Spectrum of Hemophagocytosis in Bone Marrow Aspirates: Experience from a Tertiary Care Hospital in North India.

Background: Hemophagocytosis refers to the engulfment of hematopoietic cells by histiocytes. It can be seen in various conditions but is usually reported in the setting of hemophagocytic lymphohistiocytosis (HLH). Optimal interpretation of hemophagocytosis in the bone marrow in relation to the underlying disease significantly contributes to correct patient management. Aim: The present study was done to identify the spectrum of conditions associated with hemophagocytosis in the bone marrow aspirates and grade the degree of hemophagocytosis. Material and Methods: This retrospective observational study included all the bone marrow aspirates showing hemophagocytosis, identified over a period of 5 years (January 2015 to January 2020). Two pathologists independently reviewed bone marrow slides. Hemophagocytosis was graded as mild, moderate, or severe by observing the number of histiocytes showing hemophagocytosis per 500 nucleated cells. Results: Eighty-eight patients showing hemophagocytosis in the bone marrow aspirate smear were included in the study. The most common cause of hemophagocytosis was infection (18%). There were 4 (5%) cases of HLH. Grade 1 (mild) hemophagocytosis was seen in 25 (29%) cases followed by Grade 2 (moderate) in 53 (60%) cases and Grade 3 (severe) in 10 (11%) cases. Fever was the most common clinical symptom present in 45 (51%) cases. Conclusion: Hemophagocytosis in bone marrow aspirates is a common and under-reported finding. It is not only seen in cases of HLH but also in infections and other conditions. Documenting hemophagocytosis, even in the absence of fulfilled HLH criteria, is vital to explain cytopenias.

Detection of focal lesions in the clot section with negative bone marrow aspirate and trephine biopsy-A series of 5 cases.

Bone marrow aspiration and trephine biopsies are commonly used procedures in clinical practice. The practice of making a clot section by using the leftover blood from the bone marrow aspirate material is not a commonly followed practice across centers. A clot section has the advantage of studying the added material with an increased possibility of detecting focal lesions such as myeloma, lymphoma, granuloma, and metastasis in the bone marrow. Bone marrow aspirate, trephine biopsy, and clot section were compared for the detection of focal lesions in a series of 5 patients, 3 of who presented with a history of fever and 2 were already diagnosed cases of Hodgkin lymphoma. Focal lesions were detected in the 5 cases in the clot section alone, whereas bone marrow aspirate and trephine biopsy did not show any focal lesion. Granulomatous infiltration was detected in 3 patients, and lymphomatous infiltration was detected in 2 patients in the clot section, whereas bone marrow aspirate and trephine biopsy were negative for any focal lesion in all 5 cases. A clot section is particularly useful in the detection of bone marrow lesions with a focal distribution. Hence, it must be studied alongside bone marrow aspirate smears, touch smears, and trephine biopsy to increase the diagnostic yield.

Macrothrombocytopenia: Role of Automated Platelet Data in Diagnosis.

Purpose: Inherited macrothrombocytopenia is an underdiagnosed condition and may result in misdiagnosis and inappropriate management. This research was done to study this condition in a hospital setting. Materials and Methods: This study was conducted over 6 months in a teaching hospital. Patients whose complete blood count (CBC) samples were sent to the hematology laboratory were included. Patients were suspected to have inherited macrothrombocytopenia according to pre-defined criteria. Demographic information, automated CBC and peripheral smear examination was carried out. Seventy five healthy individuals and 50 patients with secondary thrombocytopenia were also analyzed. Results: Likely inherited macrothrombocytopenia was identified in 75 patients. Automated platelet count in these patients ranged from 26 × 10^9/L to 106 × 10^9/L while MPV ranged from 11.0 to 13.6 fL. There was significant difference (p < .001) in mean platelet volume (MPV) and platelet large cell ratio (P-LCR) amongst patients with likely inherited macrothrombocytopenia, those with secondary thrombocytopenia and the control group. Mean platelet diameter was significantly higher (3.5 ± 1.1µm) in patients with likely inherited macrothromboctopenia compared to those with secondary thrombocytopenia (2.4 ± 0.7µm) and control group (1.9 ± 0.7µm). All patients with suspected inherited macrothrombocytopenia showed abnormal platelet histograms with descending limb in the high volume and red cell zone. Four distinct histogram patterns were identified. Conclusion: Inherited macrothrombocytopenia is an underdiagnosed condition. The patient's history, clinical examination, judicious use of automated CBC data including platelet histograms and careful review of the peripheral blood smear are useful tools to suspect this condition. Supplementary Information: The online version contains supplementary material available at 10.1007/s12288-022-01590-6.

Psychological implications of Covid-19 in healthcare workers.

BACKGROUND: The Covid-19 outbreak has led to an unprecedented burden on the healthcare infrastructure. High morbidity and mortality rates have resulted in a state of stress and distress among the general population which has also impacted health professionals. AIMS: This study was conducted to identify mental health disturbances among health professionals during the Covid-19 pandemic. MATERIALS AND METHODS: It was a cross-sectional study, conducted in a Medical College in Himachal Pradesh, India. A self-administered anonymized questionnaire was administered to the healthcare workers. Mental health status was assessed using Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS). In addition, a 15-item questionnaire was prepared to identify the probable causes of stress in HCWs during the Covid-19 Pandemic. A statistical analysis used t-test was used to find the significance of the correlation between the PHQ-ADS score and the agreement score of different factors. RESULTS: The response rate for the questionnaire was 27%. Anxiety and depression were seen in 29% of participants, ranging from mild (18.3%), moderate (4.7%), and severe (5.9%). Among females 43.7% of the participants and among males, 13.1% had anxiety and depression. High PHQ-ADS scores were seen in nursing staff (70%) and postgraduate students (30%), who were in the third decade of life. Most (81.7%) of the HCWs were concerned about transmitting the disease to their near ones. Fear of coming to the hospital and dealing with patients. CONCLUSION: Even sub-threshold syndromes among HCWs need to be identified before they evolve into overt diseases. The psychological needs of healthcare workers should be prioritized as they are key players in the fight against Covid-19.

Role of Automated Volume, Conductivity and Scatter (VCS) Parameters of Neutrophils as Indicators of Sepsis.

This study was done to evaluate the role of automated volume, conductivity and scatter (VCS) parameters of neutrophils as indicators of sepsis and its differentiation from other inflammatory disorders. In this cross-sectional study, 225 patients with culture proven or with clinical evidence of sepsis were included along with an equal number of healthy controls. In addition, 138 patients with non-infective inflammatory conditions-acute pancreatitis (50), burns (45) and acute myocardial infarction (43) were also included. Complete blood count was done on LH750 automated hematology analyser (Beckman Coulter). VCS data; mean neutrophil volume (MNV), mean neutrophil conductivity (MNC) and mean neutrophil scatter (MNS) for all patients was recorded. MNV was high (p < .0001) while MNS was lower (p < .0001) in patients with sepsis compared to the control group. MNC was comparable between the two groups (p = .4735). On subgroup analysis of patients with sepsis, significant difference in MNV (p = .0009) and MNS (p = .0210) was observed in patients with leukopenia, normal TLC and leucocytosis. Youden Index was maximum (71%) at MNV of 144.6 (sensitivity-82.7%; specificity-88.5%) and MNV of 147.9 (sensitivity-75.6%; specificity-95.6%) for sepsis. On comparing patients with sepsis with acute pancreatitis and myocardial infarction, MNV and MNC were significantly higher in patients with sepsis. MNV is a useful, inexpensive parameter which can be accessed during a routine CBC run from the raw data. It can be utilized as an early indicator of sepsis as an adjunct to the clinical diagnosis in suspect patients. However, its availability in only select hematology analyzers may limit its use.

Screening chronic myeloid leukemia neutrophils using a novel 3-Dimensional Spectral Gradient Mapping algorithm on hyperspectral images.

Background and objective Early diagnosis of chronic myeloid leukemia (CML) is important for effective treatment. The high spectral and spatial resolution of hyperspectral cellular or tissue images coupled with image analysis algorithms may provide avenues to detect and diagnose diseases early. Many algorithms have been used to analyze medical hyperspectral image data, each having their own strengths and short-comings. We present a novel 3-Dimensional Spectral Gradient Mapping (3-D SGM) method to analyze hyperspectral image cubes of CML versus healthy blood smears. Methods In the present study, we analyzed 13 hyperspectral image cubes of CML and healthy neutrophils. The 3-D SGM algorithm was compared to the conventional Windowed Spectral Angle Mapping (Windowed SAM) method. The 3-D SGM exploited the spectral information of the image cube together with the inter-band and inter-pixel data by extracting the 3-D gradient vector from each pixel. The Windowed SAM determined the similarity between the averaged window of a 2×2 training pixel group and the test pixel, in the multidimensional spectral angle. Results The specificity measure of 3-D SGM (97.7%) was superior to Windowed SAM (72.7%) at ruling out the presence of the disease, making it potentially ideal for screening patients. The positive likelihood ratio value of 3-D SGM (16.70) was superior in diagnosing the presence of the disease (i.e., positive test for CML) versus Windowed SAM (2.26). An accuracy value of 84.2% was achieved with 3-D SGM versus only 70.2% for Windowed SAM. Conclusion The new method is efficient and robust for analyzing hyperspectral images of CML versus healthy neutrophils. It has the potential to be developed into an inexpensive, minimally invasive method for screening CML, and could directly facilitate early diagnosis and treatment of the disease.

A Comparative Study of Bone Marrow Squash and Wedge Aspiration Smears.

Bone marrow examination entails study of aspirate smears, touch imprints and trephine biopsy. Bone marrow aspirate smears can be prepared by the squash (crush) or wedge method. Both techniques have their own advantages and disadvantages. There is paucity of studies that have compared these smear types. This study was conducted over a period of one year. Two hundred and five bone marrow aspirates were included. Both squash and wedge smears were made. Blinded slide review was done. Bone marrow cellularity, megakaryocyte number, myeloid to erythroid (M:E) ratio, morphology and final diagnosis on each smear type was compared. Chi square test, t-test and Kappa were applied to study the agreement between the wedge and squash smears. Among the 205 patients studied, squash smears showed significant over estimation of cellularity and megakaryocyte number (p < 0.05). There was no significant difference (p > 0.05) in the M:E ratio and morphological scores. Most patients (188/205 [91.7%]) showed complete diagnostic concordance while 17 (8.3%) patients had discrepancy in diagnosis between the squash and wedge smears. In 8 (3.9%) of these, major discrepancies were seen while 9 (4.4%) patients had minor discrepancies. Bone marrow cellularity and megakaryocyte numbers were underestimated in wedge smears with no differences in M:E ratio or morphology. Acceptable agreement for diagnosis was seen for patients with most disorders. Major diagnostic discrepancies were seen in patients with lesions known to have focal distribution-lymphoma, myeloma and tuberculosis (granulomas). Both squash and wedge smears should be studied for bone marrow examination.

Disseminated Cryptococcosis in a Young Immunocompetent Male.

Cryptococcosis is an opportunistic infection caused by encapsulated yeasts of genus Cryptococcus. It usually infects immunocompromised patients and has multisystemic involvement, the common sites being lungs, central nervous system, skin and bone marrow. Disseminated cryptococcosis has also been reported in immunocompetent individuals. We present an immunocompetent patient with disseminated cryptococcosis and extensive bone marrow involvement.

Chronic neutrophilic leukemia presenting as secondary gout: Report of a rare myeloproliferative disorder.

Chronic neutrophilic leukemia is a rare leukemia seen in middle aged and elderly people, characterized by neutrophilic leukocytosis with no significant increase in granulocytic precursors. The chief criteria for diagnosis include total leukocyte count ≥25 × 109/L, >80% of white blood cells being mature neutrophils (segmented and band forms), immature granulocytic precursors ≥10% in the peripheral blood, and hypercellular marrow. In addition to this, there must be no evidence of dysplasia, monocytosis or BCR-ABL1, PDGFR-A, PDGFR-B, or FGRF-1 rearrangements. Moreover, the cause of neutrophilia should not be attributed to any other myeloproliferative disorders or to physiologic neutrophilia.We present two patients with this rare disorder who presented with gout as the initial symptom.

Hb Rush (HBB: c.304G>C): A Rare Variant Hemoglobin Mimicking the Hb S (HBB: c.20A>T) Variant on High Performance Liquid Chromatography.

High performance liquid chromatography (HPLC) is a useful and rapid tool in the evaluation of hemoglobin (Hb) disorders that include thalassemia and various hemoglobinopathies. Most of the techniques or programs used in automated testing platforms are customized to identify the common variants seen in that particular region. At times, variant Hbs may be identified which are not commonly seen in the local population. This may cause diagnostic dilemma and may require further studies for definitive characterization. We present a patient with Hb Rush (HBB: c.304G>C), a rare unstable Hb variant eluting in the Hb S (HBB: c.20A>T) window on HPLC.

Comparison of Rapid Centrifugation Technique with Conventional Centrifugation for Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) Testing.

Prothrombin Time (PT) and activated partial thromboplastin time (APTT) are frequently performed coagulation tests in patients with coagulation disorders especially in critical care areas and in monitoring patients on anticoagulation therapy. In coagulation testing, sample processing especially centrifugation is one of the most critical steps that affect turnaround time (TAT). This study was carried out over a period of 1 year. Three hundred paired samples from patients sent for PT and APTT estimation were included. One sample was centrifuged in a regular bench top centrifuge at 1500g for 20 min. The other sample was divided into two polypropylene aliquots and centrifuged in a microcentrifuge at 13000g for 3 min. The plasma obtained from both methods was tested for PT and APTT using the automated method on STA Compact coagulometer (Stago) using commercial thromboplastin STAR-NeoplastineR C1 Plus and phospholipid (cephalin), STAR-C K PRESTR 5 respectively. Data were analyzed using descriptive statistics, Student t test, correlation coefficient and Bland-Altman plots. Mean PT, INR and APTT for both centrifugation methods was comparable with no statistically significant difference (p > 0.05). PT, INR and APTT also showed good correlation (r > 0.98) when compared between the two methods of centrifugation. Bland-Altman comparison between rapid and conventional methods of centrifugation for PT, INR and APTT also showed acceptable agreement. Rapid centrifugation technique for routine coagulation testing can be used safely with a significant reduction in the TAT. This can benefit patients in critical care settings and those on outpatient oral anticoagulant therapy.

Unrelated and related donor transplantation for beta-thalassemia major: A single-center experience from India.

Hematopoietic stem cell transplantation (HSCT) remains the only curative treatment in patients with ß-thalassemia major. A matched sibling or a related donor is usually found in only 25%-30% of the patients. There are limited data on matched unrelated donor (MUD) transplants from India. We reviewed HSCT outcome in 56 children with TM who underwent 57 transplants at our center. Related donor (RD) (n=43) and MUD (n=14) transplants were performed with TreoFluT-based conditioning regimen in majority (95%) of patients. Peripheral blood stem cells (PBSC) were the preferred (85%) source of stem cells. The overall survival (OS) at 1 year in RD and MUD groups was 87.6±5.2% and 85.7±9.4% at a median follow-up of 25 (1-92) months and 22.5 (1-50) months, respectively (P=.757). The thalassemia-free survival (TFS) at 1 year was 87.6±5.2% and 77.1±11.7% with a median follow-up of 24 (1-92) and 16.5 (1-50) months, respectively (P=.487). Although acute (14% vs 64%) and chronic graft-versus-host disease (GVHD) (13.9% vs 42.9%), infectious (39.5% vs 71.4%), and non-infectious (37.2% vs 78.5%) complications are higher in MUD transplant group, the present data show a comparable OS and TFS among RD and MUD group with treosulfan-based regimen using PBSC grafts.

Lower Total Leukocyte and Neutrophil Counts in Healthy Young Africans from Uganda.

The total leukocyte count (TLC) is an important component of the complete blood count and influences many clinical decisions. The effect of race or ethnicity on TLC is not well known. The African population has been reported to have lower than normal TLC and neutrophil counts. In this study, thirty eight African students referred for medical check up to a tertiary care hospital were included. Complete blood count was done on a three part automated hematology analyzer. Blood smear examination and manual differential count was also done. The control group included 38 age and sex matched healthy individuals. Student t test was used to compare the differences between the groups. The mean TLC in African students (4.95 ± 1.09 × 109/l) was significantly lower (p < 0.0001) than that seen in the control group (7.42 ± 1.7 × 109/l). The mean neutrophil percentage was also lower (49 ± 7.5%) in African students compared to the control group (63.6 ± 9.8%) [p < 0.0001] while lymphocyte percentage was higher (45.2 ± 7.5%) in the African students as compared to the control group (31.0 ± 9.3%) [p < 0.0001]. Absolute neutrophil count was also lower (2.45 ± 0.76 × 109/l) in African students compared to the control group (4.76 ± 1.47 × 109/l) while absolute lymphocyte count was comparable (2.21 ± 0.5 × 109/l vs. 2.26 ± 0.72 × 109/l) [p = 0.7212]. This study has shown lower leukocyte and neutrophil counts in apparently healthy African individuals. Knowledge of this variation from normal white cell and neutrophil counts is important in avoiding unnecessary investigations and influencing therapeutic decisions in these individuals.

Clinico-Hematological Profile of Hb Q India: An Uncommon Hemoglobin Variant.

Inherited hemoglobin disorders include thalassemias and structural variants like HbS, HbE, and HbD, Hb Lepore, HbD-Iran, Hb-H disease and HbQ India. HbQ India is an uncommon alpha-chain structural hemoglobin variant seen in North and West India. Patients are mostly asymptomatic and often present in the heterozygous state or co-inherited with beta-thalassaemia. This study was done in a tertiary care teaching hospital in North India over a period of 7 years among patients referred from antenatal and other clinics for screening of hemoglobin disorders. Complete blood count, peripheral blood smear examination and cation exchange high performance liquid chromatography (HPLC) was done to quantify various hemoglobins. HbQ India was diagnosed if the unknown variant hemoglobin was detected within the characteristic retention window. Of a total of 7530 patients screened, 31 (0.4%) were detected to have HbQ India. Of these, 25 (0.3%) patients had HbQ India trait and 6 (0.1%) patients had compound heterozygosity for HbQ India and Beta Thalassemia trait (HbQ India-BTT). All patients were clinically asymptomatic and were detected as part of the screening for hemoglobin disorders. Only two patients with HbQ India-BTT had hemoglobin less than 10 g/dL. In 25 patients with HbQ India trait, HbQ ranged from 13.6 to 24.4% and in 6 patients with HbQ India-BTT, HbQ India ranged from 7.4 to 9.0%. HbQ India is an uncommon structural hemoglobin variant. Although asymptomatic, it may cause diagnostic difficulty in the compound heterozygous state with beta thalassemia. HPLC provides a rapid, accurate and reproducible method for screening of this condition to identify and counsel individuals.