Journal of Haematology and Stem Cell Research

Genetic Analysis of Gaucher Disease in Pakistani Population and its Diagnostic Comparison.

Qurat Abedin, Arshi Naz, Shariq ahmed, Saima Siddiqui — Mon, 01 Jan 2024 00:00:00 +0000

Gaucher disease is a rare lysosomal storage disease that is caused by the lack of enzyme ?-Glucocerebrosidase which results in a buildup of an uncatalyzed substrate. Clinical manifestations are mainly hepatosplenomegaly, anemia, thrombocytopenia, and bone problems. It is inherited in an autosomal recessive pattern. GBA gene is responsible for deficient enzyme function and comprises 11 exons and 10 introns. Genetic analysis of Pakistani patients with Gaucher disease that were diagnosed either on bone marrow or enzymatic assays showed distinctive results. Patients who were diagnosed with low enzyme levels were found to have L444P mutation which is most prevalent in our ethnicity. But the patients that were diagnosed on basis of bone marrow morphology did not exhibit any mutation on sequencing. This is an interesting finding that emphasizes the value of enzyme level estimation in all GD-suspected cases.

HaemophagocyticbLymphohistiocytosis (HLH) a Life Threatening Complication of Tuberculosis

Nadeem Ikram, Tahir Mukhtar Sayed, Fakhira Noreen, Jahanzaib Maqsood — Thu, 04 Jan 2024 00:00:00 +0000

Haemophagocytic Lymphohistiocytosis (HLH) is an uncommon , potentially fatal, syndrome, that may rarely complicate the clinical course of disseminated tuberculosis .¹Here we discuss clinico-pathologic and diagnostic parameters of a patient who satisfied the HLH diagnostic criteria 2004,as well as is showing strong probability according to H-Score for HLH

Acute Priapism as a First Manifestation of Chronic Phase CML; A Case Report

Nouman Nathani, Maria Zahid, Jawahar Laal, Abdul Hadi Mallick — Mon, 01 Jan 2024 00:00:00 +0000

Priapism is a urological emergency that, if not treated promptly, can result in erectile dysfunction. 50% of cases of priapism in leukemia are caused by chronic myeloid leukemia, but priapism is only observed in 3% of chronic myeloid leukemia and very infrequently as the initial manifestation. This is a case of a 28-year-old male with no prior co-morbid presented with acute penile erection for eighteen hours. The patient was vitally stable on examination and had a palpable spleen of 4cm below the left costal margin. Laboratory workup showed leukocytosis, low hemoglobin, normal platelets, and 2% myeloblasts on the peripheral film. Aspiration of the corpora cavernosa at the shaft of the penis was done and blood gas analysis showed acidosis, hypercarbia, and hypoxia consistent with ischemic priapism. Bone marrow aspirate showed chronic phase chronic myeloid leukemia. BCR-ABL by FISH showed p210 mRNA and the patient was started on Imatinib. Priapism in chronic myeloid leukemia is rare as the first presentation and requires urgent initiation of cytoreduction therapy to prevent worse outcomes.

Refractory Autoimmune Hemolytic Anemia in a Child with Beta thalassemia Major

Mon, 01 Jan 2024 00:00:00 +0000

Autoimmune hemolytic anemia (AIHA) in Thalassemia major is a challenging entity. This is a case of 1 year old Thalassemia major patient who developed AIHA after few transfusions and became refractory to all available medical modalities. Before transplant, patient did not respond to high dose steroid therapy, two cycles (5 days) of Fludarabine- dexamethasone, two doses of Rituximab and IV immunoglobulin. After 100% HLA matched bone marrow transplant, patient remained stable till day +10, but than his AIHA worsened along with development of severe veno-occlusive disease. In addition to Cyclosporine and methotrexate he received high dose of steroids, Rituximab and IVIG with no response. He rejected to 100% HLA matched bone marrow transplant with persistent refractory AIHA. For refractory AIHA, the Proteasome inhibitor Bortezomib was also given. This case reflects that refractory AIHA associated with Beta Thalassemia can be a challenging clinical condition requiring new or redefined treatment modalities and it can adversely affect transplant outcome even in young patients undergoing 100% HLA matched bone marrow transplant

Can Different Genetic Mutations be the Possible Cause for Thrombocytosis in Children with Beta Thalassemia Major?

Mohammad Abdul Naeem, Ambreen Tauseef, Mehwish Qamar, Farhat Ijaz, Nayyar Amin — Mon, 01 Jan 2024 00:00:00 +0000

Objective: To investigate the primary cause of thrombocytosis observed in children suffering from Thalassemia major in Pakistan.

Methodology: A cohort study was carried out at the Armed Forces Institute of Transfusion (AFIT) Rawalpindi from June to December 2020 after obtaining permission from its Ethical Review Committee. A total of 41 children with Thalassemia major, presenting persistent platelet counts ? 1000 x 10^9/l for three months, underwent a revised transfusion protocol and iron overload chelation. After six months of observation and chelation, patients with persistent thrombocytosis were further analyzed for BCR ABL1, JAK2 V617F, CAL-R, and MPN-1 mutations. Data analysis was conducted using IBM SPSS 21.

Results: Following transfusion revision and chelation, 73% of patients achieved normal platelet counts, accompanied by significant improvements in Hb levels, WBC count, ferritin levels, and platelet count. However, 27% of patients with persistent thrombocytosis showed no mutations in BCR ABL1, JAK2 V617F, CAL-R, and MPN-1 genes.

Discussion: The study suggests a potential correlation between thrombocytosis in Thalassemia major and iron deficiency, with 73% of patients responding positively to transfusion revision and chelation. However, for the remaining 27%, the cause of thrombocytosis remains elusive, necessitating further in-depth investigations with a larger sample size.

Conclusion: The research highlights the need for comprehensive studies to elucidate the underlying causes of thrombocytosis in children with Thalassemia major, especially in cases where conventional interventions such as transfusion revision and chelation do not yield conclusive results

Outcomes of Patients Treated with Brentuximab Vedotin in Relapsed or Refractory CD30 Positive Lymphomas; A Single Center Experience

Salman Arif, Natasha Ali, Usman Shaikh, Salman Adil — Mon, 01 Jan 2024 00:00:00 +0000

Objective: To assess the efficacy of Brentuximab Vedotin ± Bendamustine in the management of relapsed or refractory CD30-positive lymphomas, including classic Hodgkin lymphoma (cHL) and systemic anaplastic large cell lymphoma (sALCL).

Methodology: An observational retrospective study was conducted at Aga Khan University Hospital, Pakistan, from January 2021 to June 2022. Eligible participants were aged 17 or older with CD30-positive disease (cHL or sALCL), having undergone at least one prior chemotherapy regimen and experiencing relapse or refractory disease. Treatment involved Brentuximab Vedotin ± Bendamustine, and patients were assessed using PET-CT scans.

Results: Twenty-two patients received chemotherapy with Brentuximab Vedotin ± Bendamustine, comprising 19 with Hodgkin lymphoma and 3 with sALCL. Among them, 6 were in relapse, and 16 were refractory. At the end of treatment, 17 patients achieved complete response, 3 achieved partial response, and 1 had stable disease, yielding an overall response rate (ORR) of 90.9%. Nineteen patients survived, while 3 deceased. The median overall survival was 30 months. Commonly encountered side effects, including nausea, neutropenia, peripheral neuropathy, gastrointestinal disturbances, infusion reactions, and rash, were generally well tolerated.

Conclusions: Brentuximab Vedotin ± Bendamustine demonstrates effectiveness and tolerability in patients with relapsed or refractory cHL and sALCL, even in heavily pretreated individuals. In middle-income countries like Pakistan, affordability and accessibility play pivotal roles in determining patient eligibility for this treatment regimen.

Clinico-haematological Profile and Post-Induction Remission Status of Newly Diagnosed Paediatric Acute Lymphoblastic Leukaemia Patients with ETV6::RUNX1 Gene Rearrangement

Mon, 01 Jan 2024 00:00:00 +0000

Objectives: To determine the frequency of ETV6:RUNX1 gene rearrangement in paediatric acute lymphoblastic leukaemia in Pakistan and to determine the clinico-haematological profile and post induction remission status of newly diagnosed paediatric acute lymphoblastic leukaemia and compare them across gender and based on ETV6::RUNX1 gene rearrangement positivity.

Methodology: This descriptive cross-sectional study was conducted at Department of Haematology, Armed Forces Institute of Pathology, Rawalpindi, Oct 2021 to Aug 2023. The study sample was composed of 229 cases of paediatric acute B-cell lymphoblastic leukaemia. Patients who had B-ALL occurring as a second malignancy, Down’s syndrome, those who had received chemotherapy or corticosteroids were excluded. Patients ETV6:RUNX1 gene rearrangement status was determined by PCR. All patients underwent induction with the UK ALL 2019 protocol. Bone marrow aspiration and trephine was conducted on Day+29 of induction to assess remission and MRD status.

Results: Our study sample had a median age of 3.0 (IQR: 4.0) years, 136 (59.4%) were male. ETV6::RUNX1 gene rearrangement was seen in 36 (15.7%) cases. There were no statistical differences with regards to clinico-haematological profile at presentation and outcomes between genders and among patients with and without ETV6:RUNX1 gene rearrangement, except for MRD which had a higher frequency of being negative in the former, (p=0.023).

Conclusion: ETV6::RUNX1 rearrangement is associated with a higher frequency of negative MRD post-induction.

Correlation of FLT3 Mutation in Acute Myeloid Leukemia with Morphology and Cytogenetics

Mon, 01 Jan 2024 00:00:00 +0000

Objective: To investigate the correlation of FLT3 mutation in acute myeloid leukemia with morphology and cytogenetics in the Pakistani population.

Methodology: The study was conducted at Chughtai Institute of Pathology from January 2022 to July 2023. Fifty newly diagnosed cases of AML were included, excluding patients who had received chemotherapy. FLT3 mutations were identified using the Imegen-FLT3 kit through PCR, while cytogenetic analysis was performed using FISH. Data were analyzed using SPSS version 23.00. Normality of data was assessed using the Kolmogorov-Smirnov test, and the Mann-Whitney U test was utilized to assess the correlation of FLT3 mutation.

Results: Of the fifty patients included, 29 (58%) were males and 21 (42%) were females, with a mean age of 41.7 years. FLT3 mutation was present in 29 (58%) patients and absent in 21 (42%) patients. Morphologic analysis did not reveal a correlation with any specific FAB subtype. Cytogenetic analysis was successful in 35 patients, with FLT3 mutation being randomly distributed among different cytogenetic subgroups, showing no specific correlation with any subgroup. The most common cytogenetic chromosomal abnormality detected was gain of chromosome 8. Blast percentage was significantly higher in FLT3 mutation-positive patients (72.3%) compared to FLT3 mutation-negative patients (56.76%) (p=0.02).

Conclusion: Although FLT3 mutation was prevalent among the patients studied, no significant correlation could be established between morphology and cytogenetics.

Quantification and Frequency of Inhibitors in Congenital Coagulation Disorder Patients; An Experience at Tertiary Care Hospital

Neelam Mazhar, Shazia Yaseen, Sarah Rafi, Saima Farhan — Mon, 01 Jan 2024 00:00:00 +0000

Objective: To quantify and calculate the frequency of inhibitors in patients with congenital coagulation disorders using the Bethesda assay.

Methodology: A cross-sectional study was conducted in the Department of Hematology at Children’s Hospital Lahore, Pakistan, from September 7, 2016, to March 7, 2017. 350 Pediatric patients of 1-15 yrs of age of both genders having congenital coagulation disorders were selected in the study. Patients having Hepatitis B, C, chronic liver disease evidence, HIV or malignancies were excluded from the study. The Chi-square test was applied, and a P-value of ?0.05 was considered statistically significant.

Results: A total of 350 children were enrolled in the study, comprising 277 (79.1%) males and 73 (20.9%) females. The age of the children ranged from 1 to 15 years. Among them, 127 (36.3%) were diagnosed with Hemophilia A, 73 (20.9%) with Hemophilia B, 38 (10.9%) with rare bleeding disorders, and 112 (32%) with Von Willebrand disease. Sixteen (5.77%) patients developed inhibitors after receiving treatment, all of whom were males aged 1 to 4 years. The quantification of inhibitors in these patients was performed using the Bethesda Assay.

Conclusion: Coagulation factor inhibitors may develop against any coagulation factor, with FVIII (Haemophilia-A) being the most common target. The evaluation of coagulation factor inhibitors involves the Bethesda assay to measure inhibitor titers, which aids in treatment decision-making.

Outcomes of Patients with NPM1 Positive Acute Myeloid Leukemia, An Experience from a Tertiary Care Hospital in Karachi, Pakistan

Mon, 01 Jan 2024 00:00:00 +0000

Objectives: To determine the response to induction chemotherapy, overall survival, and relapse rate in patients with NPM1-positive acute myeloid leukaemia.

Methodology Patients diagnosed with AML from January 2015 to July 2022 at Aga Khan University Hospital Karachi were included in the study. Patient demographics, clinico-haematological parameters, and molecular analysis for the NPM1 mutation were performed. Response to standard induction chemotherapy, overall survival, and relapse rate were assessed.

Results: A total of 76 cases of AML were analysed. The mean age of the sample was 33.7 years, of which 63.2% were males and 36.8% were females. The patients were stratified into two groups: those who were positive for NPM1 while negative for FLT3 (NPM+/FLT3-), representing 18.4%, and those who were negative for both NPM1 and FLT3 (FLT3-/NPM-), representing 81.6% of cases. On day 28 post-induction, the complete remission rate was 78.6% in the NPM1 positive group and 77.4% in the NPM1 negative group. In the NPM1+/FLT3-group, 54.5% of cases who were in remission at day 28 subsequently relapsed, compared to 50.0% of NPM1-/FLT3-cases. The overall survival could not be assessed between both the groups due to the low number of deaths.

Conclusion: AML patients harbouring only the NPM1 mutation do not show significant differences in outcome as compared to those negative for both mutations.

Protein C as an Early Indicator of Severe Coagulopathy and Mortality in Patients with Sepsis

Mon, 01 Jan 2024 00:00:00 +0000

Objective: To determine Protein C as a useful early predictor of severe coagulopathy and mortality.

Methodology: It was a prospective observational study conducted at Mayo Hospital and Chughtai Institute of Pathology, Lahore from January, 2023 till September, 2023. 87 Patients admitted in Intensive Care Unit (ICU) with sepsis according to Sequential Organ Failure Assessment Score (SOFA score >2 according to sepsis-3 criteria) and without overt DIC on ISTH criteria (ISTH score <5) were included in the study. Baseline levels of Protein C activity levels of 87 adult patients were taken at Day 0 of admission. Patients were followed till Day 3 for development of DIC and 28 days for mortality. According to the development of DIC at Day 3 patients were allocated into two groups: Overt-DIC Group (n=35) and Non-DIC Group (n=52).

Results: SOFA score and Protein C both showed positive correlation with DIC and mortality with p-value being <0.05. There was a significant difference in values of baseline Protein C activity in both groups p-value (0.00). The overall sensitivity of Protein C was 90.4% ,specificity 71.4% ,Positive Predictive Value (PPV) 73% and Negative Predictive Value (NPV) 95% (CI 88.54-90.52%). Cut-off level was established for Protein C which was 52.9%.

Conclusion: Low Protein C activity levels alone on admission in hospital can effectively predict the evolution of severe coagulopathy (over-DIC) and mortality in patients with sepsis.

The Role of ISTH Bleeding Assessment Tool in Diagnosing Patients with Suspected Bleeding Disorders

Mon, 01 Jan 2024 00:00:00 +0000

Objective: To compare the ISTH-BAT score with the results of light transmission aggregometry in patients suspected of having bleeding disorders, particularly those with platelet function disorders.

Methodology: This study was conducted at the Chughtai Institute of Pathology, Lahore, from January 2022 to March 2023. A total of 183 patients with suspected bleeding disorders, aged between 3 months and 18 years, were enrolled. The ISTH-BAT questionnaire was administered, and scores were calculated and compared with the results of light transmission aggregometry. Data were analyzed using SPSS-23, with the p-value calculated using the chi-square test.

Results: The study comprised 183 patients, including 97 (53%) males and 86 (47%) females, with ages ranging from 1 to 16 years and a median age of 6 years. The BAT score was calculated for each patient using the ISTH questionnaire. A score below 3 was considered normal, while a score above 3 was considered abnormal. Among the patients, 73 (39.8%) had a normal ISTH-BAT score, while 110 (60.1%) had an abnormal score. Of the 110 patients with an abnormal ISTH-BAT score, 90 (81.8%) were diagnosed with a bleeding disorder, while 20 (18.1%) did not have a bleeding disorder.

Conclusion: In conclusion, the ISTH-BAT score is an effective tool for assessing patients with suspected bleeding disorders, particularly for those with suspected platelet function disorders, which can be rare and challenging to diagnose.

Interdisciplinary Haematology

Nadeem Ikram — Mon, 01 Jan 2024 00:00:00 +0000