiate molecular characterization of CHS to identify subgroup of patients with benign spectrum of illness, avoid more toxic treatment regimen and unveil ideal candidates for HSCT. Keywords Chediak Higashi syndrome, familial Hemophagocytic Lymphohistiocytosis
Amita Trehan, Deepak Bansal, Neelam Varma Postgraduate Institute of Medical Education and Research Introduction: Immunosuppressive therapy [IST] and stem cell transplantation have improved outcomes in children with acquired aplastic anemia [AA], with 10 year survival rates upto70 %. We assessed response of IST [equine antithymocytic globulin & cyclosporine] in children with AA. Methods: Twenty-nine children, mean age 110 months (20–150 months) received IST between January 2008 and June 2014. Diagnosis of AA was confirmed by bone marrow biopsy.
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OR 81 Outcome of Immunosuppressive Therapy in Patients with Acquired Aplastic Anemia: Experience from a Tertiary Care Hospital in North India Prof. Soniya Nityanand Sanjay Gandhi Postgraduate Institute of Medical Science
Indian J Hematol Blood Transfus We have prospectively evaluated overall response, survival and factors predicting survival after immunosuppressive therapy (IST) consisting of anti-thymocyte globulin (ATG) and cyclosporine (CSA) in patients with acquired aplastic anemia (AA). Fifty-eight patients diagnosed as having acquired AA between 1 July 2012 and 31 December 2014, were included in the study. Equine ATG (eATG) followed by CSA was administered to all patients for 15–18 months as the initial treatment. Hematological response was assessed 3 months after ATG administration and 3-monthly thereafter. Platelets were transfused if their levels were \10 9 103/L and for symptomatic bleeding. Transfusions of red blood cells were given for hemoglobin levels \70 g/L or symptomatic anemia. Febrile neutropenia was managed with antibiotics and antifungal agents after 3–4 days of unresponsive fever. We observed an overall response at 6 months after initiation of IST to be 53.44 % (31/58) and an overall survival at 12 months follow-up after IST to be 72.41 %. Two patients relapsed and 16 non-responder patients died during follow up. In addition, there were 2 deaths or adverse events among non responders after follow-up period of 12 months. Our study shows an overall survival was 72.41 % at a median follow-up of 12 months and the variables that significantly affected overall survival were time from diagnosis to ATG therapy, response to therapy at 6 months and occurrence of infectious complications.
OR 82 Comparison of Differential Leucocyte Count by Automated Hematology Analyzer Versus Manual Counts at District Hospital Level Rajeev Sen, Monika Gupta, Arushi Singh, Abhinav Civil Hospital, Rohtak Introduction: Automated hematology analyzers with ability to differentiate white blood cells usually provide quick and accurate results. However, false results in differential leucocyte count (DLC) related either to platelets or other parameters may be observed in several instances. Also, despite the sophistication of these instruments there is still need for manual techniques for primary calibration. The present study is conducted to determine the relationship between 3-part hematology analyzer DLC and manual count. Materials and Methods: This prospective study was conducted in hematology lab of district hospital, Rohtak, Haryana. Venous blood samples (3 ml) collected aseptically from 1000 consecutive patients in EDTA vacutainers were run on the 3-part hematology analyzer (Sysmex KX21). Peripheral blood smears were prepared from samples with increased mixed cells fraction, stained with Leishman’s stain. Manual DLC was done by clinical pathologist. Observations DLC by analyzer showed flagging for mixed cell fraction in 242 (24.2 %) samples. These findings were correlated with microscopy. In 92 (9.2 %) samples, mixed cells were increased. In 112 (11.2 %) samples immature granulocytes were counted as mixed cells while in 38 (3.8 %) samples activated lymphocytes were reported with mixed fraction. Importantly, identification of blasts, activated lymphocytes and Plasmodium vivax could be done on microscopic examination only. Conclusion: In present study 24.2 % sample showed flagging in mixed cell fraction. This high percentage is probably be due to inability of the machine to indentify or differentiate immature granulocytes and activated lymphocyte which is validated by microscopic examination. Keywords Automated hematology analyser, Differential leucocyte count
OR 83 Pre-Analytical Errors in Laboratory Mahatma Gandhi Mission Institute of Health Sciences Laboratory testing is a highly multifarious process. For a sample to be processed and reported accurately in a laboratory, it has to undergo through the pre-examination, examination and post-examination phases. During each of these steps, are the chances for occurrence of an error which can alter the test result and therefore has to be monitored at various check points. The pre-examination phase accounts for about 68 % of the errors, while the examination and post-examination phases constitute about 13 % and 19 % respectively. Hence, it is mandatory for a laboratory to keep regular check points in order to keep these pre-examination errors to the minimum. We, therefore conducted a surprise internal audit at our Central Clinical Laboratory, MGM Medical College & Hospital on 8th & 9th of April, 2015 to study the frequency and evaluate for pre-examination errors.
OR 84 Haematological Changes Associated with Paclitaxel Based Regimens in Solid Organ Adenocarcinomas D. Sumanth Father Muller Medical College Introduction: Paclitaxel promotes microtubulin formation, causes arrest in mitosis and initiates apoptosis and now forms a central component in the chemotherapeutic regimens for adenocarcinomas of solid organs. Need for the study: As a result of commonly association with neutropenia, paclitaxel is used in combination with granulocyte colony stimulating factor. Peripheral neuropathy forms the dose limiting effect of the drug. However, the effect on other hematopoietic cell lines is not well established. Our aim was to identify the changes seen post paclitaxel therapy on the various haematological parameters. Materials and Methods: The pre and post chemotherapy haematological parameters of 74 cases (27–88 years of age) of adenocarcinomas of the ovary, uterus, lung and gastrointestinal tract for a two year period were analysed. Results: Haematological parameter Pre chemotherapy Post chemotherapy Mean haemoglobin 11.6 g/dl 10.57 g/dl Mean packed cell volume 34.36 % 32.97 % Mean total leukocyte count 8850 cells/cumm 8790 cells/cum Mean platelet count 347680 cells/cumm 3005810 cells/cumm 96.8 % showed a reduction in haemoglobin, 94.8 % in platelet count and 41.6 % in total leukocyte count. 32.5 % showed an increase in total leukocyte count and 5.1 % in platelet count. 0.3 % showed no change in haemoglobin and 5 % in total leukocyte count. Conclusion: Hence inspite of the concomitant usage of granulocyte colony stimulating factors, a marked reduction in all three hematopoietic cell lineages was seen.
Haematological parameter Pre chemotherapy Mean haemoglobin
11.6 g/dl
Post chemotherapy 10.57 g/dl
Mean packed cell volume 34.36 %
32.97 %
Mean total leukocyte count
8850 cells/cumm
8790 cells/cum
Mean platelet count
347680 cells/ cumm
3005810 cells/ cumm
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Indian J Hematol Blood Transfus OR 85
OR 86
To Study the Spectrum of Hematological Disorders from Bone Marrow Aspiration Cytology in a Tertiary Care Hospital
Comparison of Serum Ferritin Levels in Type 2 Diabetics Versus Healthy Controls
Dr. Nisha Marwah, Dr. Sunita Singh, Dr. Rajneesh Kalra, Dr. Veena Gupta, Dr. Monika Gupta
Pushpanjali Behera, Gurdeep Buxi, Vijay Kumar, Sadhna Marwah, A.S. Nigam
Pgims, Rohtak
Dr Rml Hospital
Introduction: Hematological disorders are quite frequent in all age groups and have diverse modes of presentation that often require bone marrow aspiration (BMA) for both diagnosis and management. This simple and relatively safe procedure is important particularly in resource poor centres since access to adjuvant diagnostic techniques are often lacking. The present study aims to analyse the causes of haematological disorders, its spectrum, indications and interpretation of BMA findings. Materials and Methods: This is a retrospective and prospective study carried out in department of pathology, PGIMS, Rohtak over a period of 16 months (Jan 14–April 15). BMA of 879 cases of suspected haematological disorders was carried out. All the details of patients were obtained from record files in the department. Results: Majority of the patients were children aged less than 15 years (37 %). Male to female ratio was 1.3:1. The main indications for BMA includes: anemia (37 %), diagnosis of leukemia (30 %) and pancytopenia (9 %). Most of the marrow aspirate examined had definite pathological features (87 %) and 13 % were normal marrow elements. Anemia with erythroid hyperplasia was the most common pathology. The megaloblastic anemia was the most common type followed by microcytic hypochromic anemias. Conclusion: BMA is an important step and veritable tool to arrive at the confirmatory diagnosis of wide range of haematological disorders. Keywords Anemia, Bone marrow aspiration cytology, Megaloblastic anemia, Leukemia
Introduction: Diabetes mellitus refers to a group of metabolic disorders sharing the phenotype of hyperglycaemia. This chronic hyperglycaemia results in metabolic dysregulation which may be associated with secondary damage in multiple organ systems. This metabolic syndrome is closely linked to insulin resistance and iron overload. Serum ferritin is known as an index for body iron stores and also as an inflammatory marker. Materials and Methods: 50 healthy controls and 50 subjects of type2 Diabetes Mellitus were taken. Their serum ferritin levels were compared along with HbA1c levels. Result: The mean serum ferritin level of diabetic cases was significantly higher. 2. Significant increasing trend in serum ferritin levels was observered with increasing HbA1c levels. It indicates that serum ferritin is increased in Diabetes Mellitus, when glycaemic control is not achieved. Conclusion: Serum ferritin levels was significantly higher in type 2 diabetics as compared to normal healthy controls and this correlated well with fasting blood glucose and HbA1c levels.
BMA Diagnosis
No. of cases
Percentage (%)
Normoblastic erythroid hyperplasia
149
17
Megaloblastic anemia
109
13
Acute leukemia
94
11
ITP
35
4
Microcytic hypochromic
113
12
Infective pathology
12
1
MDS
44
5
Multiple myeloma Leishminiasis
14 2
1.5 0.2
Aplastic anemia
37
4.3
Marrow with nosignificant abnormality
116
13
Chronic leukemia
30
3
Hemodiluted smears
57
6
Blood only
79
9
Total
879
100
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OR 87 Hematological Changes in HIV Lt Col S Venkatesan, Brig Vs Nijhawan Armed Forces Medical College, Pune Introduction: Clinically significant hematological abnormalities are amongst the most common manifestations in HIV infected individuals. Impaired hematopoiesis, immune-mediated cytopenias, and altered coagulation mechanisms have all been described in HIV. These abnormalities may occur as a result of HIV infection itself, as sequelae of HIV-related opportunistic infections or malignancies or as a consequence of therapies used for HIV infection and associated conditions. Need for Study: A wide spectrum of hematological manifestations and its clinical implications mandates the need for a thorough hematological assessment of the patient. This study aims to describe the hematological manifestations in HIV. Materials and Methods: A cross sectional descriptive study was carried out in Dept of Pathology, at a tertiary health care centre between June 2014 and July 2015, in 15 symptomatic HIV infected individuals, undergoing bone marrow studies as a part of clinically indicated, routine hematological work up. Results: Range Mean No of patients Peripheral Smear Age (yrs) 19–55 41.5 Hb (gm %) 5.9–11.2 8.33 TLC (cells/ lL) 1540–16500 3570 ANC (cells/lL) 1004–4300 2198 Platelets (cells/lL) 30000–268000 195000 Bone Marrow Normocellular marrow 4/15 M:E ratio 4:1–1:4 2:1 Megaloblastic changes 9/15 Bare Megakaryocytes 4/15 Dyshematopoesis 2/15 Tuberculosis 1/15 Reticulin Fibrosis 2/15 Hemophagocytosis 2/15 Panmyelosis 1/15 Metastatic deposit 1/15 Conclusion: Peripheral blood and bone marrow abnormalities are common in HIV. Anemia of chronic disease and megaloblastic change are the most common changes in HIV infected individuals. Bone marrow examination is an easy and cheap method, which contributes to a comprehensive evaluation in HIV.
Indian J Hematol Blood Transfus
Range
Mean
No of patients
OR 89 Outcome of High Hyperdiploidy in Indian Children with Acute Lymphoblastic Leukemia
Peripheral smear Age (yrs)
19–55
41.5
Hb (gm %)
5.9–11.2
8.33
TLC (cells/lL)
1540–16500
3570
Sir Ganga Ram Hospital
ANC (cells/lL)
1004–4300
2198
Platelets (cells/lL)
30000–268000
195000
4:1–1:4
2:1
Background/Objectives: High hyperdiploid ALL (hHALL) (51–65 chromosomes per cell) is a good risk subgroup that accounts for 25–30 % cases of Pre B ALL. Design/Methods We analyzed the clinical presentation and outcome of children with hHALL diagnosed between 1995 and 2013. Results: Two hundred and eleven children diagnosed pre B ALL with evaluable cytogenetic and follow up data were analyzed. High hyperdiploidy observed in 58 (27 %). Patients with t (9,22) and high hyperdiploidy were excluded. Median age at diagnosis 4 years. High WBC count ([20,000 cells/mL) observed in 19 % hHALL. Median duration of follow up 4 years Chromosome 21 was most commonly affected (60 %) followed by 17, 6, 10, 14, 4, 5 and X. Triple trisomy (+4, +10, +17) was observed in 4 patients. Six patients had additional structural abnormalities. Three children with hHALL relapsed (5.7 %) compared to 13 (8.1 %) in the non-hHALL group. One had isolated CNS and 2 had combined relapses. Six out of 58 hHALL patients had additional cytogenetic abnormalities and had poor outcome compared to those without. No significant difference in EFS (hHDALL 68.2 ± 8.8 % vs. non hHALL 74.3 ± 4.4 %) and OS (78.3 ± 6 % vs 79.8 ± 3.9 %) between the two groups. Conclusion: The prevalence of hHALL and chromosome 21 involvement was similar to previously published literature. Pattern of relapse seems to be different in hHALL although not statistically significant. Additional structural abnormalities reduce the prognostic benefit of hHALL. Keywords High hyperdiploidy chromosome 21 Pre B ALL relapse
Nita Radhakrishnan, Veronique Dinand, Anupam Sachdeva
Bone marrow Normocellular marrow M:E ratio Megaloblastic changes
4/15 9/15
Bare Megakaryocytes
4/15
Dyshematopoesis
2/15
Tuberculosis Reticulin Fibrosis
1/15 2/15
Hemophagocytosis
2/15
Panmyelosis
1/15
Metastatic deposit
1/15
OR 88 Retrospective Study of Role of Bone Marrow Aspiraton and Trephine Biopsy in Cases of Pancytopenia-An Experience in Tata Main Hospital, Jamshedpur Amit Anand, Radhika Narayan, J. Sree Devi, Farah Rana, Minakshi Mishra Tata Main Hospital
OR 90
Introduction: Pancytopenia is described as the reduction in all the three cellular elements of blood leading to anemia, leucopenia and thrombocytopenia. Bone marrow aspiration and biopsy are extremely helpful in evaluation of pancytopenia and planning further management. The present study was carried out to evaluate the role of bone marrow aspiration and biopsy in determining the causes of pancytopenia. Materials and Methods: The present study is a retrospective cross-sectional study carried out at Tata Main Hospital, Jamshedpur over a period of three years (April 2012–March 2015). 220 cases of pancytopenia fulfilling the criteria (i.e. Hemoglobin \10gm/dl, Total Leucocyte Count \4000/cumm, Platelet Count \1,00,000/cumm) were retrieved from files. A total of 218 cases of bone marrow aspiration (BMA) and 158 cases of bone marrow biopsy (BMB) were studied. Findings were analysed to study the role of bone marrow examination in cases of pancytopenia. Results: The maximum cases of pancytopenia were in the age group of 31–40 years with male preponderance. The commonest cause of pancytopenia was megaloblastic anemia (36 %) followed by hypoplastic marrow (22 %) and myelodysplastic syndrome (14 %). Uncommon causes include Acute Leukemia, Multiple myeloma and Infective etiology. 134 out of 158 cases (85 %) showed a positive correlation between BMA and BMB. Conclusion: BMA and BMB are essential for the diagnosis of pancytopenia and both procedures are complimentary to each other and should be performed at single sitting. Megaloblastic anemia is the most common cause of pancytopenia. Keywords Bone marrow examination, Trephine biopsy, Pancytopenia, Megaloblastic anemia
A Rare Case of Still’S Disease with Macrophage Activation Syndrome and DIC D. Kishore, Amita Diwakar, Haramohan Sahoo, Ashutosh Ims Bhu Adult-onset Still’s disease (AOSD) is a systemic inflammatory disorder along with systemic onset juvenile arthritis (SOJA) is considered in same clinical spectrum. SOJA remains a painstakingly difficult to clinically diagnose, largely due to lack of pathognomic features or diagnostic tests, and thus, the diagnosis of still’ disease is often problematic. But it should be considered after several week in the evaluation of undiagnosed fever with rheumatic complaints. We present here a case of young male with features of high spiking, daily fevers, weight loss, evanescent rash, arthritis, splenomegaly, lymphadenopathy, serositis, neutrophilic leukocytosis, increased acute phase proteins and seronegative tests for ANA and RF. Together, with cytopenias (particularly thrombocytopenia), hypertriglyceridemia, and hypofibrinogenemia and excess hepatic enzyme, indicated systemic onset JA based on the Yamaguchi criteria, then the patient developed complications of the disease with altered PT, Aptt and d-dimer levels, suggesting Disseminated intravascular coagulation, which commonly overlap with Macrophage activation syndrome, bone marrow examination showed hemophagocytosis, hence he was diagnosed with systemic onset JA with hemophagocytosis (HLH)and DIC, this condition is caused by hyperactivated T cells (Th1 cells) and macrophages, and overproduction of cytokines such as IL-1, IL-6,
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Indian J Hematol Blood Transfus and IFN-c. These cytokines contribute to the development of thrombotic reactions by activation of vascular endothelial cells and monocytes. MAS is a serious complication of systemic JRA and is associated with considerable morbidity and mortality. Therefore, early recognition and intervention required. We treated patient with prednisolone (1 mg/kg/day).later high dose (5 mg/kg) cyclosporine was added to the treatment. Patient condition improved and was subsequently discharged.
OR 91 Study of Spectrum of Microorganisms & Antimicrobial Susceptibility in Febrile Neutropenic Patients from a Tertiary Care Centre Dr. Prantar Chakraborty, Dr. Tuphan Kanti Dolai, Dr. Shyamali Dutta, Dr. Rajib De, Dr. Prakas Kumar Mandal
women at term admitted for labour were grouped into anemic and non anemic with cut off hemoglobin of 12.5 gms % and 10.9gms %. The UCB of their neonates with normal birth weight and apgar score were collected in K2 EDTA evacuated tubes after cord clamping and processed in Beckman Coulter LH780 for RBC count, Hb, hematocrit and NRBC. Reticulocyte count and NRBC count were done manually. Reticulocyte parameters namely reticulocyte percentage, absolute reticulocyte count, reticulocyte index and reticulocyte production index were calculated. Data was analysed using SPSS IBM software version 19. Results: The reticulocyte parameters were significantly increased in the UCB of neonates born to anemic mothers. But there is no significant increase in NRBC counts. Conclusion: The response of fetal bone marrow to erythropoietin in chronic hypoxia had caused increase reticulocyte parameters in UCB. The NRBC were not significantly increased as the maternal anemia is mild in our study. It is understood maternal anemia has influence on fetal erythropoiesis and it is dependent on hemoglobin level.
Nrs Medical College & Hospital Introduction: Bacterial infections are the major cause of morbidity and mortality among neutropenia patients. The aim was to determine current frequency & spectrum of bacterial infections & antimicrobial susceptibility in febrile neutropenia patients. Materials and Methods: Blood specimens were cultured using aerobic BACTEC Culture method in 135 febrile neutropenia patients. Results: Out of 135 Febrile neutropenic episodes, Culture positive report was obtained in 45 cases (33 %). Overall, 81 % of the organisms were gram negative, 11 % gram positive, and 8 % Fungal spp. The most common microorganism was Klebsiella pneumoniae in 16 cases (35 %), followed by E. Coli in 7 cases (15 %), coagulase positive staphylococci & Pseudomonas aeruginosa in 5 cases (11 %) each, CoNS in 3 cases (6 %), Acinetobacter baumannii in 2 cases (4 %), Candida albicans in 4 cases (8 %), Burkholderia spp. in 2 cases (4 %) & MRSA in 1 case (2 %). Among Gram positive organisms, majority was sensitive to Beta lactams, sulphonamides & glycopeptides. Among Gram negative bacteria, majority was sensitive to carbapenems & polypeptide antibiotics. Conclusion: In our study, 33 % were culture positive cases. Gram-negative bacteria was seen in 81 % cases. Klebsiella Pneumoniae was the most common pathogen in our center (35 %). A glycopeptides & carbapenem is prudent choice in high-risk case. Keywords MRSA—Methicilin Resistant Staphylococcus aureus, CoNS—Coagulase Negative Staphylococcus aureus
OR 92 Comparison of Red Blood Cell Precursors in Umbilical Cord Blood Born to Anemic and Non Anemic Mothers Padipamula Rajesh Kanna, Ananda Kumar, Dr. Bharathi, Dr. Rithika Rejendran, Umalakshmi Sri Ramachandra Medical College and Research Institute Introduction: The influence of maternal anemia on the fetus is assessed by increased RBC precursors in the umbilical cord blood (UCB). This occurs in response to erythropoietin in conditions of hypoxia. The effect of maternal anemia on the fetus has to be studied as it is a common condition and also a preventable one. Materials and Methods: This prospective comparative study was done in the after institutional ethics committee approval.100 booked pregnant
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OR 93 Pancytopenia—A Clinico-Haematological Study Dr. C. Bharath, Dr. K. Jayashree Belgaum Institute of Medical Science Introduction: Pancytopenia is the simultaneous presence of anaemia, leucopenia, and thrombocytopenia. Peripheral pancytopenia may be the manifestation of wide variety of disorders which primarily or secondarily affect bone marrow. Bone marrow failure syndrome and malignancies are serious and life threatening causes but certain non malignant conditions such as infection and nutritional anaemia are equally important. The severity of pancytopenia and underlying pathology determine the implementation of correct management and prognosis. Objective: To evaluate the etiology of pancytopenia in patient from age group 2 to 70 years. To study their clinico-hematological profile. Materials and Methods: A prospective study was conducted from October 2011 to October 2013, in the Department of Pathology, VIMS, Bellary that evaluated 75 patients fulfilling the criteria of pancytopenia (HB \ 9, TLC \ 4000, PLT \ 1,00,000). Detailed history, thorough clinical examination, complete haemogram, peripheral smear examination and bone marrow aspiration/ biopsy were performed in all 75 cases. Results: Among 75 cases studied from age group 2–70 years, male to female ratio was 2.4: 1, most of the cases were clustered in 20–29 years age group. Most common aetiology was megaloblastic anaemia55 (73.3 %) followed by aplastic anaemia 9 (12 %), acute myeloid leukemia 4 (5.3 %), acute lymphoblastic leukemia 2 (2.7 %), malaria 2 (2.7 %) and chronic infection, multiple myeloma and myelofibrosis each with 1 (1.3 %) cases. Most common presentation was generalized weakness and fever. Commonest physical finding was pallor followed by splenomegaly, hepatomegaly and lymphadenopathy. Dimorphic anaemia was most common peripheral blood picture. Bone marrow aspiration was conclusive in all cases and commonest marrow finding was hypercellular marrow. Conclusion: Megaloblastic anaemia was the most common aetiology of pancytopenia. As a large number of patients have a reversible aetiology, early and proper diagnosis may be life-saving. Keywords Pancytopenia, Megaloblastic anaemia, Bone marrow examination
Indian J Hematol Blood Transfus OR 94
Keywords Iron overload, Female, Eastern India
Secondary Hemophagocytic Lymphohistiocytosis in Dengue Fever—A Rare Phenomenon OR 96 Sunita Sharma, Smita Singh, Manjula Jain Lady Harding Medical College, New Delhi Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a life threatening disease of immune system. It can be primary or secondary. Secondary cases are generally associated with systemic infections, immunodeficiency and malignancy. Dengue as a cause of HLH is a rare association. We present a rare case of HLH and granulomatous infiltrate in bone marrow of dengue patient. An 8 years old female child presented with fever for 2 weeks associated with hepatosplenomegaly. Complete blood count revealed anemia (Hb—5 g/dl) and thrombocytopenia (Plt count-5000/ll). Total leukocyte count was 5540/ll. Peripheral smear was negative for malarial parasite. Dengue serology for IgM was positive. Patient was treated symptomatically. However, bicytopenia did not improve. Subsequently bone marrow aspirate was done which showed increase in number of histiocytes with evidence of hemophagocytosis. There was presence of multiple epitheloid cell granulomas. No parasite was seen. Ziehl Neelson stain for acid fast bacilli was negative. Bone marrow iron was 2+ . Serum ferritin level was found to be 50 lg/L and serum fibrinogen level was 302 mg/dl. Serum triglycerides were raised [430 mg/dl (reference range B150 mg/dl)]. Based on above findings, 5 out of 8 criteria for HLH were met. So the final diagnosis of Hemophagocytic lymphohistiocytosis secondary to dengue fever was made ruling out the other causes.
OR 95 Iron Overload in Eastern Indian Female Sewage Workers, Still a Glaring Question
Changing Trends in Clinicopathological Parameters in Dengue with Evaluation of Predictors of Poor Outcome in Children Smita Ramachandran, Akriti Gera, Manas Proy Vmmc & Safdarjung Hospital, New Delhi-110029 A study was planned to evaluate the changing trends in dengue in children. It also aimed at identifying and evaluating the association between clinical features and outcomes. Methods: This was a retrospective observational study conducted in the Pediatric ward of a tertiary care hospital of north India during the period of August 2014 to October 2014. Children in the age group between 1–12 years who presented with signs and symptoms of dengue fever along with serological (IgM Elisa positive) or non structural protein antigen NS1 positivity were included for the retrospective analysis in the study. Continuous variables were analysed using percentage, mean, standard deviation. Categorical variables were analysed using Chi square test. P value \.05 was considered significant. Results: A total number of 69 patients of dengue, serologically (Ig M Elisa) or antigen (NS1 +ve) proven were admitted in Pediatric ward of the hospital. The mean age of presentation was 7.1 ± 3 years. The most common presenting complaints seen were lethargy (72.5 %), abdominal pain (71 %), persistent vomiting (63.8 %), mucosal bleed (39.1 %) mostly as gum bleed and epistaxis. Thrombocytopenia (pl count of \1,00,000) was present in 82.6 %. All patients with mucosal bleeds had thrombocytopenia which was statistically significant (p \ 0.002). There was a significant correlation between presence of [3 warning signs and prolonged hospital stay ([5 days) and progression to shock. Conclusions: Fever was found in all the patients. Lethargy, presence of more than 3 warning signs at the time of presentation, more than 5 days duration of hospital stay can be used as predictors of severe dengue.
Siddhartha Sankar Ray, Aniruddha Mukhopadhyay, Sila Chakrabarti Institute of Haematology and Transfusion Medicine
OR 97
Introduction: Anaemia affects over 800 million women worldwide and the major cause is iron deficiency especially in females. Another reason for anaemia is contamination by heavy metal like Lead (Pb) & Cadmium (Cd) which can destroy RBC and cause anaemia. The present study deals with women of Eastern India of reproductive age engaged in sewage work for last 10 years who are found to be iron overloaded. Materials and Methods: Our study population includes 21 female sewage workers aged 32 ± 1.66 and control population comprised of 26 occupationally non-exposed females of same age group. For both population Pb and Cd was estimated by GF-AAS. Whole blood iron was estimated by ED-XRF. Intensity of DNA damage was analysed by single cell gel electrophoresis (SCGE), Singh et al. 1980. Result: In control population average blood Pb concentration is 0.132 ± 0.093 compared to worker female 0.318 ± 0.12 and Cd concentration in control 0.0032 ± 0.004 and in worker female it is 0.0141 ± 0.004. Both are statistically significant (p \ 0.001). But the apple of interest is the study population showing increased iron concentration (1959 ± 130 in study population vs 1700 ± 522) despite of heavy metal overload which is also statistically significant (p \ 0.05). Intensity of DNA damage in study population is 3.57 ± 0.84 and in control 1.37 ± 0.37 (all metal concentration in mg/L). Conclusion: In female sewage workers higher Pb and Cd concentration is responsible for higher DNA damage but the iron overload in these females are contradictory which needs further meticulous study to analyse the problem.
Evaluation of Platelet Counts and Its Indices in Various Clinical Conditions Using Abx Pentra Df 120 Hematology Analyzer: Study from a Tertiary Care Hospital, Pondicherry Anand Mohanraj, Renu G’Boy Varghese Pondicherry Institue Od Medical Sciences and Research Introduction: With wide use of Automated cell counters in hematology precise information on platelet indices like Mean Platelet Volume (MPV), Plateletcrit (PCT), and Platelet Distribution Width (PDW) are easily estimated. Various diseases influence platelet number, size and maturation that are reflected in its indices. Materials and Methods: It was a cross sectional observation study during a period of three weeks. The objective was to correlate platelet indices in various clinical conditions using ABX Pentra DF120 Hematology analyzer. Results: Total of 501 samples were studied, out of which 174 (34.7 %) were females and 327 (65.3 %) were males. There were 387 cases (77.2 %) with normal counts, 56 (11.2 %) with thrombocytopenia and 58 (11.6 %) with thrombocytosis. Patients with fever, inflammatory condition constituted 34 % of thrombocytopenics followed by liver (14 %) and chronic kidney diseases (13 %) with others (39 %). Reactive thrombocytosis was common in inflammatory conditions (24 %), diabetics (14 %), trauma patients (12 %) and others (50 %). As we move from thrombocytopenia to thrombocytosis, the mean PCT increased while MPV and PDW decreased.
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Indian J Hematol Blood Transfus Table 1 Platelet count and its indices in various clinical conditions Clinical conditions
No.
Platelet count (9 106)
MPV (fl)
Mean
Mean
SD
PCT (%) SD
Mean
PDW (%) SD
Mean
SD
Acute conditions Fever
56
223
121
8.8
1.0
0.209
0.11
16.2
4.1
Inflammation
84
299
138
8.5
0.9
0.247
0.13
14.6
2.9
Sepsis
9
303
194
8.5
1.1
0.251
0.16
15.3
4
Chronic conditions Diabetes
32
345
190
8.7
0.9
0.290
0.14
14.8
2.5
Hypertension Tuberculosis
8 9
315 319
108 176
8.4 8.1
0.7 0.8
0.262 0.252
0.09 0.13
14.2 14.4
1.8 2.9
Antenatal cases
36
295
84
8.6
0.8
0.239
0.08
14.8
2.5
31
272
122
8.7
1.0
0.234
0.1
15.7
2.8
Alcoholic liver disease
6
174
107
8.8
0.6
0.151
0.09
15.7
1.1
Hepatic encephalopathy
6
115
70
9.5
1.2
0.109
0.05
18.2
4.4
Bronchiectasis
5
313
26
9.3
0.4
0.289
0.02
18.2
2.8
COPD
36
287
100
8.4
0.8
0.237
0.07
14.5
2.5
30
295
71
8.6
0.4
0.252
0.06
15
2.7
Kidney disease Chronic kidney disease Liver diseases
Lung diseases
Cardiac diseases Coronary arterial disease Congenital heart disease
10
367
152
8.6
1.3
0.274
0.14
14.7
4.4
Valvular disease
7
402
109
7.9
0.5
0.277
0.15
12.8
1.3
Neurological diseases Stroke
20
338
108
8.4
0.8
0.280
0.14
14.3
2.3
Cerebral venous thrombosis
4
309
71
8.6
0.8
0.185
0.14
14.8
2.3
Trauma cases
46
284
141
8.5
0.8
0.218
0.11
15.1
2.6
Snake bite
4
264
95
8.3
0.3
0.220
0.02
14.4
0.6
Immune thromboctopenic purpura
4
149
103
9.8
1.2
0.13
0.09
20.3
5.4
Anemia
11
248
137
8.4
0.6
0.208
0.13
15.2
1.9
Combined diseases
9
195
83
8.7
1.3
0.171
0.07
15.4
2.8
Medical check up cases (control)
38
274
67
8.6
0.8
0.233
0.05
14.7
2
Total
501
Oneway annova test, p \ 0.05 Significant decrease in platelet count and PCT with increase in MPV, PDW was seen in ITP and hepatic encephalopathy. Patients with bronchiectasis, fever and alcoholic liver disease showed increased MPV and PDW (Table 1). Conclusion: Platelet indices varied significantly in different clinical conditions. More studies will have to be undertaken to assess its routine use in other diseases. Keywords Platelet count, Mean platelet volume, Plateletcrit, Platelet distribution width
OR 98 Role of Bone Marrow Aspirate in Evaluating Causes of Splenomegaly Nishu Bhardwaj, Akash Talwar, Dr. Mrinalini Kotru, Dr. Sonal Sharma, Dr. Meera Sikka University College of Medical Sciences
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Introduction: Bone marrow aspirate examination is an invasive procedure used commonly in the workup of splenomegaly. However, there is limited data available on its usefulness in providing a definitive diagnosis. The present study was aimed at evaluating the diagnostic efficacy of bone marrow examination in cases with splenomegaly. Materials and Methods: Retrospective analysis of all bone marrow aspirates from January 2012 to January 2013 was done. Aspirate smears from 156 patients with splenomegaly were reviewed to look for a specific cause. Results: Out of 156 cases, bone marrow aspirate examination suggested a definite diagnosis in 74 cases (47.4 %). Of the remaining 52.6 %, in 18 % cases, the peripheral blood and marrow aspirate smears gave a clue to the diagnosis (e.g. hemolytic anaemia, lymphoma) which directed the patient’s subsequent evaluation. However, in 34.6 % cases, bone marrow aspirate smears were non-contributory to the assessment of splenomegaly. A majority of these (68 %) had mild splenomegaly and were reported as megaloblastic anaemia. Conclusion: Bone marrow aspirate examination is a helpful tool in the evaluation of the cause of splenomegaly.
Indian J Hematol Blood Transfus However, appropriate patient selection, careful peripheral smear examination and a therapeutic trial of hematinics could facilitate the avoidance of this invasive procedure and help improve its diagnostic efficacy. Larger studies are required to help develop an algorithm to allow its judicious use.
OR 99
need to dissect and evaluate the level of service quality being given by them and see how the different measurements impact the general fulfillment level of blood contributors. The area of dissatisfaction possibly be remedied if the administration of blood donation centers, must give careful consideration to the measurements of gap model of service quality for the better fulfillment of blood contributors, retention and building long haul association with them. Keywords Expectations and perceptions of blood donors, Blood bank, Service quality
Mesenchymal Stem Cells: Cell Biology and Potential Use in Therapy—A Review Dr. Parth Patel Cims Hospital Mesenchymal stem cells are clonogenic, non-hematopoietic stem cells present in the bone marrow and are able to differentiate into multiple mesoderm-type cell lineages and also non-mesoderm-type lineages. Several methods are currently available for isolation of the mesenchymal stem cells based on their physical and immunological characteristics. Because of the ease of their isolation and their extensive differentiation potential, mesenchymal stem cells are among the first stem cell types to be introduced in the clinic. Recent studies have demonstrated that the life span of mesenchymal stem cells in vitro can be extended by increasing the levels of telomerase expression in the cells and thus allowing culture of large number of cells needed for therapy. In addition, it has been shown that it is possible to culture the cells in a xeno-free environment without affecting their growth or differentiation potential. Finally, the mesenchymal stem cells seem to be hypoimmunogenic and thus allogenic mesenchymal stem cell transplantation is possible. It is envisaged that mesenchymal stem cells can be used in systemic transplantation for generalized diseases, local implantation for local tissue defects, as a vehicle for genes in gene therapy protocols or to generate transplantable tissues and organs in tissue engineering protocols. The results of these initial trials are very encouraging and several clinical trials are under way to study the efficacy and long-term safety of therapeutics based on mesenchymal stem cells.
OR 100 Assess Blood Donors’ Perception and Expectation on Service Quality of Blood Bank B. Chandra Indian School of Mines Introduction: The objective of the study was to assess the level of quality service being provided by blood banks and simultaneously judge the point of view of blood donors for their satisfaction level based on SERVQUAL variables, wherein, we tried to identify the effects of each variable namely reliability, assurance, tangibility, empathy and responsiveness. Materials and Methods: A self-administered structured SERVQUAL questionnaire prepared in a manner to address the expectation and perception on services being experienced by blood donors visiting blood banks. Total 280 blood donors’ responses were collected through field research. Data were analyzed, using SPSS 20.0. Results: The average of overall service quality index gap was observed 0.38. The highest gap scores were significantly perceived in ‘‘assurance’’ (Gap score 0.55), and in ‘‘empathy’’ (Gap score 0.49). However, ‘‘tangibles’’, ‘‘reliability’’, and ‘‘responsiveness’’ were found acceptable. However, the study revealed that the service quality provided by blood banks is enhancing negative perception on what donors perceived upon actual expectations. Conclusions: The study likewise contributes that blood bank
OR 101 ‘‘Antiproliferative, Cytotoxic and Apoptosis Inducing Potential of Isolated Active Compound from Leaves Azadiarchta Indica Against Pbmncs of All Patients’ Cells’’ Santanu Basu, Nirup Bikas Mondal Csir, Indian Institute of Chemical Biology Abstract: Identification of cytotoxic compounds that induces apoptosis has been the mainstay of anticancer therapeutics for several decades. In recent years, focus has shifted to inducing multiple modes of cell death coupled with systemic toxicity. The plant Azadirachta indica (Neem) has been traditionally used in ayurvedic medicine in India for treatment of broad spectrum of diseases. The anti-leukemic activity of Azadirachta indica leaves isolated active compound sulfonoquinovosyldiacylglyceride (SQDG) against human myeloid leukemia cell lines were already reported in our previous work. We further evaluated the antiprolipherative, cytotoxic and apoptotic effect of SQDG on PBMNCs of acute lymphoblastic leukemia (ALL) patient’s cells. Blood sample of 23 ALL patients and 4 normal human (5 ml each) was collected for the study. Cell viability by Trypan blue exclusion method and cytotoxicity by MTT [(4, 5-dimethylthiazol-2yl)-2,5-diphenyl-tetrazolium bromide] assay, Morphological study by florescence microscopy. DNA laddering assay by gel electrophoresis, flow-cytometric and Caspase study. SQDG was found to be responsible for antiproliferative and cytotoxic activity on PBMNCs of acute lymphoblastic leukemia (ALL) patient’s cells. Similarly morphological images and DNA laddering assay were found to be responsible for the apoptosis potentiality of acute lymphoblastic leukemia (ALL) cells. The flow-cytometric analysis confirms that the cell cycle arrest occurs at G1 phase of PBMNCs of ALL cells. The apoptosis is mediated through activation of Caspase-9 and Caspase-3. Thus, it merits consideration and further investigation as a therapeutic option for the treatment of cancer/leukemia. Keywords Acute lymphoblastic leukemia, Azardichta indica, Cytotoxic, Apoptosis
OR 102 Diagnostic Importance of Bone Marrow Biopsy In Peripheral Pancytopenia Dr. S. K. Behera, Dr. Pramita Sahu, Dr. D. P. Mishra Mkcg Medical College Introduction: Pancytopenia is an important hematological entity encountered in our day to day clinical practice. Aspiration and biopsy of the bone marrow is an indispensable adjunct to the study of hematopoietic disorders. Materials and Methods: A prospective study was conducted in MKCG medical college from August 2013 to 2015. All cases who presented with anemia were evaluated with complete blood count and peripheral smear examination. Those who satisfy the criteria of pancytopenia were included in our study and
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Indian J Hematol Blood Transfus bone marrow aspiration and biopsy were done simultaneously. RESULT: Total 206 patients of pancytopenia were studied. Both aspiration (BMA) and biopsy (BMB) were done in 141 cases. The various causes of pancytopenia that we encountered and the importance of bone marrow biopsy in diagnosing some of the cases were tabulated accordingly. Among 206 cases of pancytopenia bone marrow biopsy helps in diagnosing 42 cases and in remaining cases it acts as a complementary tool for bone marrow aspiration. The most common causes among them are aplastic anemia, MDS, myelofibrosis, storage disorders, and metastatic deposits. Also it has greater value in diagnosis of pattern of cellularity, presence of infiltrates, granulomas and staging of lymphomas. Conclusion: Hence, biopsy is not only complementary to aspiration but also has greater utility in cases where aspiration does not help. Thus, we feel that practicing bone marrow aspiration along with biopsy helps in diagnosing cases more efficiently and effectively. Keywords Pancytopenia, Bone marrow biopsy, Diagnosis
Causes
Total number Cases diagnosed of cases diagnosed only through through both BMB BMA AND BMB
Megaloblastic anemia
78
00
Hypoplastic anemia
36
00
Aplastic anemia
30
15
Myelodysplastic syndrome 21 Subleukemic leukemia-AML 15
18 00
ALL
09
00
Myelofibrosis
04
04
Non hematological Metastatic deposits
09
04
Storage disorders
02
Hypoplastic AML
02
00
TOTAL
206
42
01
OR 103 Bone Marrow in Pancytopenia People’S College of Medical Sciences and Research Centre, Bhopal Objective: Pancytopenia can be caused by a wide variety of etiologies that require evaluation of bone marrow. This study was carried out to evaluate bone marrow findings in patients presenting with pancytopenia. Methods: This was a cross sectional study carried out to identify the various findings in bone marrow aspiration in patients with pancytopenia on peripheral smear examination. Bone marrow aspiration was performed in 103 cases with pancytopenia over a period of 2 years. Result: Bone marrow aspiration was performed in 103 cases with pancytopenia. Bone marrow was hypercellular in
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46.6 % cases, normocellular in 28.2 % cases, inconclusive in 14.5 % cases and hypocellular in 10.7 % cases. Bone marrow showed megaloblastoid picture in 34 % cases, iron deficiency in 9.8 % cases, combined iron deficiency and megaloblastoid picture in 8.8 % cases, plasmacytosis in 9.8 % cases, hypoplastic anemia in 4.9 % cases, reactive changes in 2.9 % cases, acute leukemia in 1.9 % cases, chronic myeloid leukemia chronic phase in 2.9 % cases, acute lymphoblastic leukemia in 2.9 % cases, idiopathic thrombocytopenic purpura in 1.9 % cases and non-hodgkin’s lymphoma in 0.9 % cases. Bone marrow study was normal in 3.8 %, inconclusive in 15.5 % cases. Amongst the total cases 6.8 % were below 10 years of age and a total of 46.7 % were 30 years and below. Out of the total cases of combined iron deficiency and megaloblastoid picture, 57 % (4 out of 7) were males. Bone marrow aspiration was able to establish diagnosis in 80.7 % cases. Conclusion: Bone marrow aspiration can diagnose the etiological factors in majority of cases of pancytopenia. Megaloblastoid picture was seen in maximum cases. Other common diagnosis established were iron deficiency anemia, combined iron deficiency anemia and megaloblastoid picture, haematological malignancies. For maximum diagnostic yield, clinical finding, peripheral smear finding and other laboratory and radiological findings should be correlated.
OR 104 Spectrum of Hematological Manifestations of Hiv in a Tertiary Care Hospital Parul Sobti, Vikram Rajgopalan, Khuraijam Bem bem, Richa Gupta, Tejindar Singh, Mamc Spectrum of hematological Manifestations of HIV in a tertiary care hospital Introduction: HIV is associated with a variety of hematological manifestations including cytopenias in one or more cell lines in peripheral blood associated with hypo/hyper cellular marrow showing dysplasia, lymphoplasmacytosis and lymphoid aggregates. With progression of disease and a fall in CD4 count, there is an increased risk of developing secondary infections and malignancies. Aims and objectives: To study the hematological manifestations of HIV Materials and Methods: The study was carried out in the department of Pathology and Medicine, Maulana Azad Medical College from 2010 to 2015. Clinical details including the duration of seropositivity, oppurtunistic infections and treatment history were noted. The hemogram, bone marrow aspirate and biopsy findings of seropositive patients were evaluated. Additional investigations like Immunochemistry and flowcytometry was done in cases wherever indicated. Observations : Hemogram findings revealed cytopenias. The commonest findings in marrow were plasmacytosis, infiltration by macrophages and dysplasia in one or more lineages. The most common opportunisitc infections included tuberculosis and histoplasmosis were also noted. Both Hodgkins and Non Hodgkins lymphoma were seen. Conclusion: There is a wide spectrum of hematological findings observed in HIV. The pathophysiology may involve direct retroviral infection of bone marrow progenitors, abnormal regulation of haematopoiesis and/or autoimmune phenomena and effects of ART. Bone marrow examination is important for follow up of these patients and also helps to diagnose AIDS related illnesses presenting in the marrow.
Indian J Hematol Blood Transfus OR 105 Adequacy and Gross Appearance of Bone Marrow Trephine Biopsy in Routine Reporting: An Audit Renu G’Boy Varghese, Kandasamy Ravichandran, Manjiri Phansalkar, Anita Ramdas, Aneesh Basheer Pondicherry Institute of Medical Sciences, Pondicherry Introduction: We aimed to study the implications of length of bone marrow trephine biopsy (BMBx) and its gross appearance as per the International Council of Standardization in Hematology (ICSH)-2008 guidelines. Materials and Methods: The length and gross appearance of iliac crest BMBx obtained from 174 consecutive adult cases (male/female: 109/65, mean age; 47.5 ± 19.2 years, range; 17 to 85 years) were studied for their association with final diagnosis. Results: The mean BMBx length was 23.6 ± 9.3 mm (range; 9–50 mm). A positive diagnosis was rendered in a higher proportion of cases with length C15 mm (N = 155) than with \15 mm (N = 19) (85.8 vs. 73.7 %, respectively, P = 0.05). The positive diagnostic yield was highest (92 %) among 25–29 mm length compared to other groups (P [ 0.05). The mean BMBx of myeloma cases (N = 15) was significantly shorter than non myeloma hematological malignancies (N = 38) (17.1 ± 5.0 vs. 24.1 ± 9.5 mm, respectively, P = 0.01). Of the 34 cases with grossly abnormal BMBx, 32 (94.1 %) provided a positive diagnosis; whereas 115/140 (82.15 %) cases with Table 1 Adequacy and gross appearance of bone marrow trephine biopsy: an audit of 174 cases Number Diagnosis (N) Yes (N, %)
Biopsy length (mm)
P value Not possible N (%)
\15
19
14 (73.7)
5 (26.3)
C15
155
133 (85.8)
22 (14.2)
15–19
38
33 (86.8)
05 (13.2) [ 0.05
20–24
31
26 (83.9)
05 (16.1)
25–29
25
23 (92.0)
02 (8.0)
C30
61
51 (83.6)
10 (16.4)
Multiple myeloma
15
Mean length: 17.1 ± 5.0 mm
Non myeloma 38 malignancies
Mean length: 24.1 ± 9.5 mm
Abnormal Gross for age* biopsy appearance
0.01
34
31 (91.2)
1(2.9)
Normal for age (red/pale red)
140
77 (55.0)
38 (27.1) 25 (17.9)
Yellowish/ greasy*
10
7 (70.0)—Aplastic or hypoplastic marrow
Mucoid/jelly/ slimy*
17
13 (76.4)— Multiple myeloma 3 (17.7)— Metastatic adenocarcinoma 1 (5.9)—Gelatinous transformation of marrow
Necrotic*
7
3 (42.9)—Acute leukemia 4(57.1)— Granulomatous
Deep or dark red
26
26 (100)— Megaloblastic anemia
0.05
2 (5.9)
\0.001
a normal appearing marrow rendered a positive diagnosis (p \ 0.001). BMBx of myeloma cases had a peculiar mucoid/jelly like appearance (13/17, 76.4 %); whereas those of megaloblastic anemia were deep/dark red in appearance (26/26, 100 %). Conclusion: We reaffirm ICSH guideline of C15 mm unbroken trephine cores as minimum adequacy criteria for routine bone marrow reporting. Increasing the length of the biopsy to 25 mm with careful incorporation of abnormal gross appearances may be very useful for the final diagnosis. Keywords Adequacy, Appearance, Bone marrow trephine
OR 106 Diagnostic Bone Marrow Utility in Patients with Fever Dr. Renu G’Boy Varghese, Dr. Reba Kanungo, Dr. Somanath Padhi Pondicherry Institute of Medical Sciences Introduction: Diagnosis of prolonged fever still remains a clinical challenge. One investigation that stands tall through time is bone marrow study (BMS). We present a five-year study on utility of bone marrow (BM) in patients with fever. Materials and Methods: A fiveyear combined prospective and retrospective study from May 2010– June 2015 was done for analyzing utility of BMS in cases with prolonged fever. The yield of bone marrow Aspirate (BMA), imprint smears and bone marrow biopsies (BMBX) of the patients with fever were analyzed, compared and correlated with BMA culture. Results: A total of 83 cases were evaluated and the commonest BM morphological change observed was reactive change in 37 cases (45 %), followed by 15 granulomatous lesion (18 %), 8 leukemia cases (10 %), 5 megaloblastic anemia (6 %), 4 hemophagocytic lymphohistiocytic syndrome (HLH) (5 %), 3 hypocellular (4 %), 3 with dimorphic picture (4 %) and 2 aplastic anemia (2 %). myelofibrosis, myelodysplastic syndrome, multiple myeloma, lymphoma, ITP and Histoplasmosis were accounted for 1 case each. In 43 cases BMA and BMBX correlated with each other. BMA was superior in diagnosing leukemia, megaloblastic change and HLH. BMBX was superior in diagnosing granulomatous lesions, myelofibrosis and aplastic anemia and only in three out of 56 cases culture was positive. Conclusion: BMS is a useful tool in diagnosing most of the cases of fever. BMA and BMBX complement each other, hence to be done simultaneously in every case. BMA culture is less useful in diagnosing prolonged fever. Keywords Fever, Bone marrow aspirate, Bone marrow biopsy
OR 107 Efficacy and Safety of Tranexamic Acid Prophylaxis In Reducing The Bleeding Episodes, Need of Platelet Transfusion In Patients of Aplastic Anemia Dr. Sudhir Kumar Atri, Dr. Pravas Mishra, Dr. Renu Saxena, Dr. H.P. Pati, Dr. M. Mahapatra Pt. B. D. S. Pgims Rohtak Background: Patients with aplastic anemia require frequent admissions and suffer both mortality and morbidity on account of bleeds. Tranexamic acid has been found to be useful in patients with acute leukemia undergoing chemotherapy. We studied its beneficial effects in patients with aplastic anemia. Aims: To study the benefit of adding oral tranexamic acid as prophylaxis in patients with aplastic anemia. Methods: We enrolled 80 patients [18 years with acquired aplastic anemia. Group 1 received oral tranexamic prophylaxis at 500 mg
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Indian J Hematol Blood Transfus TDS throughout the study period of 3 months and group 2 patients received tranexamic acid along with platelet support only during bleeding episodes. The student test/Mann–Whitney test was applied to compare quantitative data between the two groups. Chi square test/ Fisher exact test was applied to compare qualitative data. P value \0.05 was considered as significant. Results: Of the 80 patients enrolled, 6 died and 10 were lost to followup. The baseline data in group 1 and group 2 was as follows: median age 20 years (range 18–55) and 23 years (range 19–55), 28 and 33 males respectively, median total leukocyte counts 2000/mm3 and 1800/mm3, media platelet counts 9000/mm3 in both groups, sever aplastic anemic 35 and 36, very severe aplastics 5 and 4 respectively. The average requirement of PRPs in group 1 during study period was 14.06 ± 5.29 units and in group 2 it was 11.55 ± 6.03 units. The average requirement of PRBCs was 10.61 ± 2.18 units in group 1 and 10.91 ± 2.40 units in group 2 patients. The average numbers of major bleeding episodes were 0.18 ± 0.39 in group 1 and 0.40 ± 0.50 were in group 2 patients and average numbers of minor bleeding episodes were 3.18 ± 1.74 in group 1 patients and 4.13 ± 1.76 was in group 2 patients. These differences were not statistically different. Conclusion: Tranexamic acid did not reduce the bleeding episodes or requirement of blood component support in this cohort of patients with aplastic anemia. Disclosure of Interest: None Declared. Keywords Bleeding, Platelet, Prevention, Tranexamic acid, Transfusion
OR 108 Critical Value Reporting in Hematology in a Tertiary Care Hospital and the Need for The Revision of Critical Value List Dr. Febe Renjitha Suman, Mr. Gunasekaran, Dr. Rajendiran S., Dr. Umasekar Sri Ramachandra Medical College Introduction: Critical values are abnormal laboratory results that may endanger a patient’s life if immediate corrective or therapeutic measures are not taken (1,3). Laboratories have regulatory requirements like NABL, JCIA to develop and implement critical value reporting policies (2). This study is an analysis of the critical value reporting, before and after revision of our criticalvalue list (CVL) in our hospital laboratory. Materials and Methods: We analysed the critical value alert register in our hospital laboratory from July 2014 to June 2015. All the reported critically alert values in our laboratory according to our institution CVL, during the study period were included in the study. The frequency of every parameter in the critical alert list was noted before and after revising our critical value list. The turn around time for the reporting of the critical value and single patient repeat critical alerts were also reviewed. Results: 20,02,054 tests were done in our hematology laboratory during the study period. According to our institutional CVL we have reported 8200 critical values. The methods we use to inform to critical alerts are by telephone (Read and verify -99.8 %), LIS, pop up messages in the computer and sms alerts to treating physician. Maximum critical alerts have been given in low platelet count followed by high PT INR. 65 % of alerts have been given to ICU and emergency departmentand 35 % to others. The mean turnaround time for critical alert reporting is 8.5 min. Average of 1200 critical values have been reported initially and after revising our critical value list the number of critical alerts have been reduced to around 700 per month. Conclusion: Clinical laboratories are responsible for the implementation, validation and review of their CVLfor patient safety. Review of critical values in regular interval helps to ensure that critical values meet clinical need and optimal utilization of resources.
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Keywords Critical value, Hematology, Hospital laboratory
OR 109 Gastric Carcinoma in a Young Female Masquerading As Idiopathic Thrombocytopenic Purpura Yashwant Kashyap, Vinay Br, Ravi Tandon, Vijai Tilak, Mohan Kumar Ims, Bhu Introduction: Gastric carcinoma mostly affects older males and is uncommon before the age of 40. Bone metastasis is rare. But the usual presentation with bone metastasis is mostly the bony pain. We report here a case of a 36 year female with gastric carcinoma presenting with multiple ecchymotic patches, menorrhagia and metastasis to bone marrow. Relevant Case Presentation A 36 year lady presented with the history of multiple ecchymotic patches and menorrhagia in her ongoing menstrual cycle. A clinical diagnosis of Idiopathic Thrombocytopenic Purpura was made. Routine investigations showed anaemia, thrombocytopenia, and raised alkaline phosphatase. Bone marrow biopsy revealed a cluster of metastatic mucin secreting adenocarcinoma cells. Upper GI endoscopy revealed a deep irregular ulcer present in the corpus and the base of the ulcer was covered with necrotic tissue. Biopsy of the ulcer suggested diffuse adenocarcinoma of stomach on histopathology. Need of Presenting the Case It is a very uncommon scenario where gastric carcinoma has presented in a young female with bony metastasis with symptoms masquerading as ITP. Discussion Clinical presentation of gastric carcinoma in a young female as ecchymosis and menorrhagia masquerading as ITP is extremely rare. Literature suggests that gastric carcinoma can spread to bone due to rich supply of blood capillaries in gastric mucosa. And due to bone marrow involvement it can present as depression of haemopoiesis. So, presence of bleeding manifestation with cytopenias with an isolated raised alkaline phosphatase should raise a suspicion of an occult metastasis to the bone marrow with a silent primary.
OR 110 Response to Hydroxyurea Treatment and its Correlation with Xmn1 Polymorphism in Severe Hbe-Beta Thalassaemia Arijit Nag, Soumita Chaudhuri, Sila Chakrabarti, Kanjaksha Ghosh, Maitreyee Bhattacharyya Institue of Haematology and Transfusion Medicine, Medical College, Kolkata Summary: The efficacy of Hydroxyurea, an HbF inducing agent, was evaluated in severe HbE-beta thalassemia. Hydroxyurea was found to be effective in significant increase in HbF levels and decrease in transfusion requirements in patients with Xmn1 polymorphism. Introduction: HbE-beta thalassemia is a common disorder in eastern India with varying clinical presentation. Pharmacological induction of fetal haemoglobin is shown to reduce disease severity in sickle cell disease. The efficacy of hydroxyurea and its correlation with Xmn1 polymorphism in severe HbE-beta thalassaemia was evaluated. Materials and Methods: Patients with severe HbE-beta thalassemia were started on hydroxyurea (10 mg/kg). Patients were followed up for response with frequent scheduled visits. Results: All patients were followed prospectively for transfusion requirement, drug effectiveness and toxicity. With median follow-up of 10 months, hydroxyurea was found to be associated with significant increase in HbF levels and decrease in transfusion requirements in patients who showed a high frequency of Xmn1 polymorphism, as shown in the table (uploaded in
Indian J Hematol Blood Transfus File). Conclusion: Significant increase in HbF levels and decrease in transfusion requirements was seen in patients with Xmn1 polymorphism (both heterozygous and homozygous) who responded better to Hydroxyurea treatment as compared to the wild type (i.e. patients with normal Xmn1 polymorphism). Longer follow-up with more number of patients is warranted for confirmation of these findings. Keywords Hydroxyurea, HbF, Xmn1 Polymorphism
OR 111 Clinicopathological Presentation of Hemophagocytic Disorder Dr. Vanamala Alvr, Dr. Sitalakshmi S. St. Johns Medical College Introduction: The disorder of hemophagocytosis falls under the category of Hemophagocyic lymphohistiocytosis syndrome and Laboratory investigations play a central role in the diagnosis of these disorders. AIM: To evaluate clinicopathological features of hemophagocytic disorders (HPD) cases. Materials and Methods: The study included 15 cases diagnosed over a period of 2 years. Clinical presentation, laboratory findings and bone marrow aspirates, trephine biopsies of cases diagnosed as HPD were reviewed. Results: Of 3600 bone marrow aspirates examined in 2 years, 15 cases (0.42 %) were diagnosed to have features consistent with hemophagocytosis. The mean age group was 27 years. A majority of them presented below 20 years of age (n = 7, 46.7 %). Only one case was of geriatric age group (70 yrs). The most common clinical presentation was fever (100 % cases). The laboratory findings at presentation was anemia (n = 11, 73 %), thrombocytopenia (n = 10,66.7 %) and leucopenia (n = 10,66.7 %). Serum ferritin was elevated in 9 cases (60 %). Bone marrow aspirates showed evidence of hemophagocytosis. Phagocytosis by macrophages of platelet and RBC most commonly followed by leucocytes and nucleated RBCs were noted. Bone marrow iron was assessed in 12 cases (80 %), and was increased in 7 cases (58 %). Conclusion: The present study showed that laboratory investigation of cytopenia, increased S. ferritin levels along with bone marrow aspirate showing evidence of macrophage phagocytotic activity was used to conclusively diagnose these cases, thus playing a central role in the diagnosis of hemophagocytosis syndrome. Keyword: hemophagocytic disorder, macrophages, laboratory investigations.
OR 112 Langerhans Cell Histiocytosis In Children: A Single Center Experience Anil Sharma, Mohan Kumar Department of Pediatrics, Institute of Medical Sciences Introduction: Childhood histiocytosis constitute a diverse group of disorders with variable clinical expression. Class I or Langerhans cell histiocytosis (LCH) is best recognized entity. We present clinical profile and treatment outcome of children with LCH presenting at single center. Need for Study There are few large case series on
Langerhans cell Histiocytosis from our country. Material & Methods: Retrospective data analysis of LCH patients diagnosed over 8 years was carried out. Diagnosis was based on light microscopy findings supported by supplemental stain for S-100 protein/CDIa. Electron microscopy was not available. Patients were grouped according to current classification of LCH IV as Single System (SS) LCH and Multisystem (MS) LCH. Treatment was as per guidelines. Results: Twenty patients (age 5 months–12 years; M:F ratio 4:1) were studied. Eight patients had MS-LCH; 12 had SS-LCH. Bony involvement was seen in 12/20 (60 %), hepatosplenomegaly in 7/20 (35 %) and skin involvement in 4/12 (20 %). Skull was commonest site of involvement followed by vertebrae and long bones of limbs. Skin was only site of involvement in one patient. One patient presented with diabetes insipidus (DI) and developed bony lesions after one year. Another patient developed it after 6 months. One patient had pineal gland involvement at presentation. Two patients refused treatment. 16 had complete disease resolution (NAD) and one each had stable (unchanged) and progressive disease. Progressive disease was seen in SS-LCH patient. Conclusion: Majority of patients had good response to chemotherapy. One patient with SS-LCH developed progressive disease. Keywords Histiocytosis, Langerhans cell
OR 113 Second Cancers in Adults—Our Experience Dr. Vanajakshi, Dr. Jaya Bhaskar Reddy Apollo Institute of Medical Sciences and Research Back ground and Objectives: Advances in early detection and treatment mean that more and more people are surviving cancer today. Increased long-term survival seen in patients with solid and hematologic cancers achieved as a result of aggressive chemoradiotherapy has come at a price. Some cancer survivors may develop a new, unrelated cancer later. This is called a second cancer. Reasons for second cancers are varied. Field cancerisation, shared environment, familial syndromes, Radiation and Chemotherapy are among the few risk factors affecting the risk of secondary cancers. Therapyrelated acute myeloid leukemia and secondary non-Hodgkin lymphoma has been frequently documented in these patient cohorts. We aim to analyse the factors involved in second cancers in our subset of patients. Materials and Methods: We analysed all patients presenting to the Department of pathology, Apollo Hospitals during the period January 2010 to Present. Results: Total 4 cases of Second cancers were documented in our study. Out of which 2 cases were acute myeloid leukemia’s and both of them had history of treatment with alkylating agents. The other 2 cases were diagnosed to have secondary Multilpe myeloma. Of the patient presenting with multiple myeloma one of them had history of prior Renal cell carcinoma Conclusions: Assessment of the risk of second leukemia should become part of any therapeutic plan for cancer patients. Chemo is known to be a greater risk factor then radiation. Avoidance of drugs with more leukomegenic potential will reduce the occurence of second leukemia’s. It is also important to understand the possibility of a correlation between renal cell carcinoma and multiple myeloma. Field cancerisation and increased cytokine expression probably could play a important role in these second cancers.
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Indian J Hematol Blood Transfus
Topic: Myelodysplastic Syndrome & CMPD OR 114 Primary De Novo Myelodysplastic Syndrome In Young: Indian Scenario Dr. Prabhu M., Dr. Pravas Mishra, Dr. H. P. Pati, Dr. Seema Tyagi, Dr. Manoranjan Mahapatra Aiims, New Delhi Introduction: Myelodysplastic syndrome (MDS) is usually a disease of elderly age group. The aims of the study were to study the clinicohematologic profile of primary de novo MDS occurring in young (\50 years) and to compare with older MDS patients. Materials and Methods: There were 147 primary MDS cases diagnosed, out of which 84 cases retrieved over 8 years from the tertiary care centre in Northern India. Clinical, hematological, treatment profiles and outcome were compared between younger and older MDS patients. Results: The median age of young MDS (n = 46 cases) was 35 years with M: F of 1.7:1. Weakness was the most common presenting symptom. The median Hb, ANC and platelets at diagnosis were 5.6 g %, 1.5x109/L and 60x109/L. Ten patients had peripheral blood blast and 32.4 % (12/37) had abnormal cytogentics. Fever, splenomegaly, thrombocytopenia and dyserythropoiesis were more common in young MDS. WHO subtypes include RCUD (9), RCMD (12), RAEB-1 (8), RAEB-2 (13), 5q deletion (3) and MDS-U (1). Sixteen patients died during their 8 months median follow-up (1–94 months) with AML transformation in 5 cases (median—3 months). Majority of the patients were in intermediate and high risk IPSS (89 %). Supportive care (69.5 %), hypomethylating agents (10.8 %), BMT (2.4 %) and lenolidomide (17.3 %) were given in these patients. Percentage of bone marrow blasts, dysmyelopoiesis, dysmegakaryopoiesis and IPSS scoring were the parameters predicting the progression of the disease on multivariate analyses. Conclusions: The clinico-hematological profile of young MDS is different from older MDS indicating different biology. Keywords Myelodysplastic syndrome, Acute myeloid leukemia, Progression
OR 115 Study of Cytogenetic Abnormalities in Mds—An Institutional Experience Dr. T. K. Dolai, Dr. P. K. Mandal, Dr. R. Dey, Dr. P. Chakrabarti, Dr. B. Bagchi
noted in 5 cases (7 %), Loss of Y chromosome detected in 5 cases (7 %) and remaining cases showed complex abnormalities (4 %). Conclusion: Rare cytogenetic abnormalities can be observed frequently in MDS and their prognostic impact is still unknown. In the present study cytogenetic abnormalities detected in 52 % of cases. Most of the cases have single or multiple breaks as a sole abnormality. Forty-eight percent of patients presenting with a normal karyotype. New techniques will help to further delineate the genetic background in these cases. Keywords Myelodysplastic syndrome, Cytogenetics, Karyotyping.
OR 116 Spectrum of Myelofibrosis—A Clinicopathologic Study Dr. S. Sitalakshmi Aiims, New Delhi Introduction: Primary myelofibrosis is a myeloproliferative disorder of pluripotent stem cell characterized by clonal proliferation of multiple cell lineages and bone marrow fibrosis. Primary myelofibrosis should be differentiated from secondary causes of myelofibrosis. Materials and Methods: Patients with marrow fibrosis diagnosed in our institution between August 2014 and July 2015 (1 year) were evaluated for various causes of marrow fibrosis. Bone marrow findings were correlated with clinical and other laboratory parameters. Results: Thirty-eight patients were evaluated using clinical, laboratory and pathological parameters. Patient with Primary myelofibrosis (11/38; 29 %, M:F = 4:2) were older with a mean age of 55.5 (range: 40–65) years, and presented with easy fatiguability, splenomegaly, moderate to marked marrow fibrosis with aparticulate bone marrow aspirate. Secondary Myelofibrosis (27/38 patients, 71 %; M:F = 17:15) had a mean age of 40.3 (range: 3–80) years, and included 3 patients (11 %) each with Rheumatoid arthritis treated with methotrexate, Acute Myeloblastic Leukemia and Chronic Myeloid Leukemia; 2 patients (7.4 %) each with Acute Lymphoblastic Leukemia and viral infections; one patient (3.7 %) each with polycythemia vera, autoimmune etiology, tuberculosis, metastatic disease, lymphoproliferative disease, and myelodysplastic syndrome. Splenomegaly was seen in 14/27 (52 %) patients. In the remaining 8 patients (30 %) in whom etiology remained uncertain, steroid therapy resulted in clinical and pathological improvement. Conclusion: Recognizing the characteristic morphology of Primary and Secondary Myelofibrosis and associated clinical and laboratory features helps in guiding further evaluation and management. Keywords Myelofibrosis, Leukemia, Myeloproliferative disorder
Nrs Medical College, Kolkata, West-Bengal Introduction: Myelodysplastic syndromes (MDS) comprise a group of clonal bone marrow diseases characterized by profound heterogeneity in morphologic presentation, clinical course and cytogenetic features. Roughly 50 % of patients display clonal chromosome abnormalities. The karyotype is one of the important criteria for prognostication and therapeutic decisions in MDS. Materials and Methods: This study retrospectively analysed cytogenetic changes of all the MDS cases diagnosed in our institute from 2011–15. Results: Total 76 cases diagnosed as MDS during this period in our institute with an age range of 15 to 83 years. There were 50 male and 26 female patients. Cytogenetic study was not possible in 5 samples due to grossly hypocellular condition. Out of rest 71 cases, cytogenetic abnormality detected in 37 cases (52 %), normal cytogenetics in 34 cases (48 %). Most cases had single or multiple breaks in chromosomes as sole abnormalities (25 %).3 cases shows Del 20q (4.22 %), Trisomy 8 detected in 3 cases (4.22 %), Monosomy 7 and 7q del
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OR 117 Diagnostic Challenges and Therapeutic Implications: Myeloid and Lymphoid Neoplasms With Eosinophilia and Abnormalities of Pdgfra—Case Report With Review of Literature Anil Irom Singh, Prabhu Manivannan, Seema Tyagi, Hara Prasad Pati, Manoranjan Mahapatra Cancer Institute (Wia), Adyar, Chennai Introduction: The etiology of eosinophilia is very diverse. Unusual presentation of eosinophilia is not uncommon. Case details: A 25 years old presented with cough, fever, weight loss, awareness of left upper quadrant, progressive pallor, back ache and progressive weakness of lower limbs. General physical examination showed pallor, edema, cervical lymphadenopathy and systemic examination showed anasarca, massive splenomegaly (20 cm), hepatomegaly
Indian J Hematol Blood Transfus (4 cm), and paraplegia. Hb-5.8 g %, TLC-52x109/L, Platelets10x109/L. Peripheral smear showed leucoerythroblastic blood picture with eosinophilia (AEC = 11 x109/L) and no abnormal cells. Biopsy showed streaming of normal hematopoietic cells (WHO grade II) with increased eosinophils, no dysplastic or abnormal clustering of megakaryocytes seen. Polymerase chain reaction for BCR-ABL & JAK2 were negative, FIP1L1-PDGFRA fusion assay was positive. Imatinib 100 mg OD was started and patient improved dramatically. At last follow-up, patient was walking with support, transfusion independent, with normalization of counts with no abnormal cells. Need for the case presentation: Myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA are relatively newer entity. Myelonecrosis is uncommon entity rarely reported in the literature. Targeted therapy with imatinib is essential. Discussion: Myeloid neoplasms associated with eosinophilia and abnormalities of PDGFRA should be kept in mind after ruling out all the secondary causes of eosinophilia. Most of the patients respond very well to imatinib; however relapse can occur after stopping the drug. Keywords Eosinophilia, PDGFRA, Imatinib, Polymerase chain reaction
OR 118 Nilotinib As Second Line Agent In Cml-Preliminary Experience from A Tertiary Cancer Centre In India Rejiv Rajendranath, Ts Ganesan, Venkatraman Radhakrishnan, Tg Sagar, Prasanth Ganesan All India Institute of Medical Sciences (Aiims), New Delhi Introduction: Nilotinib is approved in treatment of chronic myeloid leukemia (CML). There is limited data from India. METHODS We used nilotinib in patients after failure/intolerance to imatinib. Imatinib resistance mutation analysis (IRMA) was done whenever possible before switching. Results: Twenty patients (11 females: C50 years: 12/20; median age 51 years) received nilotinib. Indication to switch: loss of CHR:N = 9 (45 %), loss of CCyR:N = 1 (5 %), no MMR:N = 2 (10 %), loss of MMR: N = 1 (5 %), no CCyR: N = 3 (15 %), no CHR:N = 1 (5 %), Blast CrisisN = 3 (15 %). IRMA (N = 15): sensitive to nilotinib (N = 7) and no mutation detected (n = 8). Mean duration from the diagnosis: 7.6 years (0–24 years). Commonest dosage: 300 mg BD. Grade 3/4 toxicities: thrombocytopenia: N = 6 (30 %); leucopenia: N = 2 (10 %); anemia N = 1 (5 %); hyperbilirubinemia: N = 3 (15 %); hyperglycemia N = 1 (5 %); pleural Effusion N = 1 (5 %); hypokalemia: N = 1 (5 %). Dose reduction based on toxicity was required in ten (50 %) patients but only 1 patient (5 %) required stopping due to toxicity. Outcomes: Progression or no response was seen in 7 (35 %) patients including 3 blast crisis. Twelve patients are currently on nilotinib: 2 have optimal molecular response, 1 has optimal cytogenetic response and 9 others are in CHR. Median duration of Nilotinib in surviving patients is 5.6 months. One patient who started nilotinib in blast crisis achieved CHR and was progression free for an additional 51 months. Conclusion: Though limited by small number and short follow up, this study shows nilotinib can salvage a few patients after imatinib failure. Side effects were worse than reported with first line therapy in literature and more data from Indian patients should be gathered. Keywords Nilotinib, IRMA, ImatinibFailure, Side effects
OR 119 Clinico-Hematological Profile and Utility of Existing Prognostic Models In Myelodysplastic Syndrome: A Single Tertiary Care Center Experience from Northern India Dinesh Chandra, Pravas Mishra, Seema Tyagi, Renu Saxena, Manoranjan Mahapatra Dr. Rmlims, Lucknow Introduction: Myelodysplastic syndrome (MDS) is a heterogeneous group of disorders. The aims of the present study were to highlight the clinico-hematological profile in Indian MDS patients, the utility of existing prognostic models and to compare these data with the western literature. Materials and Methods: Primary de novo MDS (147 cases) were retrieved over 8 years. Complete clinico-hematological and cytogenetics profile were available only in 86 and 69 patients respectively. Different prognostic models such as International prognostic scoring system (IPSS), IPSS-R (revised), revised WHO (WPSS-R) and lower risk (LR-PSS) were evaluated. Overall survival (OS) were calculated and ‘p’ value \0.05 was considered statistically significant. Results: The median age of MDS was 50 yr with M:F ratio of 1.5:1. Weakness was the most common (98.8 %) presenting symptom. The median Hb (7.3 g %), ANC (1.5x109/L), platelet count (80x109/L), abnormal cytogenetics (34.7 %), RAEB-I (17.9 %) and RAEB-II (25 %). The follow-up & OS of all patients were ranging from 1–96 months (median-5.5 months) and 8 months respectively. Seven cases progressed into AML (median-4 months). Supportive care, hypomethylating agent, stem cell transplantation and lenalidomide were given in 64.3, 13.1, 1.2 and 21.4 % respectively. Blasts (%) in peripheral blood and bone marrow, dyserthyropoiesis, WHO subtypes, IPSS and IPSS-R are independent variables predicting progression of disease on multivariate analysis. Conclusions: Majority of Indian MDS patients are B50 yr (54.7 %), higher risk (42.9 %), OS (8 months) are less compared to western literature. The above prognostic models are equally good in Indian patients. Keywords Myelodysplastic syndrome, Prognostic scoring system and overall survival
OR 120 Htert Expression and Telomerase Activity In Myelodysplastic Syndrome Patients : Aiims Experience Sudha Sazawal, Manoranjan Mahapatra, Sunita Chhikara, Renu Saxena Christian Medical College, Vellore Background: Telomerase enzyme, containing a catalytic subunit, the human telomerase reverse transcriptase (hTERT), and a small integral RNA component, synthesises the telomeres, the ends of eukaryotic chromosomes. The rate-limiting component of telomerase is human telomerase reverse transcriptase (hTERT). Telomerase activity and hTERT expression in MDS patients were independently investigated by different groups obtaining contradictory results. We analyzed the expression of hTERT and telomerase activity in 100 MDS patients. Aim: To study the role of telomerse activity and hTERT expression in the prognosis MDS patients. Method Mononuclear cells and RNA was extracted from the 100 MDS patients. For htert expression study
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Indian J Hematol Blood Transfus cDNA was synthesized and RT-PCR was done. Telomerase activity was determined using the telomerase PCR-ELISA kit (TRAP) (Roche Molecular Biochemicals, Indianapolis, IN, USA) according to the manufacturer’s instructions. Results: Expression of hTERT was present in 17/100 (17 %) cases. Of these, disease progression was observed in five patients. Telomerase activity (TA) was increased in 17/100 (17 %) cases. The telomerase activity was ranging from 0 to 0.86 units (U) with a mean of 0.24 ± 0.21 U. Of these seventeen patients, disease progression was observed in seven patients. Out of these cases hTERT expression was present in 14 cases (82 %). The remaining 83 patients had low telomerase activity and hTERT expression was present in only three cases. This suggests that the increased telomerase activity was highly associated with hTERT expression (p \ 0.001). Conclusion: The results of the present study suggests strong association between telomerase activity and hTERT in MDS patients.
OR 121 Hypoplastic Myelodysplastic Syndrome (Hmds)—A Single Centre Analysis Dr. N. A. Fouzia, Dr. Anu Korula, M. L. Kavitha, Aby Abraham, Vivi Srivastava
Introduction: The prognostic role of an early molecular response (EMR) defined as \=10 %IS of the BCR/ABL transcript level at 3 months and \=1 % IS at 6 months following TKI therapy for chronic myeloid leukemia (CML) has been well established. But still less data is available to address this issue in Indian subcontinent. Method and Material: From dec 2014, on going prospective study, following up 47 patients of Chronic myeloid leukemia (CML), chronic phase with no other significant comorbidities. We evaluated Sokal, Hasford and EUTOS indices in these patients at diagnosis and have evaluated responses [complete hematological and early molecular response (EMR) by bcr abl1/abl1 (IS)] at 3 months and 6 months. Results: 12 patients have reached 3 months period of follow up, all patients have achieved complete hematological response, but only 7 patients have achieved the adequate EMR of\10 % and rest 5 patients have not achieved response. Majority of patients who achieved response at 3 months had been either low or intermediate scores at diagnosis and all 5 patients with inadequate response had high EUTOS score. The two patients who have reached 6 months follow up have not achieved the adequate molecular response of \1. Conclusion/Diagnosis/Impression: Our study is still ongoing and the current early results show that the EUTOS and Sokal risk scores at diagnosis might predict the EMR better than Hasford score. Bar diagram showing the patients initial prognostic scores and early molecular response at 3 months:
Nrs Medical College and Hospital Introduction: Myelodysplastic syndrome (MDS) is characterized by dysplastic morphology in the bone marrow in association with ineffective hematopoiesis. h-MDS accounts for 12–17 % of all MDS with low bone-marrow cellularity for age, is difficult to distinguish from acquired aplastic anemia and most likely respond to treatment with immunosuppressive agents (IST). There is littlepublished literature on the clinical and treatment profile in hMDS from India. Materials and Methods: All adults diagnosed with hMDSat CMCH between January/1998–June/2012 were analyzed. Data was collected from institutional medical records and analyzed using SPSS software version 16.0. Results: Out of total 1225 patients diagnosed to have MDS during study period, 173 (14.1 %; 112 males and 61 females) were diagnosed to have hMDSwitha median age of 41 years (range:18–64). Majority (n = 163;94.2 %) presented with anaemia, while 65.3 % (n = 113) hadpancytopenia and 46.2 % (n = 80) of 10 had bilineage dysplasia at diagnosis. Karyotypic data was available in 155 patients; 63.7 % (n = 116) hada normal karyotype while 15/39 with abnormal karyotype had complex karyotype or monosomy 7. Of the 111 patients who were evaluable for treatment response, 87 (78.4 %) showed response to treatment. Response to Cyclosporine (n = 59) was significantly better than response to androgens (n = 24); [69.5 % vs 47.1 %; p = 0.017]. Seven of 10 patients who received ATG with Cyclosporine also showed a response. With a median follow up period of 110 months (range: 1–178), the 5 year OS & EFS of the entire cohort is 61.9 % ± 7.2 % and 37.9 % ± 7.8 % respectively. Conclusions: hMDS, a disease of unknown etiology needs to be distinguished from aplastic anemia and is associated with a relatively good prognosis with reasonable response to IST.
OR 122 Early Molecular Response In Chronic Myeloid Leukemia Chronic Phase Patients—A Single Centre Experience Dr. Prantar Chakrabarti, Dr. Prakas K Mandal, Dr. Tuphan Kanti Dolai, Dr. Shyamali Dutta, Dr. Rajib De Kidwai Memorial Institute of Oncology
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OR 123 An Analysis of The Demographic Profile, Clinical Manifestations, Investigations and Outcome Of Paediatric Myelodysplastic Syndrome : A Single Centre, Cross-Sectional Study L Appaji, K C Lakshmaiah, Lakshmi Devi, Prasanna Kumari, Mangesh Kamath Dr. Rohini Choudhuri Paediatric MDS is a relatively rare entity, with distinct clinical features and more aggressive course than its adult counterpart. On retrospective analysis of 1094 cases of pediatric hematological malignancies over a five year period from September 2009 to August 2014, a total of seven cases of paediatric MDS were identified. Presenting complaints, physical examination, investigations including haemogram, biochemistry, bone marrow examination and cytogenetics were reviewed. The diagnosis of MDS was made if there was dysplasia in at least 10 % of cells in two or more cell lineages. All patients were risk stratified using the revised IPSS. There were only seven cases of paediatric MDS with an incidence of 0.6 %. There
Indian J Hematol Blood Transfus were no genetic predispositions nor any cases of therapy related MDS. The most common presentation was with fever and all patients had significant splenomegaly. All patients had anaemia (Median-6.2 gm/dL) with elevated WBC counts (Median-30,900/uL) and thrombocytopenia (Median-50,000/uL). The marrow cytogenetics were normal in five patients. Most patients fell into the high and very high risk category with only two patients of low risk. All seven patients were given only supportive care but one progressed to AML for which he was treated with remission induction. Only two patients were alive at the time of analysis and median survival was 9 months. Paediatric MDS is a rare disease with a short clinical history, aggressive course and generally poor outcomes as compared to the adult variant. A hematopoietic stem cell transplant may be the only viable option for survival.
OR 124 Data Base Study of Cml On Tyrosinase Kinase Inhibitors (Tki) In Last 5 Years Dr. Rohini Choudhuri B. R. Singh Railway Hospital Introduction: Chronic Myeloid Leukaemia is the commonest leukaemia in India. It occurs as a result of translocation between chromosome 9 and 22. We conducted an epidemiological study among patients of CML treated in our hospital. Primary TKI resistance defined as failure to achieve complete haematological response after 3 months or molecular response in optimum duration. Secondary resistance occurs when a patient on TKI relapsed after initial response. Aim & Objective: To study demographic and epidemiological features of CML patients in a referral central railway hospital. Subject and Methods: Total 90 patients were selected as per inclusion criteria, 65 male and 35 female from May 2010 to April 2015. Initially all patients have undergone necessary work up for diagnosis. During follow up, complete blood count with peripheral smear examination every monthly and RT–PCR every 3–6 monthly were done. ALL patients were treated with TKI. Total 70 patients received imatinib, 2 patients died of other organ dysfunction like CVA and MI. Total 10 patients received dasatinib, among them 2 patients received upfront due to their young age of 19 and 35 years. Rest 10 had resistance to imatinib. Only 1 patient in dasatinib group died due to associated pleural effusion with blast crisis. Total 8 patients received nilotinib, 4 as upfront therapy due to young age, 4 patients had resistance to imatinib. Total 2 patients receiving nilotinib died of blast crisis. Mutation study of resistant patients was not done. Conclusion: Imatinib is the best TKI as upfront therapy in CML. In resistance cases, drugs like dasatinib and nilotinib should be considered.
OR 125 Bonemarrow Fibrosis_Condition with Various Underlying Disorders G. Kanimozhi, S. Sri Gayathri, Febe Renjitha Suman Sri Ramachandra Medical College, Chennai Introduction: Bone marrow fibrosis is a common morphological finding in trephine biopsies. It can be of various grades and severity in various lesions. However histomorphology alone cannot distinguish the underlying disorders. It can be primary/idiopathic and secondary to myeloproliferative neoplasm and nonhematopoietic disorders. Fibrosis occurs relatively frequently in the evaluation of chronic myeloproliferative neoplasms. It is characterized by initially by the deposition of increased reticulin fibers. 50 % of Primary myelofibrosis patients can
be associated with JAK2V617F mutation. Materials and Methods: Clinicopathologic analysis of patients identified with marrow fibrosis in our department from June 2013 to May 2015 was done. Their clinical examination findings, hematological picture and histomorpholgical findings were analysed. Reticulin and Massons trichrome stains were done to grade the fibrosis. Results: 18 patients were identified with bone marrow fibrosis in the 2 year period. The patients ranged from 14 years to 70 years of age. M:F ratio was 4:5. The underlying etiology was identified in 30 % of patients. It included AML, CML and MDS. Others were suspected to have Primary Myelofibrosis and was advised JAK2V617F mutational analysis and BCR-ABL gene analysis. Conclusion: Thus Bonemarrow fibrosis is a common histologic finding which is easy to identify, however its difficult to point out the underlying etiology. Keywords Bonemarrow fibrosis, Primary Myelofibrosis, Myeloproliferative neoplasms, Reticulin stain
OR 126 Survival of T315I Mutated Cml Patients In Indian Scenario Dr. Madhav Danthala, Dr. P. K. Chaitanya, Dr. G. Sadashivudu, Dr. M. Lakshmi Srinivas Nizams Institute of Medical Sciences Introduction: CML with T315I mutation has been reported to have poor prognosis. We analyzed the survival and management of these patients in Indian scenario where Allogenic bone marrow transplantation and Ponatinib are out of reach for the common man due to financial constraints and non-availability of drug in India. Materials and Method: All patients of CML with T315I mutation at our institute from January 2007 to May 2015 were retrospectively analyzed with demographic characteristics, risk scores, treatment, responses, toxicity and outcomes. Results: The median age at diagnosis of mutation detection is 40 years (8–50) with male preponderance (88 %). EUTOS score is low in 12 patients (70.5 %) and it is high in 5 patients. Median time from the initiation of Imatinib to T315I mutation detection is 51 months (8–144). All of them were treated with Hydroxyurea and supportive care. Five (29.4 %) patients out of 17 diagnosed as CML with T315I mutation are in complete haematological response at the time of mutation detection and are alive. Eight patients had expired with intracranial bleed and 4 patients with sepsis and respiratory failure. Median time from the time of mutation detection to death is 17 months (1–33). Median overall survival is 57 months (11–147). Conclusion: Though CML with T315I mutation patients have poor prognosis, patients who are in complete haematalogical response at the time of mutation detection are doing well when compared to other patients. CML risk scores (Sokal, Hasford, Eutos)are neither predicting the Imatinib resistance nor survival. Early recognition of these patients before progression into accelerated/blast crisis may help in prolonged survival of these patients.
OR 127 Additional Cytogenetic Abnormalities In Cml-Cp At Diagnosis: Poor Short Term Outcome With Frontline Imatinib Therapy Dr. Uttam Kumar Nath, Dr. Siddhartha Sankar Roy Ihtm, Medical College Introduction: Additional chromosomal abnormalities have been reported in 5–15 % CML-CP patients at diagnosis. The impact of ACA at diagnosis on Imatinib treatment response is not clear. Presence of ACA at diagnosis is regarded as ‘warning’ by European LeukemiaNet (ELN2013). The objectives of our study were to (1)
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Indian J Hematol Blood Transfus Observe the incidence of ACA at diagnosis of CML-CP, and (2) Compare response to Imatinib treatment in patients with and without ACAs. Methods: Newly diagnosed CML-CP patients treated with Imatinib were included. 28 patients from December 2014 were prospectively studied and data of 46 patients from January 2013 were retrospectively analysed. Molecular response at 3 and 12 months and cytogenetic response at 6 and 12 months were studied. ELN2013 guidelines were followed for treatment response assessment. Results and Discussion: 9 out of 74 patients (12.1 %) had ACA. Out of 5 such patients in the prospective arm, 3 had warning molecular response at 3 months and only 1 who completed 6 months of therapy had PCyR. Out of 4 patients with ACA in the retrospective arm, 2 are in complete molecular response (CMR) on Imatinib, 1 had warning response at 1 year but attained CMR at 24 months and 1 had failed CCyR at 12 months and progressed to accelerated phase. The short term outcomes appear to be worse in patients with ACAs at diagnosis as compared to CML-CP patients without ACAs, where CCyR at 12 months was 85.7 % (36/42 patients) in retrospective arm and optimal molecular response at 3 months was 95.6 % (22/23 patients) in prospective arm.
OR 128 Treatment Outcomes In Chronic Myeloid Leukemia In The Tki Era: A Single Centre Experience from Kerala Neeraj Sidharthan, Pavithran Keechilat
Introduction: The Philadelphia chromosome t(9;22)(q34;q11)is the hallmark genetic abnormality in CML.sCML is a disease evolving in three phases, chronic, accelerated & blast phases, with varying presentation & outcomes. Progression is characterized by clonal evolution, with additional cytogenetic abnormalities in 80 % cases. The most frequent abnormalities are trisomy 8 (34 %), isochromosome 17 (20 %), and duplicate Ph chromosome (38 %). Others, like trisomy 19, trisomy 21, trisomy 17, and deletion 7, are found in \10 % of cases. Materials and Methods: We analyzed the cytogenetic results of CML patients treated in NRSMCH between 2010–2015. Bone marrow samples were obtained and cytogenetics studies were done. Patients were treated according to disease status. Results: Among 408 patients, median age of presentation was 40 years (range 11–72 years), M: F ratio was 1.92: 1. The most common clinical features were splenomegaly-382 (93.75 %), pallor 158 (38.8 %), hepatomegaly-84 (20.8 %) Median WBC counts at diagnosis was 74800 (range 1300–273000), mean Hb 9.7 g/dl, thrombocytopenia in 25 patients. Most patients were treated with imatinib. Additional cytogenetic abnormalities were present in 43 patients (10.5 %). The most common cytogenetic abnormalities were as follows: +8(23.25 %), complex karyotype (23.25 %), extra Ph + (18.60 %), del 7 (11.6 %), Y chromosome abnormalities & hyperdiploidy (9.3 % each), +19 (6.9 %). Other abnormalities detected were del5q, del12p & multiple rearrangements involving chromosome 1, 3, 8. Conclusion: Additional cytogenetic aberrations are present in 10.5 % cases of CML; trisomy 8, extra Philadelphia chromosome & complex karyotype being most common.
Amrita Instiute of Medical Sciences Introduction: The advent of tyrosine kinase inhibitors (TKI) has revolutionalised the therapy of Chronic myeloid leukemia (CML). From a dismal 45–50 % 5 year survival in the 1990’s, the 5 year survival in 2010’s has improved to over 93 %. There is paucity of data from Kerala in particular and from India in general. We present a retrospective analysis of survival data on patients with CML— Chronic phase on TKIs. Materials and Methods: Electronic medical records of patients with CML who had at least 6 months follow up on TKI therapy were analysed for Sokal score, hematological parameters, serial cytogenetics, serial RQ-PCR for BCR-ABL transcripts and events. The events analysed were 0.5 log increase in PCR transcripts, failure to achieve 10 % and 1 % milestones, loss of CCyR, loss of MMR, loss of CHR, TKI intolerence, disease transformation, CML mortality and non-CML mortality. Results: There were 66 patients. All but two patients were in early chronic phase at the time of initiating TKI therapy. The median follow up was 33.5 months. The median EFS, PFS and OS were 31 (S.D. 21.7), 32 (S.D. 21.3) and 33 (S.D. 25.2) months respectively. There were total 22 events in 19 patients. 43 of the 64 (67.2 %) evaluable patients achieved MMR. 34 of the 63 (54 %) evaluable patients achieved CMR. 3 patients had disease transformation and 2 died. One patient died of pulmonary disease while in MMR. Conclusions: With advent of Imatinib and the patient assistance programme (GIPAP) we are able to replicate treatment outcomes as in the West.
OR 129 Prevalence of Additional Cytogenetic Abnormalities In Patients With Cml—A Study from A Tertiary Care Centre In Eastern India Dr. Tuphan Kanti Dolai, Prof Prantar Chakrabarti, Dr. Rajib De, Dr. Prakas Kumar Mandal, Dr. Basab Bagchi Nil Ratan Sarkar Medical College and Hospital, Kolkata
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OR 130 Differences In Cell Population Data (Cpd) and Angiogenesis In Myelodysplastic Syndromes Dr. Joy Mammen, Dr. Marie Therese Manipadam, Dr. Biju George Christian Medical College Background: Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders characterized by peripheral blood cytopenia (s), dysplasia in bone marrow precursors and an increased propensity to develop acute leukemia. In addition to the bone marrow study, the dysplastic changes in the cells can be identified as alterations in the cell counter values which may point towards the presence of disease. Increased angiogenesis has been demonstrated in marrows of multiple myeloma and acute leukemia. Aims: To study the cellular changes and stromal vascular alterations in MDS. Methods: The Cell Population Data (CPD) values of 68 cases with MDS were compared with 155 non MDS patients and 98 normal healthy blood donors. The microvessel density in trephine biopsies of 101 MDS cases wascounted using immunohistochemistry for antiCD34 by ‘‘hotspot’’ method and was compared with 35 normal controls. Results: There was a significant increase in the mean neutrophil volume and monocyte volume in MDS cases compared to non MDS and healthy donors (p-value: 0.000 and 0.000 respectively). A significant decrease in the neutrophil scatter and eosinophil scatter werenoted in cases of MDS in contrast to non MDS and normal controls (p-value = 0.000 and 0.000 respectively). A significant increase in the bone marrow mean MVD in cases of MDS was noted compared to the control marrows (p-value = 0.000). Conclusion: There is a difference in the cell population data (CPD) in MDS which can be detected at an early stage even before a bone marrow examination. The increased MVD in MDS is a potential target for antiangiogeneic therapy.
Indian J Hematol Blood Transfus
Topic: Plasma Cell Disorders
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Distinct Clinico-Hematological Profile of Plasma Cell Leukemia Patients from North India: A Tertiary Centre Experience
Karyotypic Abnormalities In Multiple Myeloma Dr. Vijaya Mysorekar, Dr. Anil Kumar, Dr. Vinayak Maka, Dr. Nalini Kilara M. S. Ramaiah Medical College and Hospital Introduction: Multiple myeloma (MM), a plasma cell malignancy is a heterogenous disease both at genetic level and in terms of clinical outcome. Chromosome aberrations in MM are typically complex and represent a hallmark of the disease, involving many chromosomes that are altered numerically and structurally. Materials and Methods: MM was diagnosed based on clinical features, radiological findings, bone marrow aspiration, biopsy and protein electrophoresis. 15 such cases in a period of last 2 years were studied for their cytogenetic abnormalities. Conventional cytogenetic karyotyping was performed on the bone marrow aspirates and the metaphases of the chromosomes were analysed. Results in Breif: Out of the 15 cases analysed, 8 cases (53.4 %) showed normal karyotype and 7 cases (46.6 %) showed cytogenetic abnormalities. Of these 7 cases majority of them (71.4 %) showed both structural abnormalities and hyperdiploidy of chromosomes. Most common chromosomal abnormality was trisomy and maximum trisomies were seen in chromosome 13 and 19. Monosomy was most commonly noted in chromosome 13 and 14. Most aberrations were seen in chromosome 1 and 13. Other chromosomes with various numerical and structural abnormalities were 2,3,5,6,7,8,9,11,14, 15,16,17,19,20,21. Apart from additions and deletions, chromosome 1 was involved in translocation t(1;16) (2 cases). Conclusions: Genetic abnormalities are the main drivers of the significant heterogeneity seen in the disease in terms of clinical features, response to therapy, and the eventual survival outcomes hence it is important to analyse cytogenetics in patients of multiple myeloma. Keywords Multiple myeloma, Karyotypic abnormalities
Dr. B. K. Karthik Bommannan, Dr. Man Updesh Singh Sachdeva, Dr. Pankaj Malhotra, Dr. Neelam Varma, Dr. Radhika Srinivasan Postgraduate Institute of Medical Education and Research, Chandigarh Introduction: PCL is a rare and aggressiveplasma cell neoplasm whereclonal plasma cells comprise C20 % of peripheral blood (PB) leukocytesand/or absoluteclonal PB plasma cell count is C2 9 109/L. Primary plasma cell leukemia (PPCL) originates de novo, whereas, secondary plasma cell leukemia (SPCL) evolves from pre-existing multiple myeloma (MM). Materials and Methods: Clinico-hematologic profile (CHP)and survival of plasma cell leukemia patients were analyzed retrospectively. Results: From January 2007 to December 2014, ten PPCL and four SPCL patients were traced, all originating from Punjab and Haryana (8 PPCLs and 3 SPCLs had complete clinical data). Our patient cohort showed less frequent renal failure, more frequent hepatomegaly and non-secretory type disease. Flow cytometric immunophenotyping revealed expression of CD138 (67 %), CD56 (33 %) and CD20 (0 %), which is different from western literature. With novel therapeutic agents, these patients fared a higher median survival of 15 months. Conclusion: We highlight that our PCL patients from north-India have a distinct clinico-hematologic profile, with better survival as compared to west. The significance of our findings must be tested in a larger patient cohort and must be supported with molecular and cytogenetic investigations to unmask any significant pathogenesis. Keywords North India, Plasma cell leukemia, Immunophenotype
OR 133 Evaluation of Pet/Ct Scan In Myeloma Dr. Vandana Mahajan, Dr. Lakshmipathy K, Dr. Prasanth Ganesan, Dr. Venkatraman, Dr. Rejiv Rajendranath Cancer Institute
Figure: Karyotypic analysis of a patient diagnosed with multiple myeloma showing deletions in chromosome 1, 13. Monosomy 14, Trisomy 20, Translocation t(1;16).
Introduction: Myeloma accounts for thirteen percent of all haematological malignancies. Radiological assessment of extent of disease and assessment of response to treatment is currently by a skeletal survey or magnetic resonance imaging. We have evaluated the role of F18-fluorodeoxyglucose positron emission tomography (F18 FDGPET-CT) in myeloma. PATIENTS & METHODS Eligible patients with Multiple Myeloma (MM) and Plasmacytoma underwent a PETCT scan at the time of diagnosis and received treatment with either bortezomib or lenalidomide and dexamethasone. Patients who achieved remission (VGPR or more) were evaluated by PET-CT and conventional assessment for comparative purposes. Results: Twentyeight previously untreated patients (19 multiple myeloma, 5 solitary Plasmacytoma and 4 multiple plasmacytomas) with median age of 55 years (Range:42–77 years, M:F 17:14) underwent an initial PETCT Scan. Three patients (10.7 %) were upstaged to MM from Plasmacytoma after PET-CT Scan. After treatment, 7 (4 MM and 3 Plasmacytoma) patients underwent a PET-CT scan. Two patients had attained stringent CR and both of these were in molecular CR by
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Indian J Hematol Blood Transfus PET-CT. The other two patients had VGPR and their PET-CT scans showed uptake at a single site with SUV less than 2. All three patients with plasmacytomas following radiation had metabolic remissions. Conclusion: PET-CT Scan is a reliable tool in diagnosis and assessment of response of MM and Plasmacytoma. Larger studies and longer follow up are needed. Keywords Multiple myeloma, Plasmacytoma, PET CT
OR 134 Bone Marrow Plasmacytosis and Its Correlation With M Protein In Patients With Multiple Myeloma
survival (OS) as period from Auto-HSCT till death or last visit to clinic. TTP and OS were calculated and correlated to a number of different PET-derived parameters. Treatment or conditioning regimens were not modified irrespective of pre-transplant PET reports. Results: Of the 44 patients, data was complete for 36 patients, which were finally analysed. Presence of [20 focal lesions correlated with both lesser TTP (p \ 0.01) and poorer OS (p-0.03). Using cox regression model presence of extramedullary lesions, [20 focal FDG avid lesions, SUVmax and associated pre-transplant monoclonal gammopathy, best predicted disease progression. The mean survival and PFS were higher in pretransplant PET negative individuals, but not statistically significant (log rank p—0.668) (Fig 1A, B) secondary to smaller sample size. Conclusion: Our data underlines the prognostic value of pre-transplant 18FFDG-PET/CT in MM patients.
Vandana Puri, Meera Sikka, Mrinalini Kotru, Satendra Sharma Ucms and Gtb Hospital, Delhi Introduction: The International Myeloma Working Group criteria for diagnosis of multiple myeloma (MM) included presence of M proteins till 2014 when the new criteria were proposed, which required presence of involved:uninvolved serum free light chain ratio [100, clonal plasmacytosis [/= 60 % and [1 focal lesions on MRI, diagnosing lesions earlier than the manifest organ damage appears. The present study aims to correlate bone marrow plasmacytosis with M protein and peripheral blood rouleaux formation, and their association with CRAB features in newly diagnosed cases of multiple myeloma. Materials and Methods: A retrospective analysis of 83 cases of multiple myeloma diagnosed in our institution over a period of six years was done. Complete blood counts, examination of stained peripheral blood film, bone marrow aspirate examination, serum protein electrophoresis and urine examination for Bence Jones proteins were done. Results: Bone marrow plasmacytosis was present in 98 % cases. Peripheral blood rouleaux formation was seen in 67 % of cases. M band was present in 79/83 (95 %) cases; all the M band positive cases showed marrow plasmacytosis, however, 35 % of M band positive cases did not show rouleaux formation or increased ESR. Bence Jones proteins were positive in 40 % of cases. 80 % of patients with plasmacytosis had CRAB features at presentation. Conclusion: Five percent patients with MM did not show an M band despite having plasmacytosis in marrow. This highlights the importance of serum free light chain assay in these patients. Keywords Plasma cells, Bone marrow, M protein
OR 135 Pre Transplant 18 Fdg-Pet/Ct For Predicting Survival of Patients With Multiple Myeloma After Autologous Stem Cell Transplantation Kanhaiya, Alka Khadwal, Gaurav Prakash, B R Mittal, Neelam Varma Pgimer Background: Role of 18F-fluoro-deoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) in multiple myeloma (MM) for diagnosing, staging and prognosticating is evolving. There is scarcity of studies on the effect of role of pre-transplant PET scan in predicting the efficacy of autologous transplantation. Aim: The aim of this study was to investigate the prognostic value of 18F-FDGPET/CT in patients of MM undergoing autologous stem cell transplantation (Auto-HSCT). Patients & Methods: A total of 44 patients were recruited in the study. All patients had been heavily pre-treated with chemotherapy. All patients underwent Auto-HSCT with melphalan conditioning (140–200 mg/m2). Time to progression (TTP) was defined as period from transplantation to relapse/progression and overall
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Topic: Platelet Disorders OR 136 Stability of Immature Platelet Fraction (Ipf) On Two Automated Hematology Analyzers Dr. Aswathy Ashok Menon, Ms. Kavitha Ramanathan, Mr. Philips Jesuraj, Mrs. Josephine, Dr. Sukesh Chandran Nair Christian Medical College, Vellore Introduction: The immature platelet fraction (IPF) is a new parameter that is determined by fluorescence flow cytometry and reflects the presence of newly released platelets in peripheral blood. As it is a test that is gaining importance, we studied the stability of this parameter on two different haematology analyzers, Sysmex XN9000 and Mindray BC6800. Materials and Methods: Paired samples were collected from 23 voluntary blood donors; one was stored at lab temperature (22–24 deg C) and second stored at 2–8 deg C (specimen storage refrigerator). IPF was measured every 4th hour up to 24 h then at 32nd and 48th hours on both the analyzers. Results were tabulated using MS Excel sheet and analyzed using SAS 9.4 software. Results: The median IPF when performed on the Sysmex analyzer was 4 % (IQR = 2.5 %–5.10 %) and 4.10 % (IQR = 2 %–6.3 %) on the Mindray analyzer. The stability was found to be better at ambient laboratory temperature as compared to refrigerated storage. The IPF was stable for a longer period on the Sysmex analyzer (32 h) as compared to the Mindray analyzer (4 h), at room temperature. Bland– Altman statistics has been performed and will be discussed. Conclusion: Storage conditions, time of storage and the analytic platform, appear to be significant issues in the enumeration of IPF. These issues need to be addressed before this parameter can be offered as a reliable diagnostic tool, especially in centralized labs where pre-analytical transit time is increased or as an add-on test in others. Keywords IPF, Stability, Sysmex XN9000, Mindray BC6800
Indian J Hematol Blood Transfus OR 137 Study of Megakaryocytic Alterations In Bone Marrow Aspiration and Biopsy of Patients With Thrombocytopenia—A Hospital Based Study Dr. Sunita Y. Patil, Dr. Ashwini R Kle University, Belgaum Introduction: Thrombocytopenia is seen in various diseases where the cause is not known. Need For Study: The pathogenesis of thrombocytopenia in some diseases is still not clearly determined. At present, it is difficult to diagnose these diseases and estimate their prognosis with current clinical data only. However, since morphological alterations are seen in megakaryocytes in patients with thrombocytopenia. Hence the present study, aims to identify the different morphological alterations in thrombocytopenia of different causes. Materials and Methods: A prospective study of 100 patients with thrombocytopenia in whom bone marrow aspiration was done, were taken up for the study during the year 2014 and 2015 in KLE University’s Dr. Prabhakar Kore Charitable Hospital, Belgaum. Megakaryocytes were examined in bone marrow aspiration and biopsy specimens in terms of their number and morphology. Results: The patients in whom Bone Marrow examination was done included 29 % children, 71 % adults, 52 % males and 48 % females. The most common cause was Dimorphic anemia (46 %) followed by infectious diseases (13 %), Idiopathic thrombocytopenic purpura (12 %) and Acute Leukemia (8 %). The sensitivity and specificity of various parameters of megakaryocyte morphology like nuclear segmentation, presence of immature forms, dysplastic forms, emperipolesis, cytoplasmic and nuclear vacuolization, hypogranular forms were studied in the present study. Dysplastic forms were seen in 45 % of cases which included Megaloblastic anemia and other causes. Conclusion: Proper understanding of the morphological alterations of megakaryocytes in bone marrow specimens can lead to early detection of various haematological disorders and hence early treatment. Keywords Bone marrow aspirate and biopsy, Megakaryocyte alterations, Thrombocytopenia
OR 138 Long Term Outcome of Splenectomy For Immune Thrombocytopenia—A Single Institution Retrospective Study
therapy after splenectomy. Results: Data for evaluation was available for 29 patients. The shortest follow up was 2 months and the longest was 300 months (25 years). Median follow up 128 months. In this cohort, 9 patients had follow up up to 5 years; only 5 were in remission (CR rate 55 %). Follow up data up to 10 years were available for 17 patients out of which 9 patients had relapsed (CR rate 47 %). More than 10 year follow up data was available for 8 patients, out of which only 2 patients were in remission (CR rate 25 %beyond 10 years). Of these 8 patiens,5 had follow up up to 15 years (only 1 patient had sustained remission) and 3 had follow up beyond 15 years (1 out of 3 had sustained remission). There was no documented episodes of infection or post-operative mortality. However, patients post splenectomy relapse could be managed with a lower dose of corticosteroids compared to their pre splenectomy dose. Conclusion: This study helps to define long term outcome of patients with ITP after splenectomy. Although splenectomy normalizes platelet count acutely, sustained long term remission at 10 yrs may be achieved in less than 25 % patients. 29 ITP paents post splenectomy 1990- 2015
3 paents – 1 primary failure, 2 CR
< 1 year follow up
Follow up upto 5 years
9 paents - 5 CR ; 4 failure – 55 % CR rate.
Follow up upto 10 years
17 paents - 8 CR ; 9 failure – 47 % CR rate.
Follow up more than 10 years
8 paents - 2 CR ; 6 failure – 25 % CR rate.
Dr. V. Y. Vishnu, Dr. Shailendra Prasad Verma, Dr. Deepak Charles, Dr. K. V. Vinod, Dr. T. K. Dutta Jipmer Puducherry Introduction: Splenectomy is the only treatment that provides sustained remission in chronic ITP. Splenectomy has a success rate that approaches 50 % to 60 %. However, true long-term outcome is uncertain. This study includes follow up data from single institution retrospective analysis of adult patients with chronic ITP who had undergone splenectomy. Materials and Methods: We retrospectively reviewed the medical records of 29 patients who had undergone splenectomy for ITP in JIPMER hospital from January 1990 to June 2015. This included patients who were regularly following up in hematology clinic and those who were traceable by address. Complete response (CR) was defined as all post splenectomy platelet counts[150 9 109/L without treatment; partial response (PR) as platelet counts [ or = 50 9 109/L without treatment; and failure as platelet counts \50 9 109/L or receiving
10 – 15 year follow up = 5 paents ; 1 had CR, 4 failure.
> 15 year follow up = 3 paents ; 1 had CR, 2 failure
OR 139 Evaluation of Platelet Indices and Their Significance In Preeclampsia S K Behera, D P Mishra Mkcg Medical College, Berhampur Background: Pre-eclampsia is a condition which increases morbidity and mortality in pregnant women. Alteration in coagulation,
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Indian J Hematol Blood Transfus fibrinolysis and platelet function are believed to play an important role in pathogenesis. MPV and PDW are significantly higher and there is fall in platelet count in the patients. Aim: To evaluate the platelet indices and their significance in assessment of severity of preeclampsia. Materials and Methods: A study was conducted in the Department of Pathology, MKCG Medical College. A total number of 100 pregnant women in the third trimester of pregnancy were selected as study subjects. Among them 55diagnosed cases of preeclampsia were selected as cases (age range 18–35 years) and 45 normal healthy pregnant women as controls (age range 18–32 years). Evaluation of anticoagulated blood was done by Sysmex (XT 2000i) fully automated haematology analyser. Results: We found a significant difference in the platelet indices of patients and normal pregnant women. Platelet count decreased with severity of preeclampsia, while MPV, PDW and PLcr increased with severity of preeclampsia. Conclusion: The present study revealed that low platelet count is associated with preeclampsia. The information of the present study might enrich the knowledge of clinician for early identification of preeclampsia. Keywords Preeclempsia, Platelet indices
OR 140 A Prospective Study To Evaluate The Efficacy, Safety and Response Duration of Newly Diagnosed Adult Itp Patients Treated With Low Dose Rituximab and High Dose of Dexamethasone Dr. T. K Dolai, Dr. P. K Mandal, Dr. R. Dey, Dr. P. Chakrabarti, Dr. B. Bagchi Nrs Medical College, Kolkata, West-Bengal Introduction: Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder that involves antibody and cell mediated destruction of platelets as well as suppression of their production. Corticosteroids are initial standard therapy in adults. Initially Rituximab was approved as one of the important second line therapy in chronic ITP @ 375 mg/m2. In the present prospective study we will evaluate the efficacy, safety and response duration of low dose Rituximab (100 mg) and high dose Dexamethasone as a front line therapy in new onset adult ITP cases. Materials and Methods: Inj. Rituximab at a fixed dose of 100 mg iv infusion for four consecutive doses (day 1,8,15,22) and Dexamethasone tablet 40 mg PO for four consecutive days in a fifteen days interval (day 1–4 and day 15–18). Response rate evaluated according to published guidelines. Results: Total no. of cases enrolled 15 till date. Male-8, female-7. Age range 18 to 62 years. Median age 56 years. Course completed in 12 out of 15 patients. Median followup of the patients 6 month. CR achieved after 1st dose of rituximab in 1 cases, 2 after 2nd dose and 4 after 4th dose of Rituximab. Response achieved in 2 cases after completion of therapy and no response seen in 3 cases. All 7 cases achieving CR maintaining sustained response after 6 months of completion of therapy. Minor side effects like GI intolerance, nausea, vomiting occurred in 3 patients, High blood sugar level during treatment seen in 2 patients and severe adverse effects like pneumonitis and intestinal obstruction seen in 2 patients who needed hospitalization. We did not observe any infusion-related reaction. Conclusion: Complete response rate of Rituxiamb was 58.33 % (7/12). All Patients achieving CR shows sustained response after 6 months. Low dose Rituximab and high dose Dexamethasone is an useful treatment option in adult acute ITP patients. Keywords ITP, Rituximab, Dexamethasone
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OR 141 Effect of Carica Papaya Leaf Extract Capsule on Platelet Count In Patients of Dengue Fever With Thrombocytopenia Ajeet Kumar Gadhwal, B S Ankit, Chitresh Chahar, P. Sirohi, R. P. Agrawal Pbm Hospital Objective: Thrombocytopenia in dengue fever is a common and serious complication. However, no specific treatment is available for dengue fever induced thrombocytopenia. In few countries the leaf extract of Carica papaya has been effectively used for thrombocytopenia. Hence, the study is planned to access effect of Carica papaya leaf extract on platelet count in dengue fever patients. Methods: All participants were randomised into two groups, study group and control group; the study group was given papaya leaf extract capsule of 500 mg once daily and routine supportive treatment for consecutive five days. The controls were given only routine supportive treatment. Daily complete blood counts, plateletcounts and haematocrit level, liver function test, renal function test of both groups were observed. Result: On the first day platelet count of study group and control group was (59.82 ± 18.63, 61.06 ± 20.03 thousands, p \ 0.36). On 3rdday platelet count of study group was significantly higher than control group (82.96 ± 16.72, 66.45 ± 17.36 thousands, p \ 0.01). On 4th and 5thday platelet count of study group was also significantly higher than the control group. On 7thday platelet count of study group and control group were not significantly different (124.47 ± 12.35 and 122.46 ± 19.76 thousands respectively, p \ 0.08). Average hospitalization period of study group v/s control group was 3.65 ± 0.97 v/s 5.42 ± 0.98 days (p \ 0.01). Average platelet transfusion requirement in study group was less than control group (0.685 units per patient v/s 1.19 units per patient). Conclusion: It is concluded that Carica papaya leaf extract increases the platelet count in dengue fever without any side effect and prevents the complication of thrombocytopenia.
OR 142 Prevalence of Celiac Disease In Immune Thrombocytopenia Subhash Varma, Neelam Varma, Pankaj Malhotra, Rakesh Kochar, Sadhna Lal Pgimer Introduction: Celiac disease has proven association with numerous auto-immune diseases. There are anecdotal reports of co-occurrence of Celiac disease with ITP, but very few studies studying their relationship. Need for study To study the prevalence of Celiac disease defining autoantibodies in ITP patients. Materials and Methods: A cross sectional study of consecutive primary ITP patients presenting to our institute was performed. Patients with severe thrombocytopenia or currently on steroids were excluded. Serum tTG IgA and EMA IgA was performed. Age matched controls were included from healthy blood donors and the prevalence of tTG seropositivity was studied in them. Results: 79 cases of primary ITP and 316 controls were included. 3 ITP patients had significant titer of tTG IgA with EMA positivity. Among the controls two had significant titer of tTG IgA. tTG seropositivity showed a six times higher association with ITP. [OR:6.19 (CI:1.01–37.74)] but the difference was not significant. [Fisher’s exact test (1 tail) p = 0.0567465] Discussion The proposed theories for co-occurrence of CD with ITP include variations in the
Indian J Hematol Blood Transfus genes involved in CTLA4/TLR4 pathway, shared HLA antigens and the altered immunity due to CD leading to ITP. Till date there are only 2 studies on their co-occurence. A prospective cohort study with a similar study population failed to show a significant correlation, but a very large retrospective study conducted by Olen et al. showed significant correlation. Conclusion: Celiac disease has an association with ITP but further studies are required to conclusively prove the same. Table Shows the studies done till date on association between CD and ITP Study
Size
Design
Result
1
Altintas et al., Turkey
74
Prospective cohort study
AGA IgG significantly increased in cases.
2
Rischewski et al., Switzerland
24
Cross sectional study
0/24
3
Fisgin et al., Turkey
22
Case series
1/22
4
Olen et al., Sweden
14,347
Registry based cohort study
HR 1.91
15,382
Registry based case control study
OR 2.96
OR 144 Efficacy of Low Dose Rituximab In Chronic Immune Thrombocytopenic Purpura Institute of Haematology and Transfusion Medicine, Medical College, Kolkata Introduction: Rituximab in low dose (100 mg/m2 weekly for 4 cycles) have been shown as treatment options in chronic Immune thrombocytopenic purpura (ITP). This study describes efficacy of low dose rituximab on patient of chronic ITP. Need for study—Rituximab, in ITP, can be used in high or low dose and the response rates are different in different studies. Very little data is available on Indian population. Aim of the study is to find the efficacy of low dose rituximab in chronic ITP. Materials and Methods: It is an interventional cohort study done at IHTM, Kolkata between October 2015 to April 2015. Inclusion criteria of the study was chronic ITP with platelet count \30,000/cmm. Exclusion criteria were secondary ITP or presence of cardiopulmonary disease, T2DM, hepatic & renal impairment. Included patients were given low dose rituximab weekly for 4 weeks. Initial platelet monitoring was done fortnightly, then monthly. Response was assessed as follows-Complete response (CR): A platelet count C100 9 109/L; Response (R): A platelet count C30 9 109/L; No Response (NR): A platelet count \30 9 109/L. Adverse events were also noted. Results in brief- Out of 15 patients included in the study, all are refractory to prednisolone, and one is splenectomized. At a median follow up of 6 months, three patients achieved CR (20 %); 2 had R (13 %) & 10 had no response (67 %). Significant toxicity was observed in none of them. Conclusions: Overall response rate of low dose rituximab in this study is 33 %.
OR 143 Durable Response of Eltrombopag In Treatment of Adult Itp Anil Kumar Tripathi, Mona Vijayran King George Medical University Introduction: Immune thrombocytopenia (ITP) in adults is usually a chronic disease. First line treatment of ITP is steroids followed by splenectomy, rituximab or thrombopoietin receptor analogue (Eltrombopag) if insufficient response to steroid. Eltrombopag causes rapid elevation of platelet count but usually responses are ill sustained. In this retrospective study we analyzed the long term effect of eltrombopag in patients with ITP. Materials and Methods: We retrospectively analyzed the records of ITP patients who received Eltrombopag as second line or third line treatment. Patients receiving at least 1 month treatment of Eltrombopag were eligible. Results: Nineteen patients, 12 females and 7 males with an average age of 31.3 years were analyzed. Eltrombopag was started in these patients either alone (7 patients) on in combination/add on treatment with steroids (11 patients) or Rituximab (1 patient). Median number of prior therapies was 2 (1–4) Response data was available only for 8 patients as second line and 3 patients as third line treatment. When used as second line treatment patients achieved CR in 5 (63 %0) and PR in 3 (36.3 %) patients. When used as thirdline, all 3 patients had complete response. Average duration of Eltrombopag exposure was 5.6 months (3–10 months). Time to early response was 11 days (3–30 days) and time to maximum response was 24 days (10–60 days). In 9 eligible patients for long term response analysis, duration of response was 11.5 months (1–36 months). Three (33 %) of these 9 patients could maintain platelet count for[1 year off treatment suggesting long term effect of eltrombopag is possible. Conclusion: Eltrombopag can produce long term durable response in up to 1/3rd of the cases. It can be considered as one of the promising agents for long term responses in adult immune thrombocytopenic purpura.
OR 145 Mean Platelet Volume and Its Association With Multiple Morbidities In Very Low Birth Infants Dr. Chandrakala Bs, Dr. Suman Rao, Dr. Sitalakshmi S, Jessy Chacko St Johns Medical College Introduction: Mean platelet volume (MPV) is an important predictor of morbidities in adults. There is much data on the use of platelet count in very low birth weight infants (VLBW) with morbidities, but there is limited data regarding the MPV in this group. Hence this study was undertaken to assess the correlation between MPV and occurrence of multiple morbidities in a cohort of VLBW infants. Materials and Methods: 60 infants with birth weight of \1500 g with at least one of the following morbidity—retinopathy of prematurity, intaventricular hemorrhage, necrotizing enterocolitis, respiratory distress syndrome or sepsis, were enrolled retrospectively in the study. They were divided into two groups—29 infants with [1 morbidity and 31 infants with single morbidity. The platelet indices obtained by analyzing anticoagulated blood within 6 h of life was recorded and analyzed. Results: The platelet count in the study group was significantly lower (p = 0.002). MPV was 11.32 ± 1.07 fl and 9.94 ± 0.66 fl in infants with multiple and single morbidities respectively and was significantly higher in the study group (p \ 0.0001). MPV at a cutoff value of [10.09 fl was found to have significant predictive value for the presence of multiple morbidities with a sensitivity of 60 % and specificity of 52 %. Conclusion: High MPV values in the first few hours of life may reflect the presence of risk factor for the development of multiple morbidities in VLBW infants. Keywords Very low birth weight infants, Mean platelet volume, Morbidity
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Indian J Hematol Blood Transfus OR 146 Mean Platelet Volume In Rheumatoid Arthritis and Its Correlation With Clinical and Radiological Features
dysfunction in ITP patients (n = 43, 29 %), thyroid function tests should be a part of secondary ITP work up. Keywords ITP, Hypothyroidism
Sadhna Marwah, Vijay Kumar, A S Nigam, Gurdeep Buxi Pgimer, Dr. Ram Manohar Lohia Hospital, New Delhi Introduction: Rheumatoid arthritis (RA) is a chronic inflammatory disease marked by a symmetric, peripheral polyarthritis and elevated levels of acute phase reactants like erythrocyte sedimentation rate, C-reactive protein, ferritin, etc. Platelets are an important component of thrombogenesis and are also involved in inflammation. Some platelet markers, including Mean Platelet Volume (MPV), have been found to correlate with inflammation. The present study evaluates MPV in patients with RA and to assess its correlation with disease activity. Materials and Methods: 37 patients with RA diagnosed by the American College of Rheumatology/European League against Rheumatism 2010 criteria and who were more than 18 years of age were included in the study. Equal number of age and sex matched controls were also included. Disease severity was assessed using Disease Activity Score 28, Health Assessment Questionnaire and Sharp/Van Der Heijde Score. MPV was compared between cases and controls. Further, MPV was correlated with disease severity in patients. Results: Mean values of MPV were significantly higher in patients with RA as compared to controls. In addition, MPV showed negative correlation with platelet count. However, MPV did not show significant correlation with disease severity. Conclusion: MPV was found to be a useful inflammatory marker in RA, although no correlation was seen with disease severity. Keywords Mean platelet volume, Rheumatoid arthritis, Inflammatory marker
OR 147 Thyroid Dysfunction In Immune Thrombocytopenia: More Than An Association Renu Saxena, Nikhil Tandon, Manoranjan Mahapatra Aiims Background: Primary ITP is an autoimmune disorder characterized by isolated idiopathic thrombocytopenia. In secondary ITP, treatment of underlying condition helps in recovery of platelet counts. Mildmoderate thrombocytopenia is seen in hyperthyroidism due to reduced platelet survival and in hypothyroidism due to impaired production. This study was conducted to assess prevalence of thyroid dysfunction in ITP. Methods: This prospective study included patients aged [12 years, diagnosed as ITP. Serum T4 and TSH levels and anti thyroid peroxidise (TPO) antibodies were done by electrochemi-illuminence method. Those with thyroid dysfunction were treated accordingly in addition to immunosuppressive therapy for ITP. Results: 168 patients of ITP were enrolled, with thyroid function tests available in 146 patients. Mean age was 30.6 years, with 67.8 % females (n = 114) and only 23 newly diagnosed (15 %). Abnormal T4 were present in 29 patient and abnormal TSH in 26 patients. Anti TPO antibodies were demonstrated in 9 patients (31 %) with abnormal T4 (p value 0.038) and 14 patients (54 %) with raised TSH (p value 0.021) suggesting autoimmune pathology. Subclinical hypothyroidism was present in 14 patients. Abnormal T4 (p value 0.04), TSH (p value 0.039) and presence of anti TPO antibodies (p value 0.02) were associated with chronic ITP but not response to treatment. Summary/Conclusion: Disproportionately low TSH can be seen with patients on glucocorticoids causing abnormal relation between T4 and TSH. Due to increased prevalence of thyroid
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OR 148 Itp: A Single Centre Experience on Response To Steroids and Surgery Sanjukta Rao, Delon D’Souza, Abdul Matheen, Ratnamala Chaudhary, Rekha Pradeep St. John’S Medical College Introduction: Immune mediated thrombocytopenia (ITP) is mediated by platelet autoantibodies that accelerate platelet destruction and inhibit their production. Most cases are considered idiopathic, whereas others are secondary to coexisting conditions. Steroids form the mainstay of treatment with other drugs like Azathiporine, Danazol, Rituximab being used in conjunction. Splenectomy is a therapeutic option when there is no response to medical management. Materials and Methods: We identified 250 consecutive patients with the diagnosis of ITP treated in the hematology department at St John’s Medical College Bangalore. Necessary tests were done to evaluate any secondary causes of ITP. Baseline characteristics including symptoms and duration, initial platelet count were documented. Clinical response was assessed at the end of three months of initial treatment. In patients who underwent splenectomy, response at 3 months post surgery was assessed. Results: 179 female and 71 male patients were diagnosed with ITP. Petechiae (42 %) and gum bleeds (31.6 %) were the common presenting symptoms at admission. The mean platelet count at admission was 15606 with the mean symptom duration being 100 days. About 114 patients (45.6 %) were receiving steroids while the rest received combination therapy with another immunosuppressant. 34 % had complete response on steroids alone and 15.2 % had no response. 119 patients underwent splenectomy out of which 80 % achieved complete response. Conclusion: Immune mediated thrombocytopenic purpura is more common in women, with most common presentation being superficial mucosal bleeds and DUB. About one-third of patients achieve complete response on steroids alone. More than half the patients require combination therapy. 80 % of patients who underwent splenectomy achieved response.
OR 149 Thrombopoietin Levels In Primary Immune Thrombocytopenia Patient– A Case Series Ashutosh Kumar, Mili Jain, Rashmi Kushwah, A. K. Tripathi, S. M. Natu Kgmu, Lucknow Introduction: The pathophysiological changes in primary immune thrombocytopenic purpura patients affect megakaryocytic proliferation and maturation in addition to the immune destruction of platelets. In our study, we have evaluated alterations in megakaryocytic parameters and thrombopoietin levels in patient of primary immune thrombocytopenia. Materials and Methods: Prospective study of 41 newly diagnosed cases of primary thrombocytopenia patient was done in the Department of Pathology and Clinical Hematology, KGMU, Lucknow. The work up included clinical evaluation, complete blood count with peripheral blood smear examination, viral serology for HIV, HBsAg, HCV, ANA titres; serum thrombopoietin levels and bone marrow examination. Bone marrow reported as normal
Indian J Hematol Blood Transfus hematopoiesis was evaluated as controls. The megakaryocyte parameters analysed in our study included assessment of count, clusters, megakayoblast and micro megakaryocyte percentage, number of nuclear lobes, disjointed lobes, cytoplasmic granulations and vacuolations, platelet production, and emperipolesis. Results: Megakaryocytes were increased in around 53 % cases and decreased in 14.6 % cases. Clusters were seen in 41.5 % of cases. Megakaryoblasts were increased in 87.8 % cases. Out of all the cases, 26.8 % cases had functional megakaryocytes and in these cases the average functional megakaryocytes were only 4.3 % rest were non-functional. Dysplastic features such as Micromegakaryocytes were seen in 72.5 % cases, 65 % had disjointed forms and 85 % cases had cytoplasmic vacuolations. Emperipolesis was seen in 51.5 % cases. o Conclusion: Megakaryopoiesis shows important functional and quantitative alterations in patients of immune thrombocytopenia and have significant pathophysiological distribution. An evaluation of treatment response with respect to megakaryocytic morphology may be further studied.
OR 150 Platelet Function Tests At A Tertiary Care Centre: A Two Year Experience Dr. Arnab Chattopadhyay, Prof. Maitreyee Bhattacharyya Ihtm Introduction: Platelet function study is an important component in the workup of spontaneous mucocutaneous bleeding. Patients, otherwise asymptomatic, with complaints of such bleeds, often present at the Hematology OPD. Materials and Methods: Platelet function tests by light transmission aggregometry were performed over a period of two years (July 2012–June 2014) in one hundred and four patients who were referred to our centre for spontaneous mucocutaneous bleeds. All these patients had normal platelet counts and peripheral smears. ADP, Collagen, ristocetin and Arachidonic acid were used as the screening panel. Results: Male: Female ratio was 0.7:1, age range was 4 years to 63 years. Sixty-four patients (61.5 %) had normal platelet aggregation with ADP, Collagen, ristocetin and Arachidonic acid. of the remaining forty patients, fourteen patients were diagnosed to have Glanzmann thrombasthenia (13.5 %), seven with Von Willebrand disease (6.7 %), and two with Storage pool disease. In twelve patients where initial aggregation studies showed reduced (\30 %) aggregation to either ADP, Collagen, ristocetin or Arachidonic acid in various combination, in three patients repeat studies were found to be normal. In remaining patients, some aggregation abnormality to one or more of the agonists persisted, we could not categorize these patients into any clear cut platelet disorder. Conclusion: A screening panel is useful for Platelet function tests, but should be supplemented by additional reagents for definite categorization of platelet function disorder. Keywords Platelet function study, Light transmission aggregometry, Glanzmann thrombasthenia, Von Willebrand disease
Topic: RBC disorders OR 151 Assessment of Chronic Complications and Quality of Life In Sickle Ceell Patients Recieving Care At Three Hospitals Simeon Pierre Choukem, Eveline Dongho Ngouadjeu, Vincent Siysi Verla
Background: The World Health Organisation (WHO) has declared Sickle Cell Disease (SCD) a public health priority and has recommended that global management be implemented to reduce mortality, morbidity (chronic complications) and thus improve on quality of life (QOL). Countries such as USA and UK have reduced SCD mortality by implementing those recommendations. The implementation of these in African countries like Cameroon has been hindered by lack of information about the burden of the disease. Objectives: We aimed to record the chronic complications and estimate the QOL of patients with SCD and find their associated factors. Methodology: We carried out a hospital-based cross-sectional descriptive and analytic study in three hospitals. Data was collected using a questionnaire in which information on the yearly frequency of painful crisis, the types of SCD, the prevalence of chronic complications and mean SF-36 scores were recorded, as well as their potential respective associated factors. Data was analysed with STATA software. Results: The median age of diagnosis was 4.0 (IQR: 2.0–8.0) years and the median number of yearly painful crisis was 3.0 (IQR 1.0–7.0). The most prevalent type of SCD was SSFA2. The chronic complications that had the highest prevalence were; nocturnal enuresis, chronic leg ulcers, osteomyelitis and priapism (30.9, 24.6, 19.4, and 17.4 % respectively). The prevalence of stroke and avascular necrosis of the hip were 8.0 % and 13.1 % respectively. The median Sf-36 scores were 47.3 (IQR: 43.9–58.5) and 41.0 (IQR: 38.8–44.6) for the PCS and MCS respectively. Late age of diagnosis was found to be a potential risk factor. Conclusion and Recommendations: The prevalence of chronic complications was high and QOL below normal; and late diagnosis was found to be a potential risk factor. We recommend that national guidelines including a new-born screening program be put in place. Keywords Sickle cell disease, Chronic complications, Prevalence, Quality of life
OR 152 Spectrum of Infection In Sickle Cell Disease Children Sunil K. Agarwalla, Swayangprava Pradhan M. K. C. G. Medical College, Berhampur Introduction: Children with Sickle cell disease (SCD) are under risk for capsulated pathogens like streptococcus pneumonae, meningococcus, haemophilus influenzae type b and also salmonella, Chlamydia, mycoplasma & s.aureus. Pneumococcal sepsis and meningitis are major causes of morbidity and mortality in sicklers. The hypo-immune state in SCD is due to functional asplenia, opsonophagocytic defect, abnormal alternative complement pathway etc. Need for Study: The tribal odisha is endemic for SCD with many children dying even before getting treatment. Materials and Methods: 100 SCD children (0–14 years) presented to dept of paediatrics, M.K.C.G. MCH from 1st August, 2014 to 31st July, 2015 were investigated for routine and blood culture. Result: Out of all our cases highest incidence (40 %) of infection was seen in 6–10 years age group with male outnumber females as 3:2. Most cases found in unimmunised sicklers for both routine and specific category vaccine (40 %). Major infection noticed was malaria (36 %) followed by pneumonia (16 %). Among malaria plasmodium falciparum (50 %) leads than other species. Sicklers mortality was highest in 0–5 years (57 %) and major cause of death is malaria (57 %). After being treated 76 % child got cured, 14 % died and 10 % left hospital midway. Conclusion: The study summarise that male, homozygous (HbSS) in 6–10 years, in lower social class maximally infected in sicklers. In contradiction to previous hypothesis regarding heterozygous (HbAS) in SCD resist malaria infection, here malaria (Pf) is the major infection in sicklers also causing highest mortality. So our
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Indian J Hematol Blood Transfus study concludes that early treatment of infection and timely vaccination for VPD will give a better disease free life to sicklers. Keywords SCD, Infection, Vaccine
quality of life in terms of transfusion dependence. Therefore, aaaanti3.7 triplication along with b-thalassemia carrier detection may be a focus for genetic counseling. Keywords aaaanti3.7 triplication, b-Thalassemia carrier, Co-inheritance, Anemia
OR 153 Occurrence of Significant Anemia As A Result of Co-Inheritance of A-Triplication With B-Thalassemia Carrier State Lopamudra Chakravarty, Sila Chakrabarti, Maitreyee Bhattacharyya Institute of Haematology and Transfusion Medicine, Medical College, Kolkata Introduction: The –a3.7 rightward deletion is reported to be the most frequent a-globin deletion mutation worldwide, while frequency of the triplicated a-globin gene (aaaanti3.7 triplication) are very sporadically reported. aaaanti3.7 carriers show no clinical symptoms or significant haematological changes. Again b-thalassemia carriers are also clinically asymptomatic. But co-inheritance of aaaanti3.7 triplication and b-thalassemia worsen the clinical and haematological features having a moderate anemia ranging in severity from that of bthalassemia carrier state to that of thalassemia major. They are denoted as ‘Thalassemia Intermedia’ groups. These groups are either transfusion independent or start to become transfusion dependent later in life, usually after 3 years of age requiring transfusion at longer intervals than monthly. Objectives: To study the occurrence of aglobin gene triplication together with b-thalassemia carrier state in patients attending OPD and its effect on quality of life as defined by intermittent requirement of transfusion. Materials and Methods: A study on n = 43 individuals (mean age of 25.3 years) with 4.1 (± 1.22) A2 and 8.2 (± 2.82) haemoglobin were analyzed. Patients with Thalassemia Intermedia phenotype who’s HPLC was only suggestive of b-thalassemia carrier were investigated for the prevalence of aaaanti3.7 triplication. Genomic DNA was isolated from peripheral blood, DNA quality and quantity were measured with NanoDrop and PCR were carried out for ascertaining the presence of aaaanti3.7 globin gene by Single Tube Multiplex PCR method. Results: Among 43 individuals in this study 28 (65.12 %) were b-thalassemia carrier in which 28.57 % were co-existed with aaaanti3.7 triplication. 62.5 % population who co-inherited aaaanti3.7 triplication and bglobin gene mutation are moderately blood transfusion dependent and rest 37.5 % though did not require transfusion, still were anemic (Hb 9.53 ± 0.9). Conclusions: It may be stated from the study that coinheritance of triplicated aaaanti3.7 and b-thalassemia impair the
OR 154 Limitations of Pcr Based Assays In Prenatal Diagnosis of Thalassemia: Experience from A Tertiary Care Centre Soumita Choudhuri, Asif Iqbal, Professor Maitreyee Bhattacharya Institute of Haematology and Transfusion Medicine, Medical College, Kolkata Introduction: Prenatal diagnosis is an integral component of our endeavor to diminish the burden of thalassemia. PCR based assays have been used for antenatal diagnosis of thalassemia. Timely diagnosis is essential for effectiveness of the program. Inherent flaws in the assay have created major challenges in this respect. Materials and Methods: Women attending the Antenatal Clinic from January 01, 2014 to June 30, 2015, were screened for thalassemia carrier status. Common globin chain mutations were analyzed by ARMSPCR. Chorionic Villus Sampling under ultrasonography guidance was done in between 10–12 weeks gestational age. Results: After informed consent, 5418 mothers were screened for thalassemia carrier status by Hb-HPLC. 1019 mothers were detected as Thal-carriers. After screening of the husbands, 360 (35.32 %) carrier couples were identified. They underwent mutation analysis. Mutations that were not detected by conventional probes were labelled as ‘uncommon’ and were sent to higher centers for gene sequencing. Among antenatal mothers, 24 (6.67 %) had uncommon mutations (Table 1). 18 (5 %) carrier husbands were found to have uncommon mutations. Chorionic Villus sampling was done (n = 182, 50.56 %) in those who fulfilled all eligibility criteria. Among the CVS samples analyzed, 26 (14.3 %) had uncommon mutations. However due to logistic reasons, the results of gene sequencing could not be retrieved before the allowable period of termination of pregnancy. Conclusion: PCR was unable to detect mutations beyond the commonly used probes. We therefore suggest that Gene Sequencing be incorporated routinely in the prenatal diagnosis program for timely and effective prevention of birth of thalassemic children in our country. Keywords ARMS PCR, Prenatal diagnosis, Thalassemia, Chorionicvillus sampling, Globin chain mutations
Table 1 Distribution of Globin Chain Mutations in carrier couples and corresponding CVS samples IVS 1–5
HbD
CD15 (G-[C) CD 41/42
CD30 HbS CD879 HbE Delta Beta 126 619 Unknown Total
Father
206
1
17
17
16
5
0
75
3
2
0
18
360
Mother
223
1
13
6
7
3
1
78
1
2
1
24
360
CVS Samples Homo zygous Hetero zygous Normal Unknown
Non compliant Total
50
178
123
68
38
26
360
Indian J Hematol Blood Transfus OR 155 Thalassemia with Hepatitis C Infection and Hepatic Fibrosis: Experience at a Tertiary Care Centre of Eastern India Prof Maitreyee Bhattacharyya, Dr. P C Sadhukhan, Aritra Biswas Ihtm, Medical College, Kolkata Background: Regular blood transfusion in patients with thalassemia has improved their overall survival, but carries a definite risk of acquisition of blood-borne viral hepatitis. Moreover, HCV infection have been shown to have a potentiating effect on hepatic fibrogenesis in thalassemic patients who are already overloaded with iron. Objective: To study the prevalence of iron overload and hepatic fibrosis in thalassemia patients with hepatitis C infection in a tertiary care hospital of Kolkata. Method: Data were collected in between June 2014 to May 2015 from the patients who visited Thalassemia Clinic of the hospital. Patients’ age, gender, type of thalassemia and mutation, transfusion requirement, liver function test, serum ferritin were taken into consideration. They were assessed by transient elastography (TE) of liver by FibroScan. Fifty age and sex matched thalassemia patients who were non-reactive to anti-HCV antibody were taken as control. Detection of Hepatitis C RNA, viral load and genotype were also done. Results: Among 712 patients, 77 (10.8 %) were positive for anti-HCV antibody. 53 % patents had a diagnosis of HbE-Beta thalassemia and rest homozygous beta. Most common beta globin mutation detected was IVS-1-5 (G-C). 81 % were positive for HCV RNA with majority (60 %) having low viral load. Type 3a was the most common genotype. Mean ferritin level was 2985.68 ± 125.35 ng/ml, which was extremely significant (p \ 0.003) when compared with age and sex matched HCV–nonreactive thalassemia patients. TE revealed significantly increased liver stiffness in comparison to controls. Majority (65 %) had very high liver stiffness ([15 kPa). T2*MRI done in some patients also demonstrated significantly high liver iron concentration. Conclusion: HCV-reactive patients with thalassemia had significant hepatic fibrosis along with raised serum ferritin level. Keywords Hepatitis C, Ferritin, Transient elstography
sensitive in detecting hemoglobinopathies, cost effective investigations like peripheral smear, RBC indices and iron status should be done before HPLC. This also helps in reducing false negative cases.
OR 157 Fractures and Low Bone Mineral Density In Patients With Beta Thalassemia Major Tulika Seth, Nikhil Tandon, Jagdish Chandra, H Pati, Renu Saxena Max Hospital Objective: To assess the prevalence and degree of low bone mineral density in thalassemia. Patients & Methods: Forty patients (26 males) with transfusion dependent thalassemia with a median age of 19.5 years (15–38 years) were enrolled. Bone mineral density (BMD) assessment was performed using dual energy x-ray absorptiometry scan at lumbar, hip and forearm region. Results: Six patients complained of bony pains. There were ten fractures in 7 patients (17.5 %) at different sites. Hormonal levels were assessed in 32 patients of whom 12 (37.5 %) patients showed evidence of hypogonadism and 8 patients (25 %) were hypothyroid. In patients younger than 20 years (n = 20), 15 patients (75 %) had low bone mineral density. The BMD at forearm was significantly lower in patients with hypogonadism (p = 0.022), smaller height (p = 0.028) and weight (p = 0.025). Hypogonadism was associated with low BMD at hip (p = 0.093). The BMD at lumbar region did not correlate with any study variable. In patients 20 years (n = 20) and above, 17 patients (85 %) had osteoporosis and 3 patients (15 %) had osteopenia. The BMD at lumbar region (p = 0.039) and hip region (p = 0.043) was lower in hypogonad patients. Hepatitis C infection was associated with lower z scores at hip (p = 0.029) and lower T scores at forearm (p = 0.047). There were no differences in BMD between men and women, and did not correlate with iron overload. Conclusions: Low bone mineral density is widely prevalent in patients with transfusion dependent thalassemia. Hypogonadism, increasing age and hepatitis C infection are associated with osteoporosis or osteopenia in older patients.
OR 156
OR 158
Analysis of Hemoglobinopathies In A Tertiary Care Centre
Analysis of Bone Marrow Erythroid Series In 200 Cases With Low Haemoglobin. (Award Paper)
Dr. Febe Suman R, Dr. Sai Shalini, Ms. Uma Lakshmi Sri Ramachandra University, Chennai Introduction: Hemoglobin electrophoresis has been replaced by HPLC (high performance liquid chromatography) in recognising hemoglobinopathies. This study analyses the HPLC reports along with RBC indices which were obtained using Bio Rad D10 analyzer in our central laboratory. Materials & Methods: A prospective cross sectional study was undertaken from December 2014 to June 2015. All the patient samples requested for Hb variant analysis were enrolled. The samples were processed for complete blood count in Beckman Coulter LH 780 and the peripheral smears were examined. Hb variant analysis was done. RBC indices [Mentzer, Ehsani, Sirdah], chromatogram and iron studies were correlated. Results: 61 samples were analysed of which 22 (36 %) showed hemoglobinopathy which includes 3 children & 19 adults. Male: female ratio is 7:4. Serum iron and ferritin done on the patients with normal hematogram showed normal or low values whereas those with hemoglobinopathies were within normal limits or increased. Conclusion: Hb E heterozygous and homozygous were not found in Tamilnadu, though other variants were seen in 50 % of cases. Although HPLC technique is more
Dr. Manjiri Phansalkar, Prof. Dr. Somanath Padhi, Assoc Prof. Dr. Renu G’ Boy Varghese, Prof & Hod Pondicherry Institute of Medical Sciences Introduction: Bone marrow study is not indicated in all anemic patients, however, marrow aspiration done for other standard indications frequently show association with low hemoglobin. In such cases, marrow erythroid series is expected to show changes. There is paucity of recent literature regarding this, hence, the study was undertaken. Materials and Methods: We analysed erythroid series in 200 marrow aspiration smears in cases of low Hb (\10gm/dl) done between July 2010–June 2015 (prospective and retrospective). Morphological changes in marrow erythroid precursors regarding type of maturation, the amount, distribution of various precursors and dyspoiesis were studied and correlated with other clinico-hematological parameters like indications, hemoglobin level, RBC indices, reticulocyte count and marrow iron stores Results: Based on type of maturation all cases were divided into 6 categories as 1)normoblastic 37 % (most common), 2)micronormoblastic 7.5 %, 3)megaloblastic 9.5 %, 4)micronormoblastic + megaloblastic 17 % 5)normoblastic + micronormoblastic 15.5 %
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Indian J Hematol Blood Transfus 6)normoblastic + megaloblastic 13.5 %. Erythroid hyperplasia was a frequent finding except in normoblastic category which showed reduced erythroid series in 47.3 % cases. In micronormoblastic category, early forms (93.3 %) while in megaloblastic late forms (73.7 %) was a common finding. In mixed anemias, pattern was mixed. High dyspoiesis was noted in megaloblastic (84.2 %) group and highest in micronormoblastic + megaloblastic (91.2 %) group. However, pure micronormoblastic group also showed dyspoiesis in 46.7 % cases. Good correlation was noted between iron stores and type of maturation. Conclusion: Considering multiple parameters together may help in better understanding of anemic process, especially when type of maturation is mixed. Certain findings like dyspoiesis in almost half of micronomoblastic cases need further evaluation. Keywords Bone marrow erythroid series, Low haemoglobin, Correlation with clinico-hematological parameters
OR 159 Review of Advanced Erythrocytic Parameters of Beckman & Coulter Lh 780 Hematology Analyzer and Its Clinical Significance In A Tertiary Care Hospital
Introduction: With advances in automated cell counters, many hematological parameters are obtained which is helpful to the hematologist for the diagnosis and therapy. We have chosen Ret-He for diagnosis of iron deficiency anemia in our particle counter (Sysmex-XN1000), so that, again the Classical Iron parameters of blood may not be required to be done separately. This is cost effective too. Iron deficiency Anemia is one of the most common causes of anemia world-wide. Early diagnosis using less expensive tests, is a challenge to a hematologist. So the present study was undertaken to know the effectiveness of Reticulocyte hemoglobin equivalent (Ret He) to detect Iron deficiency Anemia. Material and Method: The study was conducted in Apollo Hospitals, Bhubaneswar, Odisha, for a period of 6 months i.e. from October 2014 to March 2015. In the routine hemogram tests performed, we have selected eighty cases of low RetHe and compared with the classical iron deficiency parameters like Serum Iron, TIBC, Serum Ferritin and % saturation levels. Results: When Ret He is compared with percentage saturation, it correlates well (r value = 0.66), but when compared with ferritin it didn’t correlate (r value—0.39). This is because ferritin is an acute phase reactant. The cases where it didn’t correlate were having CKD, Thalassemia major and Sickle cell disease. Conclusion: Ret He in conjunction with complete blood count is an effective parameter to access Iron deficiency Anemia.
Dr. Rajeshwari S. Handigund Jawaharlal Nehru Medical College Introduction: With the progress in technology, new and improved parameters are being introduced. They provide a new approach to assess the blood picture. Special parameters were launched in Beckman & Coulter LH 780, namely MAF (Microcytic Anemia Factor) and Reticulocyte indices i.e. IRF (Immature Reticulocyte Fraction), MRV (Mean Reticulocyte Volume), MSCV (Mean Sphered Corpuscular Volume), HLR % (High Light Scatter Reticulocyte percentage), and RSF (Red cell Size Factor). Materials and Methods: 1050 samples were analyzed in the CDR (CBC Differential counts & Reticulocyte counts) and R (Reticulocyte counts) of Beckman & Coulter LH780. Special parameters were reviewed with respect to CBC, other biochemical and clinical findings. All the samples included in the study were from adults of both sexes (13–90 Y). Results: IRF aids in classification of anemias based on marrow response. It could also be used as index of erythropoietic activity and to identify signs of early marrow regeneration after chemotherapy or bone marrow transplantation. MAF is reduced in patients with IDA. MRV could be used for Hereditary Spherocytosis (HS) screening and could aid in differential diagnosis of hemolytic anemias. HLR % is a sensitive parameter to detect hemolytic diseases. MSCV & MCV could be used to differentiate between HS and Thalassemia. RSF was found to be low in IDA and thalassemia trait. Conclusion: The special parameters should be considered to provide non-invasive detailed insight into the functioning of bone marrow, diagnosis of hematological diseases and its response to therapy. Keywords Reticulocyte indices, Immature reticulocyte fraction, Microcytic anemia factor
OR 160 Use of Advanced Automated Cell Counters In Diagnosis of Iron Deficiency Anemia Dr. Sreeya Das, Dr. Dipika Mohanty Apollo Hospitals, Bhubaneswar
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OR 161 Eosin-5’-Maleimide Flow Cytometry Is A Cost Effective and Efficient Diagnostic Test For Hereditary Spherocytosis: A Study on 40 Families from North India Parvati Joshi, Anu Aggarwal, Manu Jamwal, Mus Sachdeva, Prashant Sharma Pgimer Background: Laboratory diagnosis of hereditary spherocytosis (HS) commonly relies on increased incubated red cell osmotic fragility test. However other hereditary hemolytic anemias can clinically and by laboratory parameters overlap. We evaluated the role of eosin-5’maleimide-binding (EMA) test to diagnose HS. Design and Methods EMA binding test using flow cytometry was performed on 54 cases of HS, 26 cases of iron deficiency anemia, 32 cases with b thalassemia trait and 10 cases of autoimmune haemolytic anemia. Two to six normal controls were included each time that the test was performed. Patients with HS were divided into mild, moderate, moderately severe, severe and post splenectomy groups. Mean channel fluorescence (MCF) and percent decrease in MCF were studied by flowcytometry to determine the best cut-off values to diagnose HS along with sensitivity and specificity Results MCF values from HS patients overlapped with normal controls, making it impractical to set MCF range with a good sensitivity. The percent decrease of MCF in HS group (32 ± 7.7) was more significant in comparison to normal group (-0.03–5.88, p value \0.001), AIHA ((6.8) ± 10.6, p \ 0.001), IDA (1.93 ± 7.6, p value \0.001) and bTT groups (1.0 ± 9.3, p value \0.001). For flowcytometry, a cutoff point of 21 % MCF decrease showed 97 % sensitivity and 100 % specificity and was independent of clinical phenotype (severity). Conclusions: EMA dye fluorescence test is efficient to diagnose cases of HS both before and after splenectomy (despite improvement of hematological parameters). There was no overlap in percent decrease of MCF between other groups and HS with cutoff of 21 %.
Indian J Hematol Blood Transfus Table 1 Hematological parameters and MCF parameters of EMA binding test of different groups of HS patients Parameters
Mild (n = 17)
Moderate (n = 20) Moderately severe (n = 11) Severe (n = 3)
Age in years
21.9 (12–41)
18.6 (0.5–30)
Hb (g/dl)
12.4 (11–14)
MCHC (%)
27.9 (2.5–50)
9.8 (8.5–10.8)
8.6 (7.3–11.2)
36.0 (34.4–36.6)
34.8 (32.8–36.3)
34.5 (33.3–35.6)
Reticulocyte count (%)
12.7 (6.7–25)
11.2 (7–25)
MCF
2920 (1420–4770) 3010 (1753–5040)
Percent MCF decrease (%)
34 (20–48)
30.7 (21–47)
OR 162 Effect of Alpha Thalassemia In Response To Hydroxyurea Therapy In Patients With Sickle Cell Anemia Prasanta Purohit, Snehadhini Dehury, Satyabrata Meher, Kishalaya Das, Pradeep Kumar Mohanty Sickle Cell Clinic and Molecular Biology Laboratory, V. S. S. Institute of Medical Sciences and Research Introduction: Sickle-cell-anemia (SCA) is the commonest inherited hemoglobin disorder in Odisha, with varied clinical presentation. Hydroxyurea (HU) is the drug of choice in patients with SCA and found to be effective in reducing the painful-crises and blood transfusion (BT) requirement. This study was undertaken to assess the role of a-thalassemia on the efficacy of HU in patients with SCA. Methods: This study was carried out in 117 patients with SCA and included in the study for a-thalassemia analysis. Out of 117 patients, 73 patients were treated with HU and followed-up for 2 years. Out of 73 patients with HU, 39 (53.4 %) had a-thalassemia. Results and Discussion: a-thalassemia did not affect the HbF level and total Hb in patients with SCA. The rate of painful-crises, BT and hospitalization were minor increased in patients with a-thalassemia. Irrespective of a-genotypes, all the patients with SCA had a significant response to HU in terms of increased HbF level, total Hb, and reducing the rate of painful-crises, BT and hospitalization. The magnitudes of increasing HbF and total Hb after HU-therapy were found to be significantly lower in patients with a-thalassemia (n = 39) compared to normal agenotype (n = 34). The responders for HU-therapy was also found to be lowered (v2, 3.69; p \ 0.05) in patients with a-thalassemia (79.5 %, 31/39) compared to normal a-genotype (97.0 %, 33/34). Conclusion: The poor compliance of HU-therapy in some patients with SCA might be due to co-inheritance of a-thalassemia. Studies seeking genetic determinants of variable response to HU-therapy in SCA should consider co-existing a-thalassemia.
OR 163 Cyclosporine Monotherapy For The Treatment of Aplastic Anemia Dr. Anu Korula, Dr. Fouzia Na, Dr. Alok Srivastava, Dr. Vikram Mathews, Dr. Biju George Christian Medical College, Vellore Background: Though immunosuppressive therapy with ATG and allogeneic stem cell transplantation are the standard treatment options for a patient with aplastic anemia (AA), only 30 % can afford such therapy. Cyclosporine is an effective T cell agent and is used in the treatment of aplastic anemia. We describe our experience with the use of cyclosporine in AA. Material and Method: This is a retrospective
17.7 (5.9–40)
10 (4–14)
Splenectomy (n = 3) 28 (10–40)
4.8 (4.7–5)
12.9 (12.2–13.3)
32 (31–33.6)
34.3 (32.5–35.5)
22 (20–25)
4.6 (3–8)
3545 (2839–3200)
3306 (2121–4334) 2931 (2556–3490)
29.3 (20.5–38)
25.3 (23.2–26.7)
38 (32–45)
analysis of patients who underwent treatment with cyclosporine between November 1991 and December 2014. Data was retrieved from individual medical records and databases. Results: During the study period, 379 patients (166 males and 233 females) with a median age of 46 years (range: 2–77 years) received cyclosporine. One hundred and eighty-six patients (49.1 %) had non severe aplastic anaemia (NSAA) while 186 (49.1 %) had severe aplastic anemia (SAA) and 19 (5 %) had very severe AA (VSAA). Overall response rate (ORR) was 53.2 % with complete remission in 10.4 % and partial remission in 42.8 %. In patients with NSAA, ORR was 76.5 % with CR in 15 % and PR in 59.8 %. ORR in patients with SAA was 32.8 % with CR in 7 % and PR in 25.8 % while for VSAA, the ORR was 36.8 % with no CR and all achieving PR. Conclusion: Cyclosporine is an effective drug for non severe aplastic anemia while approximately 30 % achieve response in SAA and VSAA.
OR 164 Magnetic Resonance Imaging Quantification of Hepatic and Cardiac Iron Overload In Comparison To Serum Ferritin Levels In Patients With Transfusion Dependent Thalassemia: An Indian Perspective Dr. Sharat Damodar, Dr. Sunil Bhat, Dr. Vimal Raj, Dr. K. S. Natraj Narayana Hospital, Bangalore Background: Frequent blood transfusions are often associated with iron overload. This is a common feature in patients with Thalassemia. Excess iron absorption and increased transfusional iron intake causes iron accumulation in liver, endocrine organs, heart and other tissues with severe, life-threatening consequences. Iron overload cardiomyopathy remains the leading cause of death in these patients. Total amount of iron deposited in the organs correlates well with Serum Ferritin. This however, lacks specificity and can be spuriously altered by other factors such as fever or inflammation. Early detection, prompt treatment and regular monitoring is essential for these patients which in turn helps in appropriate use and titration of Iron chelation therapy. T2-star (T2*) Magnetic Resonance Imaging (MRI) is a wellestablished tool in determining myocardial and hepatic Iron concentration. In this study, we looked at the correlation between Serum Ferritin levels and MRI determined iron overload of the myocardium and the liver in patients with Thalassemia. Methods: Consecutive patients with Thalassemia Major under the age of five years were selected. All patients were transfusion dependent. T2* MRI was performed and Serum Ferritin levels were collated. Correlation of Serum Ferritin levels with MRI determined myocardial and liver iron concentration was assessed. Results: A total of 50 patients qualified for the study. There was no significant correlation between Serum Ferritin and Myocardial iron concentration determined by T2* MRI. There was significant correlation between Serrum Ferritin and liver
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Indian J Hematol Blood Transfus iron concentration determined by T2* MRI. Conclusion: T2* MRI is a powerful non-invasive test in assessing myocardial and liver iron overload. It is able to provide accurate information even in patients in the Indian Subcontinent.
OR 165 Evaluation of Pulmonary Hypertension In Ntdt-E Beta Thalassemia Patients In A Tertiary Care Center In Eastern India Dr. Prantar Chakraborty, Dr. Tuphan Kanti Dolai, Dr. Shyamali Dutta, Dr. Rajib De, Dr. Prakas Kumar Mandal
platelet count [50000/mm3, serum ferritin [800 ng/ml, nucleated RBC count [350/mm3 and pulmonary hypertension were seen in 19 (82.6 %), 10 (43.4 %), 6 (37.5 %), 18 (78.3 %) and 2 (8.3 %). Plasma protein-C, free protein-S and antithrombin-III were low in 11 (52.3 %), nil and 1 (4.7 %) patients. Neuroimaging abnormality seen in 6 (26 %); 2, 1, 3: silent stroke, overt stroke and arteriopathy. No significant difference in risk factors for hypercoagulable state was noted between patients with/without neuroimaging abnormality. Conclusion: One-fourth of our cohort had neuroimaging abnormalities. There was no association between risk factors for thrombosis and neuroimaging abnormality. This study highlights the need for very close multidiscplinary monitoring of NTDT patients.
Nrs Medical College & Hospital Introduction: Pulmonary hypertension is a major cardiac complication in NTDT. Cardiopulmonary disease, including pulmonary hypertension, requires monitoring and is secondary to microvascular injury, thromboembolism, and hemolysis-induced nitric oxide deficiency. Materials and Methods: The aim was to determine the prevalence of Cardiopulmonary complications & pulmonary hypertension in 30 NTDT- hemoglobin E/b thalassemia patients. Pulmonary hypertension was defined as increase in MPAP of [25 mm at rest or as peak Tricuspid Regurgitation Velocity C2.9 m/ s measured using echocardiography. Results: Of 30 NTDT patients, Pulmonary Hypertension was graded as Mild- 25–35 mm Hg., Moderate—36–45 mm Hg, Severe—[46 mmHg. Out of 30 patients, 12 patients (40 %) had pulmonary hypertension. Out of these 30 patients, 8 had Grade I Pulmonary Hypertension & 4 patients had Grade II disease. Median age was 28 years (range 5–38 years), males higher than females, mean Hb and ferritin levels were 7.1 ± 1.1 g/dL and 857 ± 125 ng/mL, respectively & mean life time transfusion requirement was 2–3 transfusions. Conclusion: In this cohort, 40 % had pulmonary hypertension. More than 50 % patients had Grade I disease. Increasing age & lesser transfusion requirements are associated with pulmonary hypertension but no significant association between S. ferritin & pulmonary hypertension is established in our study. Keywords NTDT—Non-transfusion Dependent Thalassemia, MPAP—Mean pulmonary Artery Pressure
OR 166 Neuro Imaging Abnormalities In Patients With Non Transfusion Dependent Thalassemia—An Observational Study
OR 167 Prenatal Diagnosis of Hemoglobinopathies In ‘‘Couples At Risk’’ By Chorionic Villous Sampling—A Single Centre Experience Mrs Aditi Sen, Dr. Rajib De, Dr. Tuphan Kanti Dolai, Dr. Prakas K Mandal, Dr. Basab Bagchi Nrs Medical College and Hospital Introduction: Around 7 per cent of the populations worldwide are thalassemia carriers. Around 3,00,000 severely affected babies born every year globally. The prevalence in India is approximately 27 million births per year. So prenatal diagnosis is an integral component of a community control programme for haemoglobinopathies. Method and Material: From 2013–2014, We counseled and carried out prenatal diagnosis by ARMS PCR for common thalassemia mutations, CD26 (HbE) and CD6 (HBS) mutations from Chorionic villous sampling (CVS) in 51 high risk couples who are carriers of hemoglobinopathies. Results: In our observation most of the ‘‘couples at risk’’ had undergone CVS by 13 weeks (Median). The mutations detected in the couples were IVS1-5 (74.5 %) followed by CD 26, CD15, CD6, CD 30 and CD41/42. CVS study showed 9 out of 51 cases had homozygous or compound heterozygous state for hemoglobinopathies and underwent termination of pregnancy. Among the rest of 42 couples with normal or heterozygous mutation state in CVS, we were able to trace out 29 couples and found them to have healthy babies age ranging between 5 months–18 months. Conclusion/ Diagnosis/Impression: The most common mutation we encountered was IVS1-5. Majority of the diagnosis provided correlated clinically. The prenatal diagnosis forms the important predictive tool in couples at risk of having thalassemic children.
Amita Trehan, Jasmina Ahluwalia, Paramjeet Singh, Deepak Bansal
OR 168
Pgimer, Chandigarh
Assessment of Growth Parameters of Beta Thalassemia Major Patients Attending A Tertiary Care Hospital
Introduction: Non-transfusion-dependent thalassemias (NTDT) is associated with a hypercoagulable state promoting thrombo embolic events. Study was done to evaluate silent stroke in NTDT patients and identify modifiable/non-modifiable risk factors for stroke. Methodology: Magnetic resonance imaging (MRI), echocardiogram evaluating tricuspid regurjitant jet velocity, plasma protein-C, free protein-S and Antithrombin-III levels were done in NTDT patients. Risk factors for hypercoagulable state: age, transfusion naivety, splenectomy, history of hypercoagulable state, hemoglobin levels, platelet count, nucleated RBC count, serum ferritin were analysed for association with neuroimaging abnormality. Results: 23 patients; median age: 14 years (IQR 13–16) diagnosed at 8 years (IQR 5–10), mean follow up being 2790 ± 1816 days were studied. 8 were transfusion naı¨ve, 15 had received occasional transfusion. 11 were splenctomised. Risk factors for thrombosis: hemoglobin B9 gm/dl,
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Dr. Ganga S. Pilli Jawaharlal Nehru Medical College, Belagavi Introduction: Beta Thalassemia Major (BTM) is transfusion dependent state where physical growth is affected in majority of patients. Very few studies have been reported in India. Need for study: It will emphasize to assess iron overload and growth parameters of transfusion dependent BTM patients. Materials and Methods: This study was done on 31 known diagnosed BTM patients with age 10 years and above. Height, weight, BMI along with hemoglobin and serum ferritin were estimated. IAP growth charts were plotted. Appropriate statistical tests were used for analysis. Results: Of 31 patients, 25 were males and 6 were females. Age range was 10–18 years with mean age of 12.45 years. There were 20 (64.5 %) patients not taking chelation.
Indian J Hematol Blood Transfus Mean and SD of pretransfusion hemoglobin of all patients was 6.85 ± 1.13 gm %. Mean and SD of ferritin of all patients, nonchelated and chelated patients was 3786 ± 2382 ng/ml, 4505 ± 2633 ng/ml and 2479 ± 963.6 ng/ml respectively. Weight for Age (W/A) charts of males and females showed 28 % and 16.6 % respectively below 3rd percentile. Height for age (H/A) charts of males showed 40 % below 3rd percentile and none of the females below 3rd percentile. BMI of males and females showed 20 % and 50 % respectively below 3rd percentile. Most of the patients were of short stature and underweight indicating growth failure. Conclusion: Growth failure in BTM is mainly due to iron overload and chronic anemia. This study emphasizes the need of screening for growth failure, regularly estimating iron overload and its control by chelation therapy. Keywords Thalassemia major, Growth failure, Percentile
OR 169 Reduced Hba0-Derivative Peaks (P2 and P3) In Persons With Hbd-Punjab and Hbe: Implications For Hba1C Estimation Prashant Sharma, Sanjeev Chhabra, Reena Das
Participants: Term, healthy, vaginally delivered neonates without any congenital malformations or birth asphyxia, born to bookedanemic (Hb 7–10 g/dl) mothers having no medical or pregnancy related complications were included in the study. Interventions: The pregnant mothers were randomised into 3 groups and their umbilical cords were clamped at 1,2 and 3 min. Neonatal hematocrit was estimated by capillary method at 24 h of life, and infants’ hemoglobin and ferritin were obtained at 3 months of life. Main Outcome Measures: Hematocrit at 24 h of life, and serum iron and ferritin levels at 3 months of age. Results: The outcome variables significantly associated (p \ 0.05) with hematocrit were cord clamping time, maternal Hb and cord Hb and ferritin. Those associated with infant’s Hb were cord clamping time and cord Hb and ferritin. Whereas only cord clamp time was significantly associated with infant’s ferritin. None of the neonates had polycythemia and Hb and ferritin was found to be highest in those whose cord was clamped at 3 min. Conclusion: In resource constrained countries, where IDA is a major public health problem, delaying the umbilical cord clamping by up to 3 min will reduce the incidence of infantile anemia. It will serve as an additional cost effective intervention in anemia control program without any adverse effect of polycythemia. Keywords Anemia, Ferritin, Hematocrit, Hemoglobin
Pgimer, Chandigarh Introduction: Hb D-Punjab and HbE in various combinations are relatively frequently encountered hemoglobinopathies in various parts of India. We had noted consistently reduced P2 and P3-levels in these cases. This may potentially interfere with HbA1c determination by CE-HPLC. Methods: Laboratory records of 53 consecutive patients with the HbD-Punjab variant and other 53 with HbE, regardless of zygosity, age, co-inherited b-thalassemia or their clinical background were tabulated. The cases were detected by Hb HPLC, Variant II instrument, Bio-Rad Laboratories, USA using beta-thal ShortTM programme and confirmed by alkaline pH electrophoresis (Genio-S, Italy) and family studies, if required. Percentage and retention time of HbD-Punjab/HbE along with P2, P3 and unknown peaks were recorded. Another 103 control subjects with normal HPLC pattern, normal range HbA2 and HbF, no variant peaks and total area 1–3 million were enrolled. Results: Mean P2 % was 1.8 ± 0.8 (range 0.0–2.9) and 1.9 ± 1.3 (range 0–4.2) in HbD-Punjab/E cases respectively while the control values were 3.8 ± 0.7 (range 2.8–7.8). P2 % reduced proportionate to the HbD/E %. For instance, all cases with HbD [65 % showed P2 \ 1.0 % and vice versa. Similarly the mean P3 % in HbD-Punjab/HbE cases were 2.1 ± 0.9 (0.1–5.3)/ 2.7 ± 0.9 (1.3–6.3) versus control levels of 4.3 ± 0.4 (3.4–5.8). HbD-Punjab and HbE cases showed extra unknown peaks (average 3.1 and 2.2 unknown peaks/case) vis-a`-vis control cases (2.1 unknown peaks/case). Conclusions: Unlike prior studies, our results suggest that HbD-Punjab/E (especially in homozygous or double/compound heterozygotes) may interfere significantly with CE-HPLC-based HbA1c estimation. This is especially important as the hemoglobin disorders in many such patients may be completely asymptomatic.
OR 171 Hemoglobinopathies in a Rural Tertiaty Care Hospital Dr. Himani Patel, Dr. Kailash Inaniya, Dr. Sanjay Chaudhari, Dr. Keyuri Patel, Dr. Menka Shah Pramukh Swami Medical College, Karamsad Introduction: Thalassemia and other haemoglobinopathies are the leading causes of anemia which can be prevented by available screening methods. High-performance liquid chromatography (HPLC) is a technique introduced for the accurate diagnosis of hemoglobinopathies and thalassemias. The advantage of the HPLC system is the excellent resolution, reproducibility & quantification of several normal & abnormal hemoglobin resulting in accurate diagnosis of thalassemia syndromes. The purpose of this study is to detect hemoglobinopathies in tertiary care hospital. Materials and Methods: A total of 83 cases were studied from June 2014 to May 2015 retrospectively at Shree Krishna Hospital, Karamsad, Anand, Gujarat. Result: Out of these 83 cases, 15 were diagnosed as b-thalassemia trait, 3 cases were HbS homozygous, 3 cases were HbS heterozygous with a-Thalassemia,1 case was sickle cell trait’AS’ heterozygous,1 case was b-thalaessemia major, 2 cases were HbD heterozygous. Conclusion: b-Thalaessemia Trait was the most common Haemoglobinopathy found in this area, followed by Homozygous Sickle cell anaemia, Heterozygous sickle cell anemia, HbD and b thalessemia major. Keywords HPLC, Hemoglobinopathy, Thalassemia, Sickle cell anaemia
OR 170 Effect of Timing of Cord Clamping on Iron Stores of Infants Born To Anaemic Mothers
OR 172 Safety and Quality Control of Blood Products For Multiply Transfused Patients
Meera Jindal, K C Aggarwal, Ajay Kumar, Aruna Batra Vmmc & Safdarjung Hospital, New Delhi-110029 Objective: To study the effect of timing of cord clamping on the iron stores of infants born to anemic (Hb 7–10 g/dl) mothers, and if late clamping leads to polycythemia. Design: Randomised Comparative Trial. Setting: Tertiary care hospital in a metropolitan city.
Ashwini Gowda, Dr. Sumithra P, Ms Radha J, Amit Sedai, Rajat Kumar Agarwal Jagriti Innovations Introduction: Provisioning of safe blood products is a cornerstone for thalassemia management. We share our experience of blood
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Indian J Hematol Blood Transfus transfusion product sourcing, selection, processing, administration and quality management for our thalassemia clinic. Materials and Methods: We studied 163 patients enrolled at our centre between 15-August-2013 to 15-August-2015 covering 3606 patient visits and 4398 transfusions. Packed red cells donated by voluntary blood donors exclusively in last seven days were selected for transfusion. Blood products were sourced from the in-house blood bank exclusively. All units were double saline washed within two hours of transfusions. Enrolled patients took transfusions exclusively at our centre. Bed side leuko-depletion filters were used for less than 1 % transfusions. No prophylactic drugs were given prior to transfusions. Transfusion reactions were recorded immediately. Quarterly screening of transfusion transmitted infections was done. ThalCare, a web based application, was used for management of clinical data. Details of each blood bag, each patient visit, each reaction and each lab test was entered on a daily basis. Results: Ten of the 4398 units (0.23 %) were sourced from other blood banks. 91 % units were collected in last seven days of transfusion. In all six mild febrile transfusion reactions (0.14 %) and no red cells alloimmunisation was observed. Hepatitis C, Hepatitis B, HIV tests were positive for 2 (1.2 %), 1 (0.6 %) and 0 patients respectively. All 3 patients who had infection, acquired it prior to joining our clinic. Conclusion: Our approach enabled achieving high degree of safety and quality control in blood transfusion service for multiply transfused patients.
OR 173 Quality Management In Thalassemia Care and Management Amit Sedai, Dr. Pooja Gujjal, Dr. Reshma Srinivas, Ashwini Gowda, Pushpa H Jagriti Innovations Introduction: The ability to measuring the performance of a healthcare delivery system ensures greater visibility and consistent outcomes. The ability to benchmark a health system’s performance in a consistent manner also allows comparison with peers. We aimed at identifying the key quality indicators and implement a quality management process to measure them for thalassemia management centers. Materials and Methods: ThalCare, a web-based application, was used to capture data associated with the delivery of care to the children suffering from thalassemia at our centres. Access to chelation therapy, adequacy of chelation therapy, adherence to periodic screening tests, availability of blood components, appropriateness of blood transfusion therapy, time of hospitalisation, adequacy of blood transfusions, adherence to transfusion schedule are some of the indicators which have been identified and are being regularly monitored and reported upon. The data was entered on the same day as the patient’s visit. ThalCare was programmed to aggregate and process the data and report upon the key performance indicators which were identified for the program on a weekly and monthly basis. Automatic email reports were sent. Result: Weekly and monthly reports have enabled better understand of the gaps in the system and facilitated corrective action. All key performance indicators have steadily improved and any seasonal or procedural lapses are being detected within short span of time. Conclusion: The quality management processes has enabled greater awareness of performance on key areas and enabled consistent delivery of service. Performance, of the centres has also improved steadily.
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OR 174 Effectiveness of Measuring For Fragmented Red Cells Using A Sysmex-Xn Automated Hematology Analyzer-A Pilot Study Dr. (Col)Jyoti Kotwal, Dr. Nita Radha Krishanan, Dr. Jasmita Dass, Dr. Amrita Saraf., Dr. Manorama Bhargava Sir Ganga Ram Hospital Introduction: Thrombotic microangiopathy (TMA) is a life threatening syndrome characterized by increased schistocytes on peripheral blood smear (PBS). The PBS examination is time consuming with high CV % in reporting due to inter-observer variation. The flow cytometry based cell counter provide fragmented red cells (FRC) estimation. The present study was carried out to look for effectiveness of this parameter in diagnosis & follow up of cases with TMA. Materials &Methods: We established the reference range for FRC % by running 60 normal samples of with 10 cases of microcytic and macrocytic anemia each. In two confirmed cases of TMA the EDTA sample were run in the Sysmex-XN for FRC %. The Schistocyte index on smear of these cases were calculated manually as per International Council for Standardization in Haematology (ICSH),2011 criteria. Results: In normal samples the FRC % range was 0.00 to 0.015 %, none of the normal samples had any schistocytes, on the smear. In microcytic and macrocytic samples the FRC % was 1.12 ± 0.97 and 0.368 ± 0.659. In both the cases the schistocyte index at the time of diagnosis were 4.0 % and 6.5 %, which correlated with the FRC % on the cell counter. The follow up samples post therapy the manual & automated schistocyte indices correlated well. Conclusions: The mannual schistocyte index is calculated on 1000RBCs and reproducibility is poor whereas cell counter counts average 30,000 cells hence better precision. The flow cytometry based FRC % estimation is an easy, sensitive, inexpensive and rapid screening assay for schistocyte index. In suspected cases this should be confirmed by PBS. In diagnosed cases with TMA it is an effective, rapid method to monitor the patients. Code: RH. Keywords Fragmented red cells, Schistocyte, Thrombotic microangiopathy
OR 175 Spectrum of Hemoglobinopathies In Odisha, An Institutional Study By Ce-Hplc Aakash Singh, Sukumar Chakrabarty, Raghumani Mohanty, Suraj Kumar Choudhury Hi-Tech Medical College and Hospital Background: Hemoglobinopathies are common genetic disorders and represent significant load of anemic patients coming to a hospital with various complaints. Objective: We aimed at assessing the different types of hemoglobinpathies prevelant in Odisha in relation to hematological profile and district wise distribution. Materials and Methods: This study was done on all patients who had undergone HPLC study in Hi-Tech medical college and hospital since 2010 uptil March 2015 whose complete history and data required for this study were available. BIO-RAD dual CE-HPLC machine was used. Results: Even though it was not a screening study, out of 331 cases 105 were found to be normal. Along with Sickle cell disease and bThalassemia, HbE andHbE/Thalassemia cases were found in significant numbers even though this region is not known for its endemicity
Indian J Hematol Blood Transfus of Hb E hemoglobinopathies.4 cases of Hb DPUNJAB carriers were also encountered. Conclusion: The present study revealed that HbS is the most common abnormal haemoglobin in Odisha, followed closely by b-thalassemia. Just like West Bengal even Odisha is endemic for HbE.
OR 176 Plasma Homocystein Level A Marker of Vaso-Occlusive Crisis In Sickle Cell Disease Mahendra M Maske, Snehadhini Dehury, Prasanta Purohit, Pradeep Kumar Mohanty, Kishalaya Das V.S.S. Institute of Medical Science and Research (Vimsar) Introduction: Vaso-occlusive events are very common in patients with sickle cell disease (SCD). Hyperhomocysteinemia is a risk factor for arteriosclerosis and venous thrombosis. Need For Study: This study was undertaken with an aim to assess the role of plasma homocystein level on vaso-occlusive events in patients with SCD. Materials and Methods: sickling slide test, alkaline Hb electrophoresis (PH8.6), CE-HPLC, HbPlasma homocysteine level was analyzed in 100 adult patients with SCD attending at Sickle Cell Clinic/Department of Medicine of V.S.S. Institute of Medical Science and Research (VIMSAR), Burla. Results in Brief: The mean age of the patients with SCD was 29.3 ± 7.7 with 69 % of males. The plasma homocysteine level is independent of age and gender of the patients with SCD (p [ 0.05). Regression analysis revealed that patients with higher plasma homocystein level were associated with increased vaso-occlusive events. (r2, 0.092; p, = 0.0021). Incidence of anemia, jaundice, splenomegaly, hepatomegaly, AVN etc. were independent of homocystein level. Conclusions: Patients with SCD with elevated plasma homocystein level have more vaso-occlusive events. Plasma homocystein level can be a marker to assess the complication like vaso-occlusive events in patients with SCD. Supplemental treatment for decreasing the plasma homocystein level is necessary for patients with SCD for reducing vaso-occlusive events. Acknowledgement: The authors express their gratitude towards Odisha Sickle Cell Project (NHM), Veer Surendra Sai Institute of Medical Science & Research (VIMSAR), Burla, Sambalpur. The authors are indebted to late Dr. Dilip Kumar Patel, Ex-Associate Professor, Department of Medicine, Veer Surendra Sai Medical College, Burla Samablpur, Odisha and Ex-Project Coordinator, Odisha Sickle Cell Project (NHM).
OR 177 Study of Thyroid Function Status In Patients of Eb Thalassemia and Correlation With Serum Ferritin Level—A Prospective Study Dr. Rajib De, Assistant Professor, Prof. Prantar Chakrabarti, Dr. Tuphan Kanti Dolai, Associate Professor, Dr. Shyamali Dutta, Associate Professor, Dr. Prakas Kumar Mandal, Assistant Professor Nrs Medical College and Hospital Introduction: Eb-thalassemia is the genotype responsible for approximately one-half of all symptomatic beta-thalassemia
worldwide. Irrespective of transfusion requirement most Eb thalassemia patients shows iron overload and related end organ damage. The prevalence of hypothyroidism among Indian population in general is approximately 11 %. Here we study the relationship of thyroid dysfunction as an indicator of iron overload in Eb thalassemia patients. Materials and Methods: Eb thalassemia patients above the age of 10 years were included in this study after detailed history and examination patients were evaluated with serum ferritin for evaluation of iron status and TSH, FT4, T3 for thyroid function status. Results in Brief: This study was conducted from January 2014 to May 2015. Out of 50 patients of Eb thalassemia there were 22 females and 28 males. Mean age of patients was 19 years (12–47 years). Overt hypothyroidism was seen in 6 (12 %) of our patients with average ferritin level of 1077 ng/ml. Compensatory hypothyroidism was seen in 1 (2 %) of patients with ferritin level of 1200 ng/ml. Subclinical hypothyroidism was seen in 14 (28 %) of patients with average ferritin level of 1200 ng/ml. Normal thyroid function was seen in 29 (58 %) of patients with average ferritin level of 1155 ng/ ml. Conclusion: Thyroid dysfunction was seen in 42 % of Eb thalassemia patients. Prevalence of hypothyroidism was found to be higher in Eb thalassemia patients but a definite correlation with the serum ferritin level could not be established. Keywords Eb thalassemia, Thyroid, Ferritin
OR 178 Unusual Presentation of Megaloblastic Anemia Lk Meher, Pk Hui, Sn Nayak Mkcg Medical College, Berhampur Unusual presentation of megaloblastic anemia Indians prefer a vegetarian diet. This fact, associated with malnutrition, gastrointestinal infections and malabsorption leads to a high prevalence of cobalamin deficiency in India. Our patient, a 25-year-old male strict vegetarian, presented with low-grade fever and pigmentation over the fingers, palms, face and soles. On examination, there was moderate anemia. Neurological examination revealed an absent ankle jerk, impaired vibration sense, proprioception up to ankle and extensor plantar bilaterally. Clinical suspicion led us to diagnose cobalamin deficiency in this setting. Peripheral smear showed pancytopenia with macrocytic red cells, and hypersegmented polymorphs. Bone marrow examination confirmed megaloblastic anemia. On biochemical investigation showed a cobalamin level of 93 pg/ml (\200 pg/ml— Low) by chemiluminescent assay. He was also found to have methylmalonic aciduria (80 lmol per milligram of creatinine), and increased homocysteine levels (20 lmol/L). Antibody to gastric parietal cell and antibody to intrinsic factor was negative (\1:20 titre). The metabolite testing and results of the antibody levels, in a strict vegetarian led us to diagnose a nutritional deficiency of cobalamin in our case. Supplementation with parenteral cobalamin showed improvement in general condition, fever, pigmentation and neuropathy. Hematological parameters also improved, as evidenced by increase in Immature reticulocyte fraction, Mean corpuscular volume and total platelet count among other parameters. This case report is to highlight this rare manifestation of nutritional cobalamin deficiency. Any case with non resolving pigmentation and fever should be evaluated for cobalamin deficiency.
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Topic: Transfusion Medicine OR 180 Platelet Transfusion In Oncological Patients: An Audit of Practices At A Tertiary Care Hospital Dr. Vandana Puri, Dr. Bharat Singh Ucms (University College of Medical Sciences) and Gtbh (Guru Tegh Bahadur Hospital)
OR 179 Evaluation of Antenatal Screening For Prevention of Thalassemia: A Single Centre Study Dr. Tuphan Kanti Dolai, Prof Prantar Chakrabarti, Dr. Rajib De, Dr. Prakas Kumar Mandal, Dr. Basab Bagchi
Introduction: Platelet transfusion is the cornerstone treatment in oncological patients with thrombocytopenia. Unnecessary platelet transfusion causes wastage of resources and contributes to poor response to platelet transfusion (platelet refractoriness can be multifactorial). Adherence to transfusion guidelines of 2014 proposed by AABB (American Association of Blood Banks) may optimize their use. Materials and Methods: A retrospective audit study conducted at GTBH & DSCI from July 2014 to till date; to assess appropriateness of the utilization, wastage, patient demographics, common and recurring indications, also transfusion practices. Results: 1426 platelet requisitions/year. Totally 19,365 units transfused/year [19,075 RDP (98.3 %) and 290 SDP (1.7 %)]. Mean wastage rate/ year = 7.66 %. Oncological patient demographics: mean age41.54 years, M:F ratio 1.8:1. Commonest indications in adultshematological malignancies (AML [ ALL/CLL [ MDS [ CML [ NHL [ Multiple myeloma) [ Carcinoma Lung [ Hepatocellular carcinoma [ Pancreatic cancer. Commonest indications in pediatric age group- hematological malignancies (AML [ ALL [ Hodgkin’s lymphoma) [ Neuroblastoma [ Renal cell carcinomas. Repeated platelet transfusion indications- Hematological malignancies [ Carcinoma Lung [ Hepatocellular carcinoma. About 88.23 % adhered to 2014 AABB transfusion guidelines. Prophylactic transfusion done for 23.88 % of the patients and therapeutic for 76.12 %. The median platelet count at which transfusion requested- 13,791/ml, averagely 13.57 units transfused/patient. Conclusions: Regular audit of transfusion practices and blood components begets judicious use and spurs paradigmal transfusion guidelines for persistent thrombocytopenic oncological indications. Keywords Platelet transfusion, Audit, Cancer
Nil Ratan Sarkar Medical College and Hospital, Kolkata Introduction: In India, there are about 20 million carriers of thalassemia & other hemoglobinopathies, and West Bengal is one of the states having huge burden of these disorders. Only 5–10 % of thalassemic children born in India receive optimal treatment. Couples at risk have the option of avoiding birth of an affected child by antenatal screening & PND techniques. The objective of this study was to determine the prevalence of thalassemia carries among prospective mothers attending the Antenatal Clinic & to find out the effectiveness of antenatal screening programme. Materials and Methods: All pregnant mothers attending antenatal clinic of NRSMCH between February 2007-April 2015 were screened for the following parameters: Hb %, RBC indices & HPLC. Husbands of all carriers were advised to undergo screening. If both parents were found to be carriers, counseling for PND was done, with the option of termination in positive cases. Results: Among 27,797 mothers, 10.1 % were found to be carriers, of whom 5.5 % were HbE trait and 4.2 % were btt. Only 48.3 % of the husbands of carrier mothers agreed for screening. Both parents were found to be carriers in 168 cases. PND could be done in 38.6 % of these cases. 5.3 % couples did not agree for PND & PND could not be offered to 56.1 % patients. Service failure in our study was 81.64 %. Conclusion: Antenatal screening is not a very effective means to prevent birth of thalassemic children.
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OR 181 Exploring The Issue of Occult Hypoperfusion In The Pre-Hospital Trauma Setting Dr. Anthony Hudson Brighton and Sussex Medical School Background: Pre-hospital emergency medicine physicians rely on clinical examination and haemodynamic markers to identify and treat trauma patients with tissue hypoperfusion. However, extensive evidence has shown biochemical markers measuring tissue perfusion, namely lactate and base deficit (BD), to be considerably more accurate and reliable. Furthermore, studies have suggested 16–25 % of normotensive trauma patients with no clinical signs of shock have abnormal lactate and BD readings evidencing shock; a phenomenon known as occult hypoperfusion (OH). In light of the scarce quantity of evidence currently documenting OH, this study also aimed to identify the prevalence of OH in the pre-hospital setting and explore ways to improve its identification and management. In addition to this, the study investigated the current factors pre-hospital physicians use to determine the management of trauma patients. Methods: A quantitative retrospective data analysis was carried out on 75 sets of patient
Indian J Hematol Blood Transfus records for trauma patients treated by KSSAAT between November 2013 and October 2014. The KSS HEMS notes and subsequent ED notes were collected. Trends between patients’ SBP on scene, whether or not they received PRBCs on scene as well as lactate and BD readings in the ED were assessed. Patients’ KSS HEMS notes written by the HEMS crew were also reviewed and recorded. Results: Suspected OH was identified in 7 % of the patients who did not receive PRBCs in the pre-hospital phase. SBP appears to heavily influence the physicians’ decision of whether or not to transfuse PRBCs in the prehospital phase. The results supported existing evidence that a weak correlation exists between SBP and lactate as well as SBP and BD in addition to a strong negative correlation between BD and lactate. Preliminary conclusions The aim of the study was to investigate the prevalence of OH in the pre-hospital setting and explore the methods available to improve its identification and management. OH appeared to be present in 7 % of the patient cohort which, if applied to all trauma patients treated by KSSAAT annually, would equate to 119 patients. Extensive research has shown BD and lactate to be far superior in detecting tissue hypoperfusion than SBP. Furthermore, results from the study indicate that the patient group with the worst recorded BD and lactate on arrival to the ED were not the patient group who received a PRBC transfusion in the pre-hospital phase. In light of this evidence, we suggest a prospective trial is carried out to evaluate whether detecting trauma patients’ tissue perfusion status in the pre-hospital phase using portable devices capable of measuring serum BD and/or lactate could aid more accurate detection and management of all haemorrhaging trauma patients, including patients with OH. If successful, accurately identifying more patients with tissue hypoperfusion in the pre-hospital phase could ensure earlier treatment with PRBC transfusions, the activation of Code Red to alert the receiving ED, ensure the patient is sent to an MTC and improve the triaging priorities in a mass casualty situation.
OR 182 Blood Donor Notification and Counseling: Indian Scenario
present and fear of breach of confidentiality can result from unguided disclosure blood bank personnel. Non-notification to donor or nonreferral to concerned centers will pose serious health hazards.
OR 183 Hemovigilance In Managing Blood Transfusion Needs Thorough Transfusion Audit Dr. Parth Patel Cims Hospital Background: Transfusion audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components. Aim: Educating clinicians to improve documentation of transfusions, in addition to appropriate indications for transfusion, may serve to enhance the efficiency of the blood utilization and safer transfusion practices. Materials and Methods: A retrospective analysis of 512 consecutive requests for transfusion in a 5-months period was performed. The blood bank requisition forms sent by the clinicians were analyzed and details of patients for the following factors— age, sex, diagnosis, department, type, amount and indication of blood products at time of retrospective data collection—were noted. Results: The total blood units supplied were 953. The male to female ratio was 2.2:1. Packed red blood cells were the most utilized product, followed by whole blood. Supply of blood was the maximum to surgical wards. The patients of elective surgery followed by trauma required blood most commonly. The most common indications for whole blood, packed red cells, fresh frozen plasma and platelets were elective surgical procedures, anemia, bleeding and thrombocytopenia, respectively. Conclusion: This retrospective study shows a positive relation between the lack of knowledge about transfusion indication prescribing medical officers. This information is relevant for quality management of transfusion practice, cost analyses and for planning local and regional blood donation programs.
Dr. Prakash Hm, Dr. Suryatapa Saha, Dr. E. Thirumagal, Dr. L. Prathiba, Dr. Vignesh Vmkv Medical College and Hospital
OR 184
Blood donor notification and counseling: Indian scenario Dr. Poojitha Datla, Dr. Prakash HM, Dr. Suryatapa Saha, Dr. Thirumagal. E, Dr. Prathiba. L Department of Immunohematology and transfusion medicine Vinayaka Mission Kirupananda Variyar Medical College and Hospital, Salem, Tamil Nadu. Background: Transfusion services, in addition to their prime responsibility of supplying safe blood to the patient, also have a responsibility toward donor safety by means of donor notification and post-donation counseling. The National Blood Transfusion Council, Government of India, formulated a strategy in 2004, which advocates the disclosure of results of TTI to (TTI status seeking) blood donors. Blood banks are now required to obtain written consent at the time of donation from the donors as to whether they wish to be informed about a reactive test result. They are required to refer donors who tested TTI reactive to the concerned centers for disclosure, counseling and referral. Aim: The aim of the study is to identify the practices regarding donor notification and counseling amongst various blood banks. Materials and Methods: The study is a multi-centric based study. The data will be collected from multiple blood banks (at least 200 blood banks) throughout India. Questionnaire regarding donor notification and counseling are sent to various blood banks. Results: Based on data received, analysis will be done and presented. Conclusion: The absence of well defined notification process is a serious lacuna. Serious ethical issues are
Profile of Blood Donors (51–60Yrs) Vinayaka Mission University Introduction: To ensure an adequate blood supply, it is crucial to recruit suitable blood donors. These are ideally individuals with low risk for infectious diseases, who are in good health, and willing to spend their time to help someone out of a sense of solidarity and altruism. Aim: To analyse the demographic profile of blood donors above 50yrs of age in our blood bank vmkv medical college. Objective: In current medical and surgical practice, a blood transfusion can be a vital, lifesaving procedure. Healthy donor recruitment and retention is a challenge that faces the health industry today. Hence studying the profile of blood donors will help to identify the population which could be targeted to increase the pool of blood donors. It is also essential that the blood collection process does not harm either the donor or the recipient and Reason for deferral was analysed. Materials and Methods: Data was collected from the records maintained by the blood bank. The study involved donors both voluntary and replacement who have donated blood to our centre during the period of 6 months. Results: A majority of the donors were under the age of 50yrs. Donors aged 51–60yrs were very less. Main reason for deferral is high blood pressure and history of use of medication.
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Indian J Hematol Blood Transfus OR 185
OR 186
Profile of Young Donors
Association Between Maternal Igg Anti A and Anti B Titres and Clinical Outcome of Neonates In Abo Incompatible Hemolytic Disease of The Fetus and Newborn (Hdfn)
Vmkv Medical College, Salem Introduction: The blood donor program is a life force in any transfusion service.nit is essentially human operation that intracts with the community and relies totally on the support and good will of individual donors. The purpose of donor screening and deferral program to minimize the transmitted infectious agents from a unit of donated blood to the recipient of that unit and to ensure the welfare of the donors. In India national aids control organization paid special attention to the condition of the blood banks and in tandem with the drug controller of India introduce stringent by laws and testing procedure for a infectious agent. Screening of blood for HIV was made manidatory in India in 1988. In 1992 testing blood for Hepatitis B, syphilis and malaria for blood banks. Similar legistation came to effect for HCV from 2001. Naco has put into a place a system for blood units rather than blood donors, on the other hands emphysis on non renunated, voluntary donation to minimize the risk of transmitted disease. Has told heavily upon the donor pool, this study was conducted with the aim of identify the profile of the donors reported at a tertiary care blood bank, and studying the efficacy of donors screening program. AIMS & OBJECTIVES; To explore and compare the demographic profile and seropositivity among donors donating whole blood at fixed and mobile sites. 3. MATERIALS; Prospective study of profile of blood donors. This prospective study was conductive over one year period at tertiary care blood bank on salem. Study period : 6 months Study Population : tertiary care hospital (blood bank) Sample size : 1200 Type of sample : human volunteers 4. METHODS (PARAMETERS OF MEASUREMENTS) : 1 age 2. male : female 3.literarcy 5. STATISTICAL ANALYSIS : Chi square test 6. REVIEW OF LITERATURE : the blood donor program is a life force in any transfusion service.nit is essentially human operation that intracts with the community and relies totally on the support and good will of individual donors.the purpose of donor screening and deferral program to minimize the transmitted infectious agents from a unit of donated blood to the recipient of that unit and to ensure the welfare of the donors. In India national aids control organization paid special attention to the condition of the blood banks and in tandem with the drug controller of india introduce stringent by laws and testing procedure for a infectious agent.Screening of blood for HIV was made manidatory in india in 1988. In 1992 testing blood for Hepatitis B, syphilis and malaria for blood banks. similar legistation came to effect for HCV from 2001. Naco has put into a place a system for blood units rather than blood donors, on the other hands emphysis on non renunated, voluntary donation to minimize the risk of transmitted disease. Has told heavily upon the donor pool, this study was conducted with the aim of identify the profile of the donors reported at a tertiary care blood bank, and studying the efficacy of donors screening program 7. INFORMED CONSENT FORM FROM PATIETNS: C. Synopsis (Brief summary of the Protocol) Name of the Principal Investigator : 1. I. TITLE & OBJECTIVES; To explore and compare the demographic profile and seropositivity among donors donating whole blood at fixed and mobile sites. Materials and Methods: Prospective study to identify blood volunteer donors among male and female. III. Study Design : profile of blood donors IV. Study period: 2015 to 2016 V. No. of patients :1000 VI. Parameters of Measurements : male : female ratio age :18–27 occupation; literacy; no.of donations; VII. No. of specimens/Blood sample per patient. Statistical Analysis: Chi square study IV. Previous latest report/References : Sampath S, Ramsaran V, Parasram S, Mohammed S, Latchman S, Khunia R, Budhoo D, Poon King C, Charles KS. Attitudes towards blood donation in Trinidad and Tobago. Transf Med. 2007; 17:83–87.
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Dr. Nittin Henry, Dr. Susheela J Innah Jubilee Mission Medical College & Research Institute Introduction: Due to the widespread use of RhIg, the incidence of Rh incompatible HDFN has reduced over years. ABO incompatible HDFN develops when group O mother conceive group A and group B babies and as most of the Anti A & Anti B in O group maternal blood will be of IgG class, which crosses the placenta and causes fetal RBC lysis. Significant high titre IgG antibodies can also occur due to environmental factors and vaccination. Hemolysis of fetal red cells leads to hyperbilirubinemia and neonatal jaundice. Anemia is rare in ABO incompatibility and degree of hemolysis is not well correlated by fetal Direct Antiglobulin Test (DAT) unlike in Rh HDFN. AIMS: 1. To find out the relation between severity of hyperbilirubinemia of the baby and IgG Anti A & Anti B titers of the mother. 2. To find out the association between maternal antibody titre and neonatal treatment modality (phototherapy/transfusions/IvIg). 3. To find out the incidence of ABO incompatible pregnancies. METHODOLOGY: Prospective Cohort study. Every O group mothers and all ABO incompatible pregnancies are included in this study. Blood samples of all group O mothers are analysed for IgM & IgG antibody titres by serial dilution method and treating maternal serum with Dithiotreitol (DTT). Maternal grouping is done on the first ante natal visit. Neonatal blood group was determined immediately after birth from cord blood and repeated within 48 h from venous blood. Other confounding factors such as hypothyroidism and maternal allo antibodies are excluded. Results: (Result will be published later). Keywords ABO HDN, Maternal A & B hemaglutinins, Neonatal hyperbilirubinemia
OR 187 Should We Reconsider Platelet Content Criteria For Single Donor Platelets In West Bengal? Sabita Basu Tata Medical Center Introduction: DGHS and AABB set the minimum platelet content of Single donor platelets (SDP) as 3 9 1011. However there are many reports of lower platelet counts among donors in West bengal. Need of the Study: Achieving the requisite standard in platelet content is often untenable in our region. We undertook this study to find the relation between ethnic bengali donors and low SDP platelet content. Materials and Methods: We retrospectively analyzed all SDP donations from 1st January’2015 to 31st July’ 2015. All the procedures were done on MCS + (Haemonetics, USA). All qualified SDP donors who were residents of West bengal and had bengali mother tongue were put in ‘‘Category-A’’ while the rest were labelled as ‘‘Category B’’. Age, sex, repeat donation was noted. Pre-procedure platelet counts and SDP platelet content were obtained from Coulter Ac Tdiff2 (Beckman Coulter). The difference in the platelet content was statistically analysed. Results: Out of 252 procedures were performed, only 182 SDP donations were included in the study. Category-A had 78 donors and Category-B had 104. The mean predonation platelet count for Category-A and Category-B was 189 9 103/cu.mm and 243 9 103/cu.mm respectively. The mean SDP platelet content was 2.7 9 1011 and 3.1 9 1011 respectively. The requisite SDP platelet content was achieved in 29.5 % and
Indian J Hematol Blood Transfus 87.5 % of Category-A and Category-B donors respectively. Conclusion: SDP derived from Category-A donors had a lower platelet content than Category-B. Therefore, many SDP failed to meet the minimum cut-off. Hence, SDP platelet criteria for eastern India needs to be reconsidered. Keywords SDP donations, Platelet content criteria, Eastern India
OR 188 Complications of Therapeutic Plasmapheresis In Neurological Patients In A Tertiary Neurosciences Institute Dr. Sundar Periyavan, Dr. Sangeetha Sheshagiri Nimhans, Bangalore Introduction: Therapeutic plasmapheresis involves separation of whole blood into plasma and cellular components, retaining the plasma and returning back the cellular components to the patient. Removed plasma is replaced with a replacement fluid. The procedure is recommended in certain immune mediated renal, neurological and haematological disorders. Aim: To analyse the complications of therapeutic plasma exchange in patients with neurological disorders. Materials and Methods: A prospective study of 399 patients who underwent TPE for neurological disorders was carried out in NIMHANS. 1912 sessions of TPE were performed between 1/5/14 and 30/4/15 using Haemonetics MCS 3 plus which works on the principle of intermmitent flow centrifugation. Procedure was done through peripheral venous access in 93.7 % patients. 3–5 exchanges were performed on alternate days to reach a therapeutic target of 150–200 ml plasma/kg. FFP was used as replacement fluid in 90.4 % and albumin in 9.5 % cases. Results: Out of 399 patients, 54.6 % were males. Age group ranged from 18–80 years. 9.7 % cases were on ventilator support. The commonest indication was GBS (64.6 %) followed by myasthenia gravis (!3.7 %). Commonest complication observed was hypotension (16 %); others being vasovagal attack (0.25 %), muscle cramps (2.5 %), chills (6.2 %), seizure (0.5 %), pain and haematoma at access site (7.5 %). 13.7 % had reactions to FFP infusion while 2.6 % had reaction to albumin infusion. No major procedure related complication occurred in any of the patients. Conclusion: From our experience, TPE can be considered as a safe and effective procedure in experienced hands. Keywords TPE, FFP
OR 189 Hemocue: Acceptable Replacement For Coulter For Hemoglobin Estimation In Blood Donor Screening? Kavana Soni, Dipti Shah, Bharat Singh University College of Medical Sciences Background: Blood transfusion services (BTS) forms one of the integral patient care. Hemoglobin estimation is the key screening test for accepting donor for transfusion. Different techniques like specific gravity, hemocue, photocolorimetry and automatic hemoglobin analyzers (AHA) are available for hemoglobin estimation. Automatic hemoglobin analyzers are gold standard for hemoglobin estimation. However in developing country like India, where automatic hemoglobin analyzers are not routinely available, there is a need of an easy to perform, accurate, reliable and sensitive test which is acceptable to the masses. Aim: To compare the hemoglobin screening methods in prospective donors using the semi-quantitative copper sulphate test and the quantitative portable photometer Hemocue with the gold
standard automatic hemoglobin analyzers. Methods: All the donors coming to the blood bank of a tertiary care centre in East Delhi within a period of one month were included in this study. Hemoglobin values were divided as Adequate [ 12.5 g/dL Borderline low 12–12.4 Low \12. Results: A total of 1284 donors (1208 males/76 females) were screened during the study period. Two hundred forty-three donors were rejected for donation due to causes other than low hemoglobin values. Twenty-one donors who were unfit for donation by Hemocue (routinely used for screening of donors at our centre) refused to give venous sample for coulter measurements. All the tests in this study thus, were performed on 1020 donors (997males/23females). A total of 997 donors (997/1020 i.e. 97.7 %) were fit for donation by Hemocue (Hemoglobin C12.5gm/dL). Similarly none were fit by copper sulphate method. However, 33/997 donors were found to be unfit by Coulter. 14 of these 33 (42.4 %) donors were in the borderline low category, the rest belonged to the other group. Among the 23 donors that were declared unfit due to low hemoglobin by Hemocue, Coulter results were normal in 20 donors (86.9 %). None of these normal donors were picked by the copper sulphate test. Among the 23 females in the study population, 17 were fit for donation by Hemocue test. However, Coulter results in 4 of these (23.5 %) were below the prescribed minimum. Among the 6 female patients who were declared unfit for donation by Hemocue test, 5 donors (83.3 %) had hemoglobin [12.5gm/dL. Conclusion: Hemoglobin determination remains the most crucial issue in BTS. While the use of either copper sulphate or Hemocue test, alone or in combination are justified in the field setting due to lack of better tests at present, a more stringent testing criteria are required in the hospital setting. Special care needs to be taken in case of female donors, as they had very high discordance rates between the tests being evaluated and the gold standard. Keywords Blood transfusin, Hemoglobin, Coulter
OR 190 Antibody Screening and Identification In Red Cell Crossmatch Incompatibility Patients Samples Arun R Svims, Tirupati Aim and objective: To study the antibody specificity in red cell crossmatch incompatible patient samples during pretransfusion testing. Introduction: Provision of safe blood for transfusion not only implies thorough testing for infectious markers but also protection from hemolytic transfusion reactions resulting from alloimmunization and auto immunization against red cell antigens. Ever increasing efforts at improving blood safety have led to incorporation of regular screening protocols for detection of unexpected immune antibodies. Need of the study: Our aim was to determine the specificity of red cell antibody and to provide safe compatible blood to the patient. Materials and Method: This study was carried out at our Department of Transfusion medicine from April 2012 to August 2015. Antibody screening was performed using commercially available 3 cell panel in patient samples showing red cell crossmatch incompatibility during pretransfusion testing. In case of positive antibody screen, further testing was performed to determine their specificities using 11 cell antibody identification panel. The clinical data were compiled. Results: About 24 patient serum samples showed incompatibility during pretransfusion testing in the study period. Out of 24 serum samples subjected for antibody screening, alloantibody was found in 50 % and autoantibodies in the rest 50 %. Among the alloantibodies, antibody against the Rh antigen was the most common (58.3 %), the most common being anti-D and anti-E The other alloantibodies encountered were anti-M, anti-S, anti-C, anti-N, anti-Jka. Conclusion: Our
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Indian J Hematol Blood Transfus study findings emphasize the role of antibody screening and identification for providing antigen matched blood thereby preventing hemolytic transfusion reactions.
OR 191 A Study of Deferral Among Platelet Pheresis Donors In Various Blood Banks Prakash Hm, Thirumagal, Suryatapa Vinayaka Mission Kirupananda Variyar Medical College Salem Introduction: The increasing demand for platelets, raise the need of Single donor platelets (SDP) to avoid the adverse effects of random donor platelets (RDP). The availability of platelet donors is the major significant limitation in obtaining apheresis platelets. Aim: To assess reasons for deferrals among platelet donors in various blood banks all over India. Materials and Method: To assess reasons for deferrals among platelet donors in various blood banks all over India over a period of August 2015 to October 2015. Results: Total 2450 donors were screened during the given period, 360 (14.69 %) donors did not qualify. 106 donors were rejected due to low hemoglobin level. Other reasons were low platelet count, difficult vein status, positive serology Conclusion: The overall deferral rate was 14.69 % of which 7.5 % were due to hematological reasons.; the hemoglobin criteria should be made lower after evaluation to avoid deferral. SDP deferral register must be maintained to improve the apheresis donor pool. Keywords Single donor platelet, Deferral criteria, Apheresis
OR 192 Molecular Epidemiology of Hepatitis C Virus Genotypes In India Dr. Satish Amarnath Medihope Super Specialty Hospital A total of 238 plasma samples were received from patients attending gastroenterology department across India for treatment from March 2008—Aug 2010. The samples were analyzed for viral load by real time PCR by Taqman principle. HCV genotyping was carried out on the samples whose viral load was more than 300 IU/ml. Out of 238 samples, 117 were positive for 3a, 44 samples were load negative, 43 samples were non-typable due to less viral load i.e. less than 1000 IU/ ml. 26 were type 1a, 107 were 3a, and 11 were 2a.
OR 193 A Study on The Prevalance of Dangerous Group ‘‘O’’ Donors Dr. Nittin Henry, Dr. Susheela J. Innah
titer antibody. To find out the difference in antibody titres across different age, gender and Rh groups. Materials and Methodology Prospective, Observational study. Blood samples for the study are obtained from 200 group O donors in EDTA tubes after screening. Plasma is tested for ABO antibody titers using conventional tube method. Titration is done by adding pooled A and B cells prepared in house. Equal volumes of 0.9 % saline, serum from group O donor and pooled A cell & B cell suspension is added into test tubes. The agglutination is noted after the tubes are centrifuged. Donors with high titer antibodies are treated with dithiothretiol (DTT) for characterization of Ig class (IgG/IgM). Results: results will be published later. Keywords High titer, ABO agglutinin, Blood donors, DTT
OR 194 Outcome of Aplastic Anemia Patients Treated With Horse Anti Thymocytic Globulin (Atg) and Cyclosporine– An Institutional Experience Dr. Tuphan Kanti Dolai, Associate Professor, Prof. Prantar Chakrabarti, Dr. Shyamali Dutta, Associate Professor, Dr. Rajib De, Assistant Professor, Dr Prakas Kumar Mandal, Assistant Professor Nrs Medical College and Hospital Introduction: Aplastic anemia (AA) is an immune-mediated bone marrow failure disorder and most AA patients could not afford the HSCT due to non availability of matched donor, co-morbidity and financial reasons. The aim of the study was to assess response of horse ATG and cyclosporine. Materials and Methods: This prospective study was conducted from year March’2011 to May’2015. AA was diagnosed as per established criteria. ATG was administered at the dose of 40 mg/kg/day for 4 days and cyclosporine at 5 mg/kg at two divided doses from day 14 onwards. Response assessment was done as per published criteria. Results in Brief: Among 36 patients, median age of patients was 38.5 years (6–65 yrs). Non severe AA were 4 (11 %), severe AA 26 (72 %) and very severe AA 6 (17 %). Median duration from diagnosis to ATG therapy was 90 days (25–450 days). 26 patients were treated with ATGAM and 10 patients with Thymogam. In ATGAM group, at 3 months 8 (31 %) patients had partial response (PR) and 28 (69 %) had no response. Overall response (OR) rate of 31 % was achieved. At 6 months 7 (27 %) had complete response (CR), 5 (19 %) PR and 24 (54 %) had NR and the OR rate of 46 % was achieved. In Thymogam group, at 3 months 2 (20 %) patients had PR and 8 (80 %) had no response. OR rate of 20 % was achieved. At 6 months 2 (20 %) had CR, 1 (10 %) PR and 7 (70 %) had NR and the OR rate of 30 % was achieved. Conclusion: OR rate in ATGAM group at 3&6 months are 31 % &46 % respectively. OR rate in Thymogam group at 3&6 months are 20 % & 30 % respectively. Keywords Aplastic anemia, Anti thymocytic globulin
Jubilee Mission Medical College & Research Institute Introduction: The most common blood group O was formerly called as ‘‘universal donor’’ as it can be given to A, B & AB recipients. Naturally occurring high titer ABO antibodies in group O donors may cause acute hemolysis in non group O recipients. These lytic antibodies are of IgM and IgG types. These high Antibody titre cause acute intravascular hemolysis and Hemolytic Disease of Fetus & New born. The clinical importance of this hemolysin occurs in scenarios of whole blood transfusion, Single donor platelet and multiple random donor platelet transfusion across the group. Aims and Objectives: To find out the specificity (IgG/I gM) and strength of ABO antibodies in group O donors. To find the prevalence of group O donors with high
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OR 195 Treatment For Hepatitis C In Transfusion Dependent Thalassemia Major In A Community Based Transfusion Centre Dr. S Divya, Dr. U Ramya, Dr. M Venkatadesikalu, Dr. G Mythili, Dr. S Srinivas Apollo Speciality Hospital Treatment for Hepatitis C in transfusion dependent thalassemia major in a community based transfusion centre Dr. Sreejith R, Dr. Divya S,
Indian J Hematol Blood Transfus Dr. Ramya U, Dr. Venkatadesikalu M, Dr. Mythili G, Dr. Srinivas S, Dr. Revathi Raj VHS Thalassaemia Centre, Chennai Introduction: Hepatitis C viral infection is prevalent among multiply transfused thalassaemia patients. The treatment for hepatitis C infection in these children is challenging when compared to the normal population. Materials and Methods: We performed a prospective observational study for duration of 2 years. All patients with positive serology for Hepatitis C was included and followed up. Results: Forty-one (14 %) out of 292 patients had hepatitis C infection. Genotype 1 HCV strain was 12 (29.5 %), genotype IV 7 (17 %) genotype III, 1 (2.5 %) and 21 (51 %) undetected. One-third of the patients (HCV ELISA positive) did not require treatment as viral load was lower than detectable level. Twenty-six patients received treatment and 10 patients (38 %) achieved complete remission with undetected viral load by PCR in 2 year follow up period and 16 (62 %) had reactivation. Conclusion: The prevalence of hepatitis C viral infection is high in multiply transfused patients and addition of NAT testing may help improve blood safety. The use of antiviral medication therapy for the management of hepatitis C along with iron chelation is promising and must be offered for all these patients to prevent chronic liver disease. New strategies are required as two-thirds suffer reactivation after a mean follow up of 18 months.
OR 196 Risk Factors For Transfusion Transmissible Infections Elicited on Post Donation Counselling In Blood Donors—Need To Strengthen Predonation Counselling Kshitija Mittal, Gopal Patidar, Neelam Marwaha, Ratti Ram Sharma, Ajay Kumar Duseja
OR 197 Study of Compliance of Blood Bank Regarding Blood Donor Criteria For Male Sex Male (Msm) In India Dr. Prakash Hm, Dr. Poojitha Datla, Dr. L. Prathiba, E. Drthirumagal, Dr. B. Vignesh Vmkv Medical College and Hospital, Salem Background: Blood transfusion is regarded as the vital part of the health care delivery system. Safe blood requires proper medical examination. Men who have sex with men (MSM) in India are increasingly likely to be infected with sexually transmitted infections like HIV, Chlamydia, etc. In relation to MSM group, the HIV continues to remain high similar to previous years. DGHS (Directorate General for Health Services) in India addresses MSM as the high risk group donors for HIV transmission and permanent deferral is advised. Aims: The present study is aimed to examine the compliance of the blood banks in relation to deferral of MSM. This study evaluates the knowledge and practicality of donor screening regarding MSM group amongst various blood banks. Materials and Methods: The study is a multi-centric based study. The data will be collected from multiple blood banks throughout India. The data will be collected and evaluated based on the guidelines based on DGHS and NACO (National AIDS Control Organisation) criteria. Conclusion: Several factors like political and ethical approach may help in formulating a common vision and improve the donor screening among MSM population. Few countries are lifting permanent deferral and reducing the deferral period. Strict donor screening along with use of stringent laboratory screening will help in reducing the transmission of infections. We have to come together for a dedicated blood law in order to improve transfusion services in India. Keywords HIV transmission, Blood transfusion, Donor screening
Pgimer, Chandigarh, India Introduction: The present study was done to assess the response to the disclosure of TTI reactivity results in blood donors, assess the risk factors in blood donors and follow the compliance of the disclosure and clinical referral. Materials and Methods: A retrospective study was conducted from April 2011 to November 2012. Screening was done using third generation ELISA kits approved for use in blood banks by the Drug Controller General of India. Those testing repeat reactive were referred for further management. Results: The total number of TTI reactive donors was 787 (0.93 %, N = 83865). The observed response rate in the present study is 21.6 % (167, N = 787). The risk factors for acquiring infections in TTI reactive donors were statistically significant history of high risk behaviour (20.3 %) for human immunodeficiency virus (HIV) infection and history of jaundice in themselves, family or close contacts (16.1 %) for hepatitis B virus (HBV) infection. One hundred and ten (65.8 %) of the referred donors were on outpatient clinical care when post-referral follow up was conducted. Discussion & Conclusion: The study emphasises on continuing sensitization of blood donation camp organisers to the need of privacy during blood donor selection. The study also stresses the need to strengthen the pre-donation counselling at outdoor blood donation at the same time raise awareness amongst blood donors about the importance of post-donation counselling and follow up. Keywords Blood donor, Notification, Counselling, Transfusion transmissible infection
OR 198 Prevalence of Transfusion Transmitted Infection In A Regional Blood Bank Center (Prof.) Dr. Bibudhendu Pati, Dr. Girija Nandini Kanungo Ims & Sum Hospital Introduction: Transfusion Transmitted Infections (TTIs) are a major problem associated with blood transfusion. Accurate estimates of risk of TTIs are essential for monitoring the safety of blood supply and evaluating the efficacy of the currently employed screening procedures. Need for Study: To study the prevalence of TTIs among blood donors. Materials and Methods: This prospective study was carried out in healthy blood donors aged 18–60 years, presenting to our blood bank from July 2014 to July 2015. Care was taken to exclude professional donors. Donors were screened using donor questionnaire forms and personal interview. The serum samples were screened for Hepatitis B Surface Antigen (HBsAg); antibodies against HIV I and II, Hepatitis C Virus (HCV) and Malaria, by Enzyme-linked immunosorbent assay (ELISA) method. Screening for Syphilis was carried out using immunochromatography method. Results in Brief: A total of 10,023 units of blood were collected and screened from July
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Indian J Hematol Blood Transfus 2014 to July 2015. The mean prevalence of five major transfusion transmitted infections was as follows: HIV: 0.30 % HBsAg: 0.99 %, HCV: 0.10 %, Syphilis: None. Conclusions: The number of HBs Ag positive cases was more followed by HIV, HCV, and Syphilis. Though the prevalence of TTI continues to decrease, there is still a higher prevalence of HbsAg compared to other TTIs in our population. Integrated treatment and counselling centers for TTIs should be a part of every blood bank, for treatment, counselling, increasing awareness and preventing spread of TTI. Keywords Transfusion transmitted infection
OR 199 Clinical Efficacy of Therapeutic Plasma Exchange In NeuroImmunological Disorders: A Tertiary Care Centre Exp from Tamil Nadu H. M. Prakash, L. Prathiba, D. Poojitha, Suryataba, P. Arivukkarasu Vinayaka Mission Kirupananda Variyar Medical College Background: Therapeutic plasma exchange (TPE) is commonly used in immune mediated neurological disorder that is, Guillain–Barre syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), myasthenia gravis (MG), multiple sclerosis and acute disseminated encephalomyelitis. Methods: This retrospective study was done at the Department of Transfusion Medicine, VMKV Medical College from July 2014 to August 2015. The data was obtained from TPE register. TPE was carried out on intermittent flow hematinics cell separator. All patients were classified according to Hughes functional grading scores. Results: Between 2014 and 2015,295 TPE procedures were performed on 75 patients. Among them 28 patients underwent 112 TPE for neurological causes. The study group included 17males & 11females in the ratio of 1.8:1. The mean age was 36.8 years, with age ranging from 17–75 years. Of 28 patients, there were 22 cases of GB syndrome (78.8 %), two cases of MG (7 %), two cases of CIDP (7 %) and polyradicular neuropathy (7 %). The median TPE session number was 3 with a range of 1–5. The pre-TPE median Hughes score for GBS and MG patients was 4, post-TPE scores decreased to grade 1. During the TPE procedures, the complications were mild and manageable such as hypotension, hypocalcaemia and mild anemia. Conclusion: TPE is an effective treatment in neurologic diseases in which autoimmunity plays an important role in pathogenesis, and it is safe when performed in experienced centers. Keywords Therapeutic plasmaexchange, Myastheniagravis, Guillain–Barre syndrome
Topic: Transplant—All Categories OR 200 Allogeneic Stem Cell Transplantation For The Treatment of Aplastic Anemia: Scientific Data From A Stem Cell Transplant Center In Western India Dr. Apte Shashikant, Dr. Kannan Subramanyan, Dr. Dudhatra Abhishek, Dr. Kamat Girish, Dr. Vaghasiya Dharmesh Sahyadri Speciality Hospital Introduction: Aplastic anemia encompasses a heterogeneous group of diseases with distinct pathophysiologies and a common clinical endpoint of marrow failure. Patients with severe aplastic anemia (SAA) can be treated with immunosuppressive therapy or hematopoietic stem cell transplantation (HSCT). Allogeneic stem cell
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transplantation is the preferred treatment modality in young patient with HLA-matched family stem cell donor. Material and Method: In this retrospective study data from patients with SAA, who underwent allogeneic HSCT at our center from 1999 to 2013, was reviewed under following headings. 1. Patient (Age/sex, transfusions, infections, PNH) 2. Donor (Age/sex, relation, HLA-match) 3. Transplant (conditioning, graft-source, GvHD-prophylaxis, MNC/CD34-dose) 4. Engraftment (y/n, day, chimerism) 5. GvHD (acute/chronic, grade, treatment, outcome) 6. Complications (infections/VOD/CMV) 7. follow up and overall outcome. Results: Data of 53 patients was analyzed. Overall survival at two years was 71.56 %. Significant improvement in OS after 2010 (90.46 %) as compared to before 2010 (68.57 %). 13 patients died. 7 due to aGvHD + sepsis, 4 due to sepsis, and 1 due to accident. 51/53 patients engrafted. 2 died before engraftment. 10 patients had grade 3–4 aGvHD. 2 improved. 7 died due to sepsis, 1 had graft failure following intensive immunosuppression. Conclusion: Allogeneic HSCT is a curative and cost effective treatment modality for patients with SAA who qualify for it. Analysis of our center’s data shows a definite improvement in OS of patients who undergo HSCT, parallel to the global trends. Thus, it should be offered to all eligible patients with SAA, as primary treatment.
OR 201 Initial Experience With Haploidentical Stem Cell Transplantation For Hematological Disorders—Single Centre Data Fouzia Na, Eunice Sindhuvi, Vikram Mathews, Alok Srivastava, Biju George Christian Medical College and Hospital, Vellore Allogeneic stem cell transplant is the only curative option for many hematological disorders. Up to 70 % of patients requiring allogeneic transplant do not have a matched family donor, and are unable to proceed with matched unrelated donor (MUD) transplants either due to economic or time constraints. Since almost every patient potentially has an available haplomatched donor, haplo-identical transplants (Haplo SCT) are increasingly being performed around the world. Methods: We retrospectively analysed data on 42 consecutive patients who underwent haplo-identical stem cell transplants carried out at CMC Vellore, between June 2010 and June 2015. Data was retrieved from individual medical records and electronic databases. Analysis was performed using SPSS version 13.0. Results: Forty-two patients underwent 43 haplo-identical SCTs during the study period. There were 26 males (61 %), and median age was 19 years (Range: 1–52). Twenty-eight (66 %) patients had Haplo SCT for malignant disorders while 14 (44 %) had non-malignant indications (aplastic anemia, immunodeficiency syndromes etc.). Graft source was PBSC in 40 cases and bone marrow in 3 cases. Conditioning regimen varied according to the indication for transplant (Flu/Cy (n = 17), Flu/Bu (n = 18), Flu/Mel (n = 2), Cy/TBI (n = 1), Treo/Flu (5)). TBI 200 cGy was given in all cases except two patients (age \ 1 year). GVHD prophylaxis consisted of Cyclophosphamide 50 mg/kg on Day +3 and +4, with Tacrolimus, MMF and growth factor starting on Day +5. All patients received acyclovir prophylaxis from Day +1 while no antibacterial or anti-fungal prophylaxis was used. Weekly CMV monitoring was started following engraftment till Day + 100. Twenty-nine patients (69 %) engrafted, 12 patients (28 %) died of sepsis or other complications prior to engraftment, and one patient had primary engraftment failure, and went on to successfully engraft after a 2nd haplo SCT. The median time to neutrophil engraftment (ANC [ 500/mm3) was 16 days (range: 11–44) and platelet engraftment was 16 days (range: 12–112). Eleven patients (35.4 %) developed acute graft versus host disease, with Grade III and IV
Indian J Hematol Blood Transfus GVHD in 5 patients (16.1 %). CMV reactivation was seen in 23 patients (74 %) and all were successfully treated with ganciclovir. Five out of 20 (25 %) patients with malignant disorders relapsed, at a median of 171 days (range: 34–212) post SCT. The overall survival at one year was 45.9 % + 8.0 %. The causes of death included infection in 14, GVHD in 3 and relapse in 2. Three patients who relapsed after transplant are alive at present, on palliative chemotherapy. Conclusion: Haplo-identical stem cell transplantation is feasible and may be considered for patients requiring urgent allogeneic stem cell transplant, in the absence of a matched donor. Overall survival of 46 % in this group of patients is encouraging, and with more experience, outcomes with Haplo-SCT will improve in the Indian setting.
Table 1 continued Parameter
N
PFS in months (median)
P (log rank test)
\200 mg/m2
21
48
0.34
200 mg/m2
25
53
7
25
37
53
2
24
20 26
47 53
Melphalan dose
Pre transplant disease status PR VGPR/CR Progressive disease
0.53
Maintenance post ASCT OR 202 Outcomes In Multiple Myeloma Post High Dose Chemotherapy and Autologous Stem Cell Transplantation—Single Institute Experience
Yes No
0.97
T. G. Sagar, Krishna Rathinam, Ganesan Trivadi, Rajendranath Rejiv, Ganesan Prasanth Cancer Institute (Wia) Introduction: Standard therapy for young patients with multiple myeloma (MM) involves induction chemotherapy followed by autologous stem cell transplantation (ASCT). Method Patients of MM who underwent ASCT between 2001 and 2014 with a minimum of 1 year of post-transplant follow up were analysed. Patients received 4–6 cycles of chemotherapy (lenalidomide and bortezomib were used after 2010) prior to ASCT. Results: Forty-six patients [29 (63 %) males; mean age: 49.04 (25–67) years]. Pre transplant therapy: thalidomide and dexamethasone : 24 (52 %); lenalidomide and dexamethasone : 10 (22 %); bortezomib and dexamethasone: 8 (17 %), others: 4 (9 %). Disease status prior to transplant—VGPR/CR: 37 (80.4 %), PR = 7 (15.2 %); Progressive: 2 (5 %). Melphalan dose: \200 mg/m2 = 25(54 %); 200 mg/m2 = 21 (46 %). At the last follow up 24 (53.3 %) had progressed. The median post-transplant progression free survival was 48 (25–71) months. Only 1 patient died due to post transplant complications (2 % TRM). No prognostic factor was identified on univariate analysis (Table 1). Conclusion: Results with ASCT at our institute are comparable to western literature. With proper selection of patients, the procedure can be performed with minimum morbidity and mortality.
OR 203 Table 1 Univariate analysis of factors predicting progression free survival Parameter
N
PFS in months (median)
P (log rank test)
\50
24
53
0.9
[50 Sex
21
48
Male
29
69
Female
17
40
Age
0.86
Pre-transplant therapy Lenalidomide/bortezomib based
18
40
Thalidomide based
24
68
4
27
Others
0.297
Clinical Outcomes in Abo Incompatible Allogenic Hematopoetic Stem Cell Transplants with Reduced Intensity Conditioning for Hematological Malignancies Santhosh Kumar Devadas, Anant Gokarn, Alok Gupta, Sachin Punatar, Deepan Rajamanickam Tata Memorial Centre Advanced Centre For Treatment, Research & Education In Cancer Introduction: With the popular use of reduced intensity conditioning (RIC) allogeneic hematopoietic stem cell transplants (allo-HSCT) using peripheral blood stem cell (PBSC) graft source, reports on outcomes of ABO blood group incompatibility is limited. Methods: All patients (n = 96) who underwent RIC allo-HSCT for any haematological malignancy using PBSC graft between July 2008 – December 2014 were included. Majority of patients received fludarabine with melphalan RIC and cyclosporine + methotrexate as Graft versus host disease (GVHD) prophylaxis. Patients were categorised as ABO blood group compatible or incompatible. ABO incompatibility was further categorised as major, minor and bidirectional as per standard definition. Number of single donor platelets (SDPs) and packed red cells (PRCs) required within 28 days post transplant along with time to neutrophil (NE) and platelet engraftment (PE) were compared between the groups. Incidences of relapse, transplant related mortality (TRM), acute and chronic GVHD were compared. Overall Survival (OS) and Relapse Free Survival (RFS) between the groups were compared by Log-Rank test. Results: Median follow-up was 24 months. ABO Incompatibility was seen in 45.8 % of patient-donor pairs. The median time for PE was 14 days (range: 8–22) in the major incompatible allo-HSCT group (P = 0.013). There was no difference in NE between groups. Median number of SDPs & PRCs required did not significantly vary between the groups. There was no difference in incidence of acute GVHD & chronic GVHD between the ABO compatible and incompatible groups. The OS and RFS at 2 years was 60 % and 57 % respectively for all patients with no significant difference between the groups. Conclusion: With the use of ABO incompatible patient-donor pairs with PBSC grafts, there were no adverse clinical outcomes in patients undergoing allo-HSCT with RIC regimens for hematological malignancies.
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Indian J Hematol Blood Transfus OR 204
OR 205
Haematopoietic Stem Cell Transplantation For Childhood Acute Lymphoblastic Leukemia—A Single Centre Experience
Post Transplant Cyclophosphamide As A Tool For Preventing Rejection and Graft Versus Host Disease In Children Undergoing Second Haematopoeitic Stem Cell Transplantation
Deenadayalan M, Jose Easow, Lakhsmanan V, Sreejith R, Ramya U Apollo Hospital Allogeneic stem cell transplantation is an effective curative option for children with relapsed and high risk acute lymphoblastic leukemia (ALL). The effect of minimal residual disease (MRD) prior to transplantation and the donor source have a significant impact on the overall outcome. We performed a retrospective analysis of children with ALL who underwent HSCT at our centre from 2002 to 2015. Disease status was determined by flow cytometry from 2008 and by morphology and karyotyping in the patients from 2002 to 2008. A total of 37 children were transplanted for ALL at our centre. 48 % of children were MRD positive prior to HSCT out of which 16 % relapsed. Out of the 52 % children who were MRD negative, only 5.2 % relapsed. The overall mortality percentage was 33 % in the MRD positive group and 31.5 % in the MRD negative group. A fully matched family donor was the source of stem cells in 36 % children and 64 % had received a mismatch family donor or unrelated graft. Graft versus host disease was the major cause of mortality at 66 % in this group. Molecular remission prior to HSCT shows a trend towards lesser chance of relapse, but did not provide a survival advantage. Children who had received fully matched family donor had a better survival compared to unrelated and mismatch family donor. We conclude that pre HSCT MRD status and graft choice play a vital role in determining the post transplant outcome in children transplanted for ALL. Keywords HSCT, MRD, Stem cell source
Dr. Sreejith R, Dr. Ramya Uppuluri, Dr. Hemalatha Doss, Dr. Atish Bakane, Dr. Revathi Raj Apollo Hospital Background: Post transplant cyclophosphamide is being increasingly used as part of haplotransplants with improved outcomes in terms of decreasing rejection and GVHD rates. We present two cases where post transplant cyclophosphamide was used as part of second transplant from a fully matched family donor. Patients and Methods: The two children who underwent matched family donor transplantation were a 1 year old male child with T-B-NK + severe combined immunedeficiency (SCID) and the other, a 6 year old male child with Thalassaemia major. They had complete chimerism up to day 100 post HSCT and then rejected their grafts at around 8–9 months. They underwent a second transplant from the same donor with 50 mg/ kg/day of cyclophosphamide on day 3 and 4 post HSCT during the second transplant. The conditioning protocols used were Fludarabine/ Treosulphan for SCID and Fludarabine/Thiotepa/Treosulphan for Thalassemia during both the transplants. Results: Early engraftment was achieved by day 18 in both the children during the second transplant. Tacrolimus was used for GVHD prophylaxis which was subsequently tapered by day 100. The child with SCID developed skin GVHD and elevated liver enzymes which settled with the use of steroids. The children are more than 1 year post BMT at present, with stable grafts and no end organ toxicities. Conclusions: The use of post transplant cyclophosphamide in second transplants for children with benign diseases has been able to ensure a durable graft. It has also reduced the requirement for long term immunosuppression which significantly adds to the cost of second transplant.
OR 206 Changes In Recipient Anti-Donor Isoagglutinins In Post-Transplant Pure Red Cell Aplasia Sabita Basu, Deepak Mishra, Mammen Chandy Tata Medical Center Introduction and need for the Study: According to literature the incidence of post transplant (PRCA) in major or bi-directional ABO incompatible HSCT is around 15 %. The anti-donor isoagglutinin titers play a key role in its development. We reviewed the changes in isoagglutinin titers in four cases of post-transplant PRCA at our center. Materials and Methods: The analysis included 3 major and 1 bi-directional ABO incompatible allogenic HSCT. The pre-transplant workup included blood group, direct and indirect antiglobulin test, red cell phenotyping, major and minor cross-match and recipient antidonor antibody titration (saline and AHG). Post transplant serial antidonor isoagglutinin titer was performed and PRCA was confirmed on bone marrow examination. Complete blood counts, reticulocyte percentage, chimerism studies and transfusion requirements were noted in all the cases. Results: The study included two cases of AML and one case each of chronic idiopathic myelofibrosis and aplastic anemia. Post transplant, in two patients the anti-donor isoagglutinin titer initially declined, then persisted up to day-110. Amongst them, PRCA responded to therapy and resolved in one, but the other patient
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Indian J Hematol Blood Transfus relapsed and died. In the other two cases, the anti-donor isoagglutinin titers spiked from 16/16 and 64/128 to 256/1024 and 16/256 (saline/ AHG) on day-60 and day-90 respectively. Mixed chimerism was observed in one patient, who eventually expired. The other case showed a steady decline in titers over a period of four months and survived. Conclusion: Persistence or increase in recipient anti-donor isoagglutinins correlates with post-transplant PRCA and can predict its onset. Keywords Transplant, PRCA, Isoagglutinins, Titer
OR 207 Long Term Viability of Stem Cells Stored At Minus 80Oc With Dmso At Concentration of 4.35 % In Hematopoietic Stem Cell Transplant Minal Poojary, Alok Gupta, Pallavi Rane, Ananth Gokarn, Navin Khattry Tata Memorial Hospital Background and Objectives: Hematopoietic stem cells (HSC) are cryopreserved routinely prior to autologous stem cell transplant (auto-SCT) and also cryopreserved for future use as donor lymphocyte infusion (DLI) in the allogeneic stem cell transplant (allo-SCT) setting. Commonly used method to cryopreserve is in liquid/vapour phase nitrogen by controlled freezing up to -156 C. However, another cost effective method employed by many institutes is by using uncontrolled rate freezing (URF) at -80 C. Stem cells stored by URF method have shown good viability during short term storage, though there is limited data for its role in long-term storage. With the need to store hematopoietic stem cells for longer durations in the present era, especially for second transplants in multiple myeloma and DLI for late relapses, the efficacy of URF for longer period needs to be assessed. Dimethyl-sulfoxamide (DMSO) is the most commonly used cryoprotectant. A final concentration of 10 % DMSO is widely used. Lower concentration of approximately 5 % DMSO has been used with an aim to decrease infusional toxicity, with no adverse effect on viability during short term storage. However data on long-term storage with 5 % DMSO is limited. We analyzed the efficacy of cryopreservation of HSC by URF at -80 C, while using DMSO at a final concentration of 4.35 %. Patients and Methods: Three hundred eighty-nine patients who underwent autologous (203 patients) and allogeneic (186 patients) hematopoietic stem cell transplant (HSCT) from November 2007 to January 2015 were included. Stem cells were cryopreserved with 8.7 % DMSO in equal volumes to attain a final volume of 100 ml per bag and final DMSO concentration of 4.35 %. Stem cells were then stored in -80C freezer. For patients undergoing auto-SCT, cryopreserved bags were thawed in 37C water bath and each bag infused within 20 min on the day of transplant. For patients undergoing alloSCT, the bags were thawed only if patient required DLI for slippage of chimerism or frank relapse. Viability of thawed HSC was measured using trypan blue dye exclusion method. Toxicity during stem cell infusion was documented. Results: A total of 2167 bags were
cryopreserved. 1541 bags for auto-SCT patients and 626 bags as DLI for patients who underwent allo-SCT. A total of 1064 bags (1022 for auto-SCT; 42 for DLI) were thawed. DLI was used for 24 patients with 10 receiving more than one DLI. For auto-SCT median CD34 + cell dose infused was 4.73x106cells/kg and for patients requiring DLI median CD3 + cell dose infused was 2.05x107/kg. Median time from cryopreservation to stem cell infusion for autologous HSCT was 1.6 months (range 0.23–72 months) while median time to DLI infusion was 8.2 months (range 0.7–36 months). The duration between cryopreservation and thawing of bags was subdivided as \3 months (n = 816), 3–6 months (n = 160), 6–12 months (n = 68), 12–18 months (n = 10), 18–24 months (n = 3), 24–36 months (n = 1) and [36 months (n = 6). Mean stem cell viability was 98 % (range 78–100 %) across all time periods. The median time to engraftment (in auto-SCT) was 11 days (range 7–19 days) and median time to platelet engraftment was 13 days (range 6–90 days). DMSO related toxicity was seen only in 10 (4.4 %) patients. Conclusion: Stem cells can be safely cryopreserved at minus 80 C with DMSO at a final concentration of 4.35 % for more than 3 years. Infusion of DMSO at 4.35 % concentration is associated with low toxicity.
OR 208 Study of Quality of Life In Multiple Myeloma Patients After Autologous Stem Cell Transplantation Dr. Ashok, Dr. Krishna Mani, Dr. Sadashivudu G, Dr. Laxmi Srinivas M Nizam Institute of Medical Sciences Abstract Study of Quality of life in Multiple Myeloma patients after Autologous Stem Cell Transplantation. Objectives: 1) To characterize the impact of multiple myeloma on the quality of life of patients treated in a tertiary care centre using a questionnaire specific for oncologic patients (QLQ-C30) upon diagnosis, after the clinical treatment, and at day +100 after autologous stem cell transplantation. 2) To evaluate whether autologous stem cell transplantation can improve the quality of patients aside from providing a clinical benefit and disease control. Methods: Evaluation of 31 patients with multiple myeloma using the QLQ-C30 questionnaire was done. The scores upon diagnosis, post-treatment/pre-autologous stem cell transplantation, and at D + 100 were compared using ANOVA (a comparison of the three groups), post hoc tests (two-by-two comparisons of the three groups), and paired t-tests (the same case at two different times). Results: The QLQ-C30 questionnaire demonstrated that global health, physical function, role-physical, social function and bodily pain were statistically different across all three groups and favored the D + 100 ASCT group (ANOVA). The QLQ-C30 questionnaire results favored the D + 100 ASCT with respect to fatigue, the lack of appetite, insomnia and constipation. The post hoc tests and paired t-tests confirmed a better outcome after autologous stem cell transplantation.
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Indian J Hematol Blood Transfus Analysis of variance (ANOVA) comparing the three groups according to the QLQ-C30 questionnaire
2008 and December 2013 in our centre were included in this study. CC was defined as growth of a known pathogen from any lumen of the catheter without any evidence of fever. CRBSI was defined as growth of a known pathogen from any lumen with or without growth from peripheral vein and presence of fever ([38 C), chills or hypotension. Antibiotic lock was used in all patients with CC according to sensitivity pattern. Results: 224 patients underwent HSCT. The incidence of CC was 9.8 % (22/224) while CRBSI was seen in 10.7 % (24/224). Coagulase Negative Staphylococcus (CONS) and Gram Negative Bacteria (GNB) were seen in 10 each (45 %) of CC. Antibiotic lock was used in 21 of 22 CC cases. Catheter salvage was successful in 95 % (20/21) cases. Amongst CRBSI, GNB accounted for 83 % (20/24) of the cases. 45 % of these isolated confirmed to be Extended Spectrum Beta Lactamase (ESBL) producers. Antibiotic lock was used for 15 of the 24 cases of CRBSI. Catheter salvage was successful in 86 % (13/15) patients. Conclusion: More than 80 % of patients with catheter colonization and CRBSI could be salvaged with appropriate antibiotic locks making them an effective strategy for catheter salvage in our setting.
Scale
Upon diagnosis, Mean (± SD)
Global health
28.49(± 18.2) 55.37 (± 14.5)
65.6 (± 13.9) 0.0001
Physical
46.88 (± 15.4)
50.53 (± 12)
56.50 (± 15)
0.03
Role
38.16 (± 22)
53.22 (± 22)
66.66 (± 20.2)
0.0001
Emotional
71.5 (± 10.9) 72.04 (± 11.1)
73.92 (± 9.56)
0.64
Cognitive
57.51 (± 18.2)
54.82 (± 25.5)
0.85
Social
54.8 (± 20.7) 62.36 (± 19.2)
63.4(± 21.3)
0.2
OR 210
0.0011
Correlation of CMV Reactivation Post Haematopoietic Stem Cell Transplant With Type of Graft and Its Impact on Viral Monitoring
Post-treatment/ Pre-ASCT, Mean (± SD)
D + 100 ASCT, Mean (± SD)
p-value
Functional scale
54.83 (± 20.7)
Symptom scale Fatigue
52.3(± 18.4)
41.8(± 16.9)
Nausea
21.49 (± 20.3)
20.96(± 20.6) 19.88(± 21.5) 0.95
36.6(± 11)
Pain
62.89 (± 18.1)
27.41(± 23.8) 19.88 (± 21.3)
0.0001
Dr. Divya S, Dr. Ramya Uppuluri, Dr. Hemalatha Doss, Dr. Atish Bakane, Dr. Revathi Raj Apollo Speciality Hospital
Quality of life scale Dyspnea
13.97 (± 20.7)
11.8 (± 20.3) 7.5 (± 14.2)
0.30
Insomnia
55.17 (± 34.8)
20.42 (± 26.8)
13.92 (± 22.4)
0.0001
Lack of appetite 25.28 (± 29.1)
9.67(± 15.4)
13.92 (± 22.4)
0.028
Constipation
29.88 (± 27.2)
9.67 (± 15.4) 8.6(± 19.2)
0.0002
Diarrhea
3.22 (± 10)
1.02 (± 5.94) 3.22 (± 10)
0.55
Financial difficulties
50.5 (± 38.4) 36.55 (± 34.8)
29.03(± 31.9) 0.055
Patients and Methods Data from children aged up to 18 years who underwent haematopoeitic stem cell transplantation from 2002 to 2015. We analysed CMV reactivation in autografts versus allografts, matched sibling allografts versus unrelated or mismatched grafts, and unrelated PBSC versus unrelated cord. Results: A total of 360 paediatric HSCTs including 15 autografts and 345 allografts have been performed at our centre from 2002 to 2015. None of the children with autografts had CMV reactivation. Seven out of 240 children who underwent MSD transplants had CMV reactivation (2.9 %). The overall CMV reactivation rate in unrelated or mismatched transplants was found to be 19 %. Reactivation rates were 10 % (4/40) in unrelated PBSCs, 19.5 % (8/41) in unrelated cords and 33 % (8/24) in mismatched or haploidentical grafts. Conclusions: CMV reactivation is rare in matched sibling allograft and this setting does not warrant routine weekly PCR monitoring. Significant CMV reactivation is seen with the use of unrelated or mismatched family donors, hence early and serial monitoring for CMV viraemia in these children is imperative.
OR 209
OR 211
Use of Antibiotic Lock For Salvage of Tunneled Central Venous Catheters With Catheter Colonization and Catheter Related Blood Stream Infection In A Tertiary Care Haematopoietic Stem Cell Transplantation Unit—A Strategy Revisited
Techniques For T Cell Depletion on Survival and Outcome: A Single Paediatric Centre Experience
Anant Gokarn, Santhosh Kumar, Sajid Qureshi, Vivek Bhat, Navin Khattry Tata Memorial Centre, Mumbai Background: Catheter Related Blood Stream Infection (CRBSI) and catheter colonization (CC) represent a significant problem encountered in hematopoietic stem cell transplantation (HSCT) frequently requiring Central Venous Catheter (CVC) removal. Materials and Methods: All patients who underwent HSCT between September
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Dr. Divya S, Dr. Ramya U, Dr. Hemalatha Doss, Dr. Atish Bakane, Dr. Revathi Raj Apollo Speciality Hospital Background: Haploidentical transplants require T depletion in order to facilitate engraftment and prevention of graft versus host disease. We present data on haploidentical transplants the various methods of T depletion and outcomes. Patients and Methods: Patients aged up to 18 years were included in the study after informed consent from parents. Results: A total of 12 haploidentical transplants have been performed at our Centre, parent donors, 7 sibling donors, 6. CMV
Indian J Hematol Blood Transfus reactivation was noted in 5 of the 12 children (41 %). In the post transplant cyclophosphamide group, 3 are alive while 3 died of infections. Among the 3 children where CD3 4 selection was used, one child rejected his graft (retransplanted) and the other 2 died. Campath use resulted in refractory CMV disease and resulted in death. The 2 children where TCR a/b depletion and CD3/19 selection was used, died of progressive leukoencephalopathy. Survival rates were found to be 50 % with post-transplant cyclophosphamide while it was found to be 16 % where other methods of T cell depletion were used. Conclusions: Haploidentical transplants with post-transplant cyclophosphamide have been found with survival rates of 50 %. Engraftment can be achieved, although it is important to monitor for late rejection. There is a significant risk of CMV reactivation of up to 40 %.
Topic: Vascular Disorders OR 212 Thrombophilic Factors, Clinical Profile and Management In Budd Chiari Syndrome—Study from A Tertiary Centre Priyanka Saxena, Ajeet S Bhadhoria, Sk Sarin
Platelets have a major role in development of these vascular complications. Platelet activity is found to be increased in cases of diabetes. Platelet indices indicators of platelet activity and size. Aim: To find out whether the platelet activity is increased in diabetes and its related vascular complications in diabetics and its correlation with fasting blood sugar. Materials and Methods: We carried out the study in 100 diabetics and 60 non diabetics in our hospital. The study included diabetics with complications and without any vascular complications. The counts were done in anticoagulated blood using automated haematology analyser (Sysmex XT 2000i). Results: The platelet indices were found to be significantly increased in patients with complications than those without complications and non diabetics. Also there was a significant correlation between the platelet indices and fasting blood glucose and duration of diabetes. Conclusion: Our study suggested a significant association between platelet indices and development of vascular complications in diabetes. So the platelet indices can be used as prognostic marker for assessing development of vascular complications in type 2 diabetes mellitus. Keywords Diabetes mellitus, Platelet indices, Vascular complications
Topic: WBC Disorders
Department of Hematology, Institute of Liver and Biliary Sciences Introduction: Budd-Chiari syndrome (BCS) is defined as hepatic venous outflow tract obstruction at the level of the hepatic venules, hepatic veins and inferior vena cava (IVC). Factors predisposing to the development of BCS include hypercoagulable states, trauma, infection and other causes. The study was done to evaluate the etiology, presentation and management strategies. Materials and Methods: A retrospective study of patients with BCS who visited the centre from Jan 2014 to May 2015 was conducted. Characteristics including presentation, etiology, management and outcome of these patients were analyzed. Results: A total of 28 patients of BCS were diagnosed during this period. Out of these, 22 were males and 6 were females. Mean age of presentation was 27.69 ± 10.31 years. Most common presentation was pain abdomen (82 %) followed by bleeding and jaundice. 17 patients had involvement of hepatic vein, 6 had both hepatic vein plus IVC involvement and 5 had IVC involvement only. Thrombophilic work up showed protein S deficiency in 2, protein C deficiency in 1, heterozygous factor V leiden in 1 and homozygous MTHFR in 2 patients. One patient was positive for PNH clone. Mean MELD score was was significantly higher (16.33 ± 8.73) in patients with hepatic vein involvement (p value 0.006). Nine patients underwent transjugular intrahepatic porto-systemic shunt, 8 underwent direct intrahepatic porto-systemic shunt and 4 patients taken for liver transplant. Conclusion: Hepatic vein and hepatic vein plus IVC involvement is common in India. Role of thrombophilic work up and treatment guidelines in BCS need to be formulated. BuddChiari syndrome, Thrombophilia.
OR 213 A Study on Correlation of Platelet Indices and Vascular Complications of Diabetes Mellitus S K Behera, D P Mishra Mkcg Medical Colleg, Berhampur Background: Vascular complications are one of the important causes of morbidity and mortality in type 2 diabetes mellitus.
OR 214 Xcellnt Morphology: Continuing Paradigm Shift In Peripheral Blood Examination Ananthvikas J, Sukesh Chandran Nair, Joy John Mammen, Josephine, Philips Jesuraj Cmc Vellore Introduction: Modern cell counters have progressed beyond the basic haemogram, providing a host of additional information in the form of graphical and numerical cell distribution data which when used appropriately can add immense value to a peripheral blood examination, possibly leading to reduced slide reviews and more specific diagnoses. Aim: To identify patterns in scatterplots and cell distribution data in patients with and without malignancy on the Sysmex XN platform, and to establish the reliability of these in screening peripheral blood samples. Materials and Methods: A Sysmex XN-9000 analyser was used. Samples were collected in lavender capped EDTA tubes from a total of over 200 cases, including daily follow up samples where available. These comprised patients with malignancy (leukemia, lymphoma, myelodysplastic syndrome) and without (dengue, viral fever among others). The cell distribution data from the Sysmex platform was based on fluorescence, forward scatter and side scatter data obtained on cells analysed in the flow cells following hydrodynamic focusing. Over 300 healthy donor samples were assayed to establish a reference range. Results: Consistent patterns in the WDF (WBC-differential), WNR (WBC-NRBC) and WPC (White Precursor Cell) scatterplots and cell distribution data permitted classification of cases into benign, ALL, APL, non-APL AML, CLL, CML-chronic and blast crisis phases, and cases of MDS which especially showed consistently low neutrophil side scatter. Conclusion: We are in the era of the automated cell counter, with ‘Haemocytomorphometry’ as a science progressing at a feverish pace, and understanding these machines and their data adds new dimensions and tremendous value to a routine peripheral blood examination. Keywords Sysmex XN, Leukemia, Peripheral blood, Scatterplot
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Indian J Hematol Blood Transfus OR 215 Cml With Microfilaria : A Rare Case Report Dr. Meera Rameshbhai Khoont, Dr. Monica Gupta, Dr. Kirti Rathod, Dr. Mustafa Ranpurwala, Dr. Menka Shah Shree Krishna Hospital and Research Center CML with Microfilaria: A Rare Case Report Author :Dr. Grishma Chaniyara, Dr. Meera Khoont, Dr. Monica Gupta, Dr. Kirti Rathod, Dr. Mustafa Ranpurwala, Dr. Menka Shah Filariasis is a major public health concern in tropical and subtropical countries including India. There have been very few case reports of incidental filariasis in the bone marrow aspirate smears in patients with hematological malignancies. We present a case of chronic myeloid leukemia (CML) with associated filariasis. A 40-year-old female, presented with low grade fever and abdominal lump for 2–3 months. Physical examination revealed splenomegaly and hepatomegaly. USG suggestive of splenomegaly. Her hemoglobin was 9.5 g/dl, total leukocyte count was 224.5 lacs with platelet count of 5.42 lacs. Differential leukocyte count on peripheral smear showed 01 % blasts, 04 % promyelocytes, 21 % myelocytes, 36 % metamyelocytes, 35 % polymorphs, 02 % lymphocytes,01 % eosinophils. Bone marrow aspirate smears showed 03 % blasts, 03 % promyelocytes, 26 % myelocytes, 49 % metamyelocytes, 13 % polymorphs, 03 % lymphocytes, 2 % eosinophils. In addition, one microfilaria of Wuchereria bancrofti was also seen in the aspirate smear. Heparinized bone marrow sample was sent for cytogenetics, suggestive of Philadelphia positive chromosome complement. Based on the above findings, a diagnosis of CML with microfilaria of W.bancrofti. Keywords Filariasis, Chronic Myeloid Leukemia, W.bancrofti, Splenomegaly
OR 216 Utility of VCS Parameters in Distinguishing Benign-VersusMalignant Lymphocytoses Prashant Sharma, Shano Naseem, Ishwar Chand, Manupdesh Singh Sachdeva, Neelam Varma Postgraduate Institute of Medical Education and Research Title: Utility of VCS parameters in distinguishing benign-versus-malignant lymphocytoses Pulkit Rastogi, Prashant Sharma, Shano Naseem, Ishwar Chand, Manupdesh Singh Sachdeva, Neelam Varma Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh. Introduction: Modern 5-part hematology analyzers yield quantitative data on various leukocyte populations that are diagnostically helpful in conditions like sepsis, myelodysplasia, malaria/dengue etc. We evaluated the usefulness of VCS (Volume, Conductivity and Scatter) indices in distinguishing clonal from reactive lymphoproliferations. Need for study: Determining the etiology of lymphocytosis can be challenging. Automated leukocyte parameters are relatively under-explored for this problem. Methods: The study groups were, Group-1 (n = 19): Patients with immunophenotypically-proven chronic lymphocytic leukemia (CLL); Group-2 (n = 10): Patients with non-CLL lymphoproliferative disorders (LPDs); Group-3 (n = 130): Healthy controls; and Group-4 (n = 34): Patients with absolute or relative non-clonal lymphocytosis of varied causes including marrow aplasia, viral infections etc. Blood samples were run on LH780 instruments (Beckman Coulter Inc, FL) to obtain complete blood counts and VCS data. Results: Several VCS indices were significantly altered in CLL patients vis-a`-vis healthy controls (p \ 0.001 for increased MNV, MNV-SD, MNC-SD, MMoVSD, MMoC-SD, MLV-SD and MLC-SD; p \ 0.01 for increased MNSSD and MMoV; and p \ 0.05 for reduced MNS). Only two parameters
123
distinguished CLL from non-clonal reactive lymphocytosis (p \ 0.001 for reduced MLS-SD and p \ 0.01 for increased MLV-SD). Leukocytes of healthy individuals were successfully resolved from those with non-clonal lymphoproliferations—all 6 neutrophil indices, and 5 each of the 6 lymphocyte and monocytes indices showed significant differences between these 2 groups. Conclusions: Our results, similar to only a few prior studies on VCS indices in LPDs, suggest that cellular parameters might useful screens for healthy patients. MLS-SD and MLV-SD hold promise for further study into their role in distinguishing CLL-versus-reactive lymphocytosis. Keywords VCS, Lymphocytosis, Automated analyzers
OR 217 Cyclic Neutropenia: A Rare Scenario T. V. Ramkumar, Ashok K. Nanda, Sunil K. Agarwalla, Geetanjali Sethy, N. N. Soren M.K.C.G Medicaal Colege, Brahmapur, Odisha-760004 Cyclic neutropenia (Periodic neutropenia, Sutton’s disease) is a rare (1 in 1 million) congenital blood dyscrasia caused by ELANE gene mutation. An 18 month old child presented with an upper respiratory infection. Past history revealed recurrent infections from 12 months of age at 2–3 week intervals with fall in absolute neutrophil count (\1000) during infections, rest of the counts normal. Bone marrow aspiration revealed 19 %hematogones/? atypical cells. Malignancy was ruled out by bone marrow biopsy and flow cytometry demonstrated reduced tdt; myeloid progenitors MPO, CD13, CD15, CD117 being negative. Neutropenia was diagnosed and its various aetiologies were evaluated and ruled out. Repeated WBC counts monitored every alternate day at the same hour for a period of 6 weeks demonstrated 2 episodes each of 5 days of significant fall in neutrophils with simultaneous rise in monocytes with intervening periods of normal counts. Cyclic neutropenia was diagnosed and the child was treated with G-CSF, antibiotics and regular follow up revealed decrease in duration and severity of symptoms and reduced frequency of cycles. The case is discussed to highlight the significance of serial monitoring of blood counts 3 times/week for 6 weeks (at least 2 neutrophil count drops is diagnostic), as a single count would fail to diagnose the condition. Patients with cyclic neutropenia have normal growth and development and leads normal life, thus should not be misdiagnosed. Hence any child with recurrent infections and neutropenia should also be investigated in the line of cyclic neutropenia. Keywords ELANE gene, GCSF, Serial monitoring
OR 218 Role of Flowcytometry In Paroxysmal Nocturnal Hemoglobinuria Vanamala A Alwar, Latha Fathima S, Parimala Puttaiah, Sitalakshmi S St Johns Medical College Hospital Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hemolytic anemia showing enhanced susceptibility of cells to complement-mediated lysis, secondary to deficiency of GPI-anchored membrane proteins like CD55, CD59, CD14, CD24 which can be analysed by flowcytometry (FCM). Need for study: To study the role of flowcytometry in detecting PNH clones in WBC and RBC. Materials and Methods: Flowcytometry for diagnosis of PNH was done using CD 55 and CD 59 on RBC, CD24 and FLAER with CD15 gating on neutrophils and CD14 and FLAER with CD 64 gating on monocytes. Results: FCM for PNH was done on 279 cases. 28
Indian J Hematol Blood Transfus positive cases were diagnosed (10 %). All cases were positive on WBC. 60 % of cases showed big PNH clones in WBC resulting in a diagnosis of PHN of which 11 (40 %) showed big clones in WBC and RBC. Three cases (10 %) were positive in WBC alone 3 (10 %) showed big clones in WBC but small clones in RBC. FCM is done only on RBC will miss these cases. 40 % of cases showed only small PNH clones of which 8 cases showed small clones in WBC alone and 3 cases which showed small clones in both WBC and RBC. The clinical significance of these cases is not well established There were no cases positive only in RBC Conclusion: FCM a good tool for diagnosis of PNH. The FCM panel should include markers for WBC as panels having only for RBC will miss out on 20 % cases. Keywords PNH, Flowcytometry, WBC
OR 219 Comparison of Automated Immature Granulocyte Count With Other Hematological Parameters In Early Diagnosis of Sepsis
with painless lump in neck since 1 year and was diagnosed with papillary carcinoma of thyroid. Patient underwent thyroidectomy and started chemotherapy. All blood indices were normal at the time of starting chemotherapy. One and a half month after starting chemotherapy patient developed weakness and skin rashes. Peripheral smear examination was done and showed normocytic normochromic blood picture with elevated TLC (86.5 9 1000/ml). Differential count showed 85 % blasts with 3 % NRBC and only 07 % Neutrophils and 08 % lymphocytes. Platelet count was decreased (54,000/ml). Bone marrow aspiration and biopsy were advised, which showed accelerated leukopoisis with 84 % blasts which were negative for SBB. A diagnosis of acute leukemia was given. Flowcytometry confirmed it as AML. Need for presenting the case— Normal incubation period for developing t-AML is 1–3 years. Our case is a rare case which presented with t-AML before normal incubation period for such malignancies probably due to some cytogenetic abnormalities and augmentations due to accumulation of more of mutational/cytogenetic abnormality by chemotherapy. Discussion: t-AML represent a unique clinical entity in patients treated with chemotherapy or radiotherapy and carry a poorer prognosis than de novo disease. Keywords t-AML, Flowcytometry, Incubation period, Chemotherapy
S. K. Behera, D. P. Mishra Mkcg Medical College Introduction: The immature granulocyte count (IG) measured through automated cell counters include promyelocyte, myelocyte and metamyelocyte count which are usually increased in sepsis. Blood culture which is considered as diagnostic for sepsis is not helpful in early diagnosis. Materials and Methods: A prospective study was done in MKCG Medical College from January 2015 to June 2015. All patients who were suspected for sepsis clinically were evaluated. A complete blood count (CBC) using automated haematology analyzer sysmex xt- 2000i were done. Blood culture was also done in all suspected cases. Results: Totally 400 patients were studied. Out of which 80 had normal total count and they were excluded. In remaining 320 patients automated immature granulocyte count were compared with Total leucocyte count (TLC), Absolute neutrophil count (ANC). Manual band cell count were also done in all cases and compared. Final result of our study will be presented during the time of conference. Conclusion: In summary, our study shows that immature granulocyte percentage has good correlation with infection and positive blood culture results than the TLC and ANC. IG’s are morphologically better defined cells and automated cell counters pick up even small rise in IG % with less turn around time which is not possible by manual counting, since it is laborious and has inter observer variations. Also IG % helps in diagnosing sepsis even in cases of neutropenia where absolute neutrophil count does not help. Keywords Immature granulocytes, Sepsis, Automated analyzer
PR 2 P210 Bcr-Abl1 Positive Pediatric B-Lineage Acute Lymphoblastic Leukemia Presenting With Hypercalcemia Dr. B. K. Karthik Bommannan, Dr. Sidharth Totadri, Dr. Man Updesh Singh Sachdeva, Dr. Shano Naseem, Dr. Amita Trehan Postgraduate Institute of Medical Education and Research, Chandigarh Philadelphia chromosome positivity (Ph +) is the most common recurrent genetic abnormality seen in 20–30 % of adult B lineage acute lymphoblastic leukemia (B-ALL). However, it is uncommon in pediatric B-ALL, where it accounts for merely 3–5 % patients. Previously, prognosis was grave for Ph + ALL despite intensive chemotherapy and hematopoietic stem cell transplant (HSCT). The advent of tyrosine kinase inhibitors (TKI) has dramatically improved survival in these patients, and has even enabled therapy without HSCT. Hypercalcemia as a metabolic complication is infrequently encountered as a presenting feature in childhood malignancies. It has been reported in solid tumors and leukemias. The incidence of hypercalcemia in leukemia ranges 0.6–4.8 %. Ph + ALL has not been associated previously with hypercalcemia. We report an 18 month old male presenting with hypercalcemia and subsequently diagnosed to have Ph + B lineage ALL. Keywords Pediatric, Ph positive ALL, Hypercalcemia, MRD
Topic: Acute Leukemias PR 1 Unusual Presentation of Therapy Related Acute Myeloid Leukemia: A Rare Case Report Seema Chauhan, Prabodh Das, Kumudini Devi, Rajashree Tripathy, Sarita Pradhan Ims and Sum Hospital Introduction: Therapy-related acute myeloid leukaemia (t-AML) is a serious consequence of chemo- and radiotherapy for an antecedent disorder (carcinoma ovaries, thyroid, NHL etc.). We report a case of t-AML developing within two months after starting chemotherapy for papillary carcinoma of thyroid. Case presentation—A 32 year old male presented
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Indian J Hematol Blood Transfus PR 3 Monosomy 7 and Deletion 7Q In Acute Myeloid Leukemia—M0/ M1 With Prior Myelodysplastic Syndrome Transformed from Fanconi Anemia—A Case Report
Keywords Acute promyelocytic leukemia, Ocular infiltration, Retinal detachment
PR 5 Nizams’ Institute of Medical Sciences A 14-year-old adolescent male, second in birth order, born out of nonconsanguineous marriage, presented with complaints of intermittent low grade fever and easy fatigability of 1 month duration in February 2011. Mitomycin C induced chromosomal breakage study of cultured bone marrow cells from the patient revealed a diagnosis of low grade mosaic of Fanconi anemia with predominance of Mitomycin C susceptible cells. Four years later, at the age of 16, presented features consistent with acute leukemia arising in a known case of Fanconi anemia. Chromosomal analysis revealed a 45, XY,-7 karyotype. The patient was initiated on induction chemotherapy with a modified schedule of single agent Cytarabine at 50 % dose reduction (1 g/m2 twice daily) for 6 consecutive days. The patient did not achieve remission with Induction chemotherapy, as suggested by a complete blood count on Day 14 (Hemoglobin level of 8.3 g per deciliter, 8,400 white cells per cubic millimeter, with a predominance of Blasts (89 %), Platelet count of 10,000 cells per cubic millimeter). A repeat induction chemotherapy regimen was started on Day 15, with Daunorubicin (60 mg/m2/day) for 2 consecutive days and Cytarabine (100 mg/m2/day) for 5 consecutive days. The patient had a rapidly deteriorating clinical course, developed gingival bleeding, melena, hypotension refractory to inotropic support and died on Day 24 following the start of induction phase of chemotherapy.
PR 4 Ocular Involvement In Acute Promyelocytic Leukemia: A Rare Entity Sidharth Totadri, Vishali Gupta, Shano Naseem, Amita Trehan, Neelam Varma Postgraduate Institute of Medical Education and Research Introduction: Ocular symptoms in acute leukemia are due to intraocular hemorrhage or direct leukemia infiltration. Acute promyelocytic leukemia (APML) is better known for hemorrhagic manifestations. We present 2 unusual cases of ocular leukemic infiltration in APML. Case report: Two children diagnosed with APML [bone marrow examination, t(15,17) positivity by RT-PCR] presented with visual symptoms. Case-1: 8-years-old boy with high risk APML developed blurred vision on day-3 of induction with all-trans retinoic acid (ATRA). Examination revealed loss of vision in left eye, perception of light present. Right eye was normal. Pupils were equal and reactive. Indirect ophthalmoscopy: exudative retinal detachment secondary to leukemic infiltration. His vision is improving on chemotherapy. Case-2: 12-years-old boy with standard risk APML completed induction and entered remission. He developed blurring of vision after 1st course of consolidation. Indirect ophthalmoscopy: disc edema with subretinal leukemic deposits in right eye. Bone marrow examination was normal. Chemotherapy was continued, and there was improvement in vision after 3rd course. Discussion: Retinal detachment has not been previously reported in APML to best of our knowledge. Tissue diagnosis was not done due to difficult site, associated coagulopathy (case 1), and classical ophthalmologic findings. Leukemic retinal detachment typically responds to systemic therapy in ALL and AML. Both cases have some response to chemotherapy. Conclusion: Opthmological evaluation in all patients with acute leukemia at diagnosis and during therapy is important. Prompt initiation of therapy for leukemia and regular ophthalmological evaluation is the mainstay of management.
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Fungal Osteomyelitis of Foot: Uncommon Infection By Uncommon Species At Uncommon Site Dr. Pradeep Kumar, Dr. (Prof) S Nityanand, Dr. (Prof) R Kashyap, Dr. (Prof) S Gambhir, Dr. Sanjeev Dr. Nishad Sgpgims Summary: we present a case of fungal Osteomyelitis of the foot, uncommon infection caused by uncommon species and at uncommon site and recovered after voriconazole treatment. Introduction: Osteomyelitis means infection of bone, most commonly caused by bacteria and fungal Osteomyelitis is very uncommon. Presentation of fungal Osteomyelitis differs from bacterial Osteomyelitis because of its chronic and indolent course. This infection may prove fatal if not diagnosed and treated promptly. Here we report a fungal Osteomyelitis caused by uncommon fungal species (Pheohyphomycosis). Method and Material: A 39 yrs old male, case of acute lymphoblastic leukemia, developed left foot swelling over dorsum during treatment for pneumonia. Swelling was progressive in nature despite of initial empirical antibiotics and antifungal and improvement from pneumonia. Repeated aspiration was done for bacterial, fungal and mycobacterial infection. Technetium-Bone scan showed increased perfusion and blood pooling in left foot, SPECT CT images revealed increased tracer uptake in 1st tarso—metatarsal joint, suggestive of infective etiology (Osteomyelitis). Shifted to oral voriconazole after Amphotericin-B infusion and gradually swelling was regressed. Fungal culture was positive for black mycelial fungus (Phaeo-hyphomycosis). Voriconazole was continued and gradually his swelling totally disappeared. Follow up bone scan showed complete regression of lesion. Results: He responded well to voriconazole and post therapy remained asymptomatic clinically as well as radiological (follow up done with MDP bone scan). Conclusion: Fungal Osteomyelitis is an uncommon cause of Osteomyelitis and require high index of suspicion because of its chronic and indolent course. Definite diagnosis is made by microbiological tests.
PR 6 Azacitidine As Induction Therapy In Aml In Acutely Ill Patient, An Interesting Case Report Govind Eriat, Girish Badarkhe, Tousif Devale, Radheshyam Naik, Karan Gowda Hcg Hospital Introduction: Acute myeloid leukemia (AML) is a hematological malignancy of myeloid progenitor cells that disrupt normal hematopoiesis. Standard care revolves around remission induction with chemotherapy, followed by a matched allogeneic bone marrow transplant. However, there exists no standard therapy for acute myeloid leukemia in patients with poor performance status and ongoing infection/sepsis. The hypomethylating agent, azacitidine, is effective in a limited number of such cases. Case Presentation: We present a 39-year-old Indian male with acute myeloid leukemia M2 who presented with poor performance status, bilateral lower limb DVT, with pulmonary embolism, sepsis with bacterial pneumonia and coexisting tubercular pleural effusion. Patient had complete remission after 4 cycles of azacitidine, which was followed by reinduction with 7 + 3 regimen, once his clinical condition improved. He is currently
Indian J Hematol Blood Transfus on D + 150 post haploidentical allogeneic transplant, in complete remission. Discussion and Conclusion: We report this case to demonstrate the efficacy of azacitidine in patients of acute myeloid leukemia with poor performance status and multiple co morbidities who otherwise succumb to worsening disease in view of poor fitness to undergo standard therapy. It also demonstrates the efficacy of azacitadine to ensure a remission in AML induction. Further studies are needed to delineate subsets of acute myeloid leukemia in which azacitidine will serve as an effective upfront therapy.
PR 7 Outcomes of Adult Acute Myeloid Leukemia Patients Treated In A Tertiary Cancer Centre from South India Tenali Gnana Sagar, Prasanth Ganesan, T. S. Ganesan, Krishnarathinam Kannan, Rejiv Rajendranath Cancer Institute (Wia), Adyar, Chennai Background: Acute Myeloid Leukemia (AML) is one of the devastating diseases in adults. As the treatment requires special support and is expensive, many patients in India do not receive therapy. Reports of outcomes from India are few. Methods: Adults patients (C18 years) with AML who were treated with curative intent between 2007 and 2014 were analyzed. Patients received daunorubicin at dose of 60 mg/m2 between 2007 and 2012 and mostly 90 mg/m2 subsequently as part of the 3 + 7 induction therapy. All patients received consolidation with cytarabine (1.5–3 g/m2). Only 7 patients underwent consolidation allotransplantation. Results: We treated 93 patients with a median age of 37 (range 18–66) with males constituting 51.6 %. Cytogenetic data (N = 63) showed 23.8 % (N = 15), 55.5 % (N = 35), 26.6 % (N = 13)in good, intermediate risk and poor risk respectively. FLT3–ITD mutation analysis was done in 33 patients, of which 36.4 % (12) were positive. NPM mutation analysis was done in 23, of which 30.4 % (7) were positive. Daunorubicin was given at a dose of 60 mg/m2 in 75 % (70) and 90 mg/ m2 in 25 % (23) patients. The induction mortality was 17.2 % (16/93) [60 mg/m2:18.6 % (13/70), and 90 mg/m2:13 % (3/23); p = 0.39)]. Complete remission after induction was 60.2 % (56/93)[60 mg/ m2:52.9 % (37/70), and 90 mg/m2:82.6 % (19/23); p = 0.09)]. The overall survival at 36 months was 28.2 %. The factors identified as poor prognostic by univariate analysis were adverse cytogenetics, FLT3— ITD positive status, total counts [1,00,000 at presentation and use of daunorubicin at 60 mg/m2 dose (Vs. 90 mg/m2). Conclusions: Cytogenetic Risk, FLT3–ITD mutation status, Total count at presentation, Daunorubicin dose made a significant impact on the survival.
PR 8 A Rare Case of Hypoplastic Acute Myeloid Leukemia Bembem Khuraijam, Richa Gupta Maulana Azad Medical College Introduction: Hypocellular variants of acute myeloid leukemia are very rare and very few cases have been reported in literature. They almost always occur in old aged patients and often develop secondary to radiation or chemotherapy. In contrast, hypocellular acute lymphoblastic leukemia usually occurs in children. Materials & Method & Results: A 65-year-old male presented with fever, generalized weakness, dyspnea on exertion and easy fatigability for the past 3-months. On examination, patient had pallor and hepatomegaly. Routine CBC examination showed pancytopenia. No atypical cells were seen on peripheral smear examination. A possibility of aplastic anemia was suggested and followed by a bone marrow aspiration. The marrow aspirate smears had few hypocellular particles with scattered blasts in the background. These blasts had high N:C ratio, scant to moderate amount of cytoplasm, opened-up nuclear chromatin and conspicuous nucleoli. Normal hematopoietic elements were diminished. Flow cytometry was also performed on marrow aspirate which revealed 36.3 % as distinct cluster with dim CD45 and low side scatter. These blasts were positive for myeloperoxidase (MPO) and CD34 thus conforming the myeloid nature of the blasts. A diagnosis of hypoplastic AML was made. Conclusion: Hypoplastic variant of AML is very rare and seen in elderly patients. Hypoplastic AML should be differentiated from Aplastic anemia and Hypoplastic Myelodysplastic Syndrome. A careful examination of the smear and bone marrow is essential to enumerate the number of blasts in such cases.
PR 9 Blast Phase With P230 Positive Bcr-Abl Transcript Dr. Shashikant Apte, Dr. Kannan Subramaniam, Dr. Abhishek Dudhatra, Dr. Ankit Raiyani, Dr. Girish Kamat Sahyadri Speciality Hospital Introduction: Chronic myelogenous leukemia, BCR-ABL1 + (CML) is a myeloproliferative neoplasm that originates in a pluripotent bone marrow stem cell and is consistently associated with the BCR-ABL1 fusion gene. Three major forms of bcr-abl transcript are P210 (major), P190 (minor) and P230 (micro). P230 transcript is found extremely rare in Chronic myeloid leukemia and is typically associated with Neutrophilic Chronic myeloid leukemia. Here we describe a case of P230 positive Chronic myeloid leukemia in blast phase. 14 years female presented with c/o fever with chills, loose motions and vomiting since 1 month. Her investigation was s/o anemia with thrombocytopenia so she was treated with antimalarial and steroid. Her count was improved. After 1 month she again developed cytopenia and referred for further management. Bone marrow aspiration and biopsy was done which was s/o Acute leukemia. Hence Flowcytometry was done, s/o B cell Acute Lymphoblastic leukemia. She was started BFM protocol. ALL PCR panel was negative for t(12;21), t(1;19), t(4;11), P210 and P190. Day 14 Bone marrow aspiration was not in remission. Meantime cytogenetics reports was s/o 46XX, t(9;22)(q34;q11) (20) So we repeated multiplex RTPCR of bcr-abl consist of P210, P190 and P230. She was detected P230 bcr-abl transcript and diagnosis was changed to Chronic myeloid leukemia in lymphoid blast phase. So she was added Imatinib to BFM protocol. Day 35 bone marrow aspiration was s/o morphological remission and she also achieved molecular remission. She is continued BFM + Imatinib, maintaining CR at present.
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Indian J Hematol Blood Transfus Kerywords: Chronic myeloid leukemia, P230, lymphoid blast phase, Imatinib
PR 10 Hairy Cell Leukemia—A Report of Two Cases
CI:2.06–11.27;p = 0.000) and lower EFS than patients with score 0 (Good risk) or [0 B4.5 (Intermediate risk) (Fig. 1). On multivariate analysis (including age, WBC count, BCR-ABL1, cytogenetic, BFM95 risk stratification, post-induction status), IPTS retained significance as independent prognostic parameter (HR: 4.7, 95 % CI:1.744–12.697; p = 0.002). Conclusion: We have described a novel prognostication system based upon differential expression of CD34 and CD45.
Dr. Sreeya Das, Dr. Dipika Mohanty Apollo Hospitals, Bhubaneswar
PR 12
Introduction: Hairy Cell Leukemia is a rare B cell malignancy and is an indolent disease. It presents usually in the middle age and is amenable to treatment now. Commonest clinical manifestation is massive splenomegaly but lacks lymphadenopathy. We report two cases of Hairy Cell Leukemia. Case-1: A 24 year male presented to us with progressive abdominal distension and intermittent jaundice since 4 months. He had bilateral swelling of lower limbs and rashes since 2 weeks with breathlessness since 2 days. Ultrasound abdomen showed hepatosplenomegaly with mild ascitis. Blood picture showed pancytopenia which was followed by bone marrow aspiration and biopsy. However bone marrow aspiration was a dry tap but bone marrow biopsy revealed the diagnosis of Hairy Cell Leukemia. Case-2: A 51 year male presented to us with complaints of jaundice, breathlessness, pain abdomen with massive splenomegaly and fever since 3 months. He had features of renal failure. Ultrasound abdomen showed hepatosplenomegaly with mild bilateral pleural effusion. Blood picture showed 92 % atypical lymphocytes and a high TLC count of 25.5x103/ll. Flow cytometry confirmed the diagnosis of Hairy Cell Leukemia. The patient was treated successfully & remained well. Conclusion: These two cases were presented because of their rare entity with typical presentation. Keywords Hairy cell, B-cell malignancy
Therapy—Related Acute Leukemia—A Series of Three Cases
PR 11 Prognostic Significance of Immunophenotypic Risk Score In Childhood and Adolescent B-All Punit Jain, Anu Korula, Poonkuzhali Balasubramanian, Biju George, Vikram Mathews Christian Medical College Introduction: Risk stratification of B-ALL is based upon age, WBC count and underlying genetic abnormalities. Presence of immunophenotypic defined subpopulations and association between immunophenotype and cytogenetics abnormalities are well recognized phenomena in B-ALL. Hence, we hypothesized that immunophenotype heterogeneity may be reflective of underlying genetic heterogeneity and could be used to better prognosticate patients. Materials and Methods: Retrospectively flow cytometry list data files of 150 patients of pediatric B-ALL were reanalyzed. Four sub-populations identified:Stage 1 (CD34 +/CD45 dim), Stage 2 (CD34 +/ CD45bright), Stage 3 (CD34-/45bright). Threshold for differentiating CD45bright and dim population was placed one log below MFI of residual lymphocytes. Results and Discussion: Patients with event (death or relapse) had higher mean stage 2, 3 populations and lower stage 1 population (p \ 0.05). On univariate Cox regression analysis, stage1 B50 %, stage2 C25 % and stage3 C20 % were identified as poor risk factors (hazard for event: 2.63, 2.65 and 2.08, respectively); and a corresponding risk score was assigned to each risk factor (2.5,2.5 and 2, respectively). Each case was scored and combined score (Immunophenotypic risk score/IPTS) was calculated by summation of individual risk scores. Patients with combined score of [4.5 (Poor risk) had significantly higher risk for event (HR: 4.8,95 %
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K Arun Kumar, Rakhee Kar, Sajini Elizabeth Jacob, Debdatta Basu, Biswajit Dubashi Jipmer Introduction: Therapy related Acute leukemia (t-AML/ALL) is a recognised clinical syndrome occurring as a complication of the chemo-radiation therapy for primary malignancy. We report three cases of t-AML/ALL that were diagnosed in our institution in the past one and a half years. Relevant case presentation: Case 1: 62 year old lady, known case of carcinoma breast, diagnosed and treated with Etoposide based regimen in 2012 was diagnosed to have Acute Myelomonocytic leukemia in February 2014. Cytogenetics revealed 46XX, t(X,10)[17]/46XX[3]. The patient was started on chemotherapy but succumbed to refractory disease in May 2015. Case 2: 9 year old male child diagnosed with stage IV neuroblastoma in 2012, received chemotherapy (CCG 3891 protocol—Cyclophosphamide, Cisplatin, Etoposide, Adriamycin) for 2 years following which he was diagnosed to have Acute myeloid leukemia (AML-M1) with MLL gene translocation. The patient was started on chemotherapy, however succumbed to profound neutropenia. Case 3: A 6 year old male child, diagnosed to have retinoblastoma, five years ago, for which he underwent surgery and completed chemotherapy, presented with 83 % lymphoblasts in peripheral smear and was diagnosed to have common B-ALL. Patient is currently on chemotherapy. Discussion and need for presentation: With the increase in use of high dose chemotherapeutic regimens, higher cure rates and longer survival rate of cancer patients, the incidence of secondary malignancies is increasing. The latency period between diagnosis of the primary disease and occurrence of t-AML/ALL ranges between several months to several years and depends on the cumulative dose, dose intensity and type of preceding therapy. It is important to diagnose these cases because they have an inferior outcome than de novo leukemia.
PR 13 Pure Erythroid Leukemia With Isochromosome 12P—Leukemic Differentiation of A Germ Cell Tumor? Dr. Nabhajit Mallik, Dr. Sainath Bhethanabhotla, Dr. Lalit Kumar All India Institute of Medical Sciences (Aiims), New Delhi Introduction: We present a rare case of a young girl, who got chemotherapy for ovarian germ cell tumor (GCT) and developed pure erythroid leukemia. The blasts showed complex cytogenetics with isochromosome 12p, which is usually associated with GCT. Case—A 20-year-old nulliparous girl presented with amenorrhoea for 3 months. CECT revealed a large left ovarian mass, which was surgically removed. Histopathology suggested mixed GCT, with immature teratoma and yolk sac components. She received 3 cycles of chemotherapy post-surgery, after which, b hCG became negative, and AFP levels reduced substantially. Two months later, she presented
Indian J Hematol Blood Transfus with fever and vaginal discharge. Her AFP increased and CECT indicated recurrence of disease in the right ovary. Her hemogram showed anemia and thrombocytopenia and a possibility of bone marrow metastasis was considered clinically. However, the peripheral smear examination revealed 52 % blasts. The bone marrow aspirate was diluted and showed scattered blasts with globular PAS positivity. On flow immunophenotyping, the blasts expressed CD71, CD36 and CD235a and were negative for CD45, CD34, CD13, CD33, CD117, MPO, CD41, CD61, CD3, CD79a, and CD19. A diagnosis of acute erythroid leukemia (pure erythroid type) was made. Cytogenetics revealed complex karyotype, alongwith isochromosome12p. She was started on chemotherapy, but succumbed to her disease within a few days. Conclusion: This rare case posed a pathogenetic dilemma about whether the leukemia developed through differentiation of the GCT or was secondary to chemotherapy. In addition, the possibility of leukemic differentiation of GCT should be considered when suspecting the bone marrow spread of disease.
PR 14
fold increased risk of developing acute myeloid leukemia and acute lymphoblastic leukemia. Relevant case presentation: An one and a half year old female child presented with fever. She was a full term vaginal delivery baby. Ultrasound was done only once at 5 months of gestation and revealed microcephaly. But mother refused to abort the baby. After birth babhad facies suggestive of downs syndrome. The patient prey sented with fever. Blood count and peripheral Smear was done. Total leukocyte count was 28900 per cumm with 64 % blast cells, 14 % neutrophils and 22 % lymphocytes. Morphologically, on peripheral Smear and bone marrow Acute Myeloid Leukemia M7 was suspected. For confirmation flow cytometry was done. Markers were as follows : Blasts positive for CD34, CD117, CD7, CD56, moderately positive for HLA-DR, CD13, CD33 and CD36 Blasts negative for CD41, CD61, CD14, CD64, CD3 Impression: Acute Myeloid Leukemia (AML-NOS)with aberrant CD7 expression. Need for presentation: Typing and confirmation of leukemia is important for proper management of patients as prognosis is good in patients of acute myeloid leukemia in children with downs syndrome. Discussion: The typing of Acute Myeloid Leukemia cannot be made solely on the basis of morphological picture, confirmation by flow cytometry is important.
Prevalence of Genomic Alterations In B-Cell Acute Lymphoblastic Leukemia (B-All) Dr. Sameer Bakhshi, Dr. Lalit Kumar, Dr. Rajive Kumar All India Institute of Medical Sciences (Aiims), New Delhi Introduction: The copy number changes in genes related to cell proliferation and differentiation are often seen in B-cell acute lymphoblastic leukemia (B-ALL). Some of these changes like in CDKN2A/B and IKZF1 have been reported to be associated with disease outcome in B-ALL. This study was carried out to establish the prevalence and profile of DNA copy number alterations in Indian B-ALL patients. Methods: The genomic DNA from newly diagnosed B-ALL cases was analyzed for copy number alterations in various genes including CDKN2A/B, IKZF1, PAX5, RB1, ETV6, BTG1, pseudoautosomal region 1 (PAR1) genes (CRLF2, CSF2RA, IL3RA) and EBF1 over 15 months using MLPA (SALSA MLPA P335B1 kit; MRC-Holland). Electrophoresis and quantification of amplicons was done and the data analyzed. Ten healthy controls were also included. Results: The median age of 129 cases was 9 years (2 mths-67 yrs). These included 73 males and 56 females. The gene deletions were seen in CDKN2A/B in 46 (35.7 %) cases, IKZF1-39 (30.2 %), PAX538 (29.5 %), BTG1-16 (12.4 %), ETV6-15 (11.6 %), RB1-13 (10.1 %), CSF2RA-7 (5.4 %), IL3RA-7 (5.4 %), EBF1-6 (4.7 %) and CRLF2-4 (3.8 %). The gene duplications of EBF1, ETV6, PAX5, PAR1 region genes, and RB1 were also detected. Overall, the copy number alterations in the tested genes were detected in 90 (69.8 %) cases. Conclusions: The DNA copy number alterations were detected in at least one of the tested genes in 90 (69.8 %) out of 129 cases of B-ALL. The most commonly affected genes were CDKN2A/B, IKZF1, and PAX5. The frequency and profile of copy number changes was comparable to the reported western literature. Keywords ALL genetic profile, Copy number changes in leukemia, MLPA in B-ALL
PR 16 Early Onset Acute Myeloid Leukemia In Dyskratosis Congenita Dr. Dinesh, Dr. Seema Tyagi, Dr. Hp Pati Aiims New Delhi Introduction: Dyskeratosis Congenita is one of the commonest cause of inherited bone marrow failure syndrome due to mutation in Dyskerin gene which is usually X linked. It presents with pancytotopenia and aplastic anemia in late childhood, which may progress to MDS over time and 01 % cases to acute leukemia by age of 40y, which is usually resistant to chemotherapy and the only definitive treatment for bone marrow symptoms is allogenic transplant. Here we describe a rare case of Dyskeratosis Congenita progressing to acute myeloid leukemia by the age of 20 years, which responded to chemotherapy. Materials & Methods: The patient was diagnosed as acute myeloid leukemia on bone marrow aspirate with biopsy, cytochemistry and flowcytometry. MPO was positive by flowcytometry. He was started on 3 + 7 chemotherapy and day 28 bone marrow was in remission. Patient during treatment developed toxicity due to cytarabine. Autologous bone marrow transplant was not possible in the patient as most of the family members are also affected. Conclusion: Dyskeratosis Congenita is a rare inherited disorder leading to bone marrow failure due to a telomeropathy. Progression from bone marrow failure to acute leukemia in young age is very rare, the usual age of progression is mid forties with poor response to chemotherapy. Our patient progressed to acute myeloid leukemia by 19 years. There is a strong family history with most of the members being affected thus suggestive of anticipation of the mutation in the present generation.
PR 17 PR 15 Aml In A Child With Downs Syndrome A Case Report Dr. Trupti Dongre, Dr. Sabiha Maimoon Nkp Salve Institute of Medical Sciences Nagpur Introduction: Children with downs syndrome have a unique genetic susceptibility to develop leukemia in particular. They have 10 to 20
Hypocellular Acute Myeloid Leukemia—A Diagnostic Challenge Dr. Sushma Belurkar, Dr. Chethan Manohar Kasturba Medical College Manipal Introduction: Hypocellular Acute Myeloid Leukemia (AML) is a rare cancer of myeloid lineage defined as having\20 % bone marrow cellularity. It comprises 10 % of AML cases. Diagnostically its a challenge because it shares common features with hypocellular
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Indian J Hematol Blood Transfus Myelodysplastic syndrome and Aplastic anemia with marrow dysplasia. Case report—We present a case of AML with hypocellular marrow in a 58 year old female patient who presented with complaints of intermittent, high grade fever since one week associated with dry cough which increases in the night. She was a known case of Chronic Obstructive pulmonary disease. On examination there were no significant findings. Complete blood counts and peripheral smear report showed pancytopenia with hemoglobin—5.2 g/dl, Total Leucocyte—3.5 9 103/ll, Platelet—92.0 9 103/ll. No abnormal cells were seen. Bone marrow aspiration report showed hypocellular marrow with 35 % blasts. Based on morphology and immunohistochemistry on bone marrow biopsy she was diagnosed with hypocellular AML. Conclusion: Hypocellular AML is a rare variant which affects the elderly and mainly females. It can occur both de novo and in patients with prior exposure to chemotherapy. Its advisable to do Immunohistochemistry and Molecular studies in such cases as it shares a similar morphological picture with aplastic anemia and hypocellular MDS.
PR 18 T/Myeloid Leukemia Nos : Case Report Mili Jain, Rashmi Kushwaha, U S Singh, Archana Kumar, Ashutosh Kumar Kgmu Introduction: T/Myeloid leukemia are rare entities comprising \1 % of all leukaemias as per the WHO 2008 classification. We report a rare case of T/Myeloid NOS with normal cytogenetic. Materials and Methods: A 7 year old male child was referred to our laboratory with symptoms of marrow failure, petechial rashes, generalised lymphadenopathy and hepato-splenomegaly. His TLC was markedly raised to 65.56 X10^3 cells/lL, with 92 % blast cells; Hb 4.8gm/dl and platelet count reduced to 15 9 10^3 cells/ll. His chest X ray did not reveal any mediastinal widening. Liver function, renal function, viral markers were not significant. Immunophenotyping was done on the bone marrow aspirate sample using a three/four color antibody panel on BD FACS Calibur and analysed using cell quest pro software. The panel used was PerCP CD45 as gating marker, FITC: CD2, CD7, CD10, CD20, MPO, CD5, CD4, CD8 and PE: CD13, CD33, CD19, CD117, CD3, cytoplasmic CD3, CD34 and APC: HLADr. Conventional karyotyping was done using G-banding. Molecular analysis for t (9; 22), t (12; 21), t (1; 19) and t (4; 11) was done using PCR. Results: The blasts were positive for CD7, CD5, CD3, CD8, cytoplasmic CD3, CD34, MPO and CD117. The cytogenetic screen was normal and no molecular abnormality was detected. Conclusion: Appropriate immunophenotyping panel is essential for correct differentiation of prognostically differing MPAL, AML with aberrant expression of lymphoid antigens, and ALL with aberrant expression of myeloid antigens. Keywords MPAL—Mixed Phenotype Acute Leukemia
PR 19
eosinophilia, with end organ damage, which preceded/masked the diagnosis of ALL by 2 months. Case: A 11 year old boy presented with fever since a month. On examination:liver, spleen were palpable. His CBC revealed WBC count of 113000/mm3 with 90 % eosinophils (Absolute eosinophil count (AEC) = 90,153/mm3). Peripheral smear (PS) confirmed eosinophilia. On bone marrow aspiration (BMA) increased eosinophilic precursors were noted. Blast cells were not seen, morphologically. Cytogenetics were negative for PDGFRA, PDGFRB, FGFR1 tested by FISH. He was dewormed & started on diethylcarbamazine. While being simultaneously evaluated for endorgan damage secondary to severe eosinophilia, he developed cough with gradually progressive respiratory distress. His chest x-ray was suggestive of bilateral inhomogeneous infiltrates & he became progressively hypoxic.2Decho was suggestive of mild TR with concentric hypertrophy/infiltration with normal functions. In view of rapidly worsening clinical condition, he was administered high dose methyl-prednisolone. He had a dramatic improvement & his AEC normalized. On follow up, he developed thrombocytopenia with rising AEC. His BMA at this time, was suggestive of ALL, with t(5;14). He was started on induction chemotherapy but succumbed to the illness. Highlight: Children with eosinophilia, especially with signs of end-organ damage, should be kept under close surveillance, since eosinophilia can present before, concomitantly or after the diagnosis of leukemia. Discussion: The cytogenetic abnormality, t(5;14) is a consistent abnormality associated with eosinophilia in ALL. The prognosis of ALL presenting with eosinophilia is significantly worse than ALL alone probably due to concomitant cardiorespiratory dysfunction, like in the present case.
PR 20 Acute Myeloid Leukemia With Filariasis-A Dual Haematological Surprise Dr. Avril Dias, Dr. R. G. Wiseman Pinto Goa Medical College Introduction: Filariasis is a mosquito borne parasitic infection affecting the lymphatic system presentic with pyrexia, lymphadenopathy or elephantiasis. Presence of microfilaria in peripheral smear in association with a hematological neoplasm has infrequently been described. Materials and Methods: A 16 year old boy presented to medicine opd with fever, upper respiratory tract infection and swelling of right leg for 20 days. A complete hemogram revealed anemia, thrombocytopenia and raised total leucocyte count and myeloblast of myelomonocytic type and presence of microfilaria without eosinophilia. Bone marrow studies and molecuar cytogenetic study was advised. Results: Bone marrow was hypercellular with increase in blasts along with shift to left. Erythroid and megakaryocytic series were suppressed. No microfilaria were detected. Molecular cytogenetic studies results are awaited. Conclusion: Microfilaria is a common parasite in some parts of India but its association with leukemia comes as a hematolgical surprise. The patient was started on diethyl carbamazine and subsequently received chemotherapy and is currently doing well. Keywords Leukaemia, Microfilaria
Severe Eosinophilia Masking Childhood Acute Lymphoblastic Leukemia Dr. Ankit Parmar, Dr. Anupa Mishra, Dr. Yashashree Gupta, Dr. Sangeeta Mudaliar, Dr. Archana Swami Bai Jerbai Wadia Hospital For Children Introduction: Acute lymphoblastic leukemia (ALL) with eosinophilia is a rare but distinctive entity. We present here a case of
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PR 21 Clinicopathological Correlations of The T(11;19) A Nancy, Arpana Palle, A Abraham, B George, V Mathews Christian Medical College, Vellore
Indian J Hematol Blood Transfus Introduction: The MLL gene is involved in translocations with several partner chromosomes. The t(11;19) is one such translocation and involves one of three unrelated genes on 19p13—ELL at 19p13.1 and ENL and EEN (SH3GL1) at 19p13.3. The 19p breakpoints are often indistinguishable by conventional Cytogenetics. Materials and Methods: G-banded karyotypes of patients with the t(11;19) seen in Haematology department, CMC, Vellore between January 2009 and December 2014 were correlated with blood and bone marrow findings. Results: There were 11 patients with the t(11;19). Eight had myeloid neoplasms (five AML and one MDS, CMML and myelofibrosis each) and three had ALL. There were 1111 AML and 956 ALL seen during this period. Patients were 0.5–65 years old (median age 26). Three were below 15 years of age. There were seven males. The median haemoglobin was 9 g/dl (4–16.3 g/dl), median WBC count, 7.7 9 109/L (range 1.9–319.9 9 109/L) and median platelet count, 10 9 109/L (range 18–288 9 109/L) and bone marrow blast percentage, 2–82 %. The t(11;19) was the sole abnormality in seven patients (63 %). Three patients had single additional abnormality (gain of chromosome X, trisomy 8, deletion 5q) and one had a complex karyotype. Conclusion: This data documents the presence of this rare abnormality among patients with acute leukemias and other myeloid neoplasms in India. The frequency of the t(11;19) is indeed very low (0.4 % in AML and 0.3 % in ALL) but it is important to look specifically for these abnormalities in G-banded samples as the changes can be subtle.
PR 22 Acute Myeloid Leukemia In A Retrovirus-Positive Patient—An Uncommon Occurrence Shano Naseem, Neelam Varma, Subhash Varma Pgimer, Chandigarh Introduction: Introduction of anti-retroviral therapy (ART) has resulted in improvement of immunological status of retrovirus-positive patients leading to increased life expectancy and decreased incidence of various acquired immunodeficiency syndrome (AIDS) defining malignancies (Kaposi’s Sarcoma, PCNSL). However, the incidence of non-AIDS defining malignancies (Hodgkin’s lymphoma, leukemias) has increased with estimated incidence being 4.5 times more in the last decade. Of these, lymphoid malignancies and myelodysplasias are common, however myeloid neoplasms, including acute myeloid leukemia (AML) are rarely seen. Case report: A 29-year old female diagnosed with retrovirus infection since 3 months, presented to hematology clinic in November 2014 with bicytopenia and fever. Her hemoglobin (7.4gm/dL) and platelet counts (59 9 109/L) were reduced with increased total leucocyte count of 25.9 9 109/L. Peripheral blood and bone marrow respectively showed 82 % and 77 % blasts with Auer rods and MPO positivity. Molecular genetic analysis was found to be negative for recurrent genetic mutations including t(8;21), t(15;17) and inv (16). The case was diagnosed as AML with maturation (FAB AML-M2). Discussion: Only a few cases of AML have been reported in retrovirus-positive patients, limited to the case reports. Duration between HIV infection and development of the AML is variable and in few of the cases HIV infection was found at the time of diagnosis of AML. The proposed pathogenesis for AML development is that the retrovirus infects the CD4 positive lymphoid cells which lead to release of transactivator protein (TAT). TAT displaces preformed basic fibroblast growth factor (bFGF) bound to heparan sulfate proteoglycans into a soluble form which augment myelopoiesis via FGF receptors on myeloid progenitors. In addition, HIV affects bone marrow microenvironment altering cytokines production making it more permissive to the growth of leukemic cells. Till now only 50 cases of AML have
been reported in retrovirus-positive patients. Here, we report another case of AML in a retrovirus-positive patient. Keywords Acute myeloid leukemia, Retrovirus-positive
PR 23 Preliminary Results of Risk Adapted Indian Pediatric All Protocol (Icicle) from A Tertiary Cancer Centre R. Venkatraman, T. G. Sagar, G. Prasanth, T. S. Ganesan, R. Rejiv Cancer Institute (Wia), Adyar, Chennai Introduction: ICICLE is a collaborative multicentric randomized open label phase 3 national trial for newly diagnosed pediatric ALL patients. It incorporates a risk adapted approach in management of acute lymphoblastic leukemia patients in Indian context. Materials and Methods: Prospective analysis of the induction data of the children enrolled onto the ICICLE protocol (October 2014–June 2015). Baseline characteristics, response to treatment including MRD & adverse effect profile were recorded. Results: Total 71 patients were enrolled with median age of 6 (range 9 months–17 years). Pre B: T ratio was (3:1). Initial ICICLE Standard, intermediate and high risk were 26.5 % (14/53), 43.4 % (23/53), 30.1 % (16/53) respectively. Poor prednisolone response was seen in 14 %. Marrow nonremission and MRD positivity, at the end of induction were 14.8 % and 58 % respectively. At the end of induction 71.4 % (10/ 14), 60.8 % (14/23) of the standard & intermediate risk respectively, moved to high risk. This shift to high risk predominantly was based upon MRD Positivity (7/10 and 10/14 in standard and intermediate risk respectively). Total numbers of deaths were 2.8 % (2/71). Refractory disease was present in 8.4 % (6/71). Febrile neutropenia was observed in 40 % of the patients. Invasive probable fungal pneumonitis was noted in 2.8 % (2/71). L-Asparaginase induced CVT was observed in 1 case. Mucositis was observed in 8.4 % (6/71). Conclusion: Our limited experience shows that ICICLE can be used as a risk adapted approach in treatment of Paediatric ALL. However longer follow up of these children are necessary for better characterization of the protocol.
PR 24 Gene Mutations In Flt3-Itd, Npm1, Cebpa, Kit, Dnmt3A, Idh1 Genes In Pediatric Acute Myeloid Leukemia Swapnali Joshi, Shripad Banavali, Brijesh Arora, Gaurav Narula, Pg Subramanian Tata Memorial Hospital Introduction: Pediatric acute myeloid leukemia (AML) is a relatively rare hematolymphoid malignancy. Mutations in FMS-like tyrosine kinase 3 (FLT3), nucleophosmin1 (NPM1), CCAAT/enhancer-binding protein alpha (CEBPA) and cKIT genes are of established importance in AML where, DNA (5-cytosine) Methyl Transferase 3A (DNMT3A) and isocitrate-dehydrogenase 1 (IDH1) genes have profound prognostic significance in AML. We sought to evaluate the baseline frequencies of these mutations in pediatric AML in a large tertiary care cancer hospital. Materials and Methods: A total of 50 patients of newly diagnosed AML (other than APML) were evaluated. Patients ranged between 1–16 years with a male: female ratio 1.5:1. Genomic DNA was extracted and subjected to multiplexed PCR with fluorescently labeled (FAM, NED) PCR was followed by capillary electrophoresis. cKIT, DNMT3A and IDH1 mutations: Detected by a PCR followed by bidirectional Sanger sequencing. Results: We
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Indian J Hematol Blood Transfus categorized the cases according to FAB classification as follows: AML-M0 (2 %), AML-M1 (24 %), AML-M2 (36 %), AML-M4 (12 %), AML-M5 (14 %), AML-M7 (6 %). t(8;21), v(11q23) & inv16 were seen in 16, 4 and 6 % patients respectively. Mutations in CEBPA (26 %) were most commonly seen followed by FLT3-ITD and NPM1 mutations (14 % and 18 % respectively). c-KIT (6 %) and DNMT3A (2 %) mutations were less common. No mutations were observed in the IDH1 gene. The subcategories of mutations were as follows: [FLT3 +/NPM1-/CEBPA-(12 %)], [FLT3 +/NPM1 +/ CEBPA-(2 %)], [FLT3 +/NPM1-/CEBPA + (0 %)], [FLT3-/ NPM1 +/CEBPA -(8 %)], [(FLT3-/NPM1-/CEBPA + (18 %)], [(FLT3-/NPM1 +/CEBPA + (8 %)]. No biallelic mutations in CEBPA genes were found. Conclusion: The frequencies of these mutations are comparable with published data. These parameters are used in risk stratification of pediatric AML patients and in decision making for treatment of various risk groups.
PR 25 Fish Negative Rt-Pcr Positive Apml: A Case Series Dr. Ravikiran Narayansing Pawar, Biswajoy Pal, Poonam Santra, Kallol Saha, Saheli Banerjee Tata Medical Center Introduction: The diagnostic algorithm for Acute Promyelocytic Leukaemia (APML) arising from reciprocal t(15;17) involving the PML gene on 15q24, and RARA gene on 17q21, relies on a multifaceted approach using morphologic, immunophenotypic, cytogenetic and molecular analysis. The aim of the study is to evaluate the cryptic FISH negative, RT-PCR for PML-RARa positive APML Materials and Methods: This was a retrospective study carried out in the Departments of Molecular Genetics Tata Medical Center, Kolkata from Aug 2012 to Aug 2014. All newly diagnosed cases of acute leukemia referred to the molecular laboratory from Aug 2012 to Aug 2014 were included. Results: 486 diagnostic specimens referred from 239 unique patients were tested by nested RT-PCR for seven common recurrent translocations: t(8;21), t(15;17), inv(16), t(9;22), t(12;21), t(4;11), and t(1;19), with a detection rate of 18.9 % (92/486). Of these 92 cases FISH was performed on 44 (71 %) cases with discordance (15.9 %; 7/44) cases and karyotyping (CC) was done on 30 (48.4 %) with discordance (13.3 %;4/30) cases. Of 7 discordant cases there were 5 cases with immunomoprhological findings consistent with APML. All these five cases had characteristic flow finding, FISH negativity (5/5) and RT PCR positive (BCR1 transcript). Conclusion: Although there is sporadic discordance between these two techniques and each method has its own limitations, the judicious use of these techniques will deliver the cost effective treatment in our country.
PR 26 Acute Megakaryoblastic Leukemia In Children…. A Trail For Down Syndrome??? Jyoti. R. Kini, M. Nirupama, Deepa Adiga, Harsha Prasad Kasturba Medical College Introduction: Acute megakaryoblastic leukemia comprises less than five percent of all acute myeloid leukemias. Acute megakaryoblastic
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leukemia occur more commonly in Down syndrome or arise de novo or sequelae following chemotherapy, myeloproliferative neoplasms. We present two cases of children with acute megakaryoblastic leukemia. Materials and Methods: A one year old child with Down syndrome presented with recent onset petechiae. Peripheral blood showed low hemoglobin and low platelet count. There were 67 % blasts in peripheral smear. A eleven month old child with suspected chromosomal breakage syndrome presented with progressive weakness, hypopigmentation, failure to thrive and developmental delay. Clinical examination showed dysmorphism, pallor and peripheral blood showed bicytopenia, with low hemoglobin and platelet count. Result: Flow cytometry done in both cases revealed findings compatible with acute megakaryoblastic leukemia. Cytogenetics of the second case revealed chromosomal breakages. GATA-1 gene mutations were not tested. Conclusion: Children with Down syndrome have a 500 fold increased incidence of acute megakaryoblastic leukemia. However the prognosis here is good. The major differential diagnosis is transient myeloproliferative disorder which can be clinically and hematologically indistinguishable, however transient myeloproliferative disorder would present in early infancy. Just as a child with transient myeloproliferative disorder is monitored for acute megakaryoblastic leukemia, a child with acute megakaryoblastic leukemia warrants cytogenetic workup for presence of trisomy 21. Keywords Acute megakaryoblastic leukemia, Down syndrome
PR 27 T-Cell Blast Crisis of Chronic Myeloid Leukemia Dr. P. S. Ghalaut, Dr. Sudhir Kumar, Dr. Ashima Mittal, Dr. Arvind Chahal, Dr. Naresh Gaur Pt. B. D. Sharma Pgims Rohtak Introduction: Chronic myeloid leukemia is a myeloproliferative disorder with an overall incidence of 0.6 to 2 cases/100,000/year. Disease progression to accelerated or blast phase remains the main cause of mortality. The incidence of myeloid blast crisis is *50 % compared to *25 % each for lymphoid blast crisis and undifferentiated phenotypes. Almost 95 % of lymphoid blast crises are of B cell phenotype with very few cases of T cell phenotype. CASE HISTORY A 53yrs old female known case of CML since 1 yr on Tab Imatinib 400 mg OD on irregular follow-up presented with 10 days history of bleeding gums and bleeding spots all over body. Examination showed pallor and petechiae all over body with no icterus/lymphadenopathy/hepatospenomegaly. RT-PCR was 4.14 % positive for BCR–ABL. A bone marrow evaluation showed solidly cellular aspirate with 44 % blasts that were Sudan black negative. Flow cytometry revealed T cell phenotype. Bone biopsy showed hypoplastic marrow with myelofibrosis. CSF examination was normal. Laboratory parameters are given in Table 1. A diagnosis of CML with blast crisis was made based on clinical presentation, blasts on peripheral smear and positivity for BCR-ABL, later diagnosed as CML with T cell ALL transformation. Patient was switched to Dasatinib 70 mg BD and was started on chemotherapy with steroids and vincristine for 4 weeks. Patient responded initially however developed intracranial haemorrhage on day 1 post chemotherapy and expired later. Conclusion: Sudden onset blast crisis is more common with lymphoid than myeloid blast transformation. T cell-ALL reflects an aggressive form of tumour and
Indian J Hematol Blood Transfus requires myeloid directed chemotherapy along with ALL therapies, however prognosis remains poor. Table 1 .
PR 29 Evaluation of P53, Bcl-2, Survivin, Mib 1 By Immunohistochemistry In Adult Acute Myeloid Leukemia Dr. V Manu
Hb
TLC
DLC
PLT COUNT
PBF
\20,000
90 % blasts
ON ADMISSION (25/03/2015)
8.6 55,000 5/7/1/1/2
1 week after dasatinib (31/03/2015)
3.2 \1000 Not \20,000 possible
80 %blasts
1 week after steroids (18/04/2015)
10.8 3,000
26/70/2/2 \20,000
Dimorphic
After completing 4 weeks of chemotherapy
11.6 5,000
36/60/2/2
Dimorphic
80,000
Inhs Sanjivani Introduction: A common component of leukaemogenesis and drug resistance in acute AML is resistance to apoptosis. Apoptosis occurs as a result of caspase activation. Survivin prevents apoptosis by blocking caspase activity. The association of survivin expression with tumor progression is known in solid tumours. Several antisurvivin preclinical trials in solid tumor models have shown that disrupting survivin can reduce tumor growth. Need for Study: The study will help in better understanding of tumour biology in devising better targeted strategies to manage the disease in the future. Materials and Methods: Paraffin-embedded bone marrow biopsy sections of 30 acute adult myeloid leukaemias cases were immunostained for survivin, bcl-2, p53 and MIB1. Suitable controls were included .200 cells were counted in each case visually. Expression was evaluated in nuclei and cytoplasm, on an intensity scale. (0–2). The IHC finding will be correlated with the clinical and biological status of the disease. Results and Conclusion: Preliminary results show AML cases strongly expressing p53 and positive for survivin.
PR 28 Case Report: Two Rare Cases of Acute Promyelocytic Leukemia With The Variant Rara Translocation Pg Subramanian, Swapnali Joshi, Shruti Chaudhary, Prashanttembhare, Sumeet Gujral Tata Memorial Hospital Introduction: Majority of (98 %) of acute promyelocytic leukemia (APL) are characterized by t(15;17) that encodes the PML-RARA fusion gene. We present two rare cases of APL with variant RARA translocation. Relevant case presentation: Case 1: A 32 year old male showed 35 % blasts along with 8 % promyelocytes in the blood. Bone marrow examination showed abnormal promyelocytes with Pelgerlike nuclei and microgranular cytoplasm which were strongly positive for MPO. FISH was negative for PML-RARA fusion; the RARA breakapart probe was normal. A reverse transcription PCR was negative for PML-RARA fusion. The patient who was empirically started on ATO was switched over to 3 + 7 AML induction. Soon TLC rose rapidly and PB showed promyelocytes and differentiating myeloid cells. At that time, molecular testing revealed that patient tested negative for PLZF-RARA, STAT5b-RARA fusion transcripts by realtime PCR but positive for NPM-RARA fusion transcript which is a result of t(5;17). Case 2: A 37 year old male patient presented with a history of low grade intermittent fever, easy fatiguability and dyspnea on exertion for duration of 2 weeks. Peripheral blood showed abnormal promyelocytes and pelgeroid neutrophils. FISH was negative for PML-RARA fusion, however the RARA breakapart probe showed an abnormal signal. Real time PCR detected PLZF-RARAfusion transcript. Need of presenting the case and discussion: The classical APML with PML-RARA t(15;17) is well defined with typical morphology and responsiveness to retinoids. Case 1 would represent cytogenetically normal cryptic acute promyelocytic leukemia. However it is responsive to ATRA based treatment. It is important to diagnose case 2 as it is resistant to ATRA based therapy.
PR 30 Acute Promyelocytic Leukemia Unmasking Familial Hlh Khushnuma Mullanfiroze, Anupa Mishra, Ankit Parmar, Archna Swami, Mukesh Desai Bai Jerbai Wadia Hospital For Children Malignancy associated secondary hemophagocytic lymphohystiocytosis (HLH) is known. Acute promyelocytic leukemia (APML) in a case of primary HLH is a rare but distinctive clinical entity. We present herewith a case of APML who was diagnosed with primary HLH and tuberculosis during the course of chemotherapy for APML.10 year old male child born out of third degree consanguineous marriage presented with mucosal bleeds and fever since 20 days. Child had history of contact with sputum positive tuberculosis. On examination there was pallor, significant cervical lymphadenopathy, herpes labialis, bone tenderness and no organomegaly. Investigations showed pancytopenia, bone marrow s/o APML cytogenetics were t(15;17). Child was started on all-trans retinoic acid and arsenic trioxide. CT chest s/o of multiple necrotic lymphnode? tuberculosis. Child was started on ATT. In view of persistent fever spikes, cytopenias HLH work up was sent which was positive. Child was worked up for familial HLH–GRA was positive. Child was started on 2004 HLH protocol of the histiocyte group to which he responded. Child is presently on consolidation cycle of APML treatment, and continuation therapy for HLH and tuberculosis and is clinically well. This case highlights the rare association of familial HLH with APML and tuberculosis. Whether primary HLH which was clinically silent predisposed the child to develop APML in presence of tuberculosis or whether tuberculosis predisposed the child to develop APML and HLH activation, remain an unsolved mystery. More research into the molecular and genetic aspects of the disease needs to be established.
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Indian J Hematol Blood Transfus
Topic: Coagulation Disorders PR 31 Cerebral Venous Thrombosis In Hiv Patient: A Case Report
trauma and menorrhagia in female sibling. Factor V deficiency was seen in adolescent and young adults with varied patterns of bleeding, one of whom had inhibitors. Conclusion: The common pathway defects are rare coagulopathies with varied spectrum of presentation, the diagnosis of which is arrived at by a systematic approach. Keywords Inherited Coagulopathies, Common pathway defects
S. Sharma, P. Thomas, J. Chandra, A. Nangia Lady Hardinge Medical College Department of Pathology and Paediatrics*, Lady Hardinge Medical college and Associated Kalawati Saran Children’s hospital New Delhi 110001. Introduction: Thrombosis in HIV (Human immunodeficiency virus) infected patients is an infrequent complication. The pathogenesis of hypercoagulability in HIV infection is complex and not yet fully understood. Chronic inflammation, endothelial cell dysfunction, acquired deficiency of natural anticoagulants, and presence of antiphospholipid antibody (APLA) are some of the postulated mechanisms of hypercoagulability in HIVpatients. Cerebral Venous Thrombosis (CVT) is a rare complication of HIV. Case details: A 5 year female, diagnosed with HIV infection (not on HAART) presented with headache for 3 weeks. There was no fever or vomiting or seizures or altered sensorium or focal deficit. No evidence of any opportunistic infection. CBC, CT head and CSF were normal. MRI brain (with venography) revealed thrombosis in the contiguous transverse and sigmoid sinuses. A diagnosis of CVT was made. Investigations for thrombophilia was initiated. There was no family history of clotting disorders. Prothrombin time, Activated partial thromboplastin time (APTT) and Fibrinogen were normal (12.5,35.2and248 respectively). D dimer was deranged (2.66 lg/ml). Protein C and Protein S assays showed reduced activity (46 % and 18 % respectively). Anti thrombin activity was normal (108 %). Lupus Anticoagulant (LAC) and APLA IgM were negative (1.06&8 MPL AU/ml), however (APLA) IgG levels was increased 22.4 (Normal \10 GPL AU/mL). Conclusion: Results suggest that acquired protein S and C deficiency may predispose the HIV infected individuals to develop thrombosis. Keywords HIV, THROMBOSIS, Protein S & C deficiency
PR 32 Prolonged Pt and Aptt: How Common Are Common Pathway Defects? Rakhee Kar, S Sushya, R Sundharamurthi, Debdatta Basu Jipmer Introduction: Prolonged PT and APTT in the workup of an inherited bleeding disorder points towards a common pathway defect. This includes deficiencies/defects in factors I (Fibrinogen), II (Prothrombin), V and X. These coagulopathies are relatively rare with varied presentation. This study was undertaken to document these defects. Materials and Methods: This was a record based descriptive study over a period of six years (June 2009 to June 2015) in a single large tertiary-care centre. The inherited coagulopathies were screened and all the cases with common pathway defects were analysed regarding their clinical profile and coagulation work up which included PT, aPTT, TT, mixing studies with normal and deficient plasmas and confirmatory factor/fibrinogen assay. The acquired bleeding disorders and platelet function disorders were excluded. Results: There were a total of 148 inherited coagulopathies diagnosed in this period of which common pathway defects were 10 (14.8 %, 6 males and 4 females). They included factor I (n = 3), factor II (n = 2), factor V (n = 4)and factor X (n = 1). Age ranged from 20 days to 23 years with fibrinogen and factor X deficiencies presenting in infancy with intracranial bleed. The two cases of prothrombin deficiency were adolescent siblings with recurrent epistaxis, prolonged bleeding after
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PR 33 Paraganglioma In A Case of Inherited Factor Vii Deficiency: A Case Report Tushar Sehgal, Narender Kumar, Jasmina Ahluwalia, Ritambhra Nada, Anil Bhansali Postgradute Institute of Medical Education and Research Introduction: Inherited FVII deficiency is a rare autosomal recessive hemorrhagic disorder with a population prevalence estimated to be 1 in 500,000. Mild cases of inherited factor VII deficiency usually does not have clinically apparent bleeding; however they may bleed in situations which may pose a haemostatic challenge. Case presentation Here we present a case of a 26-year-old female known case of inherited mild factor VII deficiency. She later developed a urinary bladder mass which was diagnosed histopathologically as paraganglioma. She underwent successful resection of the tumor with fresh frozen plasma support and there was no excessive bleeding. Need of presenting the case The index case was diagnosed as inherited factor VII deficiency with factor VII levels of 17 % and 11 % on two separate occasions. Urinary bladder paraganglioma in a case of factor VII deficiency has been reported earlier. Knowledge of factor levels prior to major surgery is necessary in such cases to avoid any catastrophic event. Discussion Inherited Factor VII deficiency is the most common of the ‘‘rare bleeding disorders.’’ Patients with factor VII levels[10 to 15 IU/dl rarely manifest bleeding; however bleeding can occur either spontaneously or in response to hemostatic challenges. The association of urinary bladder paraganglioma in a case of factor VII deficiency is uncommon and has not been reported in literature. Keywords Paraganglioma, Factor VII deficiency
PR 34 Inherited Factor V Deficiency Complicated By Inhibitors At First Presentation—Confounders In Laboratory Testing Rakhee Kar, Deepak Charles, Pl Ambika, B Hitha, Tk Dutta Jipmer Introduction: Inherited Factor V deficiency/Owren’s disease has varied clinical manifestations ranging from asymptomatic laboratory abnormalities to massive hemorrhage. Acquired condition due to inhibitors following antibiotic therapy, infection or surgery is less common. A young patient presents with low factor levels as well as positive inhibitor screen. Case presentation: 18 year old boy presented with bleeding axillary and groin ulcers. First bleeding diathesis was a spontaneously subsiding mucocutaneous bleed at 14 years of age. At age 15, for recurrent epistaxis and gum bleed, he was diagnosed with acquired factor V deficiency, treated with fresh frozen plasma (FFP) transfusion and Azathioprine briefly. Coagulation workup done at age 15 and at current presentation revealed common pathway defect. Mixing studies performed with factor deficient plasmas and factor assays revealed deficiency of factor V. However, there was only partial correction with control normal plasma indicating the presence of inhibitors by Rosner and Chang’s indices. Patient was on FFPs with partial control of bleeding, and the tests
Indian J Hematol Blood Transfus were repeated after 6 weeks. The differences observed included negative inhibitor screen, complete correction on mixing studies BUT factor V level was 2 %. Need of presentation: Discussion of confounding variables in laboratory testing and unanswered questions in this particular case. Discussion: Lack of family history and evidence of inhibitors at presentation favored acquired disease. However, young age of onset, detection of inhibitors one year after first episode of self-regressing bleed, lack of identifiable triggers, and persistent bleed with reduced factor levels after disappearance of inhibitors favour inherited deficiency. Keywords Factor V deficiency, Inhibitors, Mixing studies
Impact of Thrombosis on Standard Treatment In Solid Tumors
associated with various drawbacks due to its polyanionic nature, thus giving rise for the development of safer agents which offer significant advantage over the heparins. We set out to rationally design, synthesis and characterize a small molecule with anticoagulant activity and here we report the screening, synthesis and characterization of a novel flavonoid based compound; Naringin Sulfate. In silico docking of naringin and naringin sulfate with antithrombin showed a differential interaction pattern, where naringin sulfate interacts with critical residues of AT that are either directly involved in heparin binding or in the conformational rearrangement of AT on heparin binding. The sulfation was conformed initially by TLC and later on verified by FTIR, LC–MS, NMR, Mass spectrometry. The activity of naringin sulfate showed prolongation of clotting time by influencing the extrinsic as well as intrinsic coagulation pathways (APTT, PT, and TT) in vitro. Therefore it can be concluded that naringin sulfate can be a potent anticoagulant for further testing.
Atanu Bhattacharjee, Vineetha Raghavan, Satheesh Babu, Satheesan Balasubramanian
PR 37
Malabar Cancer Centre
Is F Viii –Inhibitor Screen Sensitive?
Introduction: That cancer is a hypercoagulable state is a well established concept. The frequency of venous thrombotic events in cancer patients is 5–8 %. There is paucity of data on the influence of thrombosis on treatment decisions in solid tumors. Methods: An audit of all cases of thrombosis developing in newly diagnosed solid tumors from 1st January 2011 to 31st December 2014 was performed. Changes in treatment decisions for malignancy (deferral of surgery/ chemotherapy, changes in the planned course of chemotherapy or changes in the planned dates of chemotherapy) after the documentation of thrombosis were noted. Results: A total of 11,796 solid tumor cases were registered in our centre. 61 cases with thrombosis (0.52 %) were identified. In 14 patients (23 %), treatment decisions for malignancy had to be changed after the documentation of thrombosis. 2 patients were deferred surgery, 9 could not undergo chemotherapy according to planned schedules, and 3 were deferred chemotherapy. In survival analysis by multivariate model, stage (p = 0.01) and ECOG performance status (p = 0.01) significantly predicted survival whereas thrombus location (p = 0.09), symptomatic thrombosis (p = 0.06), and age (p = 0.19) did not. Conclusions: Thrombotic events in solid tumors in our centre was less compared to previous reports. There was a significant deviation (nearly one-fourth patients) from standard of care for malignancy after the documentation of thrombosis. Survival of patients with thrombosis did not significantly vary depending on location of thrombosis or whether it is symptomatic or not.
V. Ramya, G. Surendar Singh, Sukesh C Nair
PR 35
PR 36 Screening, Synthesis and Characterization of A Novel Non-Heparin Anticoagulant Agent With Potent Anticoagulant Activity Mohammad Abid, Mohamad Aman Jairajpuri
Department of Transfusion Medicine and Immunohaematology, Cmc, Vellore Introduction: Inhibitors are antibodies that act against either a specific clotting factor or against phospholipids (lupus anticoagulant). Patients with prolonged activated partial thromboplastin time (APTT), which does not show correction on mixing studies with pooled normal plasma usually raises the suspicion of the presence of inhibitors. An APTT based screening test for inhibitor is routinely performed in all newly diagnosed haemophilia A patients, who needed multiple blood product or factor concentrate administration, prior to diagnosis. This test is also performed in all patients where there is a request for quantitative inhibitor (Bethesda) assay: in known hemophiliac patients with subnormal recovery of factor VIII:C levels following replacement and before any major surgical intervention. Aim: To assess the sensitivity of APTT based inhibitor screen test to identify the presence of inhibitors in Haemophilia A patients where clinically indicated. Method: Over an 18 month period in 2014–15, samples from all the patients in whom the antibody screen was positive were analysed by the classical Bethesda assay. The remaining patients who were negative in the antibody screen test were subjected to the Nijmegen modification of the Bethesda assay, which is more sensitive to low titres of antibodies. Result: 46/157 patients (29.3 %) with a median of 18.4 (range: 2.4 to 2150BU) had the inhibitor screen positive and antibodies detectable by the classical Bethesda assay. Of the remaining patients, 26.1 % showed the presence of inhibitors detected by the Nijmegen modification of the Bethesda assay, with a median of 0.9 (range: 0.6 to 4.0BU) while the inhibitor screen was negative. Conclusion: The inhibitor screen is said to be sensitive in detecting F VIII inhibitors. But according to our observation we found a large number of inhibitor screen negative patients to have F VIII inhibitor by Nijmegen modification of the Bethesda assay.
Jamia Millia Islami Abstract The counteracting coagulation and fibrinolytic systems act in coordination to maintain the physiological hemostatic balance. Aberrant clot formation inside a blood vessel due to an imbalance of procoagulant and anticoagulant factors may lead to serious pathological conditions presented clinically as life threatening thrombosis and thromboembolism. Currently, anticoagulant therapy is the first line of treatment for these conditions with heparin being most widely used. Heparin exerts its anticoagulant activity through endogenous coagulation inhibitor, antithrombin. However, heparin therapy is
PR 38 Markers of Fibrinolysis In Indian Patients With Isolated Head Trauma Ruchika Sodhi, Mrinalini Kotru, Gurubachan Singh University College of Medical Sciences, Delhi Introduction: Activation of coagulation has been reported after head injury. The initial hypercoagulability may progress to DIC which
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Indian J Hematol Blood Transfus induces secondary fibrinolysis. Though enhanced fibrinolytic activity has been reported in 40 % of trauma patients, clinically recognisable symptoms of DIC are seen in a small number of patients only. Post traumatic hypercoagulability is associated with a poor prognosis. Need for Study: Early recognition of abnormality in fibrinolytic markers: D-dimer and Fibrinopeptide A (FPA) will help in better management and improved prognosis in these patients. Materials and Methods: Platelet count, PT, APTT, Plasma fibrinogen (Clauss), D-dimer and FPA were measured (ELISA) in patients admitted within 12 h of isolated head trauma. DIC score was calculated using standard criteria. Results: Elevated D-dimer ([250 ng/ml) and FPA ([3 ng/ ml) were observed in 64 % and 91.1 % patients respectively. Both D-dimer and FPA were elevated in 66.6 % patients. DIC score was C5 in 28 (28 %) patients indicating overt DIC. Both parameters as also DIC score were significantly (p \ 0.001) higher in non survivors as compared to survivors. The number of patients with elevated D-dimer and FPA as also DIC score C5, increased with increasing severity of injury. Conclusion: Measurement of fibrinolytic markers and early identification of DIC may help mitigate or prevent secondary cerebral ischemia by better management of these patients. Keywords Disseminated intravascular coagulation, Fibrinopeptide A, D-dimer, Fibrinolysis
PR 39
Christian Medical College Hemophilia A (HA) is caused by mutations in gene coding for F8. Hemophilia is classified as severe (\1 %), moderate (1–5 %) and mild (5–40 %) based on coagulant activity. There is limited data on mutations in patients with mild and moderate hemophilia. Hence we analyzed for mutations in these patients. A total of 268 patients from 2005 to 2015 presented for molecular diagnosis. After screening for mutations in the F8 gene, for intron 22 and intron 1 inversion, limited sequencing was performed if needed. We performed insilico analysis for novel mutations. Out of 268 patients, 14 (6 %) moderate and 6 (2 %) mild hemophilia (median age: 1 yr, range:1–20). All these patients had variable bleeding symptoms. Mutations could be identified in 8/14 moderate (57 %) and 4/6 mild (66 %) hemophilia A patients. A total of 12 mutations were identified and majority (42 %) of the mutations was localized in A1 domain; four were novel. The residues p.Lys395Glu lies in random coil region, which is highly conserved. Mutations in this region could alter the secondary structure or disturb the stability of protein. The residues p.Trp1961Ser, p.His2024Leu on in silico analysis impairs the folding of protein. The residue p.Gln2119His is predicted to destabilize the structure. Unlike severe hemophilia where we are able to identify mutations in * 95 % of patients, the chance of identifying a causative mutation is low in this cohort by this methodology. Hence alternative strategies should be adopted to identify the molecular defect in mild and moderate haemophilia.
Is Transferrin Saturation Reliable In Identifying Iron Deficient Erythropoiesis In Chronic Kidney Disease Patients: A CrossSectional Study PR 41 Neha Garg, Meera Sikka, O. P. Kalra, Anil Yadav University College of Medical Sciences Introduction: Anemia is one of the most common complication associated with Chronic Kidney Disease (CKD). Iron Deficieny (ID) is a common etiology that co-exists and can be treated easily. Its detection hence becomes important. NEED FOR STUDY: The ratio of sTfR/log ferritin is the best parameter for identification of Iron Deficient Erythropoiesis (IDE) but Soluble Transferrin Receptor (sTfR) assays lack standardization and are expensive. Transferrin Saturation (TSAT) \16 % is highly suggestive of ID. KDOQI guidelines recommend a cut-off of \20 % in CKD. However, TSAT is normal in many cases and a diagnosis of ID is missed. This study assesses the efficacy of TSAT in detecting IDE in CKD patients. Materials and Methods: Seventy-seven clinically diagnosed patients of CKD (Stage 3, 4 and 5) of either sex, age [ 18 years with Hb \11 g/dL were included in the study. Complete hemogram, Serum Iron (SI), Total Iron Binding Capacity (TIBC), TSAT, Serum Ferritin (SF), sTfR were estimated. Taking sTfR/log ferritin as gold standard, patients were divided into two groups. Group A: IDE (33/77) and Group B: Non-IDE (46/77). Efficacy of TSAT was assessed. Results: Sensitivity of TSAT \16 % was 29.0 % and TSAT \20 % was 48.3 % in identifying IDE. Also, mean values of TSAT showed only a marginal difference between two groups which was not statistically significant (p = 0.852). Conclusion: TSAT is not an efficient parameter in detecting IDE in CKD patients.
PR 40 Spectrum of Mutations In Mild and Moderate Hemophilia A Patients G. Sankari Devi, E. Sumitha, Sukesh C. Nair, Aby Abraham, Auro Viswabandhya
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Comparison Between Clauss Fibrinogen Assay and Prothrombin Time (Pt) -Derived Fibrinogen Assay In Cancer Patients Shilpa Kushte, Shashikant Mahadik, Daniya Maneri, Prasanna Bhanshe, Dr. Prashant Tembhare Tata Memorial Hospital, Mumbai Introduction: Fibrinogen level is a useful indicator in evaluation of several diseases like DIC, dysfibrinogenaemia, liver diseases, inflammatory diseases and malignancies. FA is performed using different methods, however, there is no consensus regarding the preferable method. A limited data is available highlighting comparison of these two methods. We present the comparison between Clauss and prothrombin time (PT) derived method in an oncology setting. Methods: We performed FA using Clauss and PT-derived method in citrated plasma-samples from 444 patients using ACL ElitePro. Results were compared and sensitivity and specificity of PT-derived method was determined. Results: Normal range for PTderived was 177–456 mg/dl and Clauss method was 180–360 mg/dl. Of 444 samples tested, FA revealed normal levels in 196 (44.1 %), low in 75 (16.9 %, mean-142 mg/dl, range 65.5–178 mg/dl) and high in 173 (39 %, mean-493 mg/dl, range 361–890 mg/dl) by Clauss method and normal levels in 227 (51.1 %), low in 47 (10.6 %, mean-161 mg/dl, range 61.5–173 mg/dl) and high in 170 (38.3 %, mean-654.6 mg/dl, range 458–1572 mg/dl) by PT-derived method. Both methods showed high degree of correlation (R2 = 0.83 Fig. 1) and on considering Clauss method as a reference method, the sensitivity and specificity of PT-derived method in detecting abnormal fibrinogen levels was 61 % and 99.97 % respectively. Conclusion: PT derived method significantly correlated with Clauss method and can be reliably used in cases with high fibrinogen values. However, in cases with low fibrinogen levels, Clauss method is a method of choice as PT-derived method gives false normal values in such sample.
Indian J Hematol Blood Transfus Abstract is uploaded as word document as it contains one table. Thanks.
PR 44 Safety of Turoctocog Alfa For The Prevention and Treatment of Bleeds In Patients With Haemophilia A: Results For The GuardianTM Clinical Trials Irina Matytsina, Dragana Janic, Sandra Lejniece, Elena Santagostino Novo Nordisk India Pvt Ltd
Fig. 1 Correlation between fibrinogen levels estimated by using clause method and PT-derived methode
PR 42 Causative Factors of Activated Protein C Resistance In Indian Deep Venous Thrombosis Patients Teena Bhakuni, Ravi Ranjan, Kamal Kishor, Ravi Kumar, Dr. M. Mahapatra All India Institute of Medical Sciences Introduction: Phenotypic resistance to APC (APCR) is a complex mechanism associated with increased risk of deep venous thrombosis (DVT). Congenital APCR mainly due to FV Leiden mutation, apart from some rarer FV gene SNPs like FV Cambridge, Hong-Kong and HR2 Haplotype which act either independently or are found in association with FV Leiden mutation. The aim of the study was to examine the role of known FV SNPs in causing APCR in Indian DVT patients. Methods: 50 DVT patients (M:F = 30:20) who were positive for APCR and equal number of healthy controls who were negative for APCR were the study subjects. FV Leiden, Hong-Kong Cambridge, HR2 Haplotype and Met2120Thr polymorphisms were detected using PCR–RFLP. Ala485Lys polymorphism was detected by allele specific PCR. Results: FV Leiden accounted 50 % of all APCR patients and difference in group frequencies compared with controls was found to be highly significant (p = \0.001). FV HR2 Haplotype was seen in 16 % of patients and 10 % of controls and the difference was not statistically significant (p = 0.554). None of the patients and controls carried Hong-Kong and Cambridge mutations. FV Ala485Lys and FV Met2120Thr polymorphisms were seen in 26 % and 8 % of patients and 14 % and 4 % of controls respectively (Ala485Lys: p = 0.134; Met2120Thr: p = 0.678). Conclusion: FV Leiden mutation is most common cause of inherited APC resistance in Indian DVT patients. Other FV SNPs were not associated with APCR in Indian population. Low prevalence of FV Leiden mutation with APCR increased the possibility of other mutations in FV gene or acquired factors.
PR 43 Stability of Turoctocog Alfa, A New Rfviii Product from Novo Nordisk, When Stored At High Temperature and Humidity Anja R. H. Skands, Dorthe Kot Engelund, Charlotte C. Rossmeisl, Ken Sejling Novo Nordisk India Pvt Ltd
Introduction: The guardianTM2 trial is a multi-national, open-label, non-controlled trial to determine the long-term safety and efficacy of turoctocog alfa (NovoEight) for the prevention and treatment of bleeds in previously treated patients (PTP) of all ages with severe haemophilia A. It is an extension to the guardianTM1 (adolescents/ adults C12 years) and guardianTM3 (children \12 years) trials. Methods: This interim safety analysis included 200 PTPs with severe haemophilia A in the ongoing guardianTM2 trial and the pooled dataset included all patients who completed guardianTM1 and 3 as well as those enrolled in guardianTM2 up to the cut-off (n = 229). All patients were switched to turoctocog alfa prophylaxis (20–50 IU/kg every second day or 20–60 IU/kg three times weekly). Bleeds were treated with turoctocog alfa. The primary safety end point was inhibitor development (C0.6 Bethesda Units). Results: No inhibitors were reported in guardianTM2 at the interim cut-off (in 200 patients with cumulative exposure of 72,320 exposure days) and in the pooled dataset of 229 patients with a cumulative exposure of 88,977 exposure days. In total, 877 adverse events were reported for 168 (84 %) patients; 29 serious adverse events (SAEs) (including 1 death) were reported in 26 patients, and all SAEs were judged unlikely to be related to treatment with turoctocog alfa. No thromboembolic or hypersensitivity events related to turoctocog alfa were reported. Conclusion: This analysis with longer follow-up (up to 3.5 years) supports the safety and efficacy of turoctocog alfa in previously treated paediatric, adolescent and adult patients with severe haemophilia A.
PR 45 Application of A Five-Step Purification Process For Turoctocog Alfa, A Third Generation, B-Domain Truncated Recombinant Factor Viii Molecule Haleh Ahmadian, Ernst B. Hansen, Johan H. Faber, Lars Sejergaard, Johan Karlsson Novo Nordisk India Pvt Ltd Introduction: We describe the purification process for turoctocog alfa (NovoEight), a new third generation recombinant factor VIII (rFVIII) with a truncated B domain. The aim was to develop a rFVIII product that is safe, efficient and convenient to use. Methods: A 5-step purification process was applied to three batches of turoctocog alfa: protein capture on mixed mode resin; immunoaffinity chromatography (AC), anion exchange chromatography (AIEX); virus filtration; and size exclusion chromatography (SEC). AC ensures homogeneity of the final product and double nanofiltration with 20 nm filters ensures viral elimination. Results: Host cell protein content (HCP; i.e. CHO) was reduced throughout the process (reduction factor [RF] 17292–22980), with the major contribution from AC (RF 266–383) and to a further extent by AIEX (RF 5–6) and SEC (RF 10–15). The RF by AIEX and SEC for murine IgG leakage from the AC step was 160 (batch 1) and 60–75 (batch 2 and 3). High
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Indian J Hematol Blood Transfus molecular weight protein (HMWP) was reduced mainly by SEC (RF 4–18) with almost no contribution from AIEX. However, the final product from all three batches had uniformly very low murine IgG content (0.04–0.05 ng/10000 IU) and HMWP (0.3–0.8 %). Manufacturing scale data confirmed the robustness of the purification process and its ability to reduce impurities to a very low level. Conclusion: The 5-step purification process used in turoctocog alfa results in a homogeneous, highly purified rFVIII product with a minimised risk of viral contamination and no major impurities.
PR 46 Aptt-Travails of A Large and Obsessed Coagulation Laboratory
requests 38 were positive. The age groups ranged from 17–46 yrs with most of the patients in the 3rd decade. Male: Female ratio was 1:4. 9 patients had thrombotic episodes, 21 were antenatal cases with previous bad obstetric history or primigravida with suspected placental insufficiency,6 had systemic lupus erythematosus, 2 had myelofibrosis with JAK2V617 mutation. Platelet count and Mean Platelet volume was normal in all the patients. 28 % patients had prolonged PT, 24 % prolonged aPTT which was not corrected by mixing studies. b2GP1 IgG/IGM was done on 42 % of the patients of whom 19 % showed positivity. Conclusion: LA test was started recently in our laboratory and the study showed LA positivity more among females and in patients with thrombosis, SLE and bad obstetric history. The presence of LA in myelofibrosis warrants that thrombophilia panel is to be done in all cases of myelofibrosis.
V. Ramya, J. Suresh Kumar, S. C. Nair Department of Transfusion Medicine and Immunohaematology, Cmc, Vellore Introduction: Large numbers of activated partial thromboplastin time (aPTT) reagents are available in the market. The source and content of phospholipid, concentration of contact activators and the ratio of the both the phospholipids and the activators vary among the various aPTT reagents. The current study was done to evaluate the sensitivity and the responsiveness of the various aPTT reagents. Aim: The aim of the study is to select a high sensitive first line and second line aPTT reagent in the haemaostasis laboratory. Method: Eight different aPTT reagents with different Activators and Phospholipids were tested against 46 different plasmas obtained from patients with coagulation disorder along with normal and abnormal controls. All the samples were analyzed in Tcoag-Destiny max by Optical Method. Result: All the eight different aPTT reagents differed in their sensitivity to factor deficiency, heparin monitoring, detection of inhibitors and lupus anticoagulant. Of the 8 reagents tested, only three reagents were within widely published reference ranges (25.0secs–42.0secs) and all others were too low. Conclusion: Our results showed that among eight different aPTT reagents two reagents with silica as a activator were highly sensitive and were identified as best first fit line aPTT reagent in a setup that would want to cover LA detection at time of screening. One reagent with ellagic acid as a contact activator was good and sensitive for all other than lupus anticoagulant and can be used as best fit second line aPTT reagent.
PR 47 Clinico-Hematological Analysis of Lupus Anticoagulant Positive Patients D Febe Renjita Suman, M Susruthan, Uma Lakshmi, Ananda Kumar Department of Pathology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University Introduction: Lupus anticoagulants (LA) are antibodies detected by phospholipid dependent clotting tests like activated partial thromboplastin time (aPPT), kaolin clotting time (KLT) and diluted Russell viper venom test (dRVVT). LA subtype with greatest effect on dVVRT is b2 glycoprotein dependent (b2GP1). These antibodies are involved in thrombotic diseases. Aims and objectives: To analyse the clinico-hematological features of lupus anticoagulant positive patients. Materials and Methods: This retrospective study was from December 2014 to June 2015. The blood samples of lupus anticoagulant test requested from various departments were processed with dRVVT and aPTT method. LA test positive patients were analyzed for their clinical and hematological findings. Result: Out of the 146
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Topic: Lymphomas PR 48 A Clinicopathological Study of Mantle Cell Lymphoma: Experience from A Single Centre Anuradha Ananthamurthy, Poonam K Panjwani, Pritilata Rout St Johns Medical College. Bangalore Introduction: Mantle cell lymphoma (MCL) is an uncommon NonHodgkin Lymphoma (NHL) comprising of 3–10 % of all NHLs. It is characterized by the translocation t(11;14) resulting in cyclinD1 overexpression. Histopathology shows proliferation of intermediate sized lymphoid cells with nodular or diffuse growth patterns. This study aims to understand the clinical presentation, histopathology and prognosis of our patients with MCL as there is scant literature from India. Materials and Methods: 14 cases of MCL diagnosed from 2010–2015 were included in this study. Clinical details, treatment and follow-up data were retrieved. Histopathology and immunohistochemistry were reviewed. Results: The median age of the patients was 64.61 years, with male predominance (n = 8, 57.14 %) and majority in advanced stage (n = 8, 57.14 %). All patients presented with lymphadenopathy. Bone marrow involvement was seen in 6 patients (42.85 %). Other extranodal sites involved were spleen (n = 2, 14.28 %), gastrointestinal tract (n = 2, 14.28 %) and cervix (n = 1, 7.14 %). One case was blastoid on morphology. All cases were positive for cyclinD1. Ki-67 was more than 60 % in 8 cases (57.14 %). Mantle cell international prognostic index showed high, intermediate and low risk in 8, 3 and 2 patients respectively. On follow-up, 10 patients died (8 due to disease complications, 2 due to co-morbidities with median time of 8 months), 1 patient was lost for follow-up, one is in remission, one recently diagnosed. Conclusion: Mantle cell lymphoma has poor prognosis presenting with advanced stages at diagnosis. This is one of the few studies from India, describing the clinicopathological profile of MCL patients. Keywords MCL, CyclinD1
PR 49 Uncommon Presentation of Hodgkin Lymphoma In Children: A Single Center Experience Priyanka Dua, Mohan Kumar, Vineeta Gupta Ims Bhu Introduction: Hodgkin lymphoma (HL) is malignant process of lymphoreticular system accounting for 6 % of pediatrics cancers.
Indian J Hematol Blood Transfus Commonly presentation is cervical or supraclavicular lymphadenopathy. Extranodal involvement, commonly seen in non Hodgkin lymphoma, is very rare in HL. Need for Study There are very few large case series on pediatric HL from our country. Materials and Methods: Retrospective data analysis from year 2004 to 2014 was carried out. Diagnosis of HL was confirmed by lymph node biopsy and immunohistochemistry. Chest x ray, USG/CT thorax and abdomen was done for staging. Bone marrow aspiration/biopsy was done in patients with B symptoms and/or stage III/IV disease. Uncommon sites of involvement were especially looked for. Patients received chemotherapy (COPP/ABVD) with/without radiotherapy. Results: 90 patients (age group 4–15 years, M:F ratio 15:1), stage I (4), II (18), III (62), IV (6) were studied. 75 % had B symptoms. Two patients (8 and 11 years, males) presented with paraparesis with bladder involvement. Both had paravertebral mass on CT scan with involvement of multiple vertebral bodies. Both received chemo and radiotherapy with complete response. 8 year old male presented with unilateral ptosis. CT orbit showed lymphomatous deposit in superior rectus muscle. 7 year old female had cervical lymphadenopathy with anasarca, diagnosed as HL with nephrotic syndrome. All patients had mixed cellularity on histopathology. Chemotherapy resulted in complete resolution of symptoms. Conclusion: Majority of patients had advanced disease with B symptoms. Extranodal involvement was rare. Patients had good response to chemotherapy. Keywords Pediatrics cancer, Hodgkin’s lymphoma, Lymphadenopathy, Nephrotic syndrome
Table 1 Baseline characteristics of the retrospective cohort (n = 21) Parameter Total no of patients
21
Previous DHAP exposure
16/21 (76.19 %)
Median no of lines of chemo prior to GVDexa use 2 Median time from 1st diagnosis to relapse
12.867 months
Time of relapse: \1 yr from diagnosis
10/21 = 47.61 %
C1 yr from diagnosis
11/21 = 52.23 %
Definition of progression: No CR after 1st line (PPHD)
11/21 = 52.38 %
Relapse after initial CR
10/21 = 47.62 %
Histological confirmation of diagnosis by biopsy Mean no LN sites involved at relapse
19/21 = 90.47 % 3.62
Extranodal involvement
6/21 (28.57 %)
Stage at relapse: Stage 2
4/21 (19.04 %)
Stage 3
10/21 (47.61 %)
Stage 4
7/21 (33.35 %)
ECOG PS PS 1
18/21 (85.7 %)
PS 2
3/21 (14.3 %)
PR 50
Mean hemoglobin
10.905 gm %
Single Centre Experience with Gvdexa Regimen as Salvage Chemotherapy in Relapsed and Refractory Hodgkin’S Lymphoma
Mean number of cycles delivered
2.43
T G Sagar, T S Ganesan, Prasanth Ganesan, Rejiv Rajendranath, Venkatraman Radhakrishnan Cancer Institute (Wia), Adyar Introduction: Non-platinum, gemcitabine based salvage regimens like GV-doxil have proven to have high response rates of 60–80 % in first line salvage in relapsed Hodgkin’s lymphoma (HL). We substituted liposomal doxorubicin with high dose dexamethasone which reduces toxicity and cost of the regimen. We report the use of this regimen as first line and second line salvage in relapsed/refractory Hodgkin’s lymphoma. Materials and Methods: The regimen consisted of gemcitabine 1000 mg/m2 IV (D1,8), vinorelbine 25 mg/m2 IV (D1,8) dexamethasone 40 mg oral (D1-4). It was given for 2–3 cycles until best response or till patient was taken up for stem cell transplant. Results: Response rates: 1/20 (5 %) had a complete response, 8/20 (40 %) had a partial response, 5/20 (25 %) had stable disease and 6/20 (30 %) had progressive disease. The overall response rate was 45 %. Toxicity: A total of 51 cycles were delivered among 21 patients. Grade 3/4 haematological toxicities (neutropenia and thromobocytopenia) were seen in 9/51 (17.64 %) cycles of chemotherapy. Incidence of febrile neutropenia was 11.76 % (6/51). Stem cell collection: Stem cell harvesting for ASCT was attempted in 10/21 patients. Among thsese,, the mean stem cell collection was 2.52 9 106 CD34 cell/kg. 5 patients in whom stem cell collection was adequate, underwent ASCT and 2 patients underwent RIC-alloHSCT. Conclusions: GVDexa, when used as third line salvage in relapsed and refractory HL shows promising response rates, with miminal acceptable toxicity and dose not compromise stem cell collection. The potential of the above is currently being explored as a Phase II trial at our centre.
PR 51 A Case Presenting With Splenic Infarct Diagnosed As Primary Bone Marrow Cd5 Positive Dlbcl—A Clinicopathological Correlation Dr. Jasmita, Dr. Jyoti Kotwal, Dr. Gaurav Dhingra, Dr. Nitin Gupta, Dr. Ambuj Garg Sir Ganga Ram Hospital Introduction: De novo CD5 + DLBCL is a rare and aggressive subtype of DLBCL. It is a distinct clinicopathologic entity with complex molecular profile and poor prognosis. Case presentation: A 59 year old female presented with pyrexia of unknown origin since 1 month. On examination, there was severe pallor, hepatosplenomegaly and no palpable lymphadenopathy. Complete blood count revealed bicytopenia with normal total leucocyte count. Liver and renal function tests were normal. Ultrasonography abdomen revealed splenic enlargement with two focal lesions either due to splenic abscess or infarcts. Serum ferritin, triglycerides and LDH were elevated. With a clinical suspicion of infection and haemophagocytic lymphohistiocytosis bone marrow aspiration (BMA) and biopsy (BMBx) was done. BMA showed extensive haemophagocytosis and * 7.4 % large lymphoma-like cells. On this basis PET-CT was suggested which showed enlarged spleen with diffuse uptake. BMBx showed nodular collection of abnormal lymphoid cells with few areas showing intrasinusoidal pattern. Immunohistochemistry on lymphoid cells was positive for CD20, CD5, MUM1, BCL-2, BCL-6 and was negative for CD3, CD10 and
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Indian J Hematol Blood Transfus CD23. CD34 highlighted focal intrasinusoidal pattern. The complete clinicopathological profile suggested the diagnosis of de novo CD5 + DLBCL, with primary hepatosplenic pattern of involvement. Discussion: CD5 + DLBCL showing splenic infarct is a very rare presentation. This case was unusual as the diagnosis of a primary aggressive lymphoma with haemophagocytosis was established in a patient who presented with fever and splenic infarct without lymphadenopathy. This indicates the importance of good morphological assessment of a bone marrow aspirate and biopsy to make a correct diagnosis.
PR 52 Cutaneous Involvement In Lymphoma: A Diagnostic Clue Prof. I. S. Gambhir, Dr. Nilesh Kumar, Dr. Mahendra Kumar, Dr. Vinay Kr. Br Ims, Bhu Introduction: Cutaneous manifeststions of leukemia/lymphomas are classified into Specific (infiltrates of leukemic cells) or Nonspecific (inflammatory, paraneoplastic, or secondary to marrow failure). These are important diagnostic clues and direct infiltration of malignant cells may be a bad prognostic marker. Integration of different diagnostic parameters, including immunohistochemistry (IHC) is essential to diagnose rare subtypes of lymphomas for which no definitive diagnostic criteria are available. Relavant case presentation: A 50 year old male presented with complaints of high grade fever for two months and rash on upper extremities for one month. Physical examination was noteworthy for erythematous, itchy, confluent maculopapular rash and generalized lymphadenopathy. Lymph Node biopsy and IHC was suggestive of angioimmunoblastic T cell Lymphoma (AITL). Skin biopsy showed lymphohistiocytic infiltrates which was positive for CD3 and CD4, a feature concerning for T-cell lymphoma. Need of presenting the case: This case underscores the diagnostic challenges of AITL and illustrates the requirement for careful clinical evaluation and prompt integration of different diagnostic parameters. Discussion: AITL is a rare subtype of peripheral T-cell lymphoma, first described as a distinct clinicopathologic entity in the 1970s. AITL accounts for approximately 1 % to 2 % of non-Hodgkin’s lymphoma. Typically, the architecture of the lymph node is effaced with perinodal extension of atypical cells and a proliferation of high endothelial venules. The neoplastic T cells are positive for CD2, CD3, CD4, CD10, CXCL-13, PD1, and often BCL-6. Cutaneous infiltration of AITL is confirmed by IHC of skin biopsy specimen. Keywords Angioimmunoblastic, Immunohistochemistry, Lymphoma, Rash
PR 53 (Yh-A) Primary Extranodal Anaplastic Large Cell Lymphoma (Alcl) of Breast: Misdiagnosed on Biopsy
biopsy for institutional review, reported as squamous cell carcinoma of breast by an out side lab in a 20 year old girl with right breast lump of one month duration. Sections showed diffuse sheets of atypical large cells with focal tubular formations with prominent nucleoli in a background of dense mixed inflammatory cell infiltrate provisionally diagnosed as IDC (triple negative) and submitted for immunohistochemistry which showed diffuse cytoplasmic positivity for vimentin and Leukocyte Common Antigen in tumor cells, Cytokeratin, GCDFP-15, CD 3 and CD 20 negative, EMA and ALK positive in tumour cells. A final diagnosis of ‘Primary extranodal ALCL (Alk +) Null cell type’ was made. On detailed work-up, no lymph nodes or marrow involvement was found. Discussion: Primary breast lymphomas represent 1.7–2.2 % of all extra nodal lymphomas, B cell type being more common. The histomorphology of cohesive clusters of large cells perhaps misled to a diagnosis of carcinoma in the first instance which is a known diagnostic pitfall. Lesson learnt from the present case is that careful observation of morphology and attention on clinical history is essential to get a clue to the correct diagnosis.
PR 54 Treatment and Outcome of The Primary Central Nervous System Lymphoma (Pcnsl), A Two Year, Single Centre Study Sharat Damodar, Nataraj Ks Narayana Health Backgound: PCNSL, an uncommon form of extra nodal nonHodgkin’s lymphoma (NHL), constitute less than 2 % of primary brain tumors. It occurs in both immune compromised and immune competent hosts. The majority of these tumors are B-cell lymphomas with aggressive histological changes (Diffuse large B cell lymphomas). Chemotherapy and RT (Radiation therapy) together improve tumor response rates and survival. The prognosis for patients with such tumors is poor, the median duration of survival being less than 2 years with conventional therapy and the 5-year survival being less than 5 %. Purpose: To describe the outcome of primary central nervous system lymphoma (PCNSL) cases treated with chemotherapy, with chemotherapy plus cranial radiotherapy (CRT) or chemo with autologus stem cell transplantation (ASCT) Methods: Retrospective anlysis of the PCNSL at department of Haematology, Narayana hrudayalaya, between June 2013 and July 2015. Results: There are eight patients in this study. All are immune competent. Male (5) and female (3) with median age of 48 (range 18 to 66 yrs). All are biopsy proven B cell neoplasms except one which was diagnosed by CSF immunophenotyping. All patients received chemotherapy and 4 were treated with chemotherapy and RT. One case underwent ASCT after chemotherapy. Out of the eight cases three patients died during therapy (one due to progressive disease and two because of treatment toxicity). Remaining five are on follow up (one since 2 years and three since eight months) and one who underwent ASCT is in remission since sixteen months. Survival at 2 years is 62 %.
Agarwal Preeti1, Singh Ajay1, Pahawa Hs2, Singh Saumya2, Goel Madhu Mati1 Kgmu
PR 55
Introduction: Infiltrating ductal carcinoma (IDC) is the most common malignancy in breast, usually diagnosed on Tru-cut biopsy and fine needle aspiration cytology. We present herewith a case of Anaplastic Large Cell Lymphoma (ALCL) of breast initially reported as IDC on tru cut biopsy, confirmed as ALCL on immunohistochemistry. Case We received blocks and slides of breast true cut
Surprising Presentation of B Cell Neoplasm
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Dr. Debajyoti Singha Roy, Dr. Sutapa Halder, Dr. Jayati Chakraborty, Dr. Sudipta Chakraborty Pgimsr Esi Manicktala
Indian J Hematol Blood Transfus A 3 yrs old boy presented with low grade fever and multiple tiny cutaneous nodules all over the body with some ulcerated leisons specially at scalp and face. The boy was suspected to have histiocytosis and was reffered for biopsy. Histopathological examination revealed infiltration of the dermis along with adnexal structures and subcutaneous adipocytes by monotonous population of small round cells without any epidermal involvement, these cells were diffusely and strongly positive for CD45, CD10, CD79a, bcl2, tdt and focally positive for CD20, but absolutely negative for CD3, CD5, CD23, CD68, CD30, CD21, and S-100. Ki67 positivity was very high. It is a case diagnosed as B-cell lymphoblastic lymphoma. During the course of clinical work up the patient expired. This case is being presented due to rarity of its manifestation.
PR 56 Follicular Lymphoma—A Six and A Half Year Study of 36 Cases from A Tertiary Care Institute In Southern India Mary Theresa Sylvia, Debdatta Basu, Rakhee Kar, Sajini Elizabeth Jacob Jipmer, Pondicherry Introduction: Follicular lymphoma (FL) is an indolent chronic lymphoproliferative disorder of B-cells with variable clinical behaviour. It is the second most common subtype of Non-Hodgkin lymphoma in western countries but reported to have a lower incidence in Asia. Need for study Although considered indolent, FL has a variable clinical behaviour and necessitates identification of high-risk cases. The histopathological and immunohistochemical features of FL were studied in details with an idea to identify features which impact prognosis. Materials and Methods: Cases of FL diagnosed in the Department of Pathology of our Institute from January 2009 to June 2015 were included in the study. The clinicopathological parameters including staging, histological details and immunohistochemical markers CD20, CD10, Bcl2 and Ki67 were recorded in all the cases. Results: of the 497 cases of Non-Hodgkin Lymphoma reported during the study period, 36 (7.2 %) cases were follicular lymphoma. The mean age was 50 years with male to female ratio of 3.2:1. Grade 1/2 was seen in 70 % cases. 22 % cases had low grade with high proliferation index (Ki67 [ 40 %). Granulomatous response was seen in two cases. Diffuse large cell lymphoma component was present in four cases. Bone marrow involvement and peripheral blood spill was seen in 12 (37.5 %) and six cases (18.8 %) respectively. 72 % cases were in stage 3 or 4. Conclusion: Incidence of FL was lower in our study than other Indian studies. FL presented in the elderly, with male predominance and disseminated stage. Features of low grade with high proliferation index, granulomatous response, leukemic involvement and transformation to high grade lymphoma are highlighted in the study. Keywords Follicular lymphoma, Granuloma, Grade, High-proliferation-index
PR 57 Correlation of Fluorodeoxyglucose Uptake and TumorProliferating Antigen Ki-67 In Lymphomas—A Tertiary Cancer Care Center Experience Dr. Govind Eriat, Dr. Radheshyam Naik Hcg Hospital Correlation of fluorodeoxyglucose uptake and tumor-proliferating antigen Ki-67 in lymphomas—A Tertiary Cancer Care center
Experience Dr. Badarkhe Girish V. 1, Dr. Govind Eriat 2., Dr. Tausif Devale 3, Dr. Mansi Kanderia 3 Dr. Md. Musheb 4, Dr. Radheshyam Naik 5. Objective: To investigate the correlation between cellular proliferation and the fluorodeoxyglucose (FDG) uptake in positron emission tomography/computed tomography (PET/CT) imaging by comparing 50 cases of different subtypes of lymphoma. Materials and Methods: The data of fifty cases of lymphomas were anlysed retrospectively. Each case was labeled with Ki-67 stain, a marker of cellular proliferation and a PET/CT examination was performed. All lymphoma cases were sorted according to the World Health Organization’s classification, and the International Non-Hodgkin’s Lymphoma Working Formulation was used to differentiate groups of large and small cell non-Hodgkin’s lymphoma. The Ki-67 staining was described as percentage according to the nuclear staining of positive cell. FDG uptake by lesions in PET/CT images was semiquantitatively analyzed to calculate the average standard uptake value. The statistics software was used to calculate the mean and standard deviation of the FDG uptake value of the lymphoma subtypes, the difference between the large and small cell lymphoma group with a Student’s t-test and the correlation between the Ki-67 level and FDG uptake of lesion with a Spearman’s analysis. Results: The FDG uptake value of large cell origin lymphoma was significantly higher than that of small cell origin lymphoma. Conclusions: Ki-67 staining, a reflection of tumor-proliferation activity, was significantly related to the FDG uptake value in lymphoma lesions.
PR 58 Sarcoid Lymphoma Syndrome: A Case Series Dr. Arihant Jain, Dr. Gaurav Prakash, Dr. Pankaj Malhotra, Dr. Alka Khadwal Dr. Ashim Das Pgimer Chandigarh Introduction: The association of sarcoidosis and lymphoproliferative disorders has been previously described in the literature from the geographic regions with higher incidecne of sarcoidosis and lower incidence of tuberculosis. This association is relatively less understood in the populations where tuberculosis is the commonest cause of a granulomatous inflammation more so in patients who have received chemotherapy. The evaluation and management of such patients poses unique diagnostic and therapeutic dilemma. We report 4 such cases and discuss regarding the diagnostic and therapeutic challenges associated with them and possible solutions to the same. Materials and Methods: The hospital records of 4 cases having both lymphoma and sarcoidosis were retrieved. Diagnostic biopsies, FNACs, and radiological investigations of these patients were reviewed and analysed. Results: Out of these 4 patients 2 patients were diagnosed as sarcoidosis preceding lymphoma by 10 years and 1 year respectively. One patient was diagnosed to have sarcoidosis 6 months following the diagnosis of lymphoma while the fourth patient was diagnosed with sarcoidosis and lymphoma simultaneously. Three of these patients had DLBCL subtype of NHL while the fourth patient had Follicular Lymphoma grade I. In three of our cases there was difficulty in assessment of response of lymphoma to chemoimmunotherapy due to FDG avidity of coexistent sarcoidosis lesions on PET-CT scan. All patients were treated with combination chemoimmunotherapy and attained complete remission while residual lesion due to sarcoidosis were treated with corticosteroids. Conclusion: In our patient population coexistence of sarcoidosis with lymphoma is an uncommon occurrence. Yet it poses significant diagnostic difficulty in treatment response assessment due to FDG avidity of both type of lesions. Therefore, prompt pathologic evaluation is mandatory in such cases to characterise such residual lesions.
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Indian J Hematol Blood Transfus PR 59 Cutaneous Anaplastic Large Cell Lymphoma: Primary Vs. Systemic–Report of Three Cases Dr. Namrata P Awasthi, Dr. Pradyumn Singh, Dr. Kiran Preet Malhotra, Prof Nuzhat Husain Dr. Ram Manohar Lohia Institute of Medical Sciences Introduction: Primary cutaneous ALCL (C–ALCL) are rare lymphomas and account for 9 % of all cutaneous T-cell lymphomas. Systemic Anaplastic large cell lymphoma (S-ALCL) are relatively common, frequently have cutaneous involvement and comprise of 2 % to 3 % of all NHLs. Case report of three cases Case 1 & 2: A 60 yr old female& 5 yr old boy presented with nodular lesions on thigh and chest wall respectively for 4–6 months. Investigative workup did not reveal systemic involvement in both. Histopathology (HP) from skin biopsy of both showed diffuse infiltration of dermis by large anaplastic lymphoid cells. No epidermal component was seen. Immunohistochemistry (IHC) revealed a CD30 + ALK 1-tumor consistent with C-ALCL. Case 3: : 10 yr old boy presented with fever, multiple nodular lesions with multiple cervical lymph nodes. HP of skin and lymph node showed infiltration by large anaplastic lymphoid cells. Bone marrow was not involved. IHC revealed CD30 + ALK 1 + tumor consistent with S-ALCL. Need for this presentation—Two cases of C-ALCL and one S-ALCL presenting as cutaneous nodules are described. C-ALCL is an uncommon cutanoeus lymphoma and only sporadically reported in children. It should be correctly identified and differentiated from S-ALCL because of its better prognosis. Complete investigative workup including HP, IHC and radiological tests are required for a conclusive diagnosis. Pathologists must be aware of the immunophenotype of these two similar tumors to make the correct diagnosis. Conclusion: Although the nomenclature of these two entities appear similar, they are biologically distinct neoplasms with different behavior and must be
identified correctly. Occurrence of C-ALCL in young children is sporadic.
PR 60 What Not To Miss In A Disseminated Lymphoma: A Synchronous Presentation of Aitl With Carcinoma Gaurav Prakash, Pankaj Malhotra, Alka Khadwal, Pranab Dey, Vani Bharani Pgimer Introduction: Extranodal involvement is quite common in some NHL’s. However, the extranodal disease should be evaluated thoroughly when the presentation is atypical. We report a case of Angioimmunoblastic T cell lymphoma (AITL) who presented with lung mass suspected to be due to lymphomatous involvement, but turned out to be a synchronous presentation of an adenocarcinoma. Case report An elderly gentleman presented with progressive dyspnea. Examination revealed generalized lymphadenopathy with hepatosplenomegaly, pleural effusion, ascites and pedal edema. He was evaluated and diagnosed with AITL Ann-Arbor stage IVBE. His CXR showed infiltrate in the right upper lobe and CT revealed a mass with speculated margins. In view of significant smoking history a FNAC was done from the lung mass which revealed adenocarcinoma. Malignant cytology of the pleural fluid was negative. In view of poor PS, he received prophase steroids and symptomatically improved. Discussion There are numerous reports of so occurrence of AITL with another hematological malignancy. But a detailed literature search of MEDLINE and EMBASE revealed only 8 cases of co occurrence of AITL with an carcinoma (Table 1). Ours is the first report of synchronous presentation of adenocarcinoma of the lung with AITL. This synchronous presentation may be due to impairment in T cell function due to AITL and the field cancerisation effect of tobacco.
Table 1 shows the reported cases of AITL with an carcinoma No Age/ Sex
Year Initial diagnosis
Treatment
Second diagnosis
Treatment
Time to Survival diagnosis
1
52/M 1978 AITL
CVP
Adenocarcinoma Pancreas
Excision
3 months
4 months
2
78/F
MOPP
Bronchio alveolar carcinoma
NA
18 months
Diagnosed on autopsy
3
70/M 1984 Squamous Cell Carcinoma Lung
Refused AITL treatment
Refused treatment
11 months
Was alive at 48 months
4
NA
NA
Adenocarcinoma stomach with liver Mets
NA
Synchronous 12 months
5
66/M 1988 AITL
PTC-VCRP
Adenocarcinoma Colon
Excision
108 months
6
64/M 1997 AITL
Nil
Squamous Cell Carcinoma Tonsil
Excision + Radiotherapy 84 months
7
79/F
2012 AITL
Excision
Adenocarcinoma Colon
NA
8
60/M 2014 AITL
ongoing
Adenocarcinoma lung
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1983 AITL
1986 AITL
Alive at 22 months Alive at 12 months
Synchronous NA Synchronous Ongoing therapy
Indian J Hematol Blood Transfus Conclusion: We present the first repot of synchronous presentation of AITL with adenocarcinoma of the lung.
PR 63
PR 61
Mili Jain, Rashmi Kushwaha, U.S. Singh, Ak Tripathi, Ashutosh Kumar
Tcr Gamma Delta-T-Lymphoma Presenting As Large Granular Lymphocytosis Dr. Man Updesh Singh Sachdeva, Dr. Pulkit Rastogi, Dr. Jasmina Ahluwalia Pgimer, Chandigarh TCR gamma delta-T-lymphoma presenting as large granular lymphocytosis—a case report Authers: Swathi Jogunoori, Man Updesh Singh Sachdeva, Pulkit Rastogi, Jasmina Ahluwalia Department of Haematology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Introduction: Hepatospenic T-cell lymphoma is a rare extranodal and systemic neoplasm, of young adults derived from cytotoxic T-cells usually gamma delta T-cell type. They usually presents acutely with marked splenomegaly and pancytopenia. We present a rare variant of this neoplasm who initially presented with large granular lymphocytosis and a benign course. Case summary: A 70-yr-old male presented with easy fatigability, abdominal discomfort for two months along with altered sensorium for one week. There was no hepatosplenomegaly or lymphadenopathy. Hemogram showed anemia (Hb-4.9 gm/dl), normal platelet count (225X109/L) and leucocytosis (14X109/L). Peripheral smear show 82 % lymphocytes which were morphologically of large granular type. Bone marrow aspirate was hypercellular with adequate number of megakaryocytes. It showed approximately 50 % large granular lymphocytes. Flow cytometric immunophenotyping of these cells showed CD2, CD3, CD7 and TCR positivity. Bone marrow trephine biopsy showed markedly hypercellular marrow spaces with an interstitial excess of mature appearing lymphocytes. An occasional nodular aggregates of the similar cells was also seen. There was increase in fine reticulin fibrosis. On immunohistochemistry (IHC), the cells showed CD3 positivity with an intra-sinusoidal pattern. The characteristic immunophenotype and intrasinusoidal pattern was consistent with the diagnosis of hepatosplenic T-cell non-Hodgkin lymphoma. Need of presenting the case and conclusion: The present case highlights a rare presentation of gamma-delta T-cell lymphoma as a long standing anemia and large granular lymphocytosis mimicking a benign process. Clinching the correct diagnosis by flow cytometry and IHC has helped in proper further management of this aggressive neoplasm. Keywords Hepatospenic T-cell lymphoma, Large granular lymphocytosis, Immunohistochemistry
PR 62 Central Nervous System Involvement In Hodgkin’S Lymphoma In A Patient With Aids Dr. Sharat Damodar, Dr. K. S. Natraj Narayana Hospital, Bangalore Hodgkin’s lymphoma (HL) involving the central nervous system (CNS) is extremely rare. Involvement of the brain by HL can be primary or, more frequently, secondary to the compromise of adjacent lymph nodes. We report a clinical course of a patient with advanced AIDS/HIV-1 disease who developed CLASSICAL HODGKIN LYMPHOMA complicated by CNS involvement with intracranial relapse.
Pure Red Cell Aplasia In Cd5 Negative Chronic Lymphoprolifertive Disorder—A Case Report (Yh-A)
Lucknow Introduction: Pure red cell aplasia (PRCA) acquired in association with Non-Hodgkin’s lymphoma is a rare entity. Case Presentation: We report a case of a 32-year-old female with complaints of lymphadenopathy, splenomegaly and B symptoms for 5 months. Peripheral Blood Smear revealed anaemia with raised white cells (WBC) count with small to medium sized abnormal lymphoid cells. The cells were positive for CD19, CD20, Kappa and negative for CD5, CD23, CD10. The patient was treated with prednisolone and chlorambucil; her lymph node, spleen size along with WBC count were improved however there was persistent decline in haemoglobin. The patient required repeated blood transfusions. Other Cause of anaemia including of autoimmune haemolysis were ruled out. Serology for viral markers HIV, HBsAg, HCV, and Parvovirus were negative. A repeat bone marrow examination revealed absolute reduction in erythroid precursor (\1 %). Patient was treated with anabolic steroid with the diagnosis of Pure Red Cell Aplasia. Patient anaemia responded well and patient is under follow up. Discussion: PRCA is a form of autoimmune cytopenia and recommendation for diagnosis in chronic lymphocytic leukemia associated PRCA includes severe normocytic normochromic anemia with reticulocytopenia and B1 % erythroid precursors in the marrow. Also required is DAT negativity, absence of other features of hemolysis (normal haptoglobin, unconjugated bilirubin, LDH) and no parvo-B19 infection by PCR assay. Conclusion: Anemia in lymphoproliferative disorders may have several etiological mechanisms and such patients should be worked up for red cell aplasia after excluding therapy related anemia, and autoimmune hemolysis.
PR 64 A Detailed Illustration of Diagnostic Difficulties, Clinicopathologal Features and Treatment Success of Rare Tumor Subcutaneous Panniculitis Like T Cell Lymphoma Dr. K. Pradeep Kumar Reddy, Dr. Karthik Udupa, Dr. Joseph Thomas, Dr. Kanthilatha Pai Kasturba Medical College, Manipal Abstract: Subcutaneous panniculitis like t cell lymphoma is a rare and poorly characterised variant of primary cutaneous t cell lymphoma. Main obstacle in understanding this disease is in its infrequency. It represents less than 1 % of all the non hodgkins lymphoma. Its diagnosis is difficult and all the case reports till date demonstrates difficulty in making an unequivocal diagnosis of sptcl. It typically present with subcutaneous nodules or plaques predominantly affecting the extremities which may mimic more common conditiions like benign panniculitis, cellulitis, dermatitis, lupus panniculitis.clinical features may include the nonspecific symptoms like fever, chills, easy fatigability and weight loss. Furthermore it is primarily localised to subcutaneous tissue without involvement of palpable lymph node. Because of its rarity and unawareness among the clinicians and pathologists it is difficult to diagnose and lacks standard treatment protocol. Here we report a case of 19 year old female who was diagnosed to have spltc which describes the full course of the disease, from initial presentation and multiple misdiagnosis to correct recognition and successful treatment.
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Indian J Hematol Blood Transfus PR 65 Testicular Lymphoma with Bilateral Adrenal Metastasis Dr. P. S. Ghalaut, Dr. Sudhir Kumar, Dr. Ashima Mittal, Dr. Arvind Chahal, Dr. Naresh Gaur Pt. B. D. Sharma Pgims Rohtak Introduction: Primary testicular lymphoma constitutes only 1–7 % of all testicular neoplasms and less than 1 % of all non Hodgkin lymphoma. It primarily affects older men. About 80–90 % of PTLs are diffuse large B-cell lymphoma. Most patients present with unilateral testicular swelling, bilateral involvement seen in around 35 % patients CASE HISTORY We report a case of 70-year-old man without any past medical history, presenting with painless bilateral testicular swelling (right [ left) noticed 4 months back. Scrotal ultrasound showed multiple hypoechoic masses involving both testis. MDCT of abdomen showed hypodense soft tissue density mass seen in relation to right suprarenal region and similar smaller sized lesion in left suprarenal region with bulky pancreas. Histopathological examination of right suprarenal mass showed small malignant round cell tumour. Immunohistochemical study showed positivity of CD45, CD20. Ki-67 labelling index was 60 %. PET scan showed FDG avid lesion arising from right adrenal, left adrenal, both testis and pancreas. Blood investigations were unremarkable. Bone marrow aspiration showed no evidence of infiltration by lymphoma. The diagnosis of stage IV primary testicular diffuse large B-cell lymphoma with metastasis to bilateral adrenals and pancreas was made. The patient is now treated by chemotherapy with Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (RCHOP). Plan is to give 6 cycles of R-CHOP followed by bilateral scrotal radiotherapy. Conclusion: In patients above 50 years age presenting with scrotal swelling one should suspect testicular lymphoma. These patients should be investigated initially with scrotal ultrasound followed by CT of the abdomen, pelvis, thorax and neck to rule out metastasis.
PR 66 Primary Bone Marrow B Cell Lymphoma: Correlation of Results of Flow Cytometry and Morphological Findings Shalini Shah, Nisha Marwah, Megha Kathuria, Sonia Chhabra, Rajeev Sen Pgims, University of Health Sciences, Rohtak Introduction: Primary isolated bone marrow disease as presenting feature of Non Hodgkins lymphoma is very rare. The unusual hematologic manifestations in the peripheral blood lead to consideration of alternative hematologic diagnosis. Immunophenotyping by flow cytometry as an auxiliary method and in correlation with morphological findings can make the diagnosis of B-cell lymphomas faster and more specific. We describe a patient who was initially diagnosed as acute leukemia on the basis of morphology. Case Presentation A 58 years female presented with fever, generalized weakness, breathlessness and headache. Physical examination showed no lymphadenopathy and hepatosplenomegaly. Peripheral smear revealed pancytopenia with increased rouleux formation and presence of atypical cells. A provisional diagnosis of acute leukemia was made, bone marrow aspiration, trephine biopsy and flow cytometry was performed. Results: CBC showed Hb 6.1 gm %, TLC 1.8 9 106/ll, platelets 2.0 9 106/ll; DLC N30L26M04 and atypical lymphoid cells 40 %. Flowcytometric evaluation on peripheral blood showed Lambda restriction on CD19 positive cells along with positivity for CD20, CD200, CD79b, CD38. Absence of lymphocytosis in the
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diagnostic range for CLL and negative CD5, CD23 ruled out CLL while bright CD45 and negative CD34, Tdt ruled out acute leukemia. Diagnosis of B-NHL was made on flow. Bone marrow biopsy confirmed diagnosis of B-NHL. Discussion & Conclusion: NHL should be considered in the differential diagnosis of unusual hematologic presentations as in our case, particularly in the elderly. The main advantage of flow cytometry is a synchronous application of two or more antibodies marked with various fluorochromes in one sample.
PR 67 Is It Transformation Or Antigenic Aberracy: A Diagnostic Dilemma of A Mature T-Cell Lymphoma Dr. Faiq Ahmed, Dr. Sudha S Murthy, Dr. K Suseela, Dr. Manasi C Mundada, Dr. Rachna Khera Basavatarkam Indo American Cancer Hospital & Research Institute Department of Laboratory Medicine, Department of Medical Oncology, BIACH& RI. Introduction: Mature T cell lymphoma are a hetergenous group of malignant lymphoid neoplasm with aggressive clinical course and poor prognosis. We present a case of Lennert’s lymphoma a variant of Peripheral T cell lymphoma (PTCL), 3 years later post treatment presented with relapse, but with a histologic transformation to Anaplastic large cell lymphoma (ALCL). Need for Study: We discuss the diagnostic dilemma and specified evidence to support morphologic and immunophenotypic diagnosis in the case which presented as PTCL and relapsed as ALCL. Materials and Method: The case retrieved from file of BIACH&RI, was a 31 year old female who presented with a history of fatigue, weight loss and lymphadenopathy. Excision biopsy at first presentation was reported as PTCL, Lennert’s variant. Followup PET CT 3 years later post bone marrow transplantation revealed multiple active lymph nodes both axilla, bilateral neck, mediastinum and abdomen. Excision biopsy & IHC panel of markers CD 3, CD 20, CD 5, LCA, CD 30, CD 15, Ki 67, ALK 1, EBER by RISH rendered a diagnosis of ALCL. Results: During initial presentation the morphology characterised by intimately admixed lymphoepitheloid cells showing CD3, CD5 positivity and CD30 negativity. However the biopsy at relapse showed diffuse lymphoid proliferation with diffuse CD30 positivity and occasional hallmark cells characteristic of ALCL. Conclusion: CD 30 expression can be seen in peripheral T cell lymphoma, however expression is usually not diffuse. Transformation is well known from low grade to high grade in lymphomas, but morphologic and phenotypic shift is rarely described in high grade T cell lymphomas.
PR 68 Adult T Cell Leukemia/Lymphoma (Atll): An Unusual Morphology Dr. Sindhura Lakshmi Koulmane Laxminarayana, Dr. Chethan Manohar, Dr. Ranjani Kudva, Dr. Karthik Udupa Kmc-Manipal Adult T cell leukemia/lymphoma (ATLL): An Unusual Morphology. Sindhura Lakshmi Koulmane Laxminarayana1, Chethan Manohar1, Ranjani Kudva1, Karthik Udupa2, Surekha Yeresime 1 Department of Pathology1, Department of Medical Oncology2, Kasturba Medical College, Manipal, Manipal University. Introduction: Adult T cell leukemia/lymphoma (ATLL) is a rare peripheral T cell neoplasm seen in adults in regions where human leukemia virus type 1 (HTLV-1) infection is endemic. In India only six cases of ATLL have been reported so far. We present a rare case of ATLL with HTLV infection
Indian J Hematol Blood Transfus in an adult female. Materials and Methods: A 28 year old female presented with fever, loss of weight, erythematous skin lesions, cervical lymphadenopathy and massive splenomegaly. Total leukocyte count was 403,000/cmm with low normal levels of serum calcium and markedly elevated lactate dehydrogenase levels. Peripheral blood and bone marrow examination showed abnormal cells which were small round cells with scant cytoplasm, round nuclei and open chromatin with inconspicuous nucleoli. Flow cytometry revealed that the abnormal cells were positive for membrane and cytoplasmic CD3, CD4 and CD5, TCR-ab, but negative for CD34, CD8 and CD7. Skin biopsy showed lymphoma infiltration. HTLV-1 serology was positive. Hence, the patient was diagnosed as ATLL. Discussion: Typically ATLL shows pleomorphic medium to large sized cells irregular nuclei admixed with cerebriform giant cells. Rare cases may have small lymphoid cells with irregular nuclear contours. Our patient had cells with bland morphology raising a suspicion of chronic lymphoproliferative disorder. Morphology and immunophenotype of ATLL may overlap between T-prolymphocytic leukemia and Sezary syndrome, but HTLV-1 positivity clinches the diagnosis. Conclusion: This case indicates that ATLL with HTLV-1 can occur in nonendemic regions like India and may not always show typical morphology. Keywords Adult T cell leukemia/lymphoma, Human leukemia virus type 1
PR 69 Synchronous T-Non-Hodgkin Lymphoma and Chronic Myelogenous Leukemia In A Patient—A Diagnostic Conundrum Pulkit Rastogi, Nidhi Jain, Reena Das, Rajender Kumar Bashar, Amanjit Bal Pgimer Introduction: Chronic myelogenous leukemia (CML) results from somatic mutation in the haematopoietic stem cells leading to clonal expansion and proliferation of granulocytic and megakaryocytic series. Infrequently, CML can present with extramedullary blast crisis involving lymph nodes, skin and soft tissue, and nervous system. Synchronous occurrence of Non-Hodgkin lymphoma with CML is very rare and it posses diagnostic challenge by mimicking extramedullary blast crisis. Case presentation: A 66-year-old male presented with an isolated left cervical swelling of 1-month duration. On clinical examination, there was generalized lymphadenopathy, hepatomegaly and only splenic tip was palpable. Biopsy from the cervical lymph node revealed Peripheral T-cell lymphoma, NOS (CD3, CD45 positive & CD20, CD30, CD34, ALK-1 negative) along with myeloperoxidase positive cells within sinusoids and infiltrating nodal capsule. PET-CT showed multiple FDG-avid lymph nodes on both sides of the diaphragm and diffusely FDG-avid bone marrow. Hemogram showed leukocytosis (28.5X109/L) and thrombocytosis (1351X109/L) along with 4 % blasts and basophilia. Bone marrow examination was consistent with CML-chronic phase which was confirmed by RT-PCR for bcr-abl transcript. The patient was started on imatinib as well as given 6 cycles of cyclophosphamide, vincristine and prednisolone. Currently the patient is in complete remission for both for last four months. Need for Presenting Case and Conclusion: This case highlights the diagnostic challenge posed by synchronous malignancies which in present case mimicked extramedullary blast crisis of CML. It is thus imperative to make the distinction between the two as the treatment modalities and prognosis are different for each of them. Keywords Chronic myelogenous leukemia, Extramedullary blast crisis, Non-Hodgkin lymphoma, Synchronous malignancy
Topic: Miscellaneous PR 70 Sickle Cell Anemia With Dengue-A Rare Co-Existence Dr. Tejaswini Waghmare, Dr. Daksha Prabhat Seth Gs Medical College and Kem Hospital, Mumbai SICKLE CELL ANEMIA WITH DENGUE –A RARE CO-EXISTENCE Dr. Asthana Ankita, Dr. Waghmare Tejaswini, Dr. Prabhat Daksha Department of Pathology, Seth G.S.Medical College and KEM Hospital, Mumbai, India. Introduction: Dengue associated with sickle cell disease (SCD) is rare and can be fatal if the necessary changes in the management strategies are not applied. We present here a known case of sickle cell anemia (SCA) who was diagnosed with Dengue NS1 + after atypical lymphocytes were detected on peripheral blood smear (PBS). Materials and Methods: Complete blood count (CBC) with detailed peripheral smear study was done and correlated with detailed clinical findings obtained from medical records. Results: 19 year old male presented with fever with chills, yellow discoloration of urine and sclera and abdominal distension. Examination revealed pallor, icterus and mild splenomegaly. He was a diagnosed case of sickle cell anemia since the age of 8 years and on hydroxyurea therapy. Haemoglobin electrophoresis (2005) revealed an HbS level of 63.9 %. CBC revealed pancytopenia with lymphocytic predominance; PBS showed atypical lymphocytes and sickle cells. Serology revealed positivity for NS1 antigen. Patient was treated with antipyretics and intravenous normal saline. Conclusion: The fatality associated with a case of dengue with SCA makes it essential to detect atypical lymphocytes on PBS followed by confirmation using serology. Keywords Dengue, Sickle cell disease, Atypical lymphocytes
PR 71 Incidence of Syndrome of Inappropriate Anti-Diuretic Hormone Secretion (Siadh) In Hematolymphoid Cancer Patients Dr. Preeti Chavan, Dr. Vivek Bhat, Pratik Poladia, Ashwadeep Karmore, Umakant Gavhane Actrec, Tata Memorial Centre Introduction: Hyponatremia is a common electrolyte disorder in cancer and the Syndrome of Inappropriate Secretion of Anti-Diuretic Hormone (SIADH) accounts for approximately 30–33 % of all cases of hyponatremia. Other risk factors for hyponatremia include chemotherapy, treatment-induced nausea and vomiting, hydration, pain, narcotic drugs, and physical and emotional stress. In this retrospective analysis we assessed hyponatremic cases in hematolymphoid malignancy for incidence of SIADH. Methods: We analysed 50 hematolymphoid cancer patients (43 M, 7F; 4 paediatric and 46 adult) who were investigated for hyponatremia over a period of three years retrospectively. Serum electrolyte levels including serum calcium and magnesium were measured daily during their stay in the hospital as per institutional protocol. Hyponatremia was defined as serum sodium level\136 mmol/l. In hyponatremics, further serum and urine osmolality investigations were also carried out. Results: SIADH was the cause of hyponatremia in 66 % (33/50) patients studied. Incidence of SIADH was 65 % (28/43) in males, 71 % (5/7) in females, 25 % (1/4) in paediatric and 70 % (32/46) in adults respectively. Incidence of SIADH was 67 % (14/21) in Non-Hodgkin’s lymphoma, 71 % (5/7) in Hodgkin’s lymphoma, 75 % (6/8) in
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Indian J Hematol Blood Transfus acute myloid leukemia, 83 % (5/6) in acute lymphoblastic leukemia, 25 % (1/4) in chronic myloid leukemia. Concomitant hypocalcaemia & hypomagnesaemia was observed in all cases of SIADH. Conclusion: Incidence of SIADH was higher in our patients compared to published studies. However, no significant bias was observed in male versus female, pediatric versus adult age group, or the primary diseases. Keywords Hyponatremia, SIADH, Hematolymphoid, Osmolality
PR 72 Flow Cytometry on Bone Marrow Trephine Biopsy-Wash Is An Effective Technique For Immunophenotyping of Leukemia/ Lymphoma In Cases of Dry Tap Dr. Man Updesh Singh Sachdeva, Dr. B. K. Karthik Bommannan, Mrs. Praveen Bose, Mrs. Minakshi Gupta, Prof. Neelam Varma Postgraduate Institute of Medical Education and Research, Chandigarh Introduction: Evaluation of hematologic disorders involves a battery of investigations on bone marrow (BM) samples. BM aspiration (BMA) procedure may not always yield adequate material, and hence ‘‘dry tap’’ is not rare in neoplastic diseases. Literature reveals a dry tap frequency of 4 % (range, 1.6–6.8 %). Techniques to dislodge hematopoietic cells from unfixed trephine biopsy specimens are a few. We describe the diagnostic utility of vortex-dislodged cell preparation obtained from unfixed trephine biopsy specimens. Materials and Methods: Under consent, in cases with dry tap, the routine diagnostic BMA & trephine biopsies were complemented with additional trephine biopsy. This supplementary core was immediately transferred into sterile tube containing phosphate buffered saline, vortexed and centrifuged. The cell pellet obtained was subjected to routine flowcytometric immunophenotyping. Results: Of 7955 BMAs done in 42 months, trephine wash (TW) samples were available in 34 dry tap cases. TW-FCM rendered a complete immunophenotypic diagnosis in (32 of 34) 94 % of patients. Conclusion: Trephine wash immunophenotyping is efficient procedure which could be effectively utilized in leukemia/lymphoma patients with ‘‘dry tap’’ and absent/ low neoplastic cells in peripheral blood. Keywords Trephine wash, Dry tap, Flow cytometry
PR 73 Pain Perception During A Bone Marrow Aspiration and Biopsy Navreet Kaur, Inderjit Singh, Sohan Singh, Richa William, Sangeetha Samuel Christian Medical College & Hospital Introduction: Little is known about the perception and determinants of pain during a bone marrow aspiration and biopsy (BMAB). Material & Methods: We conducted a prospective analysis of 70 consecutive patients who underwent BMAB at our centre. An informed consent was taken prior to each procedure. All BMABs were obtained keeping the patient in lateral position from the posterior superior iliac spine. They received local anesthesia with subcutaneous and periosteal infiltration of 5 ml of 2 % lidocaine hydrochloride followed by a 5-minute wait time. A further 2–3 ml was needed based on the provider’s assessment. Additionally, a 50 mg tramadol infusion would be on flow during the procedure. The biopsies were performed by consultants ([100 BMBAs) or under their direct supervision by physician assistant ([100 BMBAs) or resident trainees ([10 BMBAs). Jamshidi needles of 11/13G were
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used for the procedure. Pain was rated by the patient on a 0–10 Numeric Pain Scale (Mosby). Results: The median age of the participants was 53 (5–88) years. The majority (43) were males (61.4 %). On a 0 to 10 scale, the median pain level among the 70 patients was 3.0 (1–8). Patients doing the procedure for the first time, those elder ([20) and males had a median pain score of 2. Rate of complications was low (2.6 %). The median pain score when done by the consultant was 2.5 (2–8) and 3 (1–8) when done by other providers. Conclusions: BMAB evokes feeling of intensive fear among patients1. However we found that the level of pain experienced is generally modest and was similar regardless of the provider. Patients who were male, fasting and undergoing the procedure for the first time experienced lesser pain. References 1. Talamo, Giampaolo, et al. ‘‘Perceived levels of pain associated with bone marrow aspirates and biopsies.’’ The journal of supportive oncology 10.4 (2012): 166–170.
PR 74 Association of Endothelial Nitric Oxide Synthase (Enos) Gene Polymorphism (G894T) In Diabetes Mellitus (Type 2) Satendra Sharma, Rajnish Awasthi, Mrinalini Kotru University College of Medical Sciences and Guru Teg Bahadur Hospital Introduction: Apart from various environmental factors some genetic polymorphisms also play an important role in pathogenesis of type 2 diabetes mellitus (T2DM). eNOS catalyzes production of nitric oxide (NO) which modulates glucose metabolism and insulin secretion. A functional G894T polymorphism in the eNOS gene affects its activity thereby decreasing the production of NO. Need for study: Elucidating the association of eNOS gene polymorphism in patients of T2DM may help in early intervention and treatment of the disease. Materials and Methods: This study comprised of 50 cases and 50 controls. Venous blood samples were collected for DNA extraction by phenol-choroform extraction method followed by mutation analysis by Polymerase Chain Reaction (PCR). The amplified products were digested with restriction enzymes to find out the eNOS G/T polymorphism. Results: Among cases fasting blood sugar (FBS) was 152 ± 16 mg/dl and postprandial blood sugar (PP-BS) was 244 ± 31 mg/dl. While in healthy controls FBS was 75 ± 8 mg/dl and PP-BS was 126 ± 8 mg/dl. Frequency of heterozygous GT genotype was significantly higher in cases (62 %) as compared to controls (18 %). Frequency of G and T allele among the two study groups was significant. A positive association was found between blood sugar parameters and mutant phenotypes carrying T allele. Conclusions: A positive association between blood sugar parameters and mutant phenotypes carrying T allele may indicate that eNOS polymorphism G894T has a role in development of T2DM and insulin resistance. Keywords Type 2 diabetes mellitus (T2DM), Endothelial nitric oxide synthase (enos), G894T polymorphism
PR 75 Normal Ranges of Advanced Clinical Parameters (Acp) On The Cbc Analyser Sysmex Xn-2000 Dr. Sushant Vinarkar, Dr. Kunal Sehgal, D. Rabhishek Dashora, Dr. Preeti Mansukhani, Dr. Shanaz Khodaiji P.D Hinduja National Hospital and Research Centre Introduction: Since the advent of automation in hematological cell counters there has been a constant refinement of technology and
Indian J Hematol Blood Transfus increase in the number of parameters available on CBC analysers. Many novel parameters are being put into routine clinical use. Clinical evaluation critically depends on knowledge of laboratory reference ranges for these parameters. Materials and Methods: 62 samples of healthy individuals for routine health check-ups were taken for the study. CBC and advanced clinical parameters were evaluated on the Sysmex XN-2000 analyser. The sample size selected was for transference of reference ranges from the existing Sysmex XE-2100 analyser to the new analyser Sysmex XN-2000. Results: Normal reference intervals for the novel research parameters were evaluated and compared with data from our previous analyzer XE2100 and the published literature. The reference intervals derived from our study on XN-2000 were in concordance with those published in literature. Conclusion: The advanced clinical parameters available on XN-2000 were assessed and reference intervals for the same were calculated. This study was performed for validation of previous reference intervals established by us on the XE-2100 hematology analyser. Keywords XN-2000, Novel parameters, Reference intervals, Normal ranges
examination-Vitals: Hypertension (160/110 mmHg) Rest NAD. Investigations: Hyponatremia (Na + : 116 mEq/L). On gastroscopy proximal severe gastritis was detected. There was no improvement so Acute porphyria was suspected and the urine test for porphobilinogen was advised which came out positive by Watson Schwartz Test. Results: Pink rose colour to the aqueous phase at the bottom consistent with presence of porphobilinogen. Conclusion: Acute intermittent porphyria has signs and symptoms common to various neurological, psychiatric and gastrointestinal disorders, which complicate diagnosis. In such cases a simple urine test for porphobilinogen can give early diagnosis. Majority of patients with acute porphyria excrete large amount of porphobilinogen throughout the course of disease thus false negative results occur less frequently. Keywords Acute intermittent porphyria, Watson Schwartz test
PR 78 Hypoplastic Marrow With Assosiated Serous Atrophy—A Rare Finding Dr. Ruchee Khanna, Dr. Chethan Manohar
PR 76
Kmc Manipal
Evaluation of The Prbc Flag on The Sysmex Xn Analyzer
Introduction: Serous atrophy in bone marrow is a rare finding, characterized by fat cell atrophy, focal loss of hematopoietic cells, deposition of extracellular gelatinous substance. It can be associated with cancer related cachexia, end stage renal disease, myxedema, anorexia nervosa and infections. Case report: We present a case of 8 year old male patient with bilateral knee joint pain since 1 year. On peripheral blood examination dimorphic anaemia with reduced reticulocyte, low normal WBC count and thrombocytopenia was noticed. Bone marrow aspirate was dilute for opinion. Bone marrow biopsy from both the sides showed hypoplastic marrow with marrow spaces showing fat, pinkish amorphous material and few preserved cellular clusters comprising of lymphoid cell and plasma cells. Erythropoiesis and myelopoiesis was suppressed. Megakaryocytes were reduced in number. Fat cells were also reduced in size and number. With Acian Blue stain on bone marrow biopsy pinkish amorphous background was seen at pH of 2.5 Conclusion: The diagnosis of hypoplastic marrow with associated serous atrophy was made.
Shanaz Khodaiji, Kunal Sehgal, Dia Mansukhani, Monisha Sethi P.D Hinduja National Hospital and Research Centre Introduction: Gaps between reported and true incidence of malaria occur due to inadequate surveillance and under-reporting of malaria cases. The aim of this study was: To determine sensitivity and specificity of the malaria detection flagging algorithm (pRBC?) compared to microscopic and immuno-chromatographic methods (RDT). To examine factors interfering with malaria detection. Materials and Methods: Samples collected in K2-EDTA vaccutainers were run in CBC + DIFF + RETIC mode on XN-1000 and XN-L Sysmex analysers. All samples were tested by microscopy and RDT. Results: A total of 575 samples were screened of which 187 were positive for malaria by microscopy. On XN-1000, 166 were positive while 21 were negative resulting in a sensitivity of 88.8 % and specificity of 100 %. On the XN-L, the sensitivity was 86.1 % and specificity was 100 %. The sensitivity was lower in samples with low infestation rate (\0.1 %) as compared with higher IR ([0.1 %) Conclusion: Malaria is detected in the WDF channel of the Sysmex analysers, based on the principle of fluorescence flow cytometry. This study shows that the pRBC flag is a good screening tool for detection of P.vivax as it can detect malaria along with a CBC, thus shortening the TAT appreciably. Keywords Malaria, Sysmex XN-1000, Sysmex XN-L, pRBC flag
PR 79 C Reactive Protein and Total Leukocyte Count As A Marker For The Screening of Early Sepsis L Raghavendra, Vikas Gaur, Amrita Soni, Shubham Rastogi, Sarman Singh Aiims
PR 77 Early Diagnosis of Acute Porphyria With Simple Urine Test Anjali Kelkar, Sazal Aggrawal, Ravindra Nimbargi, Amit Nisal Bharati Vidyapeeth Deemed University Introduction: Acute intermittent porphyria is an unusual pathology with potentially severe consequences if detection is delayed. A case with gastrointestinal symptoms clinically suspected to be acute intermittent porphyria was diagnosed at our hospital with a simple urine test i.e. Watson Schwartz test for porphobilinogen. Materials and Methods: Case Report: A 19 year old male came with complaints of abdominal pain, nausea and vomiting since one week. On
Sepsis is a major cause of morbidity and mortality worldwide. The diagnosis of sepsis and evaluation of its severity are complicated by the highly variable and non-specific nature of the signs and symptoms of sepsis. Early identification of high-risk patients and timely intervention for sepsis are therefore crucial to improving outcomes. Aim: The present study was aimed at finding out the utility of C reactive protein and total leukocyte count in the screening of sepsis. Materials and Methods: Five hundred and eleven patients were enrolled in the study and after detailed clinical evaluation were distinctively divided into two groups culture positive sepsis (n = 87) and the non sepsis group (n = 434). Blood samples were collected from all patients for various hematological parameters such as hemoglobin, total leukocyte count, differential counts platelet count etc. and for quantitative CRP
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Indian J Hematol Blood Transfus estimation from whole blood simultaneously on microsemi CRP instrument. The results of CRP and total leukocyte count were compared among the two groups and receiver operating curve were drawn to evaluate the diagnostic efficacy of both the parameters collectively in screening of sepsis. Results and Conclusion: The concentration of C reactive protein and total leukocyte count was found to be significantly higher in the sepsis group as compare to the non sepsis group (p value \0.001) the area under the curve for CRP band TLC was 0.85 and 0.95 with a sensitivity of 80 % and 93 %, and we suggest an optimal cutoff range for both the parameters for the screening of patients with early sepsis. We conclude total leukocyte count along with quantitative C reactive protein together could be a better marker to screen early sepsis or before the culture report is released and may help in early management, thereby reducing morbidity and mortality.
PR 80 Spectrum of Blood and Bone Marrow Infectious Diseases Udayakumar Ds, Tushar Kalonia, Richa Gupta Mamc A retrospective analysis of infectious diseases involving the blood and bone marrow specimens of 3 years was done. Peripheral blood, bone marrow aspirate smears and bone marrow biopsy specimens were included in the study. A total of 123 cases were diagnosed with infectious etiology. The age of the patients varied from 1.5 months to 65 years. A spectrum of infective agents were seen. The most common infections encountered were Malaria and Tuberculosis followed by pure red cell aplasia due to parvovirus, leishmania donovani, histoplasma capsulatum, malaria, microfilaria. An association of HIV infection was seen with Tuberculosis which presented as febrile illness or pancytopenia. Conclusion: A variety of infective agents may be seen in the bone marrow. Tuberculosis remains by far the commonest infective etiology in bone marrow. The patients present with fever and pancytopenia. An association was seen with HIV positivity and tuberculosis.
PR 81 Gaucher Disease In 19 Year Old Female Patient : A Case Report Dr. Sadhana Mahore, Dr. Kalpana Bothale, Dr. Anjali Patrikar, Dr. Hrushikesh Kolhe
Gauchers disease is a important cause of pancytopenia. If early diagnosis is made by bone marrow examination and enzyme study, enzyme replacement therapy can be started and splenectomy can be avoided. Discussion– Patient presented with Pancytopenia with massive splenomegaly. If Early diagnosis is made, enzyme replacement therapy (cerezyme) could be started and further complications of splenectomy can be avoided. Storage disorder is one of the important cause of cytopenia, so there should be a high degree of suspicion while investigating a case of cytopenia.
PR 82 Bacteriological Spectrum of Organisms Isolated from Picc and Peripheral Blood In Bone Marrow Transplant and Haematological Malignancy Patients Dr. V.G. Bhat, Dr. Preeti Chavan, Ms. Nayana Baraskar, Ms. Ulka Gosavi, Mr. Sanjay Pal A.C.T.R.E.C., Tata Memorial Centre, Kharghar Introduction: Peripherally inserted central catheters have been used increasingly in patients who often have decreased intravascular volumes and obtaining intravascular access for resuscitative efforts can be difficult. A potentially serious complication is bloodstream infection. The purpose of this study is to document the microbiological spectrum of PICC and peripheral blood infections in bone marrow transplant (BMT) and haematological malignancy patients. Materials and Methods: Peripheral & PICC Blood cultures collected from patients of hematolymphoid ward and BMT unit over a three year period were included in the study. All blood cultures were processed in the Bactec 9050 automated blood culture system, the organisms identified up to species level and susceptibility tests performed as per CLSI guidelines. Organisms growing in both PICC and peripheral blood were categorised as catheter associated infections. Results A total of 890 blood cultures (PICC-445 and peripheral-445) were processed during the study period. Of these, 29 were PICC positive and 27 were peripheral blood positives. Fourteen cases were positive for both PICC and peripheral blood and were identified as catheter related. The commonest organisms isolated were Klebsiella pneumoniae (13), Coagulase negative Staphylococci—CoNS (10), E. coli (8) and Pseudomonas aeruginosa (6). Conclusion: The common organisms isolated from PICC catheter and peripheral blood in BMT and haematological cancer patients included Klebsiella pneumoniae, CoNS, E. coli & Pseudomonas aeruginosa. Approximately half of these were catheter related infections.
Nkp Salve Institute of Medical Sciences Introduction: Gauchers disease is a lysosomal storage disorder caused due to deficiency of enzyme Glucocerebrosidase with incidence of 1:40000. The main clinical features are organ enlargement (liver and spleen), bone marrow infiltration leading to pancytopenia and skeletal involvement leading to bone pain and pathological fractures. Case—A 19 year old female patient presented with history of weakness and breathlessness along with pain and dragging sensation in abdomen. Clinical diagnosis was pancytopenia with splenomegaly? Cause. On Gross examination spleen was markedly enlarged (4 kg), measuring 30 9 20 9 8 cm, greyish brown in colour and firm consistency. Microscopy reveals expansion of red pulp with dilated sinusoidal spaces filled with macrophages with granular cytoplasm and centrally or eccentrically placed nuclei; suggestive of storage disorder (Gauchers disease). Need for presentation—
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PR 83 An Unusual Cause of Neck Swelling—Unicentric Castleman’S Disease Rudresh Ah, Kc Lakshmaiah, Premalatha Cs, D Loknatha, Linu Jacob Kidwai Memorial Institute of Oncology Introduction: Castleman’s disease, also known as angiofollicular lymph node hyperplasia, is a rare disorder characterized by the benign proliferation of lymphoid tissue. There are two clinical entities have been described; namely, unicentric castleman’s disease with the disease confined to a single anatomic lymph node and a multicentric castleman’s disease characterized by generalized lymphadenopathy,
Indian J Hematol Blood Transfus constitutional symptoms, a more aggressive clinical course and relatively poorer prognosis. The most common histopathological subtype is the hyaline vascular variant. CASE REPORT: We present the case of an 18-year-old girl who presented to us with a painless right-sided neck swelling which was completely excised and diagnosed to have hyaline vascular variant of unicentric castleman’s disease. This disorder carries an excellent prognosis and does not require further therapy if complete excision of the involved lymph node has been done. Conclusion: Unicentric castleman’s disease is a rare cause of unilateral neck swelling albeit with an excellent prognosis. Diagnosis by excision biopsy can double up as the treatment as well in cases of solitary lymph node involvement.
PR 84 Evaluation of Bone Marrow Microvessel Density In Patients With Aplastic Anemia and Its Role In Predicting Outcome To Therapy Abhishek Purohit, Mukul Aggarwal, Prabhu Manivannan, Monica Tiwari, Manoranjan Mahapatra All India Institute of Medical Sciences Introduction: Bone marrow (BM) microenvironment plays a crucial role in the growth of hemopoietic cells. Our study assesses the microvessel density (MVD) in the BM of aplastic anemia (AA). Aim: To assess MVD in patients with AA, to correlate MVD values with severity of AA and response to therapy. Methods: BM from 60 patients including 33 patients with non severe AA (NSAA), 12 with severe AA (SAA) and 15 with very severe AA (VSAA) and 17 controls were studied. MVD was calculated on sections stained immunohistochemically for CD34. Results: The mean BM MVD in AA group was 1.28 ± 0.36, being significantly lower than that in control group (6.80 ± 1.59, P \ 0.001). MVD of SAA and NSAA patients were 1.16 ± 0.35 and 1.49 ± 0.27, respectively, being significantly different (P = 0.003). MVD of VSAA was 0.93 ± 0.25 and the difference with NSAA is significant. Four patients had partial response (PR) while four had complete response (CR) at the end of six months follow up. MVD was significantly higher among responders (mean MVD 1.96 ± 0.16) as against non responders (mean MVD 1.26 ± 0.25). Conclusion: Our study shows that AA is associated with reduced angiogenesis. BM MVD reduces with the severity of the disease. Responders had significantly higher MVD, hence may predict the behavior of the disease. This particular finding was not reported in the earlier studies. This observation advances our knowledge about the role of microenvironment in the pathogenesis of AA and this critical finding may have implications for new concepts relating to therapy and outcome of this disease. Keywords Aplastic anemia, Angiogenesis, CD 34, MVD
PR 85 Bacterial Sepsis In Cancer Patients: Role of Crp and White Cell Count Dr. Preeti Chavan, Dr. Vivek Bhat, Rajani Mohite, Swati Vaykar, Ulka Gosavi Actrec, Tata Memorial Centre Introduction: Bacterial infection is a frequent complication in cancer patients. C-reactive protein (CRP) is used mainly as a marker of inflammation and neutrophilia is an indicator of bacterial infection. In
this retrospective study we have tried to determine the significance of these parameters in predicting bacterial sepsis in cancer patients. Materials and Methods: During a period of 18 months, 488 blood samples (PICC/peripheral blood/Hickman Catheter) were received for suspected infection from hematolymphoid and hematopoietic stem cell transplant (HSCT) units. Serum CRP and Neutrophil values of these samples were estimated as part of routine investigations as per institutional protocol. Statistical evaluation was carried out to assess significance of CRP and neutrophil count in patients with culture positive blood samples. Results: Of 488 blood samples studied, 49 showed bacterial growth. Of these 67 % (33/49) samples showed leucopenia, 33 % (16/49) samples were non-leucopenic. Amongst the leucopenic samples, 79 % (26/33) showed CRP values [5 mg/dl and 31 % (5/16) samples from non-leucopenic cases had CRP value [5 mg/dl (p = 0.0019). In leucopenic cases neutrophilia was observed in 18 % (6/33) cases, while 50 % (8/16) of non-leucopenic cases showed neutrophilia (p = 0.0483) Conclusion: Although Serum CRP levels are a non-specific indicator of inflammation, a value of more than 5 mg/dl is a reliable indicator for suspected bacterial infection in leucopenic patients; however the relationship between the neutrophil counts and clinical sepsis was not clear in our group of patients. Keywords Leucopenia, CRP, Neutrophilia, Bacterial infection
PR 86 Wbc Histogram Pattern Contributes Shubham Rastogi, Aaruni Agarwal, Manuela Pastore, Se´bastien Raimbault, Esther Tournier Horiba Medical Introduction: Monsoon season triggers requests to public hospitals and private clinical laboratories for investigations for unknown origin fever and malaria. We assessed whether flagging generated in WBC histograms in 3-part differential hematology analyser, can help for malaria screening. The parasitic index and correlation with the abnormalities found on the Hematology analyzer were determined. Materials and Methods: Blood samples were collected to investigate for malaria or acute febrile illness (July-November 2014). Malaria positive samples were scored for parasitic index and species per 2000 RBCs on field stained blood smear and processed on Horiba MicrosemiCRP within 6 h of collection. Results: Of the 242 Malaria positive patients, 91 showed L1 flagging on the WBC histogram. A clear & separate peak was observed between 30–100fL region placed on the ascending limb of a small cell peak (Lymphocyte peak). Other commonest abnormal findings were macrocytosis & thrombocytopenia. Conclusion: In 3-part differential hematology counter, quantification of WBCs is carried out by Impedance with the help of dilution of whole blood by a diluent & a lyser. The generated data allow leucocyte classification by cell volume. After lysis of RBCs, bared intracellular malarial parasitic forms generate pulses smaller than the average lymphocytes and plotted as a separate peak in the small-cell region. Other elements such as platelet aggregates & NRBCs have been reported to activate this flag, presence or absence of which can be ruled out on peripheral smear examination. We believe that in future a possibility exists of having a WBC flag for Malaria suspicion as an important screening diagnostic tool by laboratory personnel. Keywords Malaria screening, Malaria flagging, Three part differential, WBC histogram, Microsemi
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Indian J Hematol Blood Transfus PR 87 Infections Occurring In Hematopoietic Stem Cell Transplant Recipients In The First 100 Days Dr. Vivek Bhat, Ms. Reshma Kamble, Mr. Pratik Poladia, Dr. Preeti Chavan, Dr. Shashank Ojha Actrec, Tata Memorial Center, Kharghar Introduction: Hematopoietic stem cell transplantation (HSCT) is a medical procedure performed for patients with certain cancers of the blood or bone marrow. This study was conducted to document the infections occurring in bone marrow transplant recipients, 100 days post transplant. Materials and Methods: All patients undergoing HSCT for period of 1 year were included in the study. All patients suspected of infection in the first 100 days post transplant were investigated microbiologically. Bacteriology samples were cultured as per standard protocol and susceptibility testing performed as per CLSI guidelines. Cytomegalovirus (CMV) DNA quantitation was performed in the Roche Light Cycler 2.0. All other samples were processed as per standard microbiology procedures. Results: A total of 70 patients underwent HSCT, out of which 56 patients documented infections during the study period. Of the 70 transplants 41 were autologous (31 infected) and 29 allogenic (25 infected). Of the specimens that were culture positive, 41 were from stool, 7 from blood, one each from sputum and urine. Two cases of parasitic infection [Giardia lamblia (2) and Cryptosporidium parvum (1) in stool] were reported. Among viral infections there were 21 cases of CMV DNA positives and 3 HBsAg positives. Klebsiella pneumoniae (44), Escherichia coli (33), Enterococci (19) Acinetobacter spp. (4) were among the common bacteria isolated. Three instances of Candida spp were also reported. Conclusion: Bacterial infections followed by CMV infections were more common in the first 100 days of post HSCT recipients. A few fungal and parasitic infections were also noted.
Keywords Sysmex XN-1000 body fluid mode, Flowcytometry, Leucocount
Sample no.
Sysmex XN-1000
Flow cytometry
1
3
3.1
3.2
2
2
1.7
1.8
3
1
1
1
4
1
0.9
1
5
2
1.8
1.5
6
3
3.6
3.2
7
2
1.6
1.8
8
5
5.1
7.1
9
4
3.6
5
10
7
7.3
3.4
11
126
136.2
12
38
41.2
13 14
102 180
15
6
130 40
129 181
125 180
5.5
6.2
16
5
4.9
17
164
165.5
4.8
18
2
0.28
1
19
1
0.56
1.2
20
10
7.8
6
163
y = 0.9795x - 0.0539
y = 1.0507x + 0.1987
PR 88 Evaluation of The Body Fluid Mode On Xn 1000
200
150
Sysmex 100 XN-1000
Flow 100 cytometry
50
50
0
123
0
0
Kokilaben Dhirubhai Ambani Hospital
R2 = 0.9993
200
R2 = 0.9915
150
Chetna Agrawal, Tushar Govekar, Chitrangi Navadkar, Bhavini Chauhan, Pankhi Dutta
Introduction: For years, automated body fluid counts have been limited by their higher limits of low count detection. Sysmex (Japan) has introduced several automated cell counters with body fluid mode (BFM) with lower limits of detection as low as one to two cells. Aims and Objectives: To evaluate BFM on XN-1000 (Sysmex, Japan) for measurement of very low WBC counts vis a vis flowcytometry (FCM) and classical manual methods. Materials and Methods: 20 samples with low cell counts (1–180 cells/ul) were analysed by manual counting method using nageotte/neubauer chamber, Sysmex XN-1000 BFM (based on fluorescence flowcytometry) and FCM method using BD leucocount kit (using propidium iodide to stain nuclei). Precision was checked for both Sysmex XN-1000 (BFM) and (FCM) using multiple control runs. Correlation and regression analysis between the results obtained by the various assays was done. Results: The coefficient of variable (CV %) for the sysmex BFM was 4.23 % while it was 3.58 % for the leucocount kit. The counts obtained by the various methos is given in the table. The correlation coefficient was found to be 0.975 or greater for the BFM versus the manual methods as well as the BFM versus FCM. Conclusion: The Sysmex XN 1000 BFM was found to be accurate and precise in analyzing low WBC counts alongwith a high throughput (analysis within a minute). Other advantages are lack of a sample preparation step, minimal training requirements.
Manual
50
100
150
200
Flow cytometry
0
50
100
150
200
MANUAL
y = 1.0302x + 0.1068 200
R2 = 0.9928
150 Sysmex 100 XN-1000 50 0 0
50
100
150
200
MANUAL
PR 89 Clinicohematological Features of Hemophagocytosis with Emphasis on Hemophagocytic Lymphohistiocytosis—An Experience from A Tertiary Care Centre In South India Rakhee Kar, Bh Srinivas, Sajini Elizabeth Jacob, Debdatta Basu Jipmer, Puducherry Introduction: Hemophagocytosis in bone marrow is a significant finding and is one of the criteria for diagnosis of Hemophagocyticlymphohistiocytosis (HLH). Hemophagocytosis may be seen as a part of HLH or as a non syndromic finding, leading to cytopenias. Need for study—It is a common finding in Bone marrow (BM) done
Indian J Hematol Blood Transfus for evaluation of Pyrexia of unknown origin (PUO) and unexplained cytopenia. Hence this study was undertaken to assess the clinicopathological features of BM hemophagocytosis with emphasis on HLH. Materials and Methods: This was a record–based descriptive study over three and a half years. The clinico-hematological profile of 40 cases with prominent bone marrow hemophagocytosis was studied. Results: Of the total 40 cases showing hemophagocytosis, 26 (17 males and 9 females) satisfied the criteria for HLH. The mean age was 26 years (6 months to 64 years). Splenomegaly was seen in 21 patients. Four cases were associated with tuberculosis, three with concurrent hematolymphoid malignancy in the bone marrow or elsewhere, six with identifiable infections including dengue, Hepatitis A, EBV, Salmonella and Enterobacter sepsis while in rest, the exact underlying etiology could not be found. Serum Ferritin and Triglycerides were elevated in most. In five cases, hemaophagocytosis was also seen in liver and lymph node. There were 14 cases which did not fit into HLH. Ten of these patients had bi/pancytopenia. Two were associated with tuberculosis, one with marrow involvement by DLBCL and one with Enterobacter sepsis. Conclusion: Hemophagocytosis whether syndromic or non-syndromic is an ominous finding with important associations with various conditions, some of which are curable. Keywords Hemophagocytic lymphohistiocytosis, Bone marrow examination, Hemophagocytosis, Pancytopenia
PR 90
Introduction: Clinical decisions depend on biochemical test reports based on reliable reference intervals which are used to describe the dispersion of variables in healthy individuals. Most of the reference intervals provided by various manufacturers for their reagents and methods are based on European or American population (Caucasian) studies. Aim of this study is to establish 95 % reference interval for select biochemical parameters in Indian voluntary blood donors and to correlate it with respect to physiognomic parameters like gender. Materials and Method: A total of 302 Samples (M:250;F:52) from voluntary blood donors were analyzed for Serum Protein, Serum Albumin, Serum Globulin, Serum Immunoglobulin G (Ig G), Immunoglobulin M (IgM) and Immunoglobulin A (IgA) on fully automated biochemistry analyzer–Siemens Dimension-RXL. A 95 % reference interval was calculated as BRI and compared with the ranges in current use. Results: BRI was calculated for Serum Protein, M: 4.18–9.46 g/dL, F: 6.35–9.67 g/dL; Serum Albumin, M: 2.3–5.26 g/dL, F: 3.42–4.95 g/dL; Serum Globulin, M:1.88–4.2 g/dL, F: 2.93–4.72 g/dL; Serum Immunoglobulin G (IgG) M:759–2114 mg/ dL, F: 788–2371 mg/dL; Serum Immunoglobulin A (IgA) M: 33–394 mg/dL, F:119–417 mg/dL; Serum Immunoglobulin M (IgM) M: 15 to 324 mg/dL, F:57–326 mg/dL. Conclusion: Lower range for Serum protein and albumin in male donors was lesser compared to established BRI. Serum globulin and IgG levels in all donors were very high compared to BRI in current use. However, further studies with larger sample size need to be conducted to substantiate the above findings. Keywords Biological reference interval, Hematology, Biochemistry, India
Clinicohematological Profile of Bone Marrow Metastasis Poojan Agarwal, Vijay Kumar, Sadhna Marwah, A. S. Nigam, Gurdeep Buxi
PR 92
Dr. R. M. L Hospital and P. G.I.M.E.R
Importance of Additional Mutation Analysis In Cvs Sample For Prenatal Diagnosis
Introduction: Bone marrow metastasis in case of systemic malignancies occurs only in advanced stages of disease and are a rare primary presentation. A positive report upgrades tumour stage and alters patient management. Materials and Methods: A retrospective study, was carried out in the department of Pathology, PGIMER, Dr. RML Hospital, New Delhi from January 2014 to July 2015. Bone marrows were assessed on account of refractory anemias, thrombocytopenia, bicytopenia, pancytopenia and PUO under evaluation. Aspirates were stained with Geimsa and PAS wherever indicated. Biopsies were stained with H& E and an IHC panel was put up to arrive at a conclusive diagnosis. Results: Out of 800 bone marrow aspirates examined,10 (1.25 %) cases had metastasis. Patient ages ranged from 2–82 years. Clinical presentations varied from fatigue, breathlessness and severe pallor to failure to thrive. Neuroblastomas were the most common to metastatize in children and epithelial malignancies were the most common to metastatize in adults (metastasis from prostate, breast and SCC). Conclusion: Metastatic bone marrow disease is mot a common finding and in all suspected cases, bone marrow examination is necessary along with immunophenotyping for a conclusive diagnosis.
PR 91 Population Based Biological Reference Intervals (Bri) For Selected Blood Biochemical Parameters In The Indian Voluntary Blood Donors Dr. Preeti Chavan, Dr. Vivek Bhat, Dr. Shashank Ojha, Dr. Minal Pujary, Asha Kumari Actrec, Tata Memorial Hospital
Aditi Sen, Maitreyee Bhattacharyya Ihtm, Medical College, Kolkata Introduction: b thalassaemia, a heterozygous genetic disorder of b globiin gene synthesis. It has a range from transfusion dependent to non transfusion dependent thalassaemia. Non transfusion dependent thalassaemia can have normal life with proper care. Whereas only curative option for transfusion dependent thalassaemia is bone marrow transplantation which is costly requires technical expertise. Carrier screening before marriage, antenatal screening and prenatal diagnosis is the only way to prevent birth of thalassaemia child. Objective of prenatal diagnosis is to identify homozygous or double heterozygous baby by mutation study. However clinical course after birth may get altered depending on associated other mutation. Till date these associated mutations are not considered in cases of prenatal diagnosis. However this can avoid termination of the baby and give parents a child. This study was carried out retrospectively in the prenatal samples to detect presence of phenotype modifying mutations. Method and Material: The study was conducted at the Institute of Haematology and Transfusion Medicine, Medical College, Kolkata. Study population consisted of 145 CVS samples and sample of carrier mother and father. Carrier status was detected by HPLC and confirmed by ARMS-PCR for b thalassaemia mutation. Co-inheritance of a-thalassaemia was assessed by GAP-PCR. Whereas polymorphism with haplotype assessment was done by RFLP-PCR. 36 parent samples were analyzed for mutation for the carrier status and also for presence of a and Xmn 1 polymorphism Result: Out of 145 CVS, 8.96 % (13 samples) were found to be homozygous, 12.41 % (18 samples) double heterozygous, 51.72 % (75 samples) heterozygous, 23.44 % (34 samples) normal and 3.44 % (5 samples) with uncharacterized for b mutation. Our results designate that the
123
Indian J Hematol Blood Transfus IVS 1–5 most common beta-thal mutation in West Bengal population (Table 1). Co-inheritance of a 3.7 deletion was found in only three affected CVS. Xmn1 Plymorphism was detected in 9 CVS samples out of these 3 was homozygous and 6 was heterozygous. Both coinheritance of a mutation and xmn1 polymorphism was detected in 22 parents sample and 18 affected CVS sample (Table 2). Out of 31 affected sample 18 samples showed presence of Xmn 1 and 4 for a deletion. Additional disease modifying mutations were detected in 6 samples (19.35 %). In cases where the 18 parents sample was positive for Xmn1 pollymorphism and 3 for a deletion in CVS sample either homozygous or double heterozygous for parents mutation. Discussion: Common thalassaemia prevalent in West Bengal is HbE and Beta thalassaemia. In cases where both the couples are carrier, beta mutation or mutation for HbE was first analyzed and subsequently decision for termination of baby was taken on the presence of both these mutations in CVS sample. But phenotype is determined by presence of additional mutations like co-inheritance of a mutation and xmn1 polymorphism. From our study it became evident that around 19.35 % cases the baby was expected to have intermedia or NTDT phenotype. Complete genotype analysis of CVS samples in prenatal diagnosis can save a life and that give a baby to parents. Conclusion: Alpha deletion and Polymorphism should be employed for prenatal diagnosis. While developing such program in his population, we save of multiple neonates.
Table 1 Common b globin gene mutation of CVS samples Beta genotype
Homozygote
Heterozygote
Compound heterozygote
Normal
Uncommon
IVS 1–5 (G ? C)
7
48
–
–
–
CD26(G ? A) HbE
1
13
5
–
–
CD15(G ? A)
8
9
–
–
–
–
–
–
–
–
–
–
–
–
34
18
CD30 (G ? C)
5
–
CD41/42(-CTTT)
2
3
CD8/9(+G)
3
–
CD6 (A ? T)
2
2
Total
13
75
–
5
PR 93 Cell Growth Inhibition and Apoptosis by Extract and Active Fraction of Basella Alba Plant on K562 cells Santanu Basu, Shila Elizabeth. Besra Csir, Indian Institute of Chemical Biology Leukaemia is one of the leading causes of death in the world particularly developing countries & it is complex group of disease with many possible cause. The synthetic drug and chemotherapies have huge side effects and these are so costly treatment for middle and lower class families. It would be extremely beneficial if an anticancer drug can be discovered from natural edible sources. Therefore our plant of interest an edible plant Basella alba reported as a natural medicinal source on the basis of its potent antibacterial and antioxidant, antiulcer, antidiabetic, hepatoprotective activity. Present study is the anti-proliferative effect of the extract & active fraction of Basella alba plants in K562 cell line. Cell viability was studied by Trypan blue exclusion and MTT assay, Morphological study by florescence and confocal microscopy. DNA laddering assay by gel electrophoresis, apoptosis and cell cycle by flow-cytometric study. MEBA and EBA were found to be responsible for antiproliferative, cytotoxic activity and both the morphological images, DNA laddering assay were found to be responsible for the apoptosis of cells. The flow-cytometric analysis confirmed that the cell cycle arrest occurred at G0/G1 phase of K562 cell lines. The extract and fraction of Basella alba plant was found to be having potent antileukemic activity in K562 cells. It can be expected in future to develop an anti-cancer compound for the treatment of human from natural source with less systemic toxicity. Thus, further more investigation is needed for mechanism and to identify the active compound responsible for this activity.
PR 94 ‘‘Cell Growth Inhibition and Apoptosis By Extract and Active Fraction of Basella Alba Plant on K562 Cells’’ Santanu Basu, Shila Elizabeth. Besra Csir, Indian Institute of Chemical Biology
Table 2 Affected CVS with additional mutations Additional mutations
Homozygous CVS
Double heterozygous CVS
Parents
a deletion
1
–
7
Homozygous Xmn1 +/+
1
1
3
Heterozygous Xmn 1 ; a deletion + Homozygous Xmn1 +/+
9 –
3 1
12 –
a deletion + Homozygous Xmn1 ;
–
2
–
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Leukaemia is one of the leading causes of death in the world particularly developing countries & it is complex group of disease with many possible cause. The synthetic drug and chemotherapies have huge side effects and these are so costly treatment for middle and lower class families. It would be extremely beneficial if an anticancer drug can be discovered from natural edible sources. Therefore our plant of interest an edible plant Basella alba reported as a natural medicinal source on the basis of its potent antibacterial and antioxidant, antiulcer, antidiabetic, hepatoprotective activity. Present study is the anti-proliferative effect of the extract & active fraction of Basella alba plants in K562 cell line. Cell viability was studied by Trypan blue exclusion and MTT assay, Morphological study by florescence and confocal microscopy. DNA laddering assay by gel electrophoresis, apoptosis and cell cycle by flow-cytometric study. MEBA and EBA were found to be responsible for antiproliferative, cytotoxic activity and both the morphological
Indian J Hematol Blood Transfus images, DNA laddering assay were found to be responsible for the apoptosis of cells. The flow-cytometric analysis confirmed that the cell cycle arrest occurred at G0/G1 phase of K562 cell lines. The extract and fraction of Basella alba plant was found to be having potent antileukemic activity in K562 cells. It can be expected in future to develop an anti-cancer compound for the treatment of human from natural source with less systemic toxicity. Thus, further more investigation is needed for mechanism and to identify the active compound responsible for this activity.
PR 95 An Unusual Presentation of Visceral Leishmaniasis—A Case Report
survival. Results: From 4/16/14–12/31/14, 824 patients were treated; 483 remained on study as of 12/31/14 and 531 had C1 on-study radiographic tumor assessment. 88 % of PS 0–1 pts and 92 % of PS 2 pts received C90 % of planned dose intensity. PD was the most common reason for discontinuing treatment. Discontinuations due to sTRAEs or treatment related serious AEs were 2 % each. Median follow-up time for this data lock was 10.4 weeks. Conclusions: Safety and tolerability were consistent with prior nivolumab experience; no new safety signals were identified. Immune-related AEs were manageable using previously developed safety algorithms. Frequency of sTRAEs of interest was similar in patients with PS 0–1 and 2. Early data suggest that patients with pretreated advanced NSCLC respond to nivolumab treatment regardless of PS, histology type, EGFR/ALK mutation status, or lines of prior therapy. N = 824
S. Marwah, A. S. Nigam, G. Buxi Pgimer, Dr Rml Hospital, New Delhi
M/F, %
Introduction: Kala azar or visceral leishmaniasis is the second largest parasitic killer in the world. It is endemic in more than 60 countries with approximately 200 million people at risk of infection. Leishmania species primarily affect the monocyte-macrophage system. Diagnosis can be made by demonstration of Leishman-Donovani (LD) bodies in bone marrow or spleen aspirates. Its demonstration in peripheral smear is however unusual. Case History: A 50 year old female resident of Bihar, presented with fever, generalised weakness and loss of weight of 3 months duration. General examination revealed severe pallor while systemic examination was unremarkable. Ultrasound abdomen showed mild splenomegaly and the hemogram was indicative of pancytopenia. The peripheral smear showed monocytes engulfing LD bodies. The bone marrow aspiration was also done and the smears showed occasional histiocytes with intracellular LD bodies. Subsequent test (rk39) was positive in this patient. Conclusion: Non-invasive serological tests such as direct agglutination test (DAT) and immunochromatographic lateral-flow assays, commonly referred to as rapid diagnostic tests (RDT) that target serum antibodies to rK39 and other antigens, e.g. rKE 16 are commonly used. Detection of LD bodies in peripheral smear is rare and diligent search for LD bodies should be made for patients from endemic regions even in the absence of massively enlarged spleen. Keywords LD bodies, Peripheral smear, Splenomegaly
Median age (range), y
66 (33–93)
SQ/NSQ, %
28/72
PS 0–1/2/NR, %
90/8/2
Prior therapies 1/2/C3/NR, %
30/29/38/3
sTRAEs, %
54/46
PS 0–1 (n = 742)
Any Grade Grade 5 Any Grade Grade 5 grade 3–4 grade 3–4 Renal
0.3
0
0
0
0
Endocrine
5.0
0.3
0
1.5
0
0
GI
6.7
0.4
0
6.2
0
0
Hepatic Respiratory
3.5 0.8
0.5 0.3
0 0
3.1 0
1.5 0
0 0
Skin
9.3
0.4
0
9.2
1.5
0
Infusion reaction 1.1
0.3
0
1.5
0
0
Overall tumor response: 1st assessment (n = 531) PR 96 An Ongoing Phase Iiib/Iv Safety Trial of Nivolumab In Patients With Advanced Or Metastatic Nsclc Who Progressed After Receiving ‡1 Prior Systemic Regimen Michael Mccleod, Jason C. Chandler, George R. Blumenschein, Jr, Lee S. Schwartzberg, Howard Burris Tennessee Oncology Introduction: Nivolumab, a fully human IgG4 programmed death-1 immune checkpoint inhibitor antibody, has demonstrated durable responses and tolerability in heavily pretreated patients with advanced NSCLC. This ongoing community-based trial explores nivolumab safety in this population. Materials and Methods: Patients with squamous (SQ) or non-squamous (NSQ) histology and C1 prior systemic therapy were enrolled. Pts receive 3 mg/kg IV Q2 W until progressive disease/unacceptable toxicity (Cohort A) or for 1 year with the possibility of retreatment upon disease progression (Cohort B). Primary objective is the incidence of high grade (3–5) select treatment-related adverse events (sTRAEs). Exploratory assessments include objective response rate, progression-free survival, and overall
PS 2 (n = 65)
0
Complete response (%)
Partial response (%)
Stable disease (%)
0
12
44
Tumor response: PS PS 0–1 (n = 489)
0
11
44
PS 2 (n = 35)
0
20
46
Tumor response: histology SQ (n = 145) NSQ (n = 386) No. of prior treatments
0
13
50
0
11
42
1 (n = 138)
0
11
44
2 (n = 160)
0
13
44
C3 (n = 220)
0
11
45
Y (n = 55)
0
16
47
N (n = 300)
0
11
41
EGFR mutation status
ALK mutation status Y (n = 12)
0
8
58
N (n = 299)
0
12
41
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Indian J Hematol Blood Transfus PR 97 Opportunistic Fungal Infections in Bone Marrow Aspirate Smear in Immunocompetent Patients Sunita Sharma, Shaileja Shukla, Jyoti Garg, Shivali Sehgal, Aasha B Lady Hardinge Medical College, New Delhi Introduction: Disseminated Opportunistic fungal infections (cryptococcal and histplasmosis) are rare in immunocompetant patients. These infections are commonly seen in immunocompromised patients like AIDS, haematological malignancies, patients on steroid therapy, transplant recepients. We present 2 cases of disseminated fungal infection detected incidentedly on bone marrow aspiration smear. Materials and Method: First case is a 3 year male child (HIV negative) presented in OPD with complaints of intermittent high grade fever, abdominal distension, jaundice and generalized lymphadenopathy for 3 months. USG and CT abdomen showed hepatospenomegaly with enlarged periportal and mesenteric lymph nodes suggestive of lymphoma/tuberculosis. Investigations revealed anaemia, netrophilic leucocytosis and deranged liver function tests. Bonemarrow examination was performed. Smears showed presence of yeasts forms of cryptococcus. Second case is a 35 year female presented with pallor and intermittent fever associated with chills and rigor. There was no history of steroid intake or diabetes and the patient was nonreactive for HIV. Complete blood count showed pancytopenia. Bone marrow aspirate smears were cellular and showing many intracellular and extracellular yeast forms of histoplasma capsulatum. Results and Conclusion: A high level of suspicion is required to diagnose fungal opportunistic infection in bone marrow in immunocompetant patients. We should include disseminated fungal infection in the differential diagnosis of patients presenting with high grade fever, hepatomegaly, lymphadenopathy in order to make early diagnosis and initiate treatment.
PR 98 Role of Haematological Profile In Diagnosis of Clinically Suspected Cases of Neonatal Sepsis Jessie C Felicitus, Dr. Sitalakshmi S St John’S Medical College Introduction: Neonatal septicaemia is a bacterial infective disease of the infants less than one month of age. Diagnosis of neonatal septicaemia is difficult as the early signs are subtle. Though blood culture is considered gold standard for the diagnosis, it takes at least 48 to 72 h. Therefore rapid and reliable diagnostics tests are needed for early diagnosis. Need for study The present study was undertaken to assess the role of haematological profile in the early diagnosis of neonatal septicaemia. Materials and Methods: The haematological profiles of 115 neonates with clinical suspicion of septicaemia were studied prospectively. The parameters included were total leucocyte count, Absolute neutrophil count, Immature to Total Neutrophil Ratio, Platelet count, Neutrophil morphological changes (Toxic granulation and cytoplasmic vacoulation), Eosinophilia and C-reactive protein. The sensitivity, specificity, positive predictive value and negative predictive value for each of these parameters were calculated, as indicators of septicaemia. Results: Out of 115, 38 (33 %) had positive blood cultures. The most sensitive parameters were C-Reactive protein (81.5 %) and Platelet count (71 %). Interestingly, most of the haematological parameters showed high specificities i.e.; I:T ratio (93.5 %), Eosinophilia (89.6 %), Neutrophil changes (88.3 %), Total leucocyte count (79.2 %). These parameters can
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therefore be useful in ruling out the likelihood of infection. Coagulase negative staphylococcus was the most common isolate noted (57.8 %). Conclusion: The outcome of a neonate with sepsis largely depends on its early identification. The present study has ratified that, while haematological changes in neonates can be used for early diagnosis of neonatal sepsis, other parameters can be useful in effectively ruling out neonatal sepsis. Thus, evaluation of haematological changes could help in early treatment of neonatal sepsis, thereby reducing neonatal morbidity and mortality. Keywords Neonatal sepsis, Haematological changes
PR 99 Thiopurine S-Methyltransferase Genotyping For Tpmt*2, *3A,*3B and *3C Alleles In North Indian Population Neha Verma, Shipla Gupta, Manorama Bhargava Sir Ganga Ram Hospital Introduction: Thiopurine methyltransferase (TPMT) enzyme plays a key role in the metabolism of azathioprine/6-mercaptopurine (6-MP). Mutations in the enzyme lead to low or intermediate enzymatic activity and generation of excess thioguanine, which causes suppression of various cell lineages. Patients with intermediate or deficient TPMT activity exposed to thiopurine drugs show severe hematopoietic toxicity. TPMT genotyping can predict TPMT activity and is not affected by transfusion or red blood cell defects. Data on the prevalence of TPMT polymorphism are available from various populations of western and some Asian countries. Data from India are sparse except one from South India. The present study was aimed to determine the prevalence of TPMT mutations in North Indian population. Methods: Peripheral blood was obtained from 252 healthy individuals of North Indian origin and genomic DNA was isolated from peripheral white blood cells. The genotypes of four major TPMT single-nucleotide polymorphisms (TPMT *2, *3A, *3B, and *3C) were determined by allele-specific polymerase chain reaction and restriction fragment length poly-morphism (PCR–RFLP). Results: The estimated genotype frequency for homozygous TPMT*1/*1 was 97.22 %, for heterozygous TPMT*1/*3A, 0.39 % and for heterozygous TPMT*1/*3C, 2.38 %. Collectively, frequency of heterozygous mutants in the studied subjects was 2.8 %. No patient had homozygous genotype. TPMT *2 and *3B were not present in the studied subjects. The study confirms significant variations in TPMT gene polymorphisms in North Indian population in relation to other populations (Caucasians, Italians, Polish). However, Frequencies reported from present study are similar to the South India. Conclusions: TPMT*3C appears to be most prevalent among the known mutant variants of TPMT in North Indian population which may have some relevance for the treatment outcome and toxicity in patients treated with thiopurine drugs.
Topic: Myelodysplastic Syndrome & CMPD PR 100 Cmml-2 Evolving from Mds-Raeb 1 Dr. Jasmita, Dr. Sabina Langer, Dr. Amrita Saraf, Dr. Jyoti Kotwal, Dr. Manorama Bhargava Sir Ganga Ram Hospital Inroduction Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic malignancy associated with monocytosis and
Indian J Hematol Blood Transfus features of a myelodysplastic syndrome (MDS) and/or myeloproliferative neoplasm (MPN). Most of the cases present as de novo disease. Only a few cases of CMML have been described to evolve from a preexisting MDS. Case presentation A 61 year old female, a follow up case of MDS-RAEB 1 post 5 cycles of Decitabine presented in February 2015 with bicytopenia and normal total leucocyte count (TLC). There was absolute monocytosis with 4 % blasts and promonocytes. Bone marrow aspirate (BMA) showed * 15 % blasts with trilineage dyshemopoiesis. Therefore, the morphologic picture was that of CMML-2. Bone marrow biopsy (BMB) showed all marrow components with prominence of blasts and dysmegakaryopoiesis. At the time of diagnosis of MDS-RAEB 1 she had bicytopenia with normal TLC, monocytes 02 %. BMA showed trilineage dyshemopoiesis and 8–9 % blasts. Absolute monocyte count was \1000/ul. After 3 cycles of decitabine she underwent a bone marrow which showed only 1 % blast and no monocytes. Hence patient showed a response to decitabine as blasts reduced from * 9 % to * 1 %. Discussion: Our patient showed progression from MDS RAEB-1 to CMML-2 after showing a response in blast count on decitabine. Thus even low TLC, absolute monocyte count should be assessed in all cases of MDS even on follow up to exclude transformation to CMML. It is important as these patients may have an inferior survival.
PR 101 Gstp1 Ile105Val Polymorphism Is Associated With Molecular Response To Imatinib In Newly Diagnosed Patients With Chronic Myeloid Leukemia Vinodhini Kumaraswamy, Senthamizhselvi Anandhan, Fouzia Na, Anu Korula, Biju George Christian Medical College Despite impressive success of Imatinib therapy in CML patients, a proportion of them exhibit suboptimal response to the drug and several factors are attributed to this. Genetic polymorphisms in the Glutathione-S-Transferase (GST) enzymes have been shown to be associated with the risk of developing CML but their role in response to imatinib therapy has not been evaluated before. We evaluated the role of GSTM1/GSTT1 deletion and GSTP1 Ile105Val polymorphisms on achieving major molecular response (MMR) at 12 months post therapy in newly diagnosed CML patients. Imatinib naı¨ve CML patients (n = 162) who received standard dose of imatinib with serial follow-up post therapy were included in this study. Molecular response to Imatinib was measured by RQ-PCR analysis of BCR-ABL fusion transcript (expressed in International scale) from peripheral blood samples collected at diagnosis, 3, 6, 9, 12, 18, 24 and 30 months post therapy. GSTM1/GSTT1 deletion as well as GSTP1 Ile105Val polymorphisms was screened using standard methods using genomic DNA. Sixty-three patients achieved major molecular response (MMR) (BCR-ABL/ABL ratio \0.1 %) while 103 did not achieve MMR (BCR-ABL/ABL ratio [0.1 %) at 12 months of imatinib therapy. Patients with GSTP1 Ile105Val variant genotype had significantly lower incidence of attaining MMR at 12 months (30 %) when compared to those with wild-type genotype (45 %; p = 0.04). GSTT1/GSTM1 deletion polymorphisms were not associated with molecular response. This study suggests that the screening of GSTP1 polymorphism in newly diagnosed CML patients could help predict their response to Imatinib therapy.
PR 102 An Unusual Terminal Event In Mds/Mpn-U: The Continuing Relevance of Morphology In The Genomics Era Narender Kumar, Prashant Sharma, Shivaprakash M. Rudramurthy, Nandini Sethuraman, Neelam Varma Postgraduate Institute of Medical Education and Research Introduction: Myelodysplastic/myeloproliferative neoplasms, unclassifiable (MDS/MPN-U) pose significant diagnostic challenges. Morphology forms the mainstay of diagnosis, as is illustrated by this intriguing case. Case presentation: A 72-year-old HIV-negative male presented with a 2-month history of weakness, fever, weight loss and hepatosplenomegaly. Hb was 118 gm/L, TLC 15.8x109/L and platelets 78x109/L. Blood film showed 3 % blasts, 6 % immature myeloid cells, 4 % basophils and 2 % monocytes. Bone marrow was hypercellular with 5 % blasts, trilineage dysplasia and reticulin fibrosis. bcr-abl1 and jak2 mutations were negative. Myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN), bcr-abl1 negative, was diagnosed. He subsequently returned after 7 months in altered sensorium with highgrade fever, and neck rigidity. CT head and CSF examinations were normal. Blood and urine cultures were sterile. Hemogram revealed anemia (60 gm/L), thrombocytopenia (19x109/L) and leucocytosis (63.5x109/L) with a differential similar to that at diagnosis. A repeat bone marrow too showed findings similar to that seen previously. In addition, both blood and marrow granulocytes displayed intracytoplasmic yeast forms. These were confirmed on peripheral blood culture as well as sequencing of the ITS (internal transcribed spacer) region to be Histoplasma species. The patient expired soon after. Need of presentation. Discussion and Conclusion: This unusual co-existence of neoplastic and infective disorders reiterates the fact that morphological skills remain indispensible for hematolopathologists. Our patient may have been predisposed to infection by his dysplastic MDS/MPN neutrophils with defective phagocytic and microbicidal activities. Tropical doctors, both clinicians and laboratorians, must therefore remain alert for uncommon infections at unusual sites in their immunocompromised patients. Keywords Myelodysplastic/myeloproliferative neoplasm, Neutrophils, Infection
PR 103 Cml In Blast Crisis In Pediatric Age Group : A Report of Two Cases Mamc CML is a myeloproliferative neoplasm commonly presenting in old age with a median age of 50 years. Pediatric CML is a rare disease accounting for less than 3 % cases in childhood. The natural history and biology of pediatric CML is similar to that of adult CML. 95 % of children present in a chronic phase of CML with blast crisis being extremely uncommon in this age group. We present two cases of undiagnosed pediatric CML presenting as blast crisis. Case 1–4 year old female with abdominal distension and hepatosplenomegaly for 2 months. Hb 5.9gm/dl, TLC-2.2 9 106/ll, platelet count—2.48x 106/ ll. Peripheral blood showed 20 % blasts (DLC-BL20, PM12, MY13, MM8, P31, L5) which were MPO positive. On flowcytometry blast were positive for CD34, CD33, CD13, CD117 and cyMPO. PCR confirmed a minor breakpoint cluster region suggest of abL—bcr transcript size of 210kD. Case 2–16 years old male with abdominal distension and fever for past 1 year and massive splenomegaly. Hb
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Indian J Hematol Blood Transfus 5.6gm/dl, TLC-1.73 9 106/ll, platelet count—5.59 9 106/ll. Peripheral blood smear examination showed BL35, MY25, MM8, P25, L2, BA1, EO4. Blast were MPO negative. On flowcytometry blasts were positive for CD 10 and CD 19 RT-PCR confirmed presence of bcr-abl (210 kDa). A final diagnosis of lymphoid blast crisis in CML was rendered. CML in children presenting as blast crisis is extremely rare with only few cases reported till date. Above cases reported add to the literature on the presence of myeloblastic transformation in CML at presentation in children. This differential should also be kept in mind before diagnosing such cases as de novo Acute leukemia.
PR 104 Immunohistochemical Analysis of Bone Marrow Angiogenesis In Primary and Secondary Myelofibosis Debdatta Basu, Rakhee Kar, T K Dutta1,, Kv Vinod
clinical presentation, hematological findings and disease outcome. Aim and Objectives: 1) To study clinical and hematological profile of CMML cases diagnosed at our hospital in last 5 years. 2) To correlate the survival of patients with prognostic score of Patnaik (Mayo clinic, 2013). 3) To study the treatment given and its response. Materials and Method: Retrospective analysis of 18 cases of CMML diagnosed from Jan 2010 to June 2015 as per WHO 2008 criteria. One case was excluded because of high hematocrit and JAK2 positivity. We studied clinical, hematological, treatment given and outcome of patients. Outcome with prognostic score and treatment was studied in 12 cases as 5 cases were diagnosed in last 5 months. Result: A total of 17 cases were analyzed. Median age of presentation was 64 years (39–81 years). Male: Female ratio of 0.7. Easy fatigability and weakness was seen in 7 cases, hyperleukocytosis in 7, anemia in 15, thrombocytopenia in 8, serous effusion in 3 and hepatosplenomegaly in 4 cases. Table 1: Summary of hematological, prognostic score and treatment outcome parameters. Conclusion: Most of the cases of CMML were high risk with poor treatment outcome.
King George Medical University Summary: CD34 staining appears better compared to CD105 for studying microvessel density at least in primary myelofibrosis. PMF patients have significantly higher angiogenesis in marrow compared to secondary myelofibrosis. Higher megakaryocytic expression of VEGF in PMF compared to secondary myelofibrosis may be an important differentiating feature. Introduction: Increased angiogenesis in marrow is a common finding in hematological malignancies. Primary and secondary myelofibrosis is associated with increased angiogenesis. Various markers including CD34, CD105 and tissue expression of VEGF have been used to study angiogenesis. We analyzed comparative utility of these markers in studying angiogenesis in cases of myelofibrosis. Materials and Methods: Bone marrow biopsies of patients with PMF (Group-1, n = 15), MPNs other than PMF (Group-2, n = 15), secondary myelofibrosis excluding MPNs (Group-3, n = 17), with WHO grade 2 and grade 3 myelofibrosis were included in this study along with 16 patients (Group-4) with normal marrows as controls. Visual microvessel grade (MVG) & microvessel density (MVD) was studied with CD34 and CD105 by standard IHC methods. Marrow expression of VEGF was also studied. Results: Median CD34 MVG was significantly higher (grade 4) in PMF group compared to all other groups (grade 2, 1.5 and 1 in group 2, 3 and 4 respectively). Mean MVD by anti CD34 was significantly high (26.93) in PMF compared to mean MVD of 18.67, 14.06 and 10.50 in group 2, 3 and 4 respectively. Mean MVD assessed by anti CD105 was not significantly different between the groups. Comparative assessment of MVD by CD34 and CD105 in all groups using paired t test showed significantly higher CD34 MVD in group1. Cellular expression and megakaryocytic expression of VEGF evaluated by Immunoreactive scale was higher in group 1 compared to other groups. Conclusion: Marrow angiogenesis is significantly more in PMF compared to secondary myelofibrosis. CD34 appears to be a better angiogenic marker compared to CD105. Megakaryocytic expression of VEGF is significantly higher in PMF.
PR 106 Frequency and Spectrum of Calr Mutations In Jak2 V617F Negative Essential Thrombocythemia and Primary Myelofibrosis Patients Prashant A Deshpande, Mobin Paul, Priyadharshini J, Fouzia Na, Biju George Christian Medical College Introduction: Diagnosis of BCR-ABL1 negative myeloproliferative neoplasm is based upon clinical presentation, bone marrow examination and/or presence of JAK2 (V617F/exon12) or MPL mutations. Recently, indel mutations in the calreticulin gene (CALR exon 9) have been described in nearly 60–80 % of JAK2 and MPL negative patients of essential thrombocythemia (ET) and primary myelofibrosis (PMF). Thus, presence of CALR mutations may be used as a clonal marker, especially in JAK2 negative patients. There are limited reports describing frequency and mutation spectrum of CALR mutations in Indian patients. Here, we describe our experience with CALR mutations in JAK2 negative MPN patients from an Indian population. Methods Retrospectively, we identified 90 patients diagnosed as JAK2 V617F negative ET or PMF (WHO 2008 criteria). CALR indel mutations were screened by PCR based assay using fluorescent labeled primers (Nangalia, NEJM 2013) and Fragment length analysis by capillary electrophoresis (ABI3130 genetic analyzer). The presence of an indel mutation was further characterized using DNA sequencing. Results: CALR mutations were identified in 39 out of 89 (43.82 %) patients screened, ET: 11/31 (34.37 %), PMF: 28/58 (48.27 %). Type 1 (c.1092_1143del) mutation was more frequent (18/39, 46.15 %) while Type 2 (c.1154_1155insTTGTC) was identified in (11/ 39, 28.20 %), while 10 other mutations were identified in remaining patients, including four novel mutations. Conclusion: Type 1 and Type 2 CALR mutations are seen in majority of CALR mutated MPN (ET/PMF) but overall frequency CALR mutations appears to be less in this cohort compared to published reports from the West.
PR 105 Five Year Experience With Chronic Myelomonocytic Leukemia At Tertiary Referral Centre
PR 107 Leukoerythroblastosis—An Unusual Case Report
Gaurav Dhingra, Manorama Bhargava, Jasmita Dass, Amrita Saraf, Sabina Langer
Vijay Kumar, Sadhna Marwah, A S Nigam, Gurdeep Buxi
Sir Ganga Ram Hospital
Pgimer Dr Ram Manohar Lohia Hospital, New Delhi
Introduction: Chronic myelomonocytic leukemia is a rare (0.3 per 100,000) hematological malignancy with marked heterogeneity in
Introduction: Leukoerythroblastosis is characterized by nucleated red blood cells, teardrop cells, giant platelets, and immature white blood
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Indian J Hematol Blood Transfus cells (e.g., myelocytes, metamyelocytes, occasionally promyelocytes and myeloblasts) in the peripheral blood smear. It results from marrow infiltrative disorders such as myelofibrosis, myeloma, metastatic carcinomas, Gaucher’s disease etc. We encountered a patient with leucoerythroblastic picture in peripheral blood which turned out to be an unusual case of myelofibrosis. Case presentation—A 47 year old female presented with fever and bicytopenia since 3 months. She was diagnosed to have autoimmune thrombocytopenia 6 years back and had taken steroid. Clinical examination revealed mild hepatosplenomegaly. Her serum lactate dehydrogenase and vitamin B12 levels were elevated. CT abdomen and thorax showed mild hepatosplenomegaly and insignificant mesentric lymphadenopathy. Peripheral blood smear showed anemia with leucoerythroblastic picture. Bone marrow aspiration revealed dry tap. Bone marrow biopsy showed cellular marrow with myelofibrosis and scattered atypical cells. JAK 2 V617F mutation was negative. Conclusion: The present case could be a case of primary myelofibrosis with unusual association with autoimmune thrombocytopenia. Differentiating primary from secondary myelofibrosis is important as it affects management and prognosis.
PR 108
Introduction: The most common genetic mutation associated with Philadelphia negative chronic myeloproliferative neoplasm is Janus Kinase 2 mutation (JAK2V617F and JAK2 exon 12) Its presence excludes secondary polycythemia, thrombocytosis, or bone marrow fibrosis from other causes. In this study, we present the prevalence of JAK2 V617F mutation in patients with chronic myeloproliferative disorders from northeast India. Need for study: There is a variation in prevelance of JAK 2 mutation in chronic myeloproliferative neoplasm in different populations. Hence we look for prevelance of JAK 2V617F mutation in patients of Northeast India. Materials and Methods: Mutation screening for JAK2 V617F was performed in all patients with myeloproliferative neoplasm (Philadelphia negative) (19 cases) attending Dept of Clinical Haematology, GMCH by polymerase chain reaction. Results: JAK2V617F mutation was detected in 68 % case of myeloproliferative neoplasm,55 % cases of primary myelofibrosis,80 % cases of essential thrombocythemia and 100 % cases of polycythemia vera. Conclusion: The prevelance of JAK2V617F mutation in essential thrombocythemia in our study was higher as compared to the western countries but is comparable to a similar study done in India. Keywords JAK2V617F, Polycythemia vera, Essential thrombocythemia, Primary myelofibrosis
Multiple Subdural Hematomas In A Patient of Chronic Myeloid Leukemia! Is Imatinibmesylate The Culprit? Namrata P Awasthi, Madhuprastogi, Rashmikushwaha, Nuzhat Husain Dr. Ram Manohar Lohia Institute of Medical Sciences Introduction: Imatinibmesylate (IM), a potent and selective tyrosine kinase inhibitor, is now a standard initial treatment for Chronic myeloid leukemia (CML) and has been found to be well tolerated with minor side effects. We report here an unusual case of subdural hematomas developing in a caseof CML treated with IM. Case history A 30 year old male, presented with extensive bruising in left thigh. After complete hematological and molecular work up, a final diagnosis of CML in chronic phase was rendered. IM was initiated at a dose of 400 mg daily. After 20 days, patient developed headache and visual disturbance which was due toa subdural hematoma (SDH) in left parietal convexity detected by computed tomography scan. IM was stopped and reintroduced after one week when he again developed after 3 days SDH on the other side. Platelet function testing performed twice at an interval of 15 days showed reduced aggregation to ristocetin and ADP. Discussion: This report describes the rare occurrence of subdural hematoma in a CML patient with acquired platelet function defect, treated with 400 mg IM daily. IM was introduced twice, both the times resulting in SDH. In patients treated with IM, central nervous system hemorrhage occurs in 0.6 % in chronic phase. Need for reporting the case Patients of CML may have acquired platelet function defect. IM as a cause of SDH in CML is extremely rare. It has previously been reported that IM produces hemostatic abnormalities. Further investigations are needed to establish the mechanism of subdural hematoma causation by IM in an already compromised hemostatic balance in a patient of CML.
PR 109 Prevalence of Jak2 V617F Mutation In Patients With Chronic Myeloproliferative Neoplasm : A Study from Northeast India
PR 110 Atypical Presentation of A Case of Myelofibrosis Dr. Sadhana Mahore, Dr. Kalpana Bothale, Dr. Anjali Patrikar, Dr. Anne Wilkinson, Dr. Trupti Dongre Nkp Salve Institute of Medical Introduction: Myelofibrosis is a term referring to the deposition of excessive collagen in the bone marrow, currently classified as a myeloproliferative neoplasm. Incidence of myelofibrosis is 1.5 cases per 1,00,000. Classical clinical findings include progressive anaemia and extramedullary hematopoeisis that results in marked hepatosplenomegaly. Case presentation: A 55 year old male patient came to the Surgery department with the complaint of dragging pain in the abdomen. Clinical examination revealed massive splenomegaly. Splenectomy was done and the spleen was received for histopathological examination. The spleen measured 32x19x8 cms weighing 3.3 kg. Microscopic examination showed evidence of myeloid metaplasia. Considering the histological findings, the pre-operative complete blood count and peripheral blood smear report was reviewed. It showed haemoglobin—14gm/ dl, total leukocyte count-13,000/cu mm, haematocrit:45.1 %, RBC:6.30millions/cu mm, platelet count:2.10 lacs/cu mm, MCV:72 fl, MCH:22.3 pg, MCHC:31.1 % and the peripheral smear showed normocytic normochromic red blood cells with polychromatophils, mild leucocytosis and few immature white blood cells. Nucleated red blood cells and tear drop cells were not seen. Bone marrow examination was advised, aspiration was dry tap & biopsy was suggestive of fibrosis. Need for case presentation : Atypical presentation of the case due to lack of anaemia and nucleated red blood cells or tear drop cells on peripheral smear. Discussion: Normally in myelofibrosis splenomegaly, progressive anaemia, immature red blood cells are present but in this case myelofibrosis could have been missed due to normal haemoglobin levels, lack of tear drop cells and nucleated red blood cells on peripheral blood smear.
Jina Bhattacharyya, Smita Das, Damodar Das, Sewali Deka Talukdar, Aishwarya Raj Guwahati Medical College and Hospital
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Indian J Hematol Blood Transfus PR 111 Idiopathic Primary Myelofibrosis In Young Adults A Rare Presentation—Repeat of 2 Cases Dr. Kumudini Devi Ims & Sum Hospital Introduction: Idiopathic primary mylofibrosis also known as myelofibrosis with myeloid metaplasia, gynogenic myeloid metaplasia mostly common in 6th to 7th decade of life. Presentation in young & childhood is extremely rare. Case presentation: We report 2 case of 26 yrs old male & 30 years old female, both presented with splenomegaly & pain in the small joints since 4 months to the hematology OPD with a provisional diagnosis of the hypersplenism in the first case the aspiration was dry tap & imprint smear showed occasional blasts. In the second case the marrow was diluted with peripheral blood & showed mild increased in blast (4 %) and basophils (6 %). Bone trephine biopsy of both shows hypercelullar marrow with increase immature precursors, increase megakaryocytes, fibrosis and increased reticulin content pointing towards possibility of mylofibrosis. Both were sent outside to a referral centre for cytogenetic study where JAK 2 was positive. Conclusion: Though Idiopathic Primary Myelofibrosis is thought to be rare in this age group, this diagnosis has to be kept in mind while dealing with patients presenting as splenomegaly.
Increased fibrous tissue deposition in bone marrow indicated by reticulin stain
Fibrous tissue deposition in bone marrow in idiopathic myelofibrosis Extensive marrow fibrosis in bone marrow demonstrated by reticulin stain
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Indian J Hematol Blood Transfus PR 112 Jak2 V617F Mutation In Bcr-Abl1 Negative Myeloproliferative Neoplasms Ruby Gupta, Man Updesh Singh Sachdeva, Jogeshwar Binota, Anil Sood Postgraduate Institute of Medical Education and Research Background: The classical BCR-ABL1 negative myeloproliferative neoplasms (MPN) include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). Frequent genetic event described in these MPN is JAK2 V617F mutation which has also been incorporated in the 2008 World Health Organisation (WHO) diagnostic criteria. The frequency of JAK2 V617F mutation varies in different MPN and the quantity of JAK2 V617F mutation (heterozygous or homozygous) correlates with disease status, progression and clinical outcomes. Methods: Mutation screening for JAK2 V617F was performed in 50 BCR-ABL1 negative MPN patients by allele specific polymerase chain reaction. Patients were diagnosed as PV, PMF and ET according to 2008 WHO diagnostic criteria. Results: Overall the median age was 55 years (range = 35–85 years) with male:female ratio of 2.1:1. Similar median age and male predominance was seen individually also for PV, PMF and ET patients (54 years, 1.7:1; 57 years, 3.5:1 and 53 years, 1.5:1 respectively). Of the 50 MPN patients studied, JAK2 V617F mutation was seen in 25 (50 %) patients. It was most common in PV patients (66.7 %, n = 18/27), followed by PMF (33.3 %, n = 6/18) and least in ET (20 %, n = 1/5). Homozygous mutation was also most frequent in PV cases. Of the 18 JAK2 V617F mutation positive PV cases, homozygous mutation was seen in 6 patients and heterozygous in 12 patients and of the 6 JAK2 V617F mutation positive PMF cases, homozygous mutation was seen in only 1 patient and heterozygous in 5 patients. Only case of ET positive for JAK2 V617F mutation was heterozygous. Detailed clinico-hematological features and follow-up data will be presented at the conference. Conclusion: In this study, we found: (i) JAK2 V617F mutational frequency in BCR-ABL negative MPN as 50 %. (ii) It was most common in PV patients, who also had higher incidence of homozygous mutation compared to PMF and ET patients.
Demographics and clinical characteristics of hospitalized pts are compared with the total SIMPLICITY population. Methods: SIMPLICITY includes three prospective pt cohorts treated with IM, DAS or NIL as 1L therapy since 2010 and a historical cohort treated with IM since 2008. Among hospitalizations reported through 22 Sept 2014, CV-related hospitalizations were identified using preferred MedDRA terms in the CV category. Based on events reported, events were categorized: valvular disease; arrhythmia; cardiac failure; cardiac ischemic disease; and pericardial disorder. TKI exposure was calculated from total duration on specified TKI regardless of initial TKI. Results: 1460 pts were enrolled prospectively on IM (n = 415), DAS (n = 416) or NIL (n = 376), and data collected retrospectively for IM (n = 253). Over half of pts were male (54.7 %) and over half were from the US (66.7 %). Median age (interquartile range [IQR]) at 1L TKI was 56.0 (45.0–67.0) years and 31 % of pts were C65 years. Overall, 329 pts (22.5 %) were hospitalized and 46 pts (3.2 %) had CV hospitalizations (retrospective IM: n = 21; prospective IM: n = 6; DAS: n = 8; NIL: n = 11). Multiple CV hospitalizations were reported in 21.7 % of CV hospitalized pts. Of pts with CV hospitalizations, median (IQR) age at 1L TKI was 70.8 (57.1–74.8) years; 60.9 % were C65 years. Most pts were male (60.9 %) and from the US (82.6 %); 62 % were on 1L TKI at first admission. Median follow-up from start of TKI to hospitalization was 370 days (retrospective IM, 484; prospective IM, 847; DAS, 105; NIL, 239 days) compared with 29.3 months for the total SIMPLICITY population. Most frequent causes of CV hospitalization were cardiac ischemic disease (34.6 %), arrhythmia (30.8 %) and cardiac failure (26.9 %). The rate of CV hospital admissions per 100 pt years exposure was 1.46 for all hospitalized pts and was highest in the NILtreated cohort (NIL: 2.61 compared with 0.77 [retrospective IM], 1.15 [prospective IM] and 1.15 [DAS]). The mean (± SD) duration of hospitalization was 5.9 (± 7.2) days. Summary: In SIMPLICITY, few patients overall were hospitalized for CV-related events. Pts with CV-related hospitalizations were older than the total SIMPLICITY population. Analysis of pre-existing CV co-morbidities in hospitalized patients will be described. Keywords: Chronic myeloid leukemia, Tyrosine kinase inhibitor (Previously presented at The European Hematology Association 20th Congress 2015, Vienna, June 11–14, 2015. Abstract no. E1099. Permissions have been obtained from all the authors to present this poster at Haematocon 2015 congress).
PR 113 Cardiovascular (Cv)-Related Hospitalization In Patients With Chronic-Phase Chronic Myeloid Leukemia (Cp-Cml) In Simplicity, A Prospective Observational Study
PR 114 Refractory Anemia With Excess Blasts2 In Childhood, A Rare Phenomenon: A Case Report
Ron Paquette, Michael Mauro, Bengt Simonsson, Elisabetta Abruzzese, David Andorksy
Dr. Anshu Palta, Dr. Anita Tahlan
Bristol-Myers Squibb India Pvt. Ltd
Government Medical College and Hospital, Sector-32, Chandigarh
Background: SIMPLICITY is an ongoing observational study of CPCML patients (pts) designed to understand the use of first-line (1L) imatinib (IM), dasatinib (DAS) or nilotinib (NIL) in the United States (US) and Europe (Eu) outside clinical trials (NCT01244750). Previous SIMPLICITY data (ASH 2013) showed pts had 3.3 (± 2.8) comorbidities (mean ± standard deviation [SD]) at start of 1L tyrosine kinase inhibitor (TKI; N = 949); C1 baseline comorbidity reported in [75 % of pts, with [3 comorbidities in majority. 40.6 % had cardiovascular (CV) comorbidities at start of 1L TKI. Baseline comorbidity did not affect initial TKI selection, although cautions regarding risks for specific adverse events (e.g. cardiac and pulmonary) have been described for individual TKIs in pts with preexisting conditions. Aims: This analysis focuses on the frequency of CV-related hospitalizations in SIMPLICITY pts and describes these events by 1L TKI and TKI received at time of hospitalization.
Introduction: Myelodysplastic syndrome (MDS), a heterogenous group of hematopoietic clonal disorders is characterized by ineffective hematopoiesis with frequent evolution to life-threatening pancytopenia. It constitutes \5 % of all childhood hematological malignancies and may occur in different etiologies like infection, drug therapy and chronic disease. The major diagnostic challenges are to distinguish MDS with excess of blasts from acute myeloid leukemia. Materials and Methods: We report a case of 13 years old male diagnosed as refractory anemia with excess blasts-2 (RAEB2) who presented with fever and jaundice since one and a half month and history of weakness for last 6–8 months. The patient had received 1unit of packed red blood cells 20 days before presenting in our hospital and was on haematinics for last 3 months. Physical examination revealed no significant organomegaly. Haemogram revealed pancytopenia i.e. haemoglobin-3.5 g/ dl, total leucocyte count-3.3X109/L, platelets-25.0X109/L,
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Indian J Hematol Blood Transfus reticulocyte count-0.7 % and corrected reticulocyte count-0.2 %. Peripheral blood film examination showed ringed neutrophils and hypogranular granulocytes. Results: Bone marrow showed mildly hypocellular marrow spaces (Myeloid:erythroid-5.2:1). Erythroid series show mild megaloblastosis. All the 3series cells showed dysplastic features: dyserythropoeisis (18 %), dysmyelopoeisis (15 %), dysmegakaryopoeisis (70 %). In view of refractoriness to haematinics and on the basis of peripheral blood findings and bone marrow findings, diagnosis was suggestive of RAEB2. The patient is still on follow up. Conclusion: Current knowledge in diagnosing paediatric MDS lags due to lower incidence, uncertain classification, difficult diagnosis, variability of clinical picture and lack of consistent cytogenetic abnormalities specific to a single disorder. Keywords MDS, RAEB2, Childhood, Marrow
PR 115 Gene Expression Profiling of Imatinib Resistant Chronic Myeloid Leukaemia Patients Sunita Chhikara, Rekha Chaubey, Manoranjan Mahapatra, Renu Saxena Aiims Background: The use Imatinib, is an established first-choice treatment for the patients with chronic myelogenous leukemia. However, the acquisition of drug resistance is a major obstacle limiting the treatment efficacy. GEP by microarray may allow the elucidation of the molecular mechanism of this resistance. Objectives: To identify predictive genes that might prove informative for resistance to imatinib in CML patients. Methods: RNA was isolated from peripheral blood using QIAamp RNA blood mini kit (Qiagen). The samples were labelled, scanned and data was extracted as per the protocol (Agilent Technologies). Data was analyzed using Agilent Genespring 12.0 software. Results: A total of 80 CML patients (M: F: 3:1), median age 42 years (range 20–60 years), CP (n = 30), AP (n = 20), BC (n = 20) and non-responders (10) were analysed. The genes involved in transporter activity (AKR1C1), biological regulation (BARX2, ZFYVE16) metabolic process (CYP26A1, PKNOX2, apoptosis (DAPK1, STAT protein, TNF and PDCD1), cell adhesion (TNXB, VWF, CD6) were significantly (p B 0.05) under expressed in CML-AP patients. Patients with BC showed significantly elevated expression of these genes. Elevated expression of SOCS-2 gene was found in both in AP and BC phase CML. The GEP of non responders showed that genes involved in cell adhesion (COL5A1, GATA1, CDC42BPA, FMOD, ASAPL) and drug metabolism (ABCB, CYP7B1, ALDH1A2) were significantly (p B 0.05) down regulated. SCHIP1 showed eightfold significant down-regulations in NR patients. The expression of these genes were absent in CML-CP patients. Conclusion: The evidence from the present study suggests that there is gene discrimination between the Imatinib responders and non responders CML patients.
Topic: Plasma Cell Disorders PR 116 Outcomes of Allogeneic Transplantation In Patients With Refractory Acute Myeloid Leukemia: Single Center Experience Sachin Punatar, Alok Gupta, Libin Matthew, Bhausaheb Bagal, Sadhana Kannan Tata Memorial Hospital
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Introduction: Refractory acute myeloid leukemia (AML) has poor prognosis even after hematopoietic stem cell transplant (HSCT). There is paucity of data on the outcome of such patients. We retrospectively analysed their outcome at our centre. Methods: Fifteen such patients underwent allogeneic HSCT between January 2009 to April 2014. Refractory state was defined as: Primary Induction failure (PIF)—those who did not achieve complete remission (CR) after 2 cycles of induction therapy or RelapseRefractory (RR)—those who failed to achieve CR with salvage therapy at first relapse or beyond. Conditioning regimens used were fludarabine + cytarabine + melphalan (3 patients) + idarubicin (6) or mitoxantrone (1). Treosulfan (2) and busulfan with cyclophosphamide (3) were used instead of melphalan in 5 patients. Overall (OS) and progression free survival (PFS) were calculated by Kaplan–Meier method. Results: Median age was 35 yrs. The median marrow blast percentage at transplant was 17 %. Based on cytogenetics, 8 patients were intermediate risk, 1 good, 3 poor and in 3 unknown. Five patients were PIF while 10 were RR at time of transplant. Fully matched donors were used in 9 patients, haploidentical in 3 and B2 antigen mismatch in 3. The GVHD prophylaxis used was cyclosporine/mycophenolate (MMF) in 8, cyclosporine/methotrexate in 4 and cyclosporine/MMF/post transplant cyclophosphamide in 3 patients. At day 28, full donor chimerism was seen in 10 while mixed in 5 patients with all patients achieving morphological CR. Incidence of grade 2–4 acute GVHD and chronic GVHD was 20 % and 33 % respectively. At a median follow up of 18 months, 8 patients have relapsed and died, 6 are alive and 1 dead due to organ toxicity. Seven patients received donor lymphocyte infusion (DLI) at relapse with none achieving CR. The cumulative probability of OS and PFS at 2.5 years was 24 % and 21 % respectively. Conclusion: As major reason for poor survival remains relapse post transplant, novel strategies to prevent relapse are required to improve outcomes.
PR 117 Utility of 6 Color Multiparametric Flow Cytometry For Minimal Residual Disease Analysis In Multiple Myeloma Patients Man Updesh Singh Sachdeva, Neelam Varma, Parveen Bose, Pankaj Malhotra Post Graduate Institute of Medical Education and Research Introduction: Minimal residual disease (MRD) analysis by multiparametric flow cytometry (MFC) is a sensitive and feasible method to evaluate treatment efficacy, predicting patient outcomes and guiding therapeutic decisions. We compared MRD levels in patients of multiple myeloma (MM) after chemotherapy/Allogenic Stem Cell Transplant (ASCT) assessed by MFC, with serum M band status, immunofixation electrophoresis (IFE) and percentage of bone marrow plasma cells (BMPC). Materials and Methods: Nineteen MM patients were included in the study (15Male, 4 Female) with mean age of 54.6 years (44–80 years). MRD was analyzed using a dual laser 6 color-flow cytometer in 9 patients of ASCT (day 100) and 10 patients on chemotherapy alone (post-induction). Pre-titrated cocktail of CD38, CD138, CD19, CD45, cytoplasmic Kappa and lambda light chain, CD81, CD27, CD28 CD200 and CD10 were used in 6-color combination of three tubes for MRD analysis. Results: MRD was detectable in 5 patients, mean of 0.61 % (0.07–6.44 %). M band and IFE were positive in 2 patients each. BMPC ranged from 0 to 22 %. MRD levels did not show significant correlation with percentage of BMPC. MRD analysis by flow cytometry had greater sensitivity to detect patients with residual disease as compared to M band and IFE. Conclusion: MRD detection by MFC is a sensitive method compared to the other parameters listed above; however, the prognostic impact
Indian J Hematol Blood Transfus needs to be evaluated. Patients are on regular follow up to assess their clinical and hematological response. Keywords Multiple myeloma, Minimal residual disease, Flow cytometry
PR 120 Evaluation of Free Light Chains (Flcs) In Normal Individuals, Patients of Renal Failure and Multiple Myeloma Dr. Jasmita, Dr. Sabina Langer, Dr. Amrita Saraf, Dr. Manorama Bhargava
PR 118 Plasma Cell Leukemia—A Report of Two Cases Indhu Kannan, Krishna Kumar Rathinam, Sivakami Meenakshi Mission Hospital Plasma cell leukemias are rare and aggressive forms of plasma cell dyscrasias. It is classified as primary form and secondary form. The primary form presents de novo without previous history of multiple myeloma and the secondary form presents as patient with relapsed/ refractory multiple myeloma showing leukemic transformation. Unlike multiple myeloma, plasma cell leukemia has an aggressive course. Here we report two cases of plasma cell leukemias with advanced bone disease and more than 20 % plasma cells in the peripheral blood. The first case presented initially with plasma cells in the peripheral blood. The second case was a known case of multiple myeloma who had undergone autologous stem cell transplant, with relapse and plasma cells in the peripheral blood. The clinical course in both cases was aggressive with short survival duration. Keywords Plasma cell leukemia, Peripheral blood
PR 119 Cutaneous Involvement In Myeloma—An Uncommon Presentation Dr. Madhup Rastogi Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow Introduction: Skin involvement in multiple myeloma is rare and occurs in a very small percentage of cases. Metastatic cutaneous lesions generally appear late in the course of the disease. Case Report: A 68 year old male, who was on maintenance therapy for multiple myeloma, presented with multiple erythematous nodules over right thigh. The nodules were painful. An incisional biopsy performed. HPE of these lesion demonstrated sheets of neoplastic plasma cells involving the dermis. Tumor cells were positive for LCA, CD 138, Kappa restricted and Ki67 index of 80–90 %. A diagnosis of high grade hematolymphoid malignancy of plasmablastic differentiation. The patient was given radiotherapy with electrons (6 meV; 20 Gy in 5 fractions) to the skin lesions while trying to preserve underlying tissue. After 1 month follow-up, a near-complete regression of the cutaneous lesions was observed. Two months later he again developed large skin nodules at multiple sites, some of which were ulcerated. He was offered palliative care which he declined and lost to follow-up. Conclusion: Cutaneous involvement in MM is a poor prognostic factor and is often a reflection of high tumour burden. The management of cutaneous involvement in myeloma is still not clear. It shows aggressive clinical and biologic course, and poor response to chemotherapy. Radiation therapy may provide worthwhile palliation in view of the relatively high radiosensitivity of myeloma cells but the overall prognosis is dismal once skin metastases develop.
Sir Ganga Ram Hospital Introduction: The present study was undertaken to determine the FLCS in normal individuals, in patients of renal failure and in multiple myeloma with and without renal dysfunction. With the objective of achieving the cut off levels of FLCs in the above defined groups. Aims & Objectives: 1) To assess quantitatively serum FLCs in healthy individuals and in patients of renal disease to validate the reference range in them. 2) To determine the cut off points for k/k ratio in patients of multiple myeloma with and without renal dysfunction. Materials and Methods: Free light chains were assayed using the Freelite TM Human kappa & lambda (MININEPH PLUS TM) in 24 normal individuals, 60 patients with renal failure, 60 patients of multiple myeloma (33 with renal dysfunction and 27 without renal dysfunction. 1: 20 dilution was used for the FLC assays, if values were higher than the detectable range then samples were assessed in serial dilutions (1:200 & 1:2000). Results: Median age for healthy individuals was 42 years (25–52 years) (Males 7 and females 19). In patients of renal dysfunction the median age was 59 years (32–89 years) (Males 33 and females 27). The range of values of j, k light chains in healthy individuals was 5.91–26.10 mg/dl and 8.78–24.09 mg/dl, respectively and k/k ratio was 0.39–1.60. The range of values of j, k light chains in patients of renal dysfunction was 50–420 mg/dl and 0–291 mg/dl, respectively and k/k ratio was 0.51–2.97. Discussion: It is clear that patients with renal failure have higher SFLC values that fall outside the normal range. In patients with multiple myeloma with renal dysfunction FLCs values were higher than the patients without renal dysfunction. The study attempts to establish the cut off values of jk ratios that can be used towards detection of patients of MM with and without renal dysfunction.
Table 1 . Variables
J secreating Myeloma (n = 34)
k secreating Myeloma (n = 26)
k (mg/L)
k (mg/L)
k/k
k (mg/L)
k (mg/L)
k/k
K Secreting14
2133
12.32
219.1
15.14
1858.1
0.042
k Secreting19
(16.47–7514)
(4.8–41.44)
(2.47–1047)
(4.7–39.76)
(66.03–5742)
(0.0013–0.26)
K Secreting12
3549.41
25.88
303.18
31.59
4264.49
0.021
k Secreting15
(79.25–18530)
(4.8–96.7)
(4.8–1266)
(9.26–111.7)
(762–9633)
(0.0012–0.14)
MM without RD
MM with RD
All Values are Expressed in Mean, MM = Multiple Myeloma, RD = Renal Dysfunction The j/k of [2.47 or \0.26 detects all patients of Multiple Myeloma without renal dysfunction The j/k of [4.8 or \0.14 detects all patients of Multiple Myeloma with renal dysfunction
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Indian J Hematol Blood Transfus PR 121
PR 123
Combination of Lenalidomide with Dexamethasone-Is an Effective Therapy For Plasma Cell Variant of Castleman’S Disease
Myelomatous Pleural Effusion—A Rare Case Entity Reported from A Tertiary Care Cancer Centre In South India
Epari Sridhar, Tanuja Shet, Manju Sengar, Sumeet Gujral, Hari Menon Tata Memorial Hospital Introduction: Castleman’s disease (CD) is a rare non-clonal lymphoproliferative disorder with varied presentation. No guidelines exists for treating CD, the options ranging from surgical excision to radiation for localized disease and steroids, anti Il-6 antibodies, Thalidomide and proteasome inhibitors for multicentric disease, albeit with no durable response. We present our data on three patients diagnosed with CD who received Lenalidomide (LD) and Dexamethasone (DX) with early and durable responses. Materials and Methods and Results: Three patients of plasma cell variant of multicentric CD were diagnosed in the last three years at our centre. All presented with generalized lymphadenopathy. Two had systemic symptoms in form of low-grade fever. They were initiated on Lenalidomide 25 mg once a day (Day1-Day21 every 28 days) and dexamethasone 40 mg weekly. Two patients had received therapy earlier with steroids and chemotherapy without benefit while the 3rd was started on frontline therapy with Len and Dexa. Tolerance was good with immediate symptomatic benefit. At six months, evaluation showed excellent clinical response in all 3 patients with a near complete metabolic response documented on PET-CT in two patients. DX was stopped at the end of six months and LD was continued as maintenance. Treatment was withdrawn in one patient who remains disease free and off therapy at 12 months post stoppage. Two patients continue to do well on maintenance LD. Conclusion: LD plus DX seem an effective combination inducing early durable responses in plasma cell variant of CD and should be considered to treat this rare entity.
PR 122 Plasma Cell Myeloma—A Clinicopathological Study Kumar V., Marwah S., Nigam A. S., Buxi G. Dr Ram Manohar Lohia Hospital Introduction: Plasma Cell Myeloma is a bone marrow based, multifocal clonal plasma cell neoplasm associated with M-protein in serum and/or urine. It comprises about 10–15 % of haematological neoplasms. Case Presentation: we present here a series of 7 cases of plasma cell myeloma that presented in our department during last 6 months. Out of 7, 5 were male and 2 were female. The clinical presentation included bone pain, easy fatiguability, swelling all over body, renal function abnormalities, haematological abnormalities such as anemia and pancytopenia. One of the cases presented with abnormal bleeding and had preserved renal function. One case was associated with systemic amyloidosis. Rouleaux formation was observed in peripheral smears in all cases. Bone marrow aspiration and biopsy revealed increase in plasma cells. This case series is a clinicopathological study providing an insight into the variable presentation of plasma cell myeloma. Discussion: Plasma Cell Myeloma spans a clinical spectrum from asymptomatic to aggressive forms. It is usually incurable, with a median survival of 3–4 years. The timely diagnosis which is based on combination of pathological, radiological and clinical features, is essential for early intervention with better outcome. Plasma cell, haematological, clinicopathological.
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Govind Babu K., Akkamaha Devi Patil, Lokesh K. N., Suresh Babu M. C., Lakshmaiah K. C. Kidwai Memorial Institute of Oncology Abstract: Multiple myeloma is a plasma cell neoplasm and constitutes 10 % of hematologic malignancies. Malignant myelomatous pleural effusions are very rare and occur in less than 1 % of cases of multiple myeloma. In this article, we report a rare case of a patient who initially presented with pleural effusion, which was subsequently found to be secondary to multiple myeloma with an underlying IgG paraprotein. The patient was improving on Bortezomib, Thalidomide and dexamethaone (VTD) chemotherapy and palliative radiotherapy.
PR 124 Light Chain Myeloma Presenting With Cast Nephropathy—A Case Report Dr. M. V. Mallya, Dr. R. G. W. Pinto Goa Medical College and Hospital, Bambolim Introduction: Multiple myeloma is a neoplastic plasma cell dyscrasia characterised by anaemia, monoclonal immunoglobulins (heavy and light chains) in serum and/or urine, lytic bone lesions, hypercalcemia and renal insufficiency. In 15 % of cases, only light chains are secreted by the malignant plasma cells and present usually with renal dysfunction. This entity is called Light Chain Myeloma or Bence Jones Myeloma. Materials and Methods: A 55 year old male presented with unexplained renal failure and nephrotic range proteinuria. Routine laboratory and certain special investigations were advised. Results: Kidney biopsy revealed lamellated casts in tubules. Glomeruli showed no significant pathology. Immunofluorescence studies were negative for granular deposits of Ig G, A, M, C3 and Clq in glomeruli. Light chain studies showed Kappa (3 +) positivity within luminal casts. A diagnosis of cast nephropathy (Kappa light chain restriction) was made. Protein electrophoresis did not reveal M band. On urine electrophoresis Bence Jones protein was detected. Patient had anaemia, serum calcium levels were within normal limits, skeletal survey showed no evidence of lytic lesions. Serum creatinine and beta 2 microglobulin levels were high. Bone marrow studies revealed increased plasma cells (8–12 %). Immunofixation studies showed a marked increase in serum kappa light chains. Conclusion: A diagnosis of Light-Chain Myeloma was made. The patient is currently awaiting chemotherapy regimen. This case is presented to highlight the fact that absence of M band does not exclude myeloma and immunofixation studies are a must in suspicious cases. Keywords Cast nephropathy, Kappa light chains, Electrophoresis, Immunofixation
Topic: Platelet Disorders PR 125 Thrombocytopenia In Children—A Clinicopathological Profile Mithun Venugopal, Dr. S Sitalakshmi St. John’S Medical College Hospital
Indian J Hematol Blood Transfus Thrombocytopenia in children is often associated with a high morbidity and mortality. The mechanism of thrombocytopenia in children remained unknown in 20–60 % of cases. Need for the study To study the etiology of thrombocytopenia in children. To study the clinical and hematological features of thrombocytopenia in children Materials and Methods: A prospective study from December 2013 to November 2014 (1 year) in children between the age of 0–18 years diagnosed to have thrombocytopenia at St. John’s Medical College Hospital was done with the sample size of 1000. Platelet counts were assessed by both automated haematology analyser and manually by peripheral smear. Clinical data was obtained from the medical records. Results: Age ranged from 1 day to 18 years. Male to female ratio was 1.2:1. The most common cause of thrombocytopenia was infections (64 %). Among them bacterial infections (32 %) ranked first followed by dengue (27 %). The next common causes were acute leukemia (12 %) and aplastic anemia (7 %). ITP, preterm baby, Wilson’s disease, Down’s syndrome, and macrocytic anemias contributed to the other causes of thrombocytopenia. Conclusion: An analysis of the causes of thrombocytopenia in children in a tertiary care hospital setting, revealed bacterial infections as the most common cause followed by dengue in children groups except in neonatal age group in which sepsis was the commonest cause. Acute leukemias and aplastic anemia were the common haematological causes. Keywords Thrombocytopenia, Dengue, Acute leukemia
PR 126 Point-Of-Care Device Whole Blood Impedance Aggregometry Versus Classical Light Transmittance Aggregometry In Thrombocytopenic Samples Suresh Kumar J, Surendar Singh G, Sukesh C Nair, Joy J Mammen Department of Transfusion Medicine and Immunohaematology, Cmc, Vellore Introduction: Platelet count is an important parameter in performing the platelet function test. Light Transmittance Aggregometry (LTA) is still regarded as the gold standard for platelet function testing, but it has its own limitations; Time-consuming, High sample volume, Sample preparation (macrothrombocytopenia). A Point-of-Care Testing (POCT) dedicated to platelet function, using pertinent devices much simpler to use, has now become available (i.e., Multiplate Whole Blood Impedance Aggregometry—Roche Diagnostics, Germany) with the use of different agonists (similar to LTA), is suitable for diagnosis of bleeding disorder and also for monitoring antiplatelet therapy. Aim: We determine whether whole blood impedance aggregometry helps in evaluating the platelet function disorder in thrombocytopenic samples as compared to Light Transmittance Aggregometry. Methodology: 20 patients with a bleeding history disproportionate to degree of thrombocytopenia were found to have macrothrombocytopenia by peripheral smear examination were enrolled in the study. Platelet aggregation was measured by both Light Transmittance Aggregometry (LTA) and Multiple Electrode Aggregometry (MEA) using Ristocetin, Collagen, Adenosinediphosphate (ADP), Epinephrine, Arachidonic Acid and Thrombin Receptor Activating Peptide (TRAP) as agonists Results: 11 cases diagnosed as Bernard Soulier Syndrome (BSS) by flowcytometry Glycoprotein Ib expression showed similar pattern of platelet function in both LTA and MEA. Platelet morphology with the features of macrothrombocytopenia, neutrophilic inclusions with dohle bodies reveals 4 cases as May Hegglin Anamoly in which the platelet function was subnormal by MEA and in 5 patients with a platelet count in the range of 40000–50000 showed normal platelet function by MEA whereas LTA inconclusive due to low counts. Conclusion:
Multiplate Platelet Function Analyzer helps in evaluating the inherited/acquired platelet disorder in thrombocytopenic samples employing whole blood without the necessity of sample processing.
PR 127 Assessment of Immature Platelet Fraction In Thrombocytopenia Cases Susheela J Innah Jubilee Mission Medical College Background: Thrombocytopenia is a common hematological abnormality. A number of causes may lead to low platelet count but two major mechanisms implicated in the pathogenesis, either increased peripheral platelet destruction or decreased bone marrow production. Examination of the bone marrow megakaryocytic pool is often required to quantify thrombocytopoiesis but it is invasive, discomforting and also unsuitable for frequent follow up in thrombocytopenic patients. In this regard, a sensitive and non-invasive test, capable of evaluating the thrombocytopoietic activity would be of substantial clinical value. Quantifying RNA platelet content by flow cytometry has been proposed for evaluating platelet turnover. Reticulated platelets (RP) are the youngest circulating platelet population that contain rough endoplasmic reticulum and mRNA. Analysis of RP provides a good estimate of the rate of platelet production in bone marrow, a quantifiable representative of which is Immature Platelet Fraction (IPF), the fraction of immature platelets by the mature platelets. Aim: To evaluate sensitivity and specificity of immature platelet fraction (IPF) as an index of reticulated platelets (RP), as a diagnostic and screening test for thrombocytopenia with increased thrombopoietic activity (caused by acceleration of peripheral consumption). Design: Prospective observational study of all thrombocytopenic patients admitted in our hospital for a 6 months period. Methods: Blood samples from thrombocytopenic patients was checked for immature platelet fraction and platelet count using the Sysmex XN 1000 automated complete blood count analyzer which is based on the principle of flow cytometry. Patients’ clinical history along with diagnosis will be compared with this parameter. Results: The most significant increase in IPF value was found in acute ITP cases. Till now following treatment it was found that as platelet recovered IPF percentage fell. Further results are awaited as this study has a prospective design. Keywords Thrombocytopenia, Immature platelet fraction, Reticulated platelets, Sysmex XN 1000.
PR 128 Persistent Neonatal Thrombocytopenia—Wiskott Aldrich Syndrome Not To Miss!—2 Case Reports Dr. Chandrakala, Dr. Farah Jijina Kem Hematology, Mumbai Introduction: Severe neonatal thrombocytopenia is uncommon in the general healthy newborn population with a reported incidence between 0.14 % and 0.24 %. Case series report that a cause of thrombocytopenia is identified in about in 50 to 75 % of neonates. Relevant case presentations Case 1: : First born, male child BONCM admitted 3 times in neonatal period for repeated episodes of petechiae & Per rectal bleed, with investigations suggestive of severe thrombocytopenia with normal sized platelets and MPV of 8.4 fl, responding to IVIG in each episodes but work up for NAIT was
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Indian J Hematol Blood Transfus negative. Patients had JMML like blood picture without organomegaly and negative work up. At 4 th month of life baby developed eczematous rash over body prompting for work up of wiskott Aldrich syndrome (WAS) revealing c.37C [ T (p.R13X) mutation. Case 2: : 10 days old male child BONCM admitted for persistent loose motions, occasionally bloody in nature. Family history of 2 elder male sibling died in infantile age with similar history of bloody diarhoea. Patient had severe thrombocytopenia not responding to IVIG. Patients peripheral smear suggestive of small sized platelets with MPV of 6.0 fl. Patients work up for Was had done and revealed c.1189_1190insCGCCA;p.P399Rfs*48, a novel mutation. Need of presenting the case and discussion: WAS can present with persistent neonatal thrombocytopenia and other features of syndrome can evolve over period of time. Its suspicion is warranted in the setting neonatal thrombocytopenia with JMML like blood picture. Rarely WAS patients can have normal MPV.
PR 129 Platelet Function Defects—A 5 Year Audit of Cases Analyzed In A Tertiary Care Hospital from 2010 to 2015 Dr. Amrita Saraf, Jasmita Dass, Jyoti Kotwal, Manorama Bhargava Sir Ganga Ram Hospital Introduction: The Present study is a five year audit of patients referred to the department of hematology of Sir Ganga Ram Hospital for clinical bleeding towards exclusion of a qualitative platelet function defect. Materials and Methods: A total of 100 cases including 53 adults (13 to 80 years, 36 females, 17 males) and 47 children (3 months to 12 years,20 females and 27 males) were investigated for platelet function studies on a Chronolog platelet aggregometer using platelet rich plasma from citrated samples. The panel of agonists used were ADP (2.5 lM and 5.0 lM), epinephrine (2.6 lM), collagen (10 lg/L), arachidonic acid (0.25 lM) and ristocetin (1.5 mg/mL & 0.5 mg/mL). A detailed history for bleeding, family history of bleeding and drug history was taken. The patients were instructed to be off medication for 4 days prior to testing with overnight fasting. Appropriate controls were used for each patient. Results: The most frequent presenting complaints were history of petechiae, easy bruisability, epistaxis and gum bleeds among children and menorrhagia in adolescent and young females. In 55 of 100 cases no platelet function defect was found. In the remaining the pattern was Glanzmann’s Thromboasthenia (GT) in 10, vonWillebrand Disease (vWD) in 6, storage pool disorder in 3, Bernard Soulier’s Syndrome (BSS) in 1,7 cases with unclassified platelet defects. In 18 of the 100 patients, drug resistance to Aspirin and or Clopidogrel was also looked for. Conclusion: The audit revealed inherited platelet disorders in children to be GT, vWD, Storage pool disorder and BSS. In adult females, vWD was the commonest. In 55 % of subjects no platelet function abnormality was detected. Code:PH. Keywords Platelet function defect, Aggregometry
PR 130 Prevalence and Etiology of Thrombocytopenia In Pregnancy Mansi Oberoi, Dr. Sunita Sharma, Dr. Manjula Jain, Dr. Manju Puri Lady Hardinge Medical College Introduction: Thrombocytopenia is defined as platelet count of less than 150,000/lL. Accounts for 7–8 % of pregnancies, classified as
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mild (platelet count of C100,000 to \150,000 ll! -1), moderate (C50,000 to \100,000 ll-1) and severe (\50,000 ll-1). The various causes of thrombocytopenia are Gestational thrombocytopenia (GT) (75 %), Immune thrombocytopenic purpura (ITP) (5 %). Preeclampsia (PE) and HELLP syndrome (21 %). Materials and Methods: Cross sectional study, from 1st June–31st JULY 2014, including 1000 pregnant women. Patients were screened for thrombocytopenia through Complete blood count. Other test like Kidney function tests (KFT), Liver function tests (LFT), HBsAg, HIV, VDRL. Coagulation tests (PT, APTT, FDP, D-dimer and fibrinogen) were performed. Detailed history of petechiae, bruising, drug usage. viral infection, neurological deficits, fever, bleeding, obstetrical history, past history of jaundice, illness, family and personal history was taken. Results and Observation: The prevalence of thrombocytopenia was 13.4 %, greater than the world’s literature (6–11.5 %). Majority were 21–25yrs of age belonged to 3rd trimester (93.3 %), 35.8 % had mild,53.7 % moderate and 10.4 % had severe thrombocytopenia. Most common etiology found was GT (34.3 %) followed by Anemia (20.1 %), PIH (12.7 %), deranged LFT (6 %), viral infections (HepB, HIV, TORCH) (5.2 %), hypothyroidism (3.7 %), APH (3 %), infective causes (3 %), PE (2.2 %), HELLP (1.5 %) Eclampsia (1.5 %), ITP (0.7 %) and APLA (0.7 %). S Conclusion: Thrombocytopenia is second only to anemia as the most common hematological abnormality in pregnancy. It is often underdiagnosed and mismanaged condition. Study helped to find out various etiological factors of thrombocytopenia during pregnancy and thus to yield best fetomaternal outcome.
PR 131 Labeling Everything As Immune Thrombocytopenia, Are We Too Rash? Dr. Anupa Joshipura, Dr. Yashshree Gupta, Dr. Khushnuma, Dr. Sangita Mudalier, Dr. Archna Swami Bai Jerbai Wadia Hospital For Children Abstract: ITP (immune thrombocytopenic purpura) is well known entity but the term is used as a diagnosis, very liberally. Here we present two cases diagnosed as ITP, at another centre, which eventually turned out to be platelet function disorder. First case is of 6 years male child, born of third degree conganguineous marriage who presented with multiple episodes of epistaxis & bluish discoloration of skin after trivial injury since 1 year. In the past, patient had hematochezia on day 7 day of life & hemetemesis at 2 years of age. On examination, there was pallor with no organomegaly. At the other centre, he was found to have thrombocytopenia. Bone marrow aspiration (BMA) was suggestive of cellular marrow, normal myelopoiesis & increased megakaryocytes. Patient was diagnosed as ITP & started on steroids & platelet transfusion. In view of no response, IVIG was also administered but patient’s platelet count ranged between 30000 to 50000/cumm. Hence he was referred to our institute as chronic ITP. At admission he presented with epistaxis. His platelet count was 25000/cumm. On PS, we observed giant platelets without platelet-clumps. Hence he was investigated for a functional platelet disorder. On platelet flow cytometry, Glycoprotein receptors measured GP Ib = 0.05 % & GP IX = 0.19 %. This confirmed the diagnosis of Bernard Soulier Syndrome. Similarly, case 2 was a 3 years female child with epistaxis & ecchymosis since 1 year. Diagnosed as ITP, treated with steroids, IV IG & platelet transfusion. Patient was referred as chronic ITP. PS at our centre, revealed Giant platelets. Flow cytometry showed nil GP Ib expression. This confirmed the diagnosis of Bernard Soulier Syndrome. Hence to conclude ITP is diagnosis of exclusion. Platelet function disorders must be screened out by performing a PS. BMA might
Indian J Hematol Blood Transfus reveal increased megakaryocytes. Also, a suspicion should be based on bleeding that cannot be explained by the level of thrombocytopenia. Misdiagnosis of ITP can be prevented and also inappropriate treatment like steroids and IV IG. Bai Jerbai Wadia Hospital For Children.
In cases of hemolytic anaemia diligent peripheral smear examination may reveal agglutination of RBCs and features of hemolysis to reach a diagnosis of autoimmune hemolytic anaemia.
PR 134
Topic: RBC disorders
A Study of G-6-P-D Activity In Common Congenital Hemolytic Anaemia With Special Reference To Sickle Cell Anaemia and Thalassemia
PR 132 Concomitant Hemophilia A With Sickle Cell Anemia: A Rare Blessing In Disguise? Dr. Yashashree Gupta, Dr. Khushnuma Mullanfiroze, Dr. Ankit Parmar, Dr. Sangeeta M, Dr. Archana S Bj Wadia Childrens Hospital, Mumbai Sickle cell anemia and hemophilia A, individually, are the commonest hematological disorders one may come across. However their coexistence is rare. Presenting a 7 year old male born out of a nonconsanguineous marriage coming with fever and chest pain along with multiple hematomas on the limbs with trivial trauma with no major mucosal bleeds. Pallor without hepato-splenomegaly and joint swellings were present. The CBC was suggestive of a macrocytic hypochromic anemia with increased WBC counts and normal platelets and a deranged aPTT with normal PT. Peripheral smear showed sickle cells which was confirmed by Hb electrophoresis showing HbS of 77.7 %. Coagulation factor assay revealed Factor VIII levels of \1 % (severe Hemophilia A). This is probably the first such case reported in literature as per our knowledge. The patient was started on hydroxyurea. It was observed that this child never suffered from any pain crisis and that there were only two episodes of joint bleeds till date requiring factor VIII transfusion. Studies reveal that increased levels of factor VIII to be associated with increase in the pain crisis. It can be hypothesized that natural deficiency of such a vital coagulant factor might be the reason for the decrease in the vaso-occlusive episodes in this patient. Such a case is likely to provide further insight into the link between sickle cell, coagulation system and sickle crises and help.
Narendra Nath Soren, Nanda Kishor Naik M.K.C.G. Medical College, Berhampur Introduction: Glucose-6-phosphate dehydrogenase deficiency is the most common self limiting X-linked enzymopathy causing haemolytic anaemia worldwide. Due to short life span of RBC without having any metabolic pathway other than G6PD catalysed HMP pathway to generate NADPH, G6PD deficiency is lethal to cell. Need for study: As G6PD deficiency, the most common enzymopathy causing haemolysis and haemolytic anaemia like sickle cell anaemia & thalassemia are prevalent in tribal odisha, the association between them needed to be studied since most children in tribal odisha remain undiagnosed due to lack of awareness and prevalent system of consanguineous marriage. Materials & Method: Out of 240 children (0–14 years) presented with anaemia, jaundice, hepatosplenomegaly, bone pain during 1st August 2014 to 31st July 2015 to dept of paediatrics, M.K.C.G. MCH, Berhampur,74 children found to be having sickle cell anaemia or thalassemia were selected and screened for erythrocytic G6PD activity. Result:Among 74 cases, Sickle cell disease contributes maximum (36) and sickle cell thalassemia, the minimum (6). The overall incidence of G6PD deficiency among hemoglobinopathy cases was 29.7 % against 11 % in general population. G6PD deficiency found to be more common in Sicklers (19.2 %) than thalassemia (10.8 %) and males outnumber females as 1.65:1. Conclusion: This small study concludes that G6PD deficiency is more prevalent in qualitative haemoglobinopathy than quantitative defect of haemoglobin. Due to endemicity of malaria and presumptive use of antimalarials in children with haemoglobinopathy might be contributing for need of repeated blood transfusion. Hence it needs extensive study to evaluate for G6PD deficiency association with hemoglobinopathy before giving any concrete conclusion. Keywords G6PD deficiency, Haemoglobinopathy, Antimalarials
PR 133 Cold Agglutinin Disease: A Case Report PR 135 Kumar V, Marwah S, Nigam A S, Buxi G P.G.I.M.E.R., Dr. R.M.L. Hospital Introduction: Cold agglutinin disease is a type of autoimmune hemolytic anemia caused by cold-reacting autoantibodies. Incidence of cold agglutinin disease is approximately 1 in 300,000. Primary cold agglutinin disease is chronic and occurs after the fifth decade of life. It is usually associated with monoclonal cold-reacting autoantibodies. Secondary cold agglutinin disease may be associated with either monoclonal or polyclonal cold-reacting autoantibodies. It predominantly is caused by infection and lymphoproliferative disorders. Monoclonal secondary disease is usually chronic, occurring in adults. Polyclonal secondary cold agglutinin disease, which occurs in children and young adults, is usually transient. Case presentation: A 50 years old male presented with jaundice and indirect bilirubin was high. On peripheral blood smear marked agglutination was seen. Results: Direct Coomb’s test was positive (2 +) and Indirect Coomb’s test was positive at 37 degree Celsius. Hence, a diagnosis of cold agglutinin was made. Case was managed conservatively. Conclusion:
Pharmacological Induction of Foxo3 Is A Potential Treatment For Sickle Cell Disease Ils Hospital Background: Although individuals with sickle cell anemia apparently have a monogenetic disease, they exhibit wide variability in the degree of clinical severity. One of the most powerful and reproducible predictors of disease severity is the level of endogenous fetal hemoglobin (HbF), composed of two c-globin and two a-globin chains. Expression of HbF is reduced in infancy and little is known about how this regulation is accomplished. A better understanding of gamma-globin regulation could aid in the discovery and design of a specific c-globin inducing agent. Aim: Taking a genomics approach to this question, we are investigated the natural human variation and its correlation with HbF levels to identify novel genes important for cglobin regulation. Methods: We enrolled a total of 160 pediatric sickle cell anemia patients (HbSS, age 3–18 years. In this study we performed whole exome sequencing (WES) and used gene-based
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Indian J Hematol Blood Transfus analysis to find correlations between rare variants and endogenous HbF levels. Results: We found seven unique non-synonymous variations in a Forkhead box O transcription factor, FOXO3, to be significantly associated with lower HbF (p = 0.00053, b-value ln HbF -0.56). We investigate the association between FOXO3 and endogenous HbF levels in an ex vivo model of erythroid differentiation from CD34 + cellsisolated from peripheral blood called primary erythroid culture. Conclusions: These results strongly suggest that FOXO3 is a positive regulator of c-globin. The c-globin specific effect of FOXO3 is critical; FOXO3 is an excellent therapeutic target for the treatment of sickle cell disease, as it selectively induces HbF, which does not sickle, without inducing HbS. Also, FOXO3 does not delay erythroid maturation, instead actually promotes erythroid maturation. Taken together, the results indicate that FOXO3 is a positive regulator of c-globin expression and an excellent therapeutic target for fetal hemoglobin induction. Their findings support a new mechanism underlying fetal hemoglobin regulation and help identify potential new HbF inducing agents. Fig. 3 (shRNA knockdown of FOXO3 reduces HbF in primary erythroid cells)
Fig. 1 (Effect of FOXO3 Variants on %HbF)
Fig. 4 (FOXO3 overexpression increases HbF in K562 cells)
PR 136 Rare Haemoglobin Variant Hb J Meerut In 27 Years Old Female Dr. Parth Patel Cims Hospital, Ahmedabad
Fig. 2 (FOXO3 siRNA knockdown reduces HbF levels in K562 cells)
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Hemoglobin has plenty of variants and fast moving hemoglobins (FMH’s) are the rare hemoglobin variants. They are having tendency to migrate anodally to hemoglobin A on alkaline gel electrophoresis. Because of the mutation in the globin genes, these hemoglobin variants have the fast moving nature. The basic pathophysiology behind it is the substitution of a negatively charged amino acid residue in either a, b or c globin chains. Hb J Meerut is an
Indian J Hematol Blood Transfus infrequently found a-globin variant. It has previously been reported in various populations around the world. Here, we are reporting a case of Hb J meerut who came to laboratory for thalassemia screening.
PR 137 Association of Beta Thalasemia With Acute Lymphoblastic Leukemia Sima Chauhan, Kumudini Devi, Suryajit Singh
presented with haematological malignancies (4cases being leukemia and 2 cases of multiple myeloma) and sickle cell haemoglobinopathies. There was no history of hydroxyurea therapy. In other 2 cases ALL & AML, the patients were known cases of sickle cell diseases and were treated with hydroxyurea. Conclusion: There is a definite association between Sickle cell disease and haematological malignancies. It could be due to (a) Treatment with hydroxyurea, (b) accumulation of multiple genetic abnormalities over the long years, due to high degree of proliferative activity. The exact association is yet to be ascertained which needs more elaborate study.
Sum Medical Collage Introduction: b-Thalssemias are characterized by production of normal hemoglobin but in reduced number due to absent or decreased synthesis of b-globin polypeptide chain. Thalasemias are autosomal recessive disorders. Immune imbalance in poorly managed patient is responsible for occurrence of different malignancies such as Leukemia and Lymphomas and their Co-existence worsens the prognosis. Materials and Methods: Patients were assessed clinically and send for complete blood count, PS comment, Hb electrophoresis and bone marrow if needed. Result: 7yrs old male child presented to Hematology OPD with low grade fever, fatigue and marked pallor (Hb-5.6 gm) for 2 months. Hb electrophoresis revealed b—Thalassemia trait. Peripheral Smear showed occasional atypical cells. Bone marrow study revealed acute Lymphoblastic Leukemia with 89 % blasts. Another 13yrs old male child known case of b-Thalassemia trait presented with persistent low Hb and CBC revealed 25 % blasts. Bone marrow study was done which showed Acute Lymphoblastic Leukemia with 88 % blast. Conclusion: Thus two bThalassemic trait patient showed associated with acute lymphoplastic Leukemia out of total 110 cases of thalassemia on our centre from July 2014-July 2015. Some other study shows incidence of cases of malignanes is up to 9.4 %. Hence all thalassemia patients with low Hb should be evaluated for presence of associated Hematological malignancies.
PR 138 Association of Haematological Malignancies and Sickle Cell Disease; Revisited—A Series of 6 Cases in the Eastern Indian State of Odisha from 2012 to 2015
PR 139 Prca Associated With Trisomy 8: A Rare Association Or Evolving Mds? : Case Report Dr. Sima Chauhan, Dr. P. K. Das, Dr. Abhishek Saini, Dr. Ripunjaya Mohanty, Dr. Kumudini Devi I.M.S.& Sum Hospital, Bhubaneswar, Odisha Introduction: PRCA is a uncommon disorder characterized by anemia, reticulocytopenia, and absence of mature erythroid precursors in an otherwise normal marrow & usually caused by immunological or viral etiology. Cytogenetics abnormality in PRCA is extremely rare. Rarely, PRCA can also be the only or initial manifestation of myelodysplasia, which poorly responds to immunosuppressive agents. Therefore, PRCA needs to be differentiated from MDS associated erythroid hypoplasia. Materials and Method: Patients attending hematology OPD were clinically examined and CBC, blood picture, bone marrow and cytogenetic study were done as required. A 73 yrs old male presented with transfusion dependant anemia for 8 months. CBC revealed Hb 8.12gm/dl, TLC—8000/ul, TPC-2.7 lakh/ul, reticulocyte count—0.2 %. Blood picture showed macrocytosis. Bone marrow study revealed marked depletion of erythroid cells (1 %of MNC) and other lineage were normal, no ALIP in trephine was seen. A diagnosis of PRCA was made. PCR for parvo B-19 was negative. Cytogenetics analysis revealed presence of a neoplastic clone (gain of chromosome 8 as trisomy) which is commonly seen in MDS/AML. Result: Final diagnosis of PRCA with cytogenetic abnormality trisomy 8 was made keeping in mind the high probability of evolution into MDS. Keywords PRCA, MDS
Dr. Prabodh Das, Dr. Kumudini Devi, Dr. Sarita Pradhan, Dr. Ripunjaya Mohanty, Dr. Abhishek Saini I.M.S.& Sum Hospital, Bhubaneswar, Odisha
PR 140
Introduction: The disorders resulting from Sickle hemoglobin (HbS) are of enormous clinical importance being wildly distributed all over the world with higher prevalence. Sickle hemoglobinopathies are autosomal recessive hereditary diseases. SCD mutation is not oncogenic directly, SCD involve multiple system and is manifested by variable degree of anemia, acute vaso-occlussive episodes and chronic organ damage. SCD is associated with high degree of proliferation of bone marrow cells, chronic inflammation and immune dysregulation predisposing to malignancy. We got 6 cases of association of sickle cell diseases with hematlological malignancies in last 3 years. Out of which only 2 cases have definite history of therapy with hydroxyurea. Materials and Methods: Detailed clinical history, complete hemogram, peripheral blood smear study, USG abdomen, capillary zone electrophoresis, bone marrow examination. Results: In all the cases patients concurrently
Chorea-Acanthocytosis: A Case Report of A Rare Neuroacanthocytic Syndrome Dr. Sima Chauhan, Dr. Sarita Pradhan, Dr. Ripunjay Mohanty, Dr. Rajashree Tripathy, Dr. Kumudini Devi Department of Lab Haematology and Pathology, I.M.S.& Sum Hospital, Bhubaneswar, Odisha Introduction: Chorea acanthocytosis is an extremely rare hereditary adult onset disease with prevalence being 1–5/10000 characterized by red cell acanthocytosis and progressive degeneration of basal ganglia resulting in movement disorders like chorea. Neuroacanthotic syndromes are spectrum of disorders including Chorea canthocytosis, McLeod syndrome, Huntington disease like 2, Pentothenate kinase associated neurodegeneration (PKAN). Materials and Methods:
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Indian J Hematol Blood Transfus 55 yr male from psychiatric ward presented with chorea having onset of symptoms approximately 10yrs back, increasing progressively. The clinical profile and imaging features were collecte along with CBC, peripheral smear & biochemistry investigations. Results: Patient presented with chorea, rubber man like gait & seizure. The coronal FLAIR revealed partial atrophy of caudate nucleus. Peripheral smear revealed acanthocytic RBCs on multiple occasions with 1:1 saline dilution. Serum creatinine phosphokinase levels were elevated (1000 U/L). Huntington’s disease as first differential diagnosis was ruled out as patient had predominantly acanthocytes in peripheral smear, absence of areflexia, weakness and atrophy of muscles. PKAN was ruled out clinically. Other causes of acanthocytes like abetalipoproteinemia, thyroid disorders, liver cirrhosis were ruled out. Western blot done from an outside lab revealed decrease chorein levels confirming the diagnosis. Conclusion: Patient with choreatic movements need to be evaluated for simple laboratory investigations like acanthocytosis on peripheral blood smears and serum creatinine phosphokinase levels. Although rare screening for acanthocytes in patients of movement disorders gives a clue to the diagnosis and further aid in opting confirmatory tests. Keywords Chorea, Acanthocytes
PR 141 Association of G6Pd Deficiency With Beta Thalassaemia Trait In A Patient Leading To Unusually Low Level of Red Cell Indices – A Rare Case Report Dr. Prabodh Das, Dr. Sarita Pradhan, Dr. Ripunjay Mohanty, Dr. Abhishek Saini, Dr. Kumudini Devi Deptt.of Haematology, I.M.S.& Sum Hospital, Bhubaneswar, Odisha Introduction: G6PD Deficiency leads to oxidant damage of erythrocyte component and haemolysis in response to certain drugs/ vegetables/immune responses. Such people are not anemic unless challenged by agents like primaquin, dapson etc. Full expression of the trait occurs in hemizygous males in whom the single 9 chromosome carry the mutant gene and homozygous state is only seen in females where both sex chromosomes carries the mutant gene. Haemoglobinopathies and G6PD deficiency are the most frequently occurring hereditary haemolytic disorders causing high morbidity and mortality in vulnerable people. Combined haemoglobinopathies and G6PD deficiency in a single individual is very rare. Materials and Methods: Patients attending haematology, paediatric, medicine OPDs were clinically assessed for anemia. Investigations like complete blood count, G6PD level and haemoglobin electrophoresis, Liver function tests were done. Results: A 40 yr male patient presented with intermittent episodes of low haemoglobin, jaundice since birth. O/E – pallor+, icterus+, Hepatosplenomegaly. Past (two month back) history showed—haemoglobin of—5.6gm %, Reticulocyte count -8 %, total bilirubin-16.8 g/dl, indirect bilirubin -15 mg/dl. Hb Electrophoresis revealed Beta Thalassaemia Trait. But Beta Thalassaemia Trait alone cannot cause such picture. Present investigation revealed Hb-12.2gm %, Reticulocyte-0.95 %, L.F.T –mildly elevated indirect bilirubin (1 mg/dl). All other haemolytic work up tests normal, excepting G6PD level, which is low 3.8U/g Hb (normal :6.4–18 U/g Hb). Conclusion: All patients with haemoglobinopathy and inappropriately low Hb level should be screened for associated G6PD deficiency as well, because both together lead to very low RBC
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indices and increase morbidity and mortality in vulnerable populations. Keywords G6PD, Haemoglobinopathies
PR 142 Baseline Characteristics, Clinical Profile and Outcomes of Patients With Paroxysmal Nocturnal Hemoglobinuria-A Single Centre Experience Over 4 Years Suresh.C.N, Dr. Sharat Damodar, Dr. K. S. Nataraj, Dr. Swasti Sinha Department of Hematology, Narayana Hrudayalaya, Bangalore Paroxysmal nocturnal hemoglobinuria is rare, acquired disease associated with hemolytic anemia, bone marrow failure, thrombosis, and, frequently, poor quality of life. Paroxysmal nocturnal hemoglobinuria (PNH) is nonmalignant clonal disorder of hematopoietic stem cells characterized by somatic mutation in the PIG-A gene, encoding the glycosyl phosphatidylinositol (GPI) moiety. PNH clones lack GPIanchored proteins (GPI-AP) which inhibit the activation and cytolytic functions of complement. In this study we assessed baseline characteristics, clinical profile of patients with a confirmed paroxysmal nocturnal hemoglobinuria diagnosis or detectable paroxysmal nocturnal hemoglobinuria clone irrespective of treatment. Here we report the characteristics of the 16 patients diagnosed between April 2012 to August 2015 and treated at our centre. Male:Female ratio is 10:6 and median age was 39 years (14–66yrs). At presentation overall, 6.25 % of patients had a history of thrombotic events and 12.5 % a history of impaired renal function. Frequently reported symptoms included fatigue (75 %), dyspnoea (45 %), hemoglobinuria (25 %), abdominal pain (44 %). 43 % of patients had been hospitalized due to paroxysmal nocturnal hemoglobinuria-related complication. 62.5 % of patients had pancytopenia,25 % had bicytopenia and 12.5 % had anemia at time of first visit. Median granulocyte paroxysmal nocturnal hemoglobinuria clone size was 39 % (range 0.5 %91 %).37.5 % patients had classical PNH, and 62.5 % patients had PNH with secondary bone marrow disorders. Therapies included anticoagulation (6.25 %), immunosuppression (56 %), bone marrow transplant (18.75 %) and intermittent blood product support (19 %). Overall mortality was 18.75 % (3/16). Presently 81.25 % (13/16) are on follow up with 38.4 % (5/13) on steroids and 23 % (3/13)on steroids with danazol. One patient (7.6 %) on cyclosporine, one on thalidomide (7.6 %) and remaining 3 (23 %) patients on intermittent blood product support.
PR 143 Case Study—Double Heterozygous For Beta Thalassaemia & Hb Q India—Family Screening Sanjeev Nandani, Falguni Jani, Kamlesh Dharajiya, Heena Kashiyani Indian Medical Scientific Research Foundation At our center we have identified beta thalassaemia trait were 512 out of 5807 cases (Incidence = 8.81 %) & Hb Q level incidence at was 13 out of 5807 tests (Incidence = \0.5 % {0.22 %}). The cases of
Indian J Hematol Blood Transfus double heterozygous Hb Q Beta thalassaemia trait were 02 out of 5807 tests.
PR 144 A Case of Refractory Anemia: Pnh Dr. A. S. Nigam, Dr. Vijay Kumar, Dr. S. Marwah, Dr. G. Buxi
Peak Name
Calibrated area %
Retention Time
Peak Area
Unknown
0.0
0.97
1063
F
0.6
1.08
17023
Unknown
1.0
1.22
27769
P2
3.4
1.35
94238
P3 Unknown
3.8 0.3
1.76 2.13
105040 7509
Ao
76.7
2.44
2114743
A2
5.4*
3.65
159116
Unknown
8.0
4.69
220821
Unknown
0.3
4.83
8768
Peak Name
Calibrated area %
Retention Time
Peak Area
Unknown
0.0
0.96
796
F
0.6
1.09
15209
Unknown
1.1
1.22
26197
P2
2.8
1.35
66556
P3
3.9
1.76
91892
Unknown
0.3
2.13
6559
Ao A2
76.6 4.7
2.46 3.65
1788560 124013
Unknown
8.9
4.70
207614
Unknown
0.4
4.84
9039
Dr. Rml Hospital, New Delhi Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder caused by deficiency of glycosyl phosphatidylinositol (GPI) anchored proteins on the hematopoietic cells and is uncommon in the Indian population. Case presentation: A forty-two years old female presented with complaints of pallor, weakness and easy fatigability suggestive of anemia for last 4 years. Since last three months she was having jaundice with severe anemia and had received multiple blood transfusions. Her iron profile as well as vitamin B12 and folate levels were normal. Peripheral smear showed features of hemolysis. Her serum LDH levels were raised, coomb’s test and antinuclear antibodies were negative. Hemolytic anemia was suspected in the patient. Urine analysis was advised which turned out to be positive for hemoglobin. Bone marrow examination suggested erythroid hyperplasia. In view of clinical history, peripheral smear and bone marrow paroxysmal nocturnal hemoglobinuria was suspected which was further confirmed by flowcytometry. Conclusion: PNH should be suspected in cases of refractory anemia. Although, presence of traid of hemolytic anemia, pancytopenia and thrombosis is unique to PNH but the diagnosis should be confirmed by flowcytometry. Keywords PNH, Hemolytic anemia, Flowcytometry
PR 145 Clinico-Hematologic Spectrum of Genetic Hemolytic Anemias Pani Kc, Sharma S., Phadke S., Agarwal S. Sgpgims Background: Genetic hemolytic anemias are broad category of hematological disorders that includes the hemoglobinopathies, enzymopathies and membrane disorders. This study presents the pattern of haemoglobinopathies amongst the referred patients of anemia in a two-year period in a tertiary hospital. Methods: Patients included in the study presented to Department of Medical Genetics, SGPGIMS, Lucknow, with clinical presentation suggestive of genetic haemolytic anemia. Clinical history and physical examination findings were recorded on a patient record proforma during the OPD visit. Appropriate radiological investigations like abdominal USG, chest X-ray etc. were done where indicated. Multiparameter hemogram, including Hemoglobin, Hematocrit, red cell indices, RBC count, WBC count, platelet count, automated reticulocyte count and red cell morphology was done in each case. Additional diagnostic tests included sickling test, hemoglobin solubility test, osmotic fragility, quantification of various hemoglobin variants by HPLC (Biorad system). Results: A total of 155 cases of genetic haemolytic anemia were diagnosed during the study period. 72 patients were diagnosed to have various Thalassemia syndromes, 29 patients had sickle cell syndromes, 24 patients had hemoglobin E disorders, 6 patients had hemoglobin D disorders and 24 patients were diagnosed as hereditary spherocytosis. Mutational analysis by ARMS-PCR was done in 62 cases of various Thalassemia syndromes as well as structural variants. Three common mutations (IVS1-5G-C, CO 41–42 AND CO 8–9) accounted for more than 87 % of all Thalassemia mutations. Other less common mutations found in the study included 619 bp deletion, CO15-16, CO30, CO16 and CO15. Ten patients underwent splenectomy during the study period. Histopathological slides were reviewed and findings were correlated with clinical findings. Conclusions: In this study we
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Indian J Hematol Blood Transfus found that thalassemia syndromes were the most common of the hemoglobinopathies. Other prevalent hemoglobinopathies included sickle-cell syndrome and hemoglobin E disorders. Few cases of some rare hemoglobinopathies were also diagnosed. The clinical severity scores did not correlate with hematological findings as several genetic modifiers affect the disease phenotype.
PR 146 Experience With A Dual System For Haemoglobinopathy and Hba1C Assay-An Ideal Tool For A Clinical Laboratory
truncal ataxia. Complete haemogram revealed, hemoglobin of 7.7 g/ dL, MCV—79 fl, MCH—21.6 pg., RDW—78.9 fl, with peripheral smear showing microcytic hypochromic with plenty of macrocytes suggestive of dimorphic anemia. Serum vitamin B12 was low. Baby was started on inj. vitamin B12 and his symptoms gradually improved. Presently, his symptoms are minimal with gradual attainment of milestones. Hence, diagnosis of infantile tremor syndrome was made. Discussion Infantile tremor syndrome, neurological manifestation of vitamin B12 deficiency, is seen in children from low socio-economic status with poor weaning diets. This report aims to generate awareness regarding this declining, but treatable cause of neuroregression in infancy. Keywords ITS, Vitamin B12
Pankhi Dutta Kokilaben Dhirubhai Ambani Hospital Introduction: Cation exchange high performance liquid chromatography (CE-HPLC) is a popular method for haemoglobinopathy/ thalassemia detection. BioRad’s D10, a table top CE-HPLC instrument has two programmes, for HbA1C assay and for thalassemia/ haemoglobinopathy detection respectively. Materials and Methods: This is a retrospective analysis of all samples sent for HPLC over a three year period, i.e., June 2012–May 2015 at a tertiary care hospital at Mumbai in order to—1) see the spectrum of abnormal haemoglobins detected 2) evaluate the performance of the dual system in haemoglobinopathy/thalassemia detection. The chromatograms alongwith a complete blood count were analysed in all cases. Additionally, sickling test, supravital staining, parental HPLC, iron studies, were done as indicated. Results and Observations: Out of 1286 samples, 165 (12.8 %) showed an abnormality of which beta thal trait were 113. The spectrum included beta-chain variants like HbE, HbS, HbD, etc., alongwith alpha thalassemia (HbH disease) and alpha chain variants like HbQ India. In most, it was possible to differentiate between hetero, homo and compound heterozygous states based on the chromatograms. The HPLC findings and haematological details of all the cases are given in the table. In only 2 cases out of 1286, a diagnosis couldn’t be made on HPLC. Iron deficiency was seen in 140/256 cases of which only 42 had HbA2 values below 2 %. In 27 cases, iron deficiency co-existed with beta thal trait and other haemoglobinopathies. Conclusion: The D10 can detect most common haemoglobinopathies. Its additional use for HbA1C assay does not compromise thalassemia/haemoglobinopathy detection.
PR 148 Isoniazid Induced Pure Red Cell Aplasia—A Case Report Dr. S. K. Behera, Dr. Jayanti Nayak, Dr. D. P. Mishra Mkcg Medical College Introduction: Pure red cell aplasia (PRCA) is a clinical syndrome defined by the absence of mature erythroid precursors in an otherwise normocellular bone marrow. Among the hematological side effects that are caused by isoniazid like eosinophilia, thrombocytopenia and autoimmune hemolytic anemia, pure red cell aplasia is one of the rare effect. Case Report: Here, we report a case of isoniazid induced pure red cell aplasia in a 43 year old patient who was under Category 2 DOTS regimen. The patients hematological profile was absolutely normal before the start of the chemotherapy following which he developed progressive pallor and bone bone marrow revealed absence of erythroid cells. Myelopoeisis and megakaryopoiesis were normal with normal pattern of maturation (Fig. 2). Prussian blue stain for iron showed increased stores of iron in marrow. Hence a diagnosis of acquired pure red cell aplasia was made and isoniazid was suspected as the culprit and particular drug was stopped from treatment. Later, the patients hemoglobin starts increasing with repeat bone marrow showing re appearance of erythroid cells. Hence, the diagnosis of isoniazid induced pure red cell aplasia was confirmed. Conclusion: We report this case because of its rarity and the need of early diagnosis since simple discontinuation of drug will result in complete cure of anemia. Keywords Pure red cell aplasia, Isoniazid, Anemia, Tuberculosis
PR 147 Infantile Tremor Syndrome: Uncommon Manifestation of Vitamin B12 Deficiency Dhanalakshmi K., Gangadhar Belavadhi Bangalore Medical College and Research Institute Introduction: Infantile tremor syndrome is an acquired neuroregression characterized by loss of milestones, coarse tremors, hyperpigmentation and anemia. Accounting for 0.2 % of hospital admissions, it is an uncommon manifestation of B12 deficiency. Here we report a case of infantile tremor syndrome, in 1year9 month old boy. Case 1 year 9 months old baby, 1st born to second degree consanguineously married couple presented with loss of normally achieved milestones, irritability, shrill cry and rhythmic clonic movements of left hand, with gradually worsening in severity. Child had normal antenatal, birth and postnatal history, with normal development till 1st birthday. He was on family pot diet (3 meals, vegetarian). On examination child was wasted and stunted, with fine silky hair, pallor, hyperpigmentation and dry skin. He had shrill cry, like bleating of lamb. On examination, he had coarse tremors and
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Topic: Transfusion Medicine PR 149 Autoimmune Hemolytic Anemia In Aml: A Case Report Anjali Susan, Jasprit K. Singh, Amrith Mathew, Chepsy C. Philip, M. Joseph John Christian Medical College & Hospital Introduction Autoimmune hemolytic anemia (AIHA) is a condition caused by autoantibodies directed against one’s own red blood cells. It is well reported with lymphoid malignancies. AIHA in association with myeloid neoplasms is rare. We report a case of AIHA in a patient AML who presented with hemolysis. Case Presentation 61 year old female presented with complaints of fever, icterus and generalized weakness for 20 days. On examination patient had pallor, icterus, lymphadenopathy and hepatosplenomegaly. Her hematological profile revealed white blood cells: 10,200/mm2 Hb: 6.0; retics-19 %:
Indian J Hematol Blood Transfus PLT: 24,000 mm2. Serum biochemical testing showed haemolysis with elevated LDH and unconjugated bilirubin. A direct antiglobulin test (DAT) was positive. She underwent a bone marrow biopsy prior to starting steroids which revealed 44 % myeloid blasts which were also verified with immunophenotyping. The complex cytogenetics and morphologic changes of dysplasia supported the diagnosis of AML with Myelodysplasia related changes. She was initiated on azacytidine (AZA) as chemotherapy and required transfusion. She has since received 2 cycles of AZA and is transfusion independent after the first cycle. Discussion Anaemia in Acute Myeloid Leukemia is postulated to depletion and impediment on the erythroid precursors 1. Autoimmune association though common with lymphoid disorders is being increasingly recognized with AML. MDS is more commonly associated with AIHA relating to the immune mediated pathogenesis 2. This possibly associates the AIHA seen in AML with Myelodysplasia related changes as seen in our patient. Our report demonstrates that in new cases with hemolysis other hematological malignancies should be assessed. Also; AIHA should be considered as one cause of anemia in AML patients, and blood transfusions should be given carefully in such cases to avoid harm. References 1. Miraki-Moud, Farideh, et al. ‘‘Acute myeloid leukemia does not deplete normal hematopoietic stem cells but induces cytopenias by impeding their differentiation.’’ Proceedings of the National Academy of Sciences 110.33 (2013): 13576–13581. 2. Giagounidis, A. A. N., et al. ‘‘Autoimmune disorders in two patients with myelodysplastic syndrome and 5q deletion.’’ Acta haematologica 113.2 (2005): 146–149.
PR 150 Minor Red Cell Antigens In Allogenic Hemopoietic Stem Cell Transplant Rizwan Javed, Mahua Reddy, Mammen Chandy Tata Medical Center Kolkata Background: Among the red cell antigens, only ABO antigens are considered for donor-recipient red cell compatibility in HSCT. Need for the study Minor red cell antigens have been implicated in post transplant immune hemolysis. We present our observations on donorrecipient red cell antigen phenotyping in allogenic HSCT. Materials and Methods: ABO blood group, major and minor cross match, antibody screen and red cell phenotype was done pre-transplant in both donor and recipient, and post transplant in the recipient. Tube technique and column agglutination technique (CAT) (Ortho Biovue micro bead system) was used. Red cell phenotyping was done using Ortho bioclone antisera. Results: This analysis included 5 cases of thalassemia major and one case each of T-ALL and B-ALL; these included 4 ABO compatible, 1 major and 2 minor mismatches. One case though ABO compatible showed minor incompatibility due to anti M (IgG) in the stem cell donor. The recipient here was M antigen positive, hence plasma depletion of the stem cell harvest had to be done prior to transfusion. Change from donor to recipient red cell phenotype was noted as early as the seventeenth day. In one donorrecipient pair, with blood groups A negative and A positive; the D and C antigens in the recipient simultaneously weakened and disappeared over 2 months, however the Fyb antigen continued to persist. Complete change to the donor red cell phenotype for all clinically significant antigens was observed in two ABO compatible, one major and one minor incompatible HSCT. Conclusion: Both major and minor cross match are necessary for pre-transplant evaluation to avoid missing clinically significant antibodies. Keywords Minor red cell antigens, Transplant
PR 151 Bombay Blood Group: A Rare Entity Ravindra Nimbargi, Anjali Kelkar, Amit Nisal, Preeti Doshi Bhararti Vidyapeeth Medical Coolege and Hospital Introduction: The Bombay phenotype was reported first by Bhende e t al in 1952 in Bombay, India. The Bombay blood group were also detected in japan, Malaysia, Thiland, Srilanka. This indicated that the Bombay Phenotype is mostly confined to South-east Asian countris. The blood group resulting from homozygous hh condition is called the Bombay (Oh) blood group. Like the O gene, the h gene appears to be amorphous and has no observable effect on the precursor substance. Materials and Methods: Blood group by tube method. Forward grouping and reverse typing. (Antisera from Tulip diagnostics) performed at BVDUMC and tertiary centre Pune. Result: Blood group by tube method showed no agglutination with ‘H’ antisera in forward grouping and showed agglutination in A cells (4 +), B cells (4 +) and O cells (+4) in reverse grouping seen in three patients over a period of one year (2014–2015). Conclusion: This highlights the importance of methodology for blood grouping to identify the persons with Bombay blood group, since they have antibodies against H, A, B and can only receive blood during tansfusion from Bombay blood group type. If Proper blood grouping and testing practices are not followed, it can lead to Bombay blood group undetected.
PR 152 Various Combination of Anti-D,-C and-G In Alloimmunizaed Pregnant Women Riti yadav, Dr. Sangeeta Pahuja, Dr. Shilpi Agarwal Department of pathology, Lady Hardinge Medical College and Srimati Shucheta Kriplani Hospital, New Delhi Background: The G antigen belongs to the Rh system and is present on most D-positive RBCs and on most C-positive RBCs. Anti-C plus anti D, initially found in alloimmunized women, could be anti G or different combination of anti-D, C and-G. The correct identification of antibodies in samples is required to know whether it is a single or multiple antibody and whether Anti D is present or not. Case Report: We present 5 cases of alloimmunization in which initial result was mimicking anti C + D. Differential adsorptions were done using R2R2 cells (D + C–G+) [due to lack of availability of r’r RBC (D– C+–G+)]; multiple times to completely adsorb D and G. The adsorbed serum and eluate was further tested with R2R2 and r’r RBCs to identify the specificities of various antibodies. Simultaneously titres of Anti C and Anti D were evaluated. Result and Conclusion: We found different combinations of anti C+ anti D+ anti G in these patients. Complete absence of antibodies after adsorption with single cell type indicates single antibody (anti G) and rules out C + D. Higher Anti C titres (as compared to anti D titres) was in favour of Anti G. Confirmation of presence can be done by using DIII b cells which lack G antigen. It is of utmost importance to identify the presence of Anti D under all these masquerading antibodies because when anti-D is absent, rhesus prophylaxis must be administrated. Pregnant woman and her partner should be correctly notified that Anti G + C have been identified, as an incorrect identification of Anti D + C in a D Neg couple can have devastating medicolegal & social consequences.
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Indian J Hematol Blood Transfus
Topic: Transplant—All Categories PR 153 Comparative Analysis of Direct Blood Amplification With Dna Pcr For Chimerism Analysis Neelagandan K, Shaji Rv, Eunice S Edison Christian Medical College Introduction: Chimerism analysis using STR (short tandem repeats) and VNTR (variable number of tandem repeats) has been a reliable method to monitor the engraftment after stem cell transplantation (SCT). Latest advances have made it possible to amplify directly the whole blood without the need for extracting DNA. The comparison of these two methods is provided. Patients and Methods: A total of 55 patients’ samples were analyzed for chimerism status by these two methods; both direct blood PCR and DNA PCR using fluorescence labeled primers followed by DNA fragment analysis. The results were compared using intra class correlation coefficient analysis. Results:The following STRs were informative:ACTBP2 in 19 (34.5 %), FGA in 10 (18 %), THO1 in 9 (16 %), F13A1 in 10 (18 %), FES in 6 (10 %) and VWF in 1 (1.8 %) patients. Out of 55 samples, 35 showed complete chimerism by DNA PCR and 27/55 samples by direct blood PCR. All markers showed good intra class correlation; ICC [ 0.800; p = 0.000. Higher values were seen in 8 samples in direct blood PCR as compared to DNA PCR. Conclusion: Direct blood PCR is also an excellent tool to evaluate chimerism status after allogenic HSCT. DNA fragments can be amplified directly from 1 %-20 % whole blood without pretreatment of blood samples and DNA isolation. The advantage of direct blood PCR is a shorter turn-around time and a reduced cost.
PR 154 Different Pharmacokinetic Behavior of Generic Intravenous Busulfan In Patients Undergoing Hematopoietic Stem Cell Transplantation—The Need For Routine Therapeutic Monitoring Ezhilpavai Mohanan, Fouzia Na, Anu Korula, Biju George, Alok Srivastava Christian Medical College Targeted dose adjustment of intravenous Busulfan (Bu) has significantly minimized the toxicity and treatment related mortality following Hematopoietic stem cell transplantation (HSCT). Since January 2015, we prospectively analyzed the PK of a new generic formulation—i.v BusleraTM and compared the systemic exposure and targeted dose adjustment pattern with another generic version, i.v BucelonTM. Eighteen patients received i.v BusleraTM as once daily (Q24H, n = 12) or 6 hourly doses (Q6H, n = 6). Blood samples were collected on day 1 and 3 and Bu levels were analyzed and adjusted to achieve target levels. In patients receiving Q24H i.v Bu, the median AUC on day 1 was 6516mMoles*min (3908–14064mMoles*min). The dose was reduced in 8 patients (median dose reduction 13 %; range: 7–18 %), increased in one (9 %) and 3 patients did not require any dose adjustment. In patients receiving Q6H i.v Bu, the AUC on day 1 was 784mMoles*min (446–960mMoles*min). Five out of 6 patients required a moderate increase in dose (median dose increase 5 %; range: 5–8 %) and one did not require any dose adjustment. This is strikingly different when compared with a historical cohort of patients receiving i.v BucelonTM, where 60 % patients receiving Q24H dose required dose increase and only 26 % required dose reduction to achieve target levels of busulfan. In general, we noticed that the clearance of BusleraTM is significantly lower compared to
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BucelonTM. Our study strongly suggests the need for routine therapeutic drug monitoring and targeted dose adjustment, especially when different generic busulfan formulations are used.
PR 155 Atypical Presentation of Acute Pancreatitis Post Stem Cell Transplant: A Case Report Sohan Singh, Tanu, Jasprit K Singh, Amrith Mathew, Chepsy C Philip Christian Medical College & Hospital Introduction: Acute pancreatitis is a reversible inflammatory process of the pancreas which is usually diagnosed based on clinical and laboratory features. Serum Amylase and Lipase are the most widely used tests in the diagnosis.1 Patients with thalassaemia undergoing an allogeneic stem cell transplant (aSCT) are at risk to develop pancreatitis to varied reasons namely GvHD prophylactic drugs, iron deposition, biliary sludge etc. We report a patient who developed acute pancreatitis post stem cell transplant with normal Amylase and Lipase levels. Case Presentation: 14 years old b Thalassemia Major, post aSCT on tacrolimus presented on day +67 with complaints of body ache, breathing difficulty, and severe abdominal pain. His symptoms emerged over a period of 4 days and worsened on the day of presentation. Amylase and Lipase done on the day of presentation were normal. Further investigations revealed him to have a hyperosmolar non ketotic state strengthening the suspicion of acute pancreatitis. CT abdomen confirmed the possibility with a bulky pancreas. Subsequent investigations done 48 h later showed increased amylase and lipase levels. Patient’s clinical course was complicated by hypotension and need for ICU stay, but he was managed conservatively and recovered in 3 weeks. Discussion: Though stem cell transplant is life-saving in many hematological conditions, it is vital to effectively deal with its complications. A careful proactive approach to identify and treat adverse events is essential to a successful transplant. Pancreatitis is a rare but troubling complication. The ACG has established guidelines in the diagnosis of acute pancreatitis which relies on laboratory, clinical and radiological criteria 2. However diagnosis might be eluded in very early presentation. On the basis of our atypical findings, we stress the possibility of acute pancreatitis presenting without a rise in blood lipase/Amylase levels and maintaining a high index of suspicion. Reference: 1. Gomez, Dhanwant, et al. ‘‘Retrospective study of patients with acute pancreatitis: is serum amylase still required?.’’ BMJ open 2.5 (2012): 2. Tenner, Scott, et al. ‘‘American College of Gastroenterology guideline: management of acute pancreatitis.’’ The American journal of gastroenterology108.9 (2013): 1400–1415.
PR 156 Lineage Specific Chimerism Analysis In Patients Undergoing Hsct With Fludarabine Based Conditioning Regimen—A Preliminary Report Rajesh Nagarajan, Eunice S Edison, Alok Srivastava, Vikram Mathews, Biju George Christian Medical College Fludarabine based (reduced intensity, toxicity reduced or myeloablative) conditioning regimens do not completely ablate the recipient’s immune system, thereby resulting in a temporary state of mixed chimerism. Increased rate of early donor chimerism in specific leukocyte subsets like CD56 + NK/CD3 + T-cells have been shown
Indian J Hematol Blood Transfus associated with lower relapse rate, improved progression free survival and clinical outcome. We aimed to set up a method to evaluate lineage specific chimerism in a prospective cohort of HSCT patients receiving fludarabine based regimen. Forty-seven patients were included in the study. CD3 + and CD56 + cell fractions obtained using magnetic bead-based sorting. DNA was extracted from enriched fractions and subjected to PCR followed by capillary electrophoresis to quantitate the amount of recipient cells in each lineage. Post HSCT chimerism on day + 28 was documented both in total leukocytes as well as in the sorted fractions. The study details and results are outlined in the flowchart. The magnetic bead based sorting method for enriching the CD3 + and CD56 + cell fractions is simple and approximately 80 % of samples tested produced sorted cells sufficient enough to give amplifiable DNA. A proportion of patients (group 1, N = 19) exhibited donor chimerism on day 28 in total cells, but an evaluable recipient chimerism in the sorted cells; another subset (group 2, N = 04) showed evaluable recipient chimerism in total as well as sorted cells. The usefulness of lineage specific chimerism over and above the total cell chimerism in predicting graft rejection/relapse or GvHD has to be explored once a larger cohort of patients are evaluated.
median RCPA value was 0.31 (range: 0.05–0.68) which is significantly not different (Correlation Coefficient, r = 0.958, 95 % CI: 0.927 to 0.976, P \ 0.0001) (Fig: 1). We have compared CD34 samples (n = 11) in single and dual platform simultaneously. The median value of CD34 % by single platform was 0.67 (range: 0.39–1.08) and by dual was 0.795 (range: 0.55–1.34, r = 0.89, P = 0.000). The median value of CD34dose (106cells/kg) by single platform is 8.0 (range: 5.05–14.1) and by dual platform was 8.15 (range: 4.5–21.4, r = 0.954, P \ 0.0001) which was not significantly different. Conclusion: In conclusion single platform offers a single tube, accurate, reproducible and rapid enumeration of CD34 + cells in a wide range of stem cell sources.
Topic: Vascular Disorders PR 158 Myeloperoxidase Polymorphism In Young Patients With Coronary Artery Disease Dr. Monika Sharma, Dr. Satendra Sharma, Dr. Rajnish Awasthi, Dr. Neelam Wadhwa Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi- 110095, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi
PR 157 Comparison of Cd34 Enumeration By Single Platform Flowcytometry Versus Dual Platform Ansu Abu Alex, Kotteeswari Kathirvel, Faranaz Khamruddin, Prashant Deshpande, Vikram Mathews Christian Medical College and Hospital Introduction: Enumeration of CD34 + cells by flow cytometry is the preferred method for assessing graft adequacy of peripheral blood and bone marrow stem cell collections. We evaluated CD34 using a single and a dual platform. We also evaluate our modified ISHAGE protocol, in comparison with data of an external quality control program RCPA that we participate at our centre. Materials and Methods: For dual platform, samples stained with CD45 FITC/CD34 PE by lyse wash method and acquired in BD FACS Calibur. For single platform, the single tube assay is performed in BD Trucount tubes by lyse no wash method in BD FACS Canto. The % of viable CD34 + cells and doses were calculated. Results: We compared 50 samples received from RCPA between August 2006 –July 2015. The median value of CD34 % by modified ISHAGE was 0.3 (range: 0.04–0.75) and the
Introduction: Considering contributory role of Myeloperoxidase (MPO) in atherosclerotic process, study of MPO—463 G/A polymorphism has potential for identification of young individuals (\45 years) at risk of CAD. Need for Study: The data on Indian population about above polymorphism is limited. Materials and Methods: Case control, analytical study. Fifty young CAD subjects and 50 age (±2 years) and gender matched healthy normotensive controls. Genomic DNA was extracted from 5 ml K2-EDTA blood sample using phenol-chloroform extraction method. MPO—463 G/A polymorphism was detected by PCR–RFLP. Results: GG was most common genotype in cases (58.0 %) followed by GA (34 %) and AA (8 %). Controls had most commonly GA (50 %) followed by GG (41.3 %) and AA (8.7 %). The differences between groups were insignificant (p value [0.05). Distribution of A and G allele between cases (G = 0.75, A = 0.25) and controls (G = 0.66, A = 0.34) did not differ significantly. The frequency of GA genotype (63.2 %) in hypertensive cases was significantly higher than other genotypes (p value = 0.001). Conclusions: MPO—463 G/A polymorphism does not alter risk of CAD. This is in concordance with results on Caucasians and Turkish population. Ours is the first Indian study to demonstrate significant positive correlation of GA genotype with hypertension. Keywords Coronary artery disease, Myeloperoxidase, Polymorphism, PCR, RFLP
PR 159 Clinical Profile of Patients With Recurrent Deep Vein Thrombosis: A Retrospective Analysis Christeena George, Pavan Kumar Boyella, Neeraj Sidharthan Amrita Instiute of Medical Sciences Introduction: There is scarcity of data with regards to recurrence and natural history of deep vein thrombosis (DVT). We did a retrospective analysis of recurrent DVT cases with regards to clinical and thrombophilia profile. Materials and Methods: Electronic medical records
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Indian J Hematol Blood Transfus of patients with recurrent DVT with an interval of at least 1 week between two events, following up at the Hematology Clinic from 2010 onwards were analysed. Also cases of initial DVT were analysed for recurrence of DVT. The site of DVT, interval between two events, the anticoagulation status at the time of recurrence and thrombophilia test details were collected. Results: 17 of 82 patients with DVT had recurrent DVT. The site of DVT, the interval between two events and the International Normalized Ratio (INR) of Prothrombin time at the time of recurrence of each patient is shown in Table 1. 11 of the 17 patients had a recurrence within 2 years. In 4
patients, the initial DVT was a provoked one. Of the 11 patients where information regarding anticoagulation status was available at the time of recurrence, 2 had therapeutic range INR. There were 7 episodes each of cerebral vein thrombosis and pulmonary embolism. Thrombophilia evaluation was done in 8 patients. Hyperhomocysteinemia was seen in 4 patients, elevated factor VIII levels in 2, one had borderline low protein S and antithrombin III levels. Conclusion: The risk of recurrence following an initial DVT is around 20 %. Hyperhomocysteinemia is the most common hypercoagulable condition in our population.
Table 1 Site of DVT and anticoagulation status of patients with recurrent DVT Serial No.
Site of 1st thrombus
1
Lower limb
2
CVT**
3
CVT
4
SVC thrombus
5
Interval bet. 1st & 2nd DVT(months)
INR value at onset of 2nd DVT
Site of 2nd thrombus
24
Off AC*
Lower limb
2
0.86
Lower limb
52
Off AC
Lower limb
8
No data
Lower limb
CVT
18
1.97
SMV***, PV*****
6
BRVO****
No data
No data
BRVO
7
Lower limb(L)
2
No data
Lower limb(R), PE******
8
PV, Lower limb
11
1.02(was off AC for 5 days)
CVT
9
Lower limb
84
On ecosprin
BRVO
10
PE, Lower limb(L)
1 week
1.02
Lower limb(R)
11
CVT
120
No AC
PE
12
Lower limb(L)
144
Off AC
Lower limb(R)
13
Both lower limbs
1
No data
Both lower limbs
14
Lower limb
No data
No data
Lower limb
15
CVT
12
No data
IJV
16
Lower limb(R)
5
2.07
Lower limb(L)
17
Lower limb, PE
18
No data
PE
*AntiCoagulation **Cortical Venous Thrombosis ***Superior mesenteric vein ****Branch Retinal Vein Occlusion *****Portal Vein ******Pulmonary Embolism
123
Interval bet. 2nd & 3rd DVT(months)
INR value at onset of 3rd DVT
Site of 3rd DVT
46
Off AC for 2 weeks
CVT
60
Non compliant with AC
PE
2
No data
PE
Indian J Hematol Blood Transfus
Topic: WBC Disorders PR 160 Transplacentally Acquired Maternal T Lymphocytes In Severe Combined Immunodeficiency Dr. Apte Shashikant, Dr. Kannan Subramanyan, Dr. Dudhatra Abhishek, Dr. Kamat Girish, Dr. Vaghasiya Dharmesh Sahyadri Speciality Hospital Introduction: Severe combined immunodeficiency (SCID) genetically heterogeneous disorder characterized by disturbances in lymphocyte development, usually resulting in defective T and B-cell functions. A repeatedly described abnormality in SCID is presence of trans-placental acquired maternal T-lymphocytes in the circulation. Whether these cells cause GVHD or provide protective immunity to host remains unclear. Case: 6 month male with SCID, referred for Allogeneic SCT. He had loose motions, chest infection, and fever. PB sample for HLA low resolution (by PCR) was sent. Patient had three allele for each HLA-antigen. 6 of the 9 allele were matching completely with maternal HLA-typing, while 3 (presumable paternal origin) were not matching. Suspecting maternal lymphocyte engraftment, we sent FISH X–Y mismatch (pre-SCT) to know origin of lymphocytes. It showed 309 cells with 46XY, 191 cells with 46 XX, proving maternal origin. Conditioning-Flu-ATG GVHD-prophylaxis-cyclosporine FISH X–Y (Day 14)-493 XX & 7 XY Patient had GUT ? Liver ? Skin aGVHD Immunosuppressants usedmethylprednisolone, mycophenolate, tacrolimus, sirolimus, eternacept. Patient recovered. Immunosuppressants gradually tapered After 6 months—sr.Ig levels WNL, lymphocyte subset-analysis normal. Discussion: In this patient, maternal T-lymphocytes engraftment may be providing immune protection. Loose motions at presentation may be a sign of GVHD. Albeit the severity was much less as compared to post SCT GVHD (Indicative of mild response from transplacentally acquired maternal lymphocytes). Keywords SCID, HLA typing, Maternal lymphocytes, Allogeneic SCT Table 1 . HLA report: A.C. (Patient)
HLA report: K.C. (Mother-donor)
HLA A : A*24 A*11 A*26
HLA A : A*24 A*26
HLA B : B*08 B*40 B*44
HLA B : B*08 B*40
HLA DRB: DRB1*10 DRB1*3 DRB1*15
HLA DRB: DRB1*03 DRB1*15
DRB3 DRB5
DRB3 DRB5
PR 161 Biphenotypic Extramedullary Blast Crisis With Mll Gene Rearrangement In A Case of Chronic Myeloid Leukemia Following Dasatinib Therapy: An Unusual Case Report Dr. Gaurav Dhamija, Dr. Tina Dadu, Dr. Anil Handoo
Chronic myeloid leukemia (CML) is a common myeloproliferative neoplasm. Tyrosine kinase inhibitors (TKI) therapy has dramatically improved the outcome of CML patients in chronic phase especially after introduction of second generation TKI’s. It has also improved the median survival in CML patients with blast crisis, however, significant risk of relapse persist in these patients. Extramedullary relapses are rare. Isolated central nervous system (CNS) involvement, as a site of extramedullary involvement is rarer. This report presents a case of isolated CNS relapse in a follow up case of CML in myeloid blast crisis. Case: 68 years old diabetic male patient presented with fever and splenomegaly. On evaluation found to have CML with myeloid blast crises and 46XY, t(9:22) (q34;q11.2). Patient achieved major molecular response with dasatinib maintainance therapy. 18 months later, he developed isolated CNS relapse with biphenotypic blasts and karyotype 46XY, t(6:11) (q27; q23). Discussion: CNS is a rare site for extramedullary relapse in CML especially with blasts of myeloid immunophenotype. Dasatinib, due to its better blood brain barrier penetration is the drug of choice for preventing CNS relapse We present a case of isolated CNS relapse in a patient of CML myeloid blast crises, after attaining remission with dasatinib. Two interesting evolutions noted in our case were: phenotypic evolution of the blasts from myeloid to biphenotypic and cytogenetic evolution to MLL gene rearrangement. These are rare findings in isolated CNS relapse, with isolated CNS relapse itself being very rare. To best of our knowledge, this is the second such case.
PR 162 Title: Blasts-Friend Or Foe! Dr. Gaurav Dhamija, Dr. Tina Dadu, Dr. Anil Handoo Bl Kapoor Super Speciality Hospital Introduction: Use of certain drugs may lead to bone marrow suppression. The bone marrow usually recovers, post insult and may show regenerative changes. These may be seen in the form of increased blasts, which usually does not cross 5 %. However, regenerative processes with [5 % blasts are a diagnostic challenge and needs to be differentiated from acute leukemia/MDS. Here, we present two such cases. Case 1: : 35 year old female presented with pancytopenia a week afer ingestion of Ayurvedic medicine for vaginitis. Vitamin B12 and folate levels were normal. Bone marrow done revealed dysplastic megakaryocytes and 16 % blasts, suggestive of Myelodysplastic Syndrome (RAEB-2). Flow cytometry confirmed the myeloid phenotype of the blasts with no antigenic aberrancies. Subsequent hemograms showed recovering counts, which confirmed the blasts to be a part of regenerating marrow and not MDS. Case 2: Patient of Rheumatoid Arthritis on methotrexate presented with pancytopenia after several years of medication. Methotrexate induced aplasia/MDS was the clinical diagnosis. Methotrexate was stopped and the patient was given folinic acid. Bone marrow examination was done after a week, which showed dysplastic changes with 7 % blasts, which confirmed the clinical diagnosis of MDS. However, hemograms done subsequently showed recovering counts, which again confirmed the blasts, to be regenerative than neoplastic Discussion: Toxic agents, including alcohol, drugs, benzene-containing chemicals, and chemotherapeutic agents, can cause bone marrow suppression. Recovering marrow post insult with excess blasts can mimic a leukemic process. A close hematological follow up is strongly suggested in such cases before labeling them as neoplastic.
Bl Kapoor Super Speciality Hospital
123