Impact of iron deficiency on hemoglobin A2% in obligate ß-thalassemia heterozygotes.

INTRODUCTION: The potential impact of concomitant iron deficiency on hemoglobin A2 (HbA2)-based identification of ß-thalassemia trait (ßTT) is a worrisome issue for screening laboratories. This is especially true for resource-constrained settings where iron deficiency is widespread and molecular confirmatory tests for borderline low HbA2 values may be unavailable. METHODS: Obligate ßTT carrier individuals (n = 752) were identified during screening studies on the parents of thalassemia major patients. HbA2%, complete blood counts and serum iron, ferritin and transferrin saturation were studied. Iron-deficient individuals (n = 135) with normal range HbA2% were taken as controls. RESULTS: Concomitant iron deficiency (defined as ferritin ≤15 ng/mL and/or transferrin saturation ≤15%) was present in 20.7% (156/752) ßTT cases, that is, 33.3% females (122/366) and 8.8% males with ßTT (34/386). Mean HbA2 in iron-replete ßTT was 5.4 ± 0.8 (range 3.1-7.9) and in iron-deficient ßTT was 5.4 ± 0.9 (range 3.3-7.6). HbA2 < 4.0% was found in 23/752 (3.1%) ßTT: 13/595 iron-replete (2.2%) and 10/157 (6.4%) iron-deficient ßTT individuals. However, five of the 10 iron-deficient ßTT cases carried the silent CAP+1 (A>C) ß-thalassemia allele accounting for the borderline HbA2%. On a separate analysis, all five severely anemic ßTT (Hb < 80 g/L) and 16/17 ßTT with severe hypoferritinemia (<5 ng/mL) had HbA2 > 4.5%. The single case with serum ferritin 4.8 ng/mL and HbA2 3.3% showed a CAP+1 (A>C) mutation. CONCLUSIONS: Iron deficiency was prevalent among north Indian ßTT individuals, especially women. After adjusting for other causes of low HbA2 in ßTT, iron deficiency, even when very severe, was very unlikely to interfere significantly with HbA2-based identification of ßTT.

Iron deficiency anemia in children presenting with lymphoreticular malignancies and the effect of induction therapy.

There is scant information regarding iron deficiency in children with malignant disorders. Serum iron status of children with lymphoreticular malignancies (LRMs) at onset and at the end of induction therapy, compared to the normal population, was evaluated. Prospective cohort study conducted between July 2002 and March 2004. Previously untreated children recently diagnosed with LRM were studied. Age-matched controls were enrolled from follow-up and growth monitoring clinics. Hematological (complete blood counts and red cell indices) parameters and markers of iron status (serum iron, serum ferritin, total iron binding capacity) were estimated at presentation and at the end of remission induction therapy, that is, 5 weeks after initial evaluation. Bone marrow iron store were only assessed in cases. Thirty-five children (31 with acute lymphoid leukemia, 2 with acute myeloid leukemia, and 2 with non-Hodgkin lymphoma; 27 boys and 8 girls; 2 to 12 years of age) were evaluated in the study cohort. Anemia was documented in 80% of children with LRM. Iron deficiency was an important etiological factor. In the majority of cases therapy resulted in significant improvement towards normalization of deranged hematological parameters. This phenomenon could be attributed to enhanced quantity and quality of erythropoietic activity and red cell transfusions. The observation suggests that therapeutic iron supplements are not indicated in the majority of children on therapy for malignant disorders. Various hematological and body iron status parameters should be assessed on a case-by-case basis.

Role of FAB classification of acute leukemias in era of immunophenotyping.

French-American-British classification for leukemias had been widely accepted due to its objectiveness and good reproducibility. WHO classification of leukemias was formulated in 1997 with a purpose of further enhancing the objectivity. However, the requirement of cytogenetics and immunophenotyping makes it difficult for many countries like India to put WHO classification in routine use. This study was carried to know the effectiveness of FAB classification in an era of technical advancement. A retrospective analysis of all acute leukemias over a period of 2 years was done. Out of total of 469 cases of acute leukemias, 193 were diagnosed as Acute Lymphoblastic Leukemia (ALL), 200 as Acute Myeloid Leukemia (AML), and 76 cases diagnosed as Acute Leukemia, cytochemically undifferentiated. Hence, only 16% of all leukemias remained unclassifiable. Subclassification of AML cases revealed a much higher percentage of AML-M3, as compared to western literature. In conclusion, FAB classification, based on morphology and simple cytochemical stains, remains effective enough, although cytogenetics and immunophenotyping can add to diagnostic accuracy in some cases.

True hermaphroditism: clinical profile and management of six patients from North India.

True hermaphroditism (TH) is an uncommon cause of genital ambiguity. This is a retrospective compilation of six cases of true hermaphroditism seen at our institute over the last one and a half decades. Clinical presentation was wide-ranging, with age at presentation varying from 2 months to 41 years and symptoms ranging from ambiguous genitalia to a lower abdominal mass. All patients had perineoscrotal hypospadias with varying degrees of labioscrotal fusion. Clinically, gonads were not palpable in four cases and internally an ovotestis was observed in half of them. Karyotyping was 46, XX in all except one. The majority of the patients were reared as males. True hermaphroditism (TH) forms an important differential in the diagnostic algorithm of ambiguous genitalia especially if gonads are not palpable and congenital adrenal hyperplasia has been ruled out.

Establishment of prenatal diagnosis for beta-thalassaemia: a step towards its control in a developing country.

Beta-thalassaemia constitutes a major health burden on the limited health resources of India and prenatal diagnosis is seen as an important preventive measure to reduce the burden of the disease. Prenatal diagnosis has been offered to 99 women in 112 pregnancies by fetal DNA analysis, using a PCR-based Amplification Refractory Mutation System (ARMS) for the common and uncommon Indian mutations. Restriction fragment length polymorphism (RFLP) for the beta-globin gene was used when the mutation remained unidentified in one of the parents or to complement the ARMS result. In 53 cases the fetus tested had beta-thalassaemia trait (betaTT) (47.3%), 22 were normal (19.6%) and 31 had thalassaemia major (27.6%). In five cases (4.5%), a definitive report could not be given due to maternal contamination. In one case (0.9%), there was a misdiagnosis. Pitfalls encountered in the diagnosis were maternal contamination and occasional non-amplification of the primers. Having established a regional centre for the prenatal diagnosis for thalassaemia, the screening programmes will be enlarged both to identify carriers and prevent the birth of further homozygous children, even during the first pregnancy.

Parvovirus B19-associated transient red cell aplasia in children: the role of bone marrow examination in unusual presentations.

Human parvovirus B19 (PV B19) infection in children commonly presents as fifth disease. Transient red cell crisis, the other manifestation of PV B19 infection, is usually reported in children with chronic hemolytic anemia, with a worsening of the anemia. However, this condition may pass unrecognized in children without an underlying hemolytic disorder, since the anemia may be of a short duration and self-limiting. The authors report 3 cases of PV B19-induced transient aplastic in different clinical settings--pancytopenia in one child, during induction phase for acute lymphoblastic leukemia in the second, and fever with joint pains in the third. Treatment for PV B19-induced transient aplastic crisis is essentially supportive. There may be a dilemma in patients on immunosuppressive therapy, since initially it is difficult to distinguish between chronic pure red cell aplasia (a condition where intravenous immunoglobulin therapy is beneficial) and transient aplastic crisis, where supportive red cell transfusions suffice. The patient with leukemia also recovered spontaneously despite being on steroids. In all the 3 patients, the pure red cell aplasia recovered spontaneously without administration of intravenous gammaglobulins.

The psuedo-Chediak-Higashi anomaly: an unusual staining pattern in an Indian child with acute myeloid leukemia.

The authors describe the psuedo-Chediak-Higashi anomaly in a 12-year-old boy with acute myeloid leukemia (AML-M2). There were large purple granules in the blasts, promyelocytes, and myelocytes. Instead of the previously described patterns, the authors observed a unique rim pattern staining of the granules in both the May-Grunwald-Giemsa and the myeloperoxidase stains. Moreover, many of the granules had central vacuoles with strong myeloperoxidase positivity at the periphery. The bone marrow had a much higher positivity for these mega-granules as compared to the peripheral blood. On remission, these granules were no longer seen. To the best of the authors' knowledge, this pattern of staining has not been previously reported in the literature.

Accelerated phase at initial presentation: an uncommon occurrence in Chédiak-Higashi syndrome.

The authors describe an Indian child, who presented in the accelerated phase of the Chédiak-Higashi syndrome. The disease usually presents in early childhood with recurrent skin and mucosal infections. This patient had subtle pigmentary abnormalities and no family history of the disease, which made the clinical diagnosis difficult. The cytopenias, hepatosplenomegaly, lymphohistiocytic infiltrate in the bone marrow, and the characteristic granules in the leucocytes clinched the diagnosis. This case underscores the importance of a bone marrow examination in patients with unusual presentations of rare disorders.

Haematological abnormalities in patients of sarcoidosis.

OBJECTIVE: To study the presence and pattern of haematological abnormalities in patients with sarcoidosis in India. METHODS: Haematological investigations including complete blood cell counts, ESR and peripheral smear examination were carried out in 30 consecutive freshly diagnosed cases of sarcoidosis and compared with equal number of age and sex matched healthy controls. Coagulation parameters such as prothrombin time (PT), prothrombin index (PTI), partial thromboplastin time (PTTK) and fibrinogen levels were also studied. RESULTS: There were 15 men (mean age 40.4 +/- 10.15 years) and equal number of women (mean age 38.6 +/- 12.14 years) in the study group. Haematological abnormalities were present in 11 (36.66%) of the patients. Four cases (13.33%, all females) were found to have anaemia and in three of them no other cause for this was evident. Lymphopenia (lymphocyte count <1500/cu mm) was present in eight (26.66%) patients and three (10%) controls (P<0.05). Only one patient (3.3%) had leucopenia. Number of subjects with raised ESR and the mean ESR was higher in the study group as compared to the controls. No coagulation abnormalities were encountered. CONCLUSIONS: Different haematological manifestations in total are common in Indian patients, leucopenia is relatively rare while anaemia, lymphopenia and raised ESR are common

Splenectomy in a case of splenic vein thrombosis unmasks essential thrombocythemia.

We report a patient with splenic vein thrombosis (SVT) in whom splenectomy resulted in the unmasking of essential thrombocythemia (ET). He had portal hypertension with haematemesis, resulting in anaemia requiring repeated blood transfusions. Investigations revealed SVT. Following splenectomy, he suffered a transient ischaemic attack episode, associated with persistent thrombocytosis (> 2000 x 10(9)/l). Other myeloproliferative disorders were excluded and a diagnosis of ET was established. He responded to hydroxyurea but, due to financial constraints, he discontinued treatment and subsequently relapsed. The association of ET with SVT is rare and the diagnosis of ET was missed initially as the platelet count was normal prior to splenectomy.

Vitamin K deficiency in diarrhoea.

The study was undertaken to determine the frequency of occurrence of vitamin K deficiency in infants with diarrhoeal illness. Infants were categorized into four groups as follows: A(acute diarrhoea), B(protracted diarrhoea) C(intractable diarrhoea) and D(healthy controls). Screening coagulation tests, PT and PTTK along with estimation of functional activity and total antigenic levels of prothrombin were performed. The ratio of functional to total prothrombin was calculated. PT was prolonged in 30% (24/75) of all infants with diarrhoea as compared to controls where the abnormality was observed in 11.1% infants (2/18). The ratio of functional to total prothrombin was significantly lower in infants with diarrhoea, the mean +/- SD values being 0.65 +/- 0.41 vs 1.1 +/- 0.26. This difference was statistically highly significant (p < 0.001). Low ratio was observed in 57.3% (43/75) infants with diarrhoea. Thus functional to total prothrombin ratio identified approximately twice as many diarrhoeal infants with vitamin K deficiency as compared to PT alone. There was no significant correlation with breast feeding as the only mode of diet, or the prior administration of antibiotics in infants with diarrhoea. The inherent malabsorptive state in diarrhoea may be a major contributory factor.

Acute erythroleukemia (AML-M6)--a study of clinicohematological, morphological and dysplastic features in 10 cases.

Acute erythroleukemia is a relatively rare form of acute myelogenous leukemia. In the present study we analysed ten cases of acute erythroleukemia. All the patients were anemic and nine were thrombocytopenic at the time of diagnosis. Peripheral blood showed blasts in nine cases. Dyserythropoiesis was seen in all the cases whereas dysmegakaryopoiesis was seen in five cases. Dysplasia in the granulocytic series was seen in five cases. Based on the overall features this study concludes that acute erythroleukemia is associated with dysplasia of variable degree.

Molecular Pathology of Thalassemia and Triplicated Locus in North Indian Population; Interaction with Heterozygous Thalassemia.

The α(+) thalassemias are the most common single gene disorders of humans. They have been documented to be at a high frequency in certain areas of India. To analyze the prevalence of α thalassemia in the north Indian population (Punjab, Haryana, Himachal Pradesh), the α globin genotype of 419 subjects, comprising 208 healthy blood donors and 211 ß thalassemia traits, has been studied. The α globin genotype revealed a high frequency of α thalassemia (deletions; 12.4%) and α gene triplications (3.1%). The α(+) thalassemia with-α(3.7)/ααα(anti 3.7) haplotype was found to be prevalent in this population. No case of α(0) thalassemia was detected, indicating its rarity in this population. A single rare case of quadruplicated α genes was also observed. In addition to molecular analysis, hematological phenotype was studied in normal subjects and in ß thalassemia traits with and without α gene defect. In the normal group a single α gene deletion (-α/αα) lowered the MCV and MCH as compared to the normal α genotype (p<0.001). In cases with heterozygous triplication (ααα/αα), MCHC was found to be raised as compared to the normal α genotype (p<0.05). However, the values of these red cell indices in the heterozygous deletions and triplications were not in the diagnostic range. In the group of ß thalassemia traits, the interaction of heterozygous α gene deletion resulted in higher Hb and MCV when compared to that of the normal α complement, though these values remained in the lower normal range. Our results indicate a high frequency of α gene defects in this population. Though these were observed mostly in heterozygous form, they can and do occur as homozygous. By themselves, these defects of α genes even in homozygous form do not cause significant change in the phenotype, but their interaction with ß thalassemia can cause modification of the clinical expression to a variable extent. Thus, the concomitant inheritance of α gene defect with ß thalassemia would influence the genetic counseling and prenatal diagnosis in these families.

Effect of maternal low dose aspirin on neonatal platelet function.

OBJECTIVE: To evaluate the effect of maternal low dose aspirin ingestion in platelet function of newborn. DESIGN: Prospective randomized placebo controlled study. METHODS: 25 neonates born to mothers receiving low dose aspirin and 25 matched neonates with no maternal exposure to aspirin were studied. 2 ml of EDTA and 4.5 ml of citrate blood was collected from umbilical vein using double clamped umbilical stump for hemogram, coagulation profile and platelet functions. RESULTS: The platelet counts (10(9)/l) of study and control groups were 186.4 +/- 22.76 (116-225) and 205.28 +/- 17.34 (176-225), respectively. There was no significant difference in coagulation parameters. Prothrombin time index (PTI) was 86.24 +/- 6.623 and 87 +/- 6.43, respectively in the study and control group while PTTK (sec) was 55.88 +/- 20.54 and 52.12 +/- 11.82 in study and control subjects, respectively. The platelet aggregation studies (platelet function) with various platelet agonists in study and control group did not show any significant difference. Clinically, none of the babies had bleeding. CONCLUSIONS: Use of low dose aspirin in pregnant women was found to be safe and had no adverse effects on platelet functions of newborn.