HIV/AIDS outbreak investigation in Jalalpur jattan [JPJ], Gujrat, Pakistan

In June-July 2008 a non-governmental organization [NGO] in Jalalpur Jattan [JPJ], Gujrat, Pakistan arranged two voluntary HIV screening camps after numerous HIV-infected persons reported to their treatment center in Lahore; 88 [35.8%] of 246 persons screened in those camps were positive by rapid test. Intense media coverage made the residents of JPJ hostile to further inquiries. The Pakistan Field Epidemiology Training and Laboratory Training Program [FELTP] was requested by the Provincial AIDS Control Program to carry out an epidemiological investigation. HIV-positive persons or family members of patients who died of AIDS and consented to be interviewed during the period 15 December 2008 to 2 January 2009 were investigated. Enhanced contact tracing was done to identify additional cases. A structured questionnaire was used to collect data regarding clinical history, risk factors, and HIV knowledge and practices. The national HIV/STI Referral Laboratory collected blood samples for HIV serology and molecular studies independently following pre- and post-counseling. A total of 53 HIV-infected persons were investigated. Out of these, 47 [88.7%] were alive at the time of investigation and 27 [50.9%] of the cases were female with 6 children aged 10 years or less. Median age was 35 years [mean 34.7, range 3-70]. Most frequent symptoms were unexplained fever 42 [79.2%], diarrhea 34 [64.15%] and skin infections 27 [50.9%]; 13 [24.5%] had co-infection with tuberculosis [TB] and 10 [18.9%] with hepatitis [B or C]. Use of injections 51 [96.2%], dental procedures 21 [40%] and barber shop visits among males 18 [72%] were common risk factors. Extramarital sex was reported by 4 [9.4%]. Only 19 [35.8%] were aware that HIV can be sexually transmitted and 18 [34%] were aware of HIV transmission by blood transfusion. Phylogenetic analysis revealed HIV infection in this group was HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather than an outbreak. The investigation indicates high rates of HIV infection in JPJ. Unlike other studies from Pakistan, a high proportion of cases in females and children less than 10 years of age were observed. Socio-cultural norms and stigmatization limited in-depth investigation of sexual and behavioral practices and history of drug abuse. A shift of HIV infection from high-risk groups to the general population was seen and requires vigilant surveillance besides targeted health education, clinical management, lab facilities for diagnosis and monitoring, and voluntary counseling and testing services to limit disease spread

False positive HIV test in low prevalence region: Pakistan

The prevalence of HIV in Pakistan is less than 0.1%, but is feared to be spreading among the general population rapidly. Screening tests for HIV is based on antibody detection. There seems to be little knowledge regarding the interpretation of HIV results among the population. Most often the patients are being issued a positive HIV report based on single screening test when in fact it should be confirmed before issuing a positive HIV result. There is a lot of stigma associated with the disease in Pakistan, on the other hand the test is done mostly without counselling services hence causing physical and mental trauma to the patients.

Peripheral blood parameters in patients of non-Hodgkin's lymphomas showing bone marrow infiltration

Non-Hodgkin's lymphomas are frequently characterized by bone marrow infiltration. Peripheral blood counts and examination of blood smears are essentially performed along with bone marrow biopsy in the pre-treatment investigations. Variations in peripheral blood counts are believed to have prognostic implication. To look into various types of cytopenias and presence of atypical lymphoid cells in the peripheral blood of patients of non-Hodgkin's lymphoma showing bone marrow infiltration. This descriptive study was performed in the department of Pathology, Pakistan Institute of Medical Sciences from January 2,004 to December, 2,004. A total of 50 consecutive patients of non-Hodgkin's lymphoma belonging to all age groups and both sexes, and showing bone marrow infiltration on aspiration and trephine biopsies were included. Peripheral blood counts were performed on an automated haematology analyzer. Blood smears stained by Wright stained were scanned for atypical lymphoid cells. In the differential leucocyte count, 500 cells were counted. Cytopenias of all types were frequently observed. Anaemia was the commonest finding [94%], followed by thrombocytopenia [62%] and neutropenia [34%]. Bicytopenia was noted in 38% and thrombocytopenia in 30%o of cases. Atypical cells were observed in the blood smears of 64% of patients. Anaemia alone or as a part of bicytopenia or pancytopenia is common finding in patients of non-Hodgkin's lymphoma showing bone marrow infiltration. A detailed examination of stained blood smears shows atypical lymphoid cells in 64% of patients.

Anemia of chronic diseases

To evaluate the etiology and clinicohematological profile of patients with anemia of chronic disease. Patients with anemia of chronic disease were included. All underwent bone marrow examination, and bone marrow trephine biopsy, where required. Etiology was elucidated on the basis of clinical history and relevant investigations. Diagnosis of anemia of chronic disease was based on increased iron in fragments with decreased or absent siderocytes and sideroblasts. Definitive cause of anemia was not ascertained in 57.1%. In the rest of the cases tuberculosis [17.1%] was the commonest. Majority of the patients [54.3%] were more than 60 years of age. Fever [51.4%] was the commonest complaint. Severe anemia was found in 25.8%. Bone marrow iron stain revealed increased iron in stores with absent siderocytes and sideroblasts. A high number of unexplained cases [57.1%] highlights the need to characterize the causes of anemia of chronic disease as treatment of underlying disease will actually improve the hemoglobin concentration in these patients.

Clinical features and hematological investigations pattern in Acute Promyelocytic Leukaemia patients

Acute Promyelocytic Leukemia [AML-M3] patients, though amenable to treatment, present with early and sometimes severe bleeding manifestations. In our setup, for various reasons, patients are diagnosed rather late and therefore these bleeding manifestations are a limiting factor in the early and effective treatment of leukemia in such cases. To look into the clinical, peripheral blood and bone marrow features of AML-M3 patients in our setup. A total of 40 consecutive cases of AML-M3 diagnosed on bone marrow biopsy over a period of 10 years were analyzed for clinico-morphological features. Majority of patients [75%] were <30 years of age. The male: female ratio was 3:2. The mean duration of symptoms was 4.2 weeks [Range 1-10 weeks]. Commonest clinical features were fever, pallor and bleeding manifestations. The spleen and liver were variably enlarged in 25% and 45.5% of cases, respectively. The hemoglobin levels ranged from 3.1 to 12.8 g/dl with a mean of 6.6 g/dl. The WBC count ranged from 0.5 to 142 x 10[9]/l with a mean of 28.3 x 10[9]/l. Platelet counts ranged from 5-150 x 10[9]/l with a mean of 28.8 x 10[9]/l. Morphologically 36 patients had hypergranular and 4 had hypogranular promyelocytic leukemia. The features identified in our study can help in early diagnosis of APL, which is known to be extremely important in effective management of patients

Red cell alloimmunization in repeatedly transfused thalassemia major patients

Thalassemia major patients managed by regular transfusion regimen may develop anti-red cell alloimmunization. If the alloantibodies are hemolyzing in nature, transfusion reaction may occur, and provision of blood thereafter requires matching of the relevant blood group in addition to "ABO" and Rh 'D' matching. We investigated 75 cases of multiply transfused thalassemia major patients for development of alloantibodies against red cells by indirect antiglobulin test, using 3-red cell panel, and when required 11-red cell panel. Anti-red cell alloantibodies were detected in 17 [22.7%] patients. Anti-Kp[a] antibodies were the commonest, followed by Anti-e, anti-E and anti-K antibodies, respectively. Anti-k, -C[W], -Fy[b], -Kp[b], -Rh 'D' and -c were detected in one patient each. It is concluded that in multiply transfused patients, alloantibodies develop in a significant number of patients. The hemolyzing nature of antibodies should be determined in patients who develop these antibodies, and transfusion should be arranged accordingly

Hepatitis C virus seropositivity in repeatedly transfused thalassemia major patients

Multiple transfusions in patients of thalassemia major who are conventionally treated by a regular transfusion regimen, are at a risk of developing Transfusion Transmitted Infections [TTIs], including HCV-hepatitis. Strict criteria of safe donor selection have to be adopted in order to minimize the risk of TTIs. The present study was conducted to evaluate the seropositivity of anti-HCV antibodies in multiply transfused thalassemia major patients. A total of 75 patients of thalassemia major who had received at least 10 transfusions were tested for anti-HCV antibodies, using third generation ELISA kits. Amongst these patients, 42% were seropositive for anti-HCV antibodies. This is a high prevalence rate and calls for a critical look into the prevailing transfusion practices and adoption of stricter donor selection criteria

Ferritin levels in patients of beta thalassaemia major

In Beta Thalassaemia Major repeated blood transfusions, ineffective erythropoiesis and increased gastrointestinal iron absorption lead to iron overload in the body. The management of the iron overload in these patients requires the administration of iron chelators continuously and evaluation of serum ferritin levels at regular intervals. In the present study serum ferritin levels, of the patients with beta thalassaemia major registered at two different centers of Rawalpindi and Islamabad, were measured. Majority of the patients revealed very high ferritin levels, with a mean of 3390 ng/ml. 21.34% patients had serum ferritin between 1000 to 2500 ng/ml, while 76% patients had values above 2500 ng/ml. These levels reflect inadequate chelation and vulnerability to develop iron overload related complications. There is a dire need to rationalize the chelation therapy, as at present no chelation, inadequate chelation, improper methods of chelators administration, non availability of infusion pumps, non affordability of patients to purchase pumps and chelators, inappropriate evaluation of iron overload and high levels of serum ferritin gives an overall bleak view

Pure red cell aplasia in children

This paper presents an aetiological breakup of 14 cases of'Pure Red Cell Aplasia [PRCA], a rare haematological entity. Congenital PRCA constituted the commonest aetiological group [28.6%]. It was followed by PRCA associated with infections in 21.4% [bronochopneumonia, urinary tract infection and enteric fever in 7.1% each], with cotrimoxazole [14.3%] and with systemic hupus erythematosus and rheumatoid arthritis [7.1% each], respectively. In 21.4% of cases, no definite cause could be established

morphological pattern of 234 cases of leukemias

Morphological pattern of 234 consecutive cases of various types of leukemias is presented. Acute leukemias [62.8%] were commoner than chronic [37.2%]. Amongst acute leukemias, myeloid leukemias [AML] were more frequent as compared to lymphoblastic [ALL]. AML:ALL ratio was 2.57:1 in adults and 1:3 in children. Amongst AML cases, M4 was the commonest, followed by M2, M1, M3 and M4 and M6 and M7 respectively. In ALL patients, L1 was the commonest, followed by L2 and L3 respectively. Amongst chronic leukemias, myelocytic leukemia [CML] was more common than lymphocytic leukemia [CLL] with a CML:CLL ratio of 3.1:1. In a total of 60 CML cases, two had junvenile CML, four were between 10 and 15 years of age and the remaining 54 were adults. Hairy cell leukemia [2 cases] and lymphoma/leukemia syndrome [5 cases] were uncommon

Clinico-biochemical pattern in acute anicteric hepatitis

A clinico-biochemical study of 37 cases [19 adults, 18 children] of anicteric hepatitis is presented. Clinical features were non-specific, nausea/vomiting, generalized aches and anorexia were the leading symptoms. Transaminases were significantly high in both the groups, thus helping in early diagnosis. Mean values were notably higher in children as compared to the adult group. Phosphatase was normal or moderately elevated. Total bilirubin levels were higher inchldren than in adults; the ratio of conjugated to un-conjugated bilirubin was more than 0.8 in all the cases of anicteric, irrespective of age and sex, thus emphasizing on its importance in diagnosis. DeRitis ratio was of some diagnostic value in children only