Linezolid-Resistant Methicillin-Resistant Staphylococcus HemolyticusIsolated from Leukemic Patient: First Case Report from Pakistan.

Methicillin-Resistant Coagulase-Negative Staphylococcusposes a challenging situation in healthcare settings. The spread of resistance among such organisms against major drugs is alarming as it limits the treatment options for serious infections. Traditionally, Vancomycin had remained a mainstay of treatment of Methicillin-Resistant Staphylococci. Linezolid introduction into the clinical practice was a major breakthrough since it provided orally administered treatment of Methicillin-Resistant Staphylococci. Widespread use of Linezolid has gradually turned the impending fear of emergence of resistance against this novel drug into a reality. We report first case of Linezolid-Resistant Methicillin-Resistant Staphylococcushemolyticusfrom Pakistan, isolated from a leukemic patient. The organism caused a necrotic lesion on the right forearm at cannulation site of intravenous catheter. Ooze swab yielded the pure growth of Linezolid-Resistant Methicillin-Resistant Staphylococcushemolyticus.

Comparative Analysis of Fluorescence In Situ Hybridization and Real Time Polymerase Chain Reaction in Diagnosis of Chronic Myeloid Leukemia.

OBJECTIVE: To compare the sensitivity and specificity of fluorescence in situ hybridization (FISH) with real time polymerase chain reaction (RT-PCR) in the diagnosis of Chronic Myeloid Leukemia (CML). STUDY DESIGN: A cross-sectional, analytical study. PLACE AND DURATION OF STUDY: Haematology Department, Armed Forces Institute of Pathology, Rawalpindi, from January 2012 to February 2014. METHODOLOGY: A total number of 87 patients of CML were studied. The diagnosis was made on the basis of clinical history, peripheral blood and bone marrow aspiration. These patients were tested for the presence of BCR-ABL1 fusion gene by RT-PCR and FISH. About 5 ml of venous blood was collected, half was taken in heparin for FISH and half in ethylenediamine tetra-acetic acid (EDTA) for CBC and PCR. For FISH, cells were cultured for 24 hours in RPMI 1640 medium and evaluated using BX51 fluorescence microscope for dual fusion signal of yellow colour. Samples having 20 or more interphases positive for dual fusion signals were taken as positive. For PCR, RNA extraction was done by Tri-Reagent LS (MRC, USA) and cDNA was synthesized using reverse transcriptase and gene specific primer. RT-PCR was done on ABI-7500. The positive samples were identified when fluorescence exceeded threshold limit. Results of RT-PCR and FISH were compared. RESULTS: Out of the 87 patients, 85 (97.7%) were PCR positive and 2 (2.3%) were PCR negative, whereas in FISH 83 (95.4%) were positive and 4 (4.5%) were negative. Sensitivity and specificity of FISH was 97.6% and 100%, respectively. CONCLUSION: FISH is a reliable supplementary method to PCR for detection of BCR-ABL1 fusion gene in the diagnosis of CML.

Clinico-Haematological Features of Paroxysmal Nocturnal Haemoglobinuria.

The aim of this study was to determine the frequency of various clinico-haematological features in patients suffering from paroxysmal nocturnal haemoglobinuria (PNH). It was an observational study carried out from October 2008 - January 2016. All the patients of PNH, diagnosed on the basis of clinical and laboratory findings and confirmed by CD55 and CD59 deficiency on red cells by means of flow cytometry, were included in the study. A total of 22 patients were diagnosed which included 18 (81.8%) males and 4 (18.1%) females. Median age was 27 years. Pallor, fever, fatigability and haemoglobinuria were the most common clinical features. Pancytopenia was seen in 13 (59.09%) and hypocellular marrow was found in 14 (63.6%) patients. One patient presented with Budd Chiari syndrome.

Gitelman Syndrome.

Gitelman syndrome (GS) is the most frequently inherited renal salt-wasting tubulointerstitial disease. It follows variable but usually asymptomatic benign course. We present a rare case of GS that remained clinical enigma. A 22-year male presented with severe episodic fatigue involving all limbs associated with episodes of sinking, palpitations, salt craving, increased thirst and frequent micturition hampering his routine daily activities. Laboratory workup revealed serum potassium, 2.7 mmol/L, serum magnesium, 0.69 mmol/L and metabolic alkalosis. Urine analysis showed surprising results, i.e. urine potassium 49.5 mmol/L, urine spot potassium creatinine ratio 5.1, chloride 93 mmol/L and low 24 hours urinary calcium excretion (1.19 mmol/day). Plasma active renin concentration was 135 mlU/L while plasma aldosterone was 1090 pmol/L, depicting secondary hyperreninemic hyperaldosteronism. Based on typical findings, a diagnosis of GS was made. Patient responded well to potassium and magnesium supplementation, 100 mg daily tablet aldactone® and liberal salt intake. The aim of this report is to revisit clinical approach to persistent hypokalemia with special emphasis to remember rare entities like GS in the differential diagnosis.

Diagnostic Accuracy of Serum Iron and Total Iron Binding Capacity (TIBC) in Iron Deficiency State.

OBJECTIVE: To determine the diagnostic accuracy of serum iron and total iron binding capacity (TIBC) in detection of iron deficiency. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, from January 2013 to October 2015. METHODOLOGY: Data of 1,815 patients with results of serum iron, TIBC and ferritin from January 2013 to October 2015 was retrieved from Laboratory information System (LIMS) of AFIP. Diagnostic Accuracy Studies (STARD) guidelines were followed. Subjects of either gender, aged 1 - 68 years were included. Cases with raised serum ferritin levels (male > 336 ng/ml, female > 307 ng/ml) were excluded. Serum Ferritin was taken as gold standard with specificity of 99% and sensitivity of 80% at concentration of 30 ng/ml. Transferrin saturation was determined by dividing serum iron by TIBC and multiplying by 100. RESULTS: Out of 1,815 subjects, 931 (51.29%) were males and 884 (48.71%) were females. The median age of the patients were 29.1 years (Inter-quartile range, IQR 19.1). Taking ferritin as gold standard, the sensitivity and specificity of serum iron was 63.5% and 38.6%, respectively; while that of TIBC was 64.5 % and 42.8%, respectively. Ferritin showed poor correlation with iron, TIBC and transferrin saturation. CONCLUSION: Serum iron and TIBC give no additional information in the diagnosis of iron deficiency anemia and these tests are redundant for the diagnosis of iron deficiency state, if serum ferritin is available.

Sensitivity Pattern of Second Line Anti-Tuberculosis Drugs against Clinical Isolates of Multidrug Resistant Mycobacterium tuberculosis.

OBJECTIVE: To determine the current sensitivity pattern of second line anti-tuberculosis drugs against clinical isolates of Multidrug Resistant Mycobacterium tuberculosis (MDR-TB). STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Department of Microbiology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from November 2011 to April 2013. METHODOLOGY: Samples received during the study period were processed on BACTEC MGIT 960 system for Mycobacterium tuberculosis (MTB) culture followed by first line drugs susceptibility testing of culture proven MTB isolates. On the basis of resistance to rifampicin and isoniazid, 100 clinical isolates of MDR-TB were further subjected to susceptibility testing against amikacin (AMK), capreomycin (CAP), ofloxacin (OFL) and ethionamide (ETH) as per standard BACTEC MGIT 960 instructions. RESULTS: Out of 100 MDR-TB isolates, 62% were from male patients and 38% from female patients. 97% were sensitive to AMK, 53% to OFL, 87% to CAP; and 87% were sensitive to ETH. CONCLUSION: The majority of the MDR-TB isolates showed excellent sensitivity against AMK, CAP and ETH. However, sensitivity of MDR-TB isolates against fluoroquinolones like OFL was not encouraging.

Frequency of Gγ-globin promoter -158 (C>T) XmnI polymorphism in patients with homozygous/compound heterozygous beta thalassaemia.

BACKGROUND: Response to hydroxyurea therapy in homozygous or compound heterozygous beta thalassaemia (BT) has been reported as more favourable in the presence of XmnI polymorphism. The prevalence of XmnI polymorphism may vary with BT phenotypes and genotypes, and differs geographically in distribution. Prevalence of XmnI polymorphism is not known in northern Pakistan. OBJECTIVE: To determine the frequency of Gγ-globin promoter -158 (C>T) XmnI polymorphism (XmnI polymorphism) in patients with homozygous or compound heterozygous beta thalassaemia. MATERIALS: Polymerase chain reaction (PCR) for common beta thalassaemia mutations and Gγ-globin promoter -158 (C>T) XmnI polymorphism was performed on 107 blood samples of transfusion dependent beta thalassaemia (BT) patients in Pakistan. One hundred samples of unrelated BT traits and 94 samples of healthy subjects as controls were also analysed for BT mutations and XmnI polymorphism. RESULTS: Out of 301 DNA samples, XmnI polymorphism was detected in 71(24%); in normal controls, XmnI polymorphism was detected in 34/94 (36%) subjects; while in homozygous/compound heterozygous BT, it was detected in 14/107(13%) patients (Fisher's exact test, p=.0002). In heterozygous BT group, XmnI polymorphism was detected in 23/100 subjects (Fisher's exact test, p=.03 with normal controls, and p=.049 with homozygous/compound heterozygous BT). The most common BT genotype was Frame Shift (Fr) 8-9/Fr 8-9, and none of the patients with this genotype had XmnI polymorphism. The second most common genotype was IVSI-5/IVSI-5; 4/26 (15%). Cases with this genotype had XmnI polymorphism. CONCLUSION: XmnI polymorphism in homozygous/compound heterozygous BT group is 13%. The most common genotype associated with XmnI polymorphism was IVSI-5/IVSI-5.

High prevalence of protein C, protein S, antithrombin deficiency, and Factor V Leiden mutation as a cause of hereditary thrombophilia in patients of venous thromboembolism and cerebrovascular accident.

OBJECTIVES: To determine the frequency of Protein C, Protein S (PC & PS), antithrombin deficiency (AT III) and Factor V Leiden mutation (FVL) as a cause of thrombophilia in the patients with venous thromboembolism (VTE) and cerebrovascular accident (CVA). METHODS: It was an observational study conducted at Department of Haematology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan. All patients referred for thrombophilia screening from July 2009 to June 2012 were screened. Patients with evidence of VTE or CVA were screened for PC & PS, AT III deficiency, and FVL. RESULTS: Total 404 patients of age between 1-71 years mean 33 ± 14 with male to female ratio of 2.4:1 had evidence of thrombophilia. Two hundred eighteen (54%) patients presented with CVA, 116 (29%) with deep vein thrombosis (DVT), 42 (10.5%) with pulmonary embolism (PE), and 28 (7.5%) with portal or mesenteric vein thrombosis (PV). Protein C & S deficiency was detected in 35/404 (8.7%), ATIII in 9/404 (2%), and FVL in 25/173 patients (14.5%). The findings were suggestive of a significant association of FVL mutation for developing DVT (OR=11.0, 95% C I 4.6-26.3), CVA (OR=5.7, 95% C I 2.1-15.1), and PV (OR=5.4, 95% C I 1.3-21.9). PC & PS deficiency was a significant risk factor for developing PE (OR=3, 95% C I 0.8-11.4). CONCLUSION: FVL mutation and Protein C & S are the leading causes of thrombophilia with strong association of Factor V Leiden mutation as risk for developing DVT.

Guidelines on the laboratory diagnosis of congenital bleeding disorders in Pakistan.

Congenital bleeding disorders are found in all racial groups and are present worldwide. Among all of them haemophilia A, B and Von Willebrand's disease are the commonest and they are characterized by the low blood levels of factor VIII, IX and Von Willebrand's factor respectively. Severity of bleeding is proportional to the severity of factor deficiency. The diagnosis of bleeding disorders can be complex, and no single diagnostic tests are suitable for all patients. The guideline was developed after reviewing relevant publications, summarizing current understanding of bleeding disorders and classification, and present a consensus diagnostic recommendation based on analysis of the literature and expert opinion. They also suggest an approach for clinical and laboratory evaluation of individuals with bleeding symptoms, history of bleeding or conditions associated with increased bleeding risk. The document summarizes needs for improvement in laboratory testing and quality which is very much needed in Pakistan to make a correct diagnosis, train master trainers, identify complications of bleeding disorders in local population, increase awareness among masses, involve government in haemophilia care, education of patients and their families and health care community. It further enhances the need for research in bleeding disorders, including clinical research to obtain more objective information about bleeding symptoms, advancements in diagnostic and therapeutic tools.

Outcome of combination antiviral therapy in chronic hepatitis C virus infection during therapy of acute lymphoblastic leukemia.

Chronic hepatitis C virus (HCV) infection is not uncommon in patients with acute leukemia due to frequent blood transfusions. The treatment of HCV in patients with acute leukemia can produce profound immune dysfunction with the risk of severe cytopenia. We report the case of a young man who was treated with combined therapy of peginterferon α 2a and ribavirin for HCV while he was on maintenance anti-leukemic treatment. The patient required reduction in the dose of peginterferon α 2a and the addition of filgrastim due to neutropenia. Therapy for HCV was continued for 72 weeks and at the end of therapy, the patient had undetectable HCV RNA. The patient maintained a sustained viral response two years after the end of therapy and developed complete remission of leukemia, whereupon his anti-leukemic therapy was also discontinued. We recommend conducting further large prospective studies in HCV patients treated for leukemia to determine the safety and efficacy of antiviral therapy in this group of patients.

Association of Helicobacter pylori infection with idiopathic thrombocytopenic purpura.

OBJECTIVE: To determine the association of Helicobacter pylori infection in patients presenting with idiopathic thrombocytopenic purpura (ITP). METHODS: From March 2007 to March 2008, thirty adult patients with ITP and 30 age and sex matched healthy controls were investigated for the presence of H. pylori infection by Helicobacter pylori stool antigen (HpSA) an enzyme immunoassay (EIA) based method. The criteria for presence of H. pylori infection was a positive stool antigen test. RESULTS: H. pylori infection was found in 19 out of 30 patients with ITP (63.3%) which is well above the frequency of 13 out of 30 (43.3%) in controls. Calculated odds ratio was 2.25 which shows significant association of H. pylori infection with ITP. CONCLUSION: The study confirms the existence of an association between H. pylori infection and ITP. Therefore the screening for H. pylori infection and an attempt to eradicate bacterium in positive cases seems appropriate in patients with ITP at diagnosis.

Successful treatment of chronic hepatitis C virus infection with peginterferon alpha-2a and ribavirin in patients with sickle cell disease.

The objective of this case series was to determine the efficacy and safety of combined treatment with ribavirin and peginterferon alpha-2a in sickle cell disease (SCD) patients with chronic hepatitis C virus (HCV) hepatitis. Eight patients in King Abdulaziz Hospital & Oncology Center, Jeddah, Kingdom of Saudi Arabia from 2003 and 2006 with chronic HCV infection were treated with peginterferon alpha-2a and ribavirin for one year. All 8 patients had a complete early virological response. Seven out of 8 had an end of treatment response with undetectable HCV RNA at the end of therapy, 5 of whom also maintained a sustained virological response when assessed 6 months after the end of treatment. Hemoglobin concentrations measured at one, 3, 6, 9, and 12 months of treatment showed no significant changes from that measured as baseline. Treatment of chronic HCV hepatitis in patients with SCD with peginterferon alpha-2a and ribavirin seems safe and effective.

Control of severe bleeding episode in case of Glanzmann's thrombasthenia refractory to platelet transfusion therapy by administering recombinant factor VIIa.

Glanzmann's thrombasthenia is an autosomal recessive inherited platelet function defect. Though, quantitatively normal, the aggregation ability of platelets is reduced leading to bleeding episodes requiring transfusion of platelet concentrates. We describe a case of 13-year-old girl who had recurrent episodes of epistaxis since birth and was managed with multiple platelet concentrate transfusions and recently admitted with severe epistaxis refractory to platelet transfusion. At this stage administration of recombinant activated factor VII (fVIIa) was considered, which was initially given at 90 microg/kg dose with little control of bleeding but subsequent second dose of 120 microg/kg was administered with excellent response and immediate control of bleeding.

Eosinophilic gastritis; an unusual and overlooked cause of chronic abdominal pain.

Eosinophilic gastritis is an extremely rare disorder. The disease is associated with eosinophilic infiltration of various layers of gastrointestinal tract along with significant peripheral eosinophilia and increased Immunoglobulin E (IgE). We report a case of 37 year old Saudi male who presented with chronic non-specific upper abdominal pain. On initial workup, the diagnosis was missed. However the diagnosis was established after subsequent work up in Gastroenterology clinic. Our case demonstrates that patients with uncharacteristic abdominal pain who are unresponsive to conventional treatment, rare illnesses like eosinophilic gastritis should be considered. We also aim to review the clinicopathological features, differential diagnosis and various treatment options of this disorder. To the best of our knowledge, this disease has not been previously reported from Saudi Arabia.

Characteristics of dengue fever in a large public hospital, Jeddah, Saudi Arabia.

BACKGROUND: This study aims to determine demographic, clinical and laboratory profile along with disease outcome of all confirmed cases of dengue fever (DF) and dengue hemorrhagic fever (DHF) admitted in King Abdulaziz Hospital & Oncology Center, Jeddah, Saudi Arabia. We also want to highlight the significance of implementing a well targeted community based disease prevention program. METHODS: All patients admitted from May 2004 till April 2005 with a suspected diagnosis of DF and DHF were followed. All cases confirmed by a positive serology (IgM alone or IgM and IgG) to dengue fever were studied in detail to determine age, gender, ethnicity, monthly distribution, clinical and laboratory profile. RESULTS: A total of 80 patients were admitted with a suspected diagnosis of DF. Among these, 39 (48.75%) patients were confirmed by positive serology to have the disease. Male to female ratio was 3.3:1. Their ages ranged from 2 to 60 years with a mean of 27.6 +/- 11.2. Twelve patients were Saudis, while the rest were non-Saudis coming from different countries in Asia, Africa and Middle East. Maximum number of patients (48.72%) was seen in the summer months of June, July and August. Commonest presentation was fever (100%), headache (48.72%), myalgias (66.7%) and vomiting (25.64%). Rash, hemorrhagic manifestations and positive tourniquet test were relatively uncommon. Only two patients fulfilled WHO criteria of DHF. Main hematological abnormalities were thrombocytopenia (79.49%) and leucopenia (48.72%). Significant elevation of PTT was observed in 25.64% of patients. Abnormal liver function tests with high transaminases were seen in about 66.7% of patients, whereas 33.33% of patients had significantly elevated creatine kinase. All patients improved clinically with improvement of chemical and hematological parameters. None of the patients died in this series. CONCLUSION: DF continues to be a significant health problem in Western region of Saudi Arabia. Large number of pilgrims coming from disease endemic areas all over the world facilitates the continued introduction of dengue virus with different strains. Fortunately there has been no serious outbreak of dengue fever in recent years. A sharp vigilance is required by concerned authorities to prevent and minimize any future outbreak. It is extremely important to implement and maintain an effective, sustainable and community based disease prevention program.

Prevalence of prothrombin gene mutation (G-A 20210 A) in general population: a pilot study.

The objective of this study was to determine the prevalence of prothrombin gene mutation in a sample population from Pakistan. Two hundred apparently healthy unrelated adults (older than 18 years) were included in the study. The sample population comprised 100 Punjabis (male 50, female 50) and 100 Pathans (male 50, female 50). Patients with a history of previous thromboembolism were excluded from the study. Five milliliters (5 mL) of whole blood was drawn in an EDTA bottle. The DNA was extracted by the standard phenol-chloroform method. The DNA was amplified between exon number 14 and the 3'-untranslated region of the prothrombin gene by a polymerase chain reaction in a thermal cycler. Amplified products were digested overnight with HindIII at 37 degrees C. The digested products were electrophoresed on 6% polyacrylamide gel. The fragments were visualized by silver nitrate staining. A heterozygous wild type and an uncut amplified product were included in the electrophoresis strip for quality control. The wild type of DNA ran as a 350-bp fragment and internal control was cut as 550- and 150-bp fragments. The abnormal prothrombin gene was cut into 350-, 322-, and 28-bp fragments. Only two cases of heterozygous prothrombin gene mutation G-A 20210A were found in the sample studied, giving an overall carrier rate of 01% (95% CI 0.4-2.4%) in the target population. Prothrombin gene mutation is present in our population but at a lower frequency than in the white population.

Effect of HCV infection on hepatic fibrosis in patients of thalassaemia major.

OBJECTIVE: To investigate the effect of HCV infection on hepatic fibrosis in patients of thalassaemia major with iron overload in order to modify Pesaro criteria for classification into prognostic groups for allogenic haemopoietic stem cell transplant in these patients. DESIGN: Cross-sectional comparative study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Pathology, Armed Forces Bone Marrow Transplant Center and Departments of Pediatrics of Military Hospital and Combined Military Hospital, Rawalpindi, from July 2003 to June 2004. SUBJECTS AND METHODS: Twenty-eight HCV- and 18 HCV+ patients of thalassaemia major, who were prospective recipients of allogeneic bone marrow transplant, were included in the study. Serum ferritin was estimated by chemiluminescent immunoassay. Degree of fibrosis in liver biopsy was scored using Knodell s scoring system. Correlation between the two was evaluated statistically through Pearson s correlation coefficient. RESULTS: Mean serum ferritin was lower and degree of hepatic fibrosis was less in hepatitis C negative patients of TM. The correlation between serum ferritin and the degree of hepatic fibrosis was much stronger in hepatitis C negative patients with r value of 0.507 and p value of 0.006, which was statistically significant. CONCLUSION: A strong correlation between serum ferritin and degree of hepatic fibrosis was observed in patients of thalassaemia major not infected with hepatitis C infection. Serum ferritin levels alone are, therefore, not sufficient to assess degree of fibrosis in HCV positive patients of TM.

Clinicopathological features of lupus anticoagulant; experience at AFIP during last seven years.

BACKGROUND: The lupus anticoagulant (LA) belongs to family of immunoglobulins, most commonly an IgG isotype. These antibodies have been identified most frequently in association with thromboembolic events, recurrent fetal loss and thrombocytopenia. The aim of the present study was to evaluate the presenting clinical and pathological features in patients LA positive presenting at AFIP Rawalpindi over the period of Jan 1993 to Nov 2000. MATERIAL/METHODS: Retrospective analysis of patients presenting with positive LA was carried out. RESULTS: 1583 suspected cases were screened for LA including 1370 females and 213 males. 1024 cases presented with history of recurrent abortions, 292 with thrombosis, 152 with thrombotic strokes before the age of 45 years, 52 with thrombocytopenia and 63 with miscellaneous disorders. Out of 1024 patients tested for recurrent abortions, 130 (13%) females were positive for lupus anticoagulant. Ten (6.5%) of 152 patients presenting with strokes were found positive. Out of 292 cases presenting with thrombosis 17 (5.9%) were found positive. CONCLUSIONS: The lupus anticoagulant prevalence in Pakistani patients with recurrent fetal loss, stroke and thrombosis is statistically significant. Clinicians should be made aware of association of LA with various diseases. The successful management of these patients depends upon close liaison with obstetricians, physicians and haematologists.

Evaluation of serum transferrin receptor concentration in diagnosing and differentiating iron deficiency anaemia from anaemia of chronic disorders.

OBJECTIVE: To diagnose and differentiate iron deficiency anaemia (IDA) from anaemia of chronic disorders (ACD) using serum concentration of soluble transferrin receptors (sTfR). METHODS: One hundred and seventy six adult anaemic patients were diagnosed on bone marrow examination as IDA and ACD in the Department of Haematology, Armed Forces Institute of Pathology, Rawalpindi from November 2001 to May 2003. They were further evaluated with sTfR, serum iron, total iron binding capacity (TIBC) and serum ferritin. These biochemical investigations were compared with results of bone marrow iron status, which served as gold standard. Absence of stainable iron in the bone marrow was diagnostic of iron deficiency, whereas abundance of iron along with decreased siderocytes and sideroblasts was considered diagnostic of ACD. Data was collected on a proforma and analysed using software SPSS (version 11.0) and t-test was used to test the statistical significance. Specificity, sensitivity positive and negative predictive value of the sTfR test was calculated. RESULTS: Out of 176 patients studied, 90 (51.1%) were diagnosed as ACD whereas 86 (48.8%) as IDA. The mean +/- SD sTfR levels in IDA patients was 9.68 +/- 2.48 mg/I, whereas mean +/- SD sTfR levels in ACD patients was 2.96 +/- 1.28 mg/I, thus clearly separating the two categories of anaemic patients. Both the sensitivity and specificity of sTfR in IDA was found to be 100%, whereas in ACD, these were 66.6% and 100% respectively. The positive and negative predictive value, in case of IDA was 100%, whereas in ACD it was 100% and 74.1% respectively. The results of serum iron, TIBC and serum ferritin correlated well in IDA, with a fall in serum iron, raised TIBC and decreased serum ferritin, except in few cases in which concomitant inflammatory conditions resulted in falsely high serum ferritin level. Serum iron and TIBC were not useful in cases of ACD. However, the serum ferritin cutoff level of 90 ng/ml was evaluated which virtually excludes IDA, and found this highly effective in cases of IDA alongwith chronic inflammatory conditions. CONCLUSION: The results show that in case of simple IDA, sTfR concentration is significantly raised and it has a very high test efficiency in this condition. However in case of ACD the positive predictive value is high (100%) but the negative predictive value is compromised (74.1%). It is therefore a reliable laboratory index of IDA and in distinguishing IDA from ACD).