Unearthing the genotype-inhibitor phenotype association in severe haemophilia A: A north Indian cohort study.

INTRODUCTION: Various risk factors for inhibitor development in haemophilia A (HA) have been described but Indian data remains scanty. AIM: We aimed to evaluate the genetic changes in Indian HA-patients that are associated with the development of inhibitors. METHODS: All HA-patients with inhibitors who availed coagulation-laboratory services from January-2015 till December-2021 and had their samples preserved for DNA extraction were included in this study. An equal number of severity-matched HA patients without inhibitors were also included as controls. Intron 22 and intron 1 inversions in Factor VIII gene were identified using inverse-shifting-PCR. Inversion-negative patients were further assessed by targeted NGS, MLPA. RESULTS: Thirty HA-patients with inhibitors were identified. All had severe-HA. Thirty severe-HA-patients without inhibitors were also included as controls. Intron 22 inversion (63.3%) and large deletions (15%) were the commonest variants identified. There was no difference in genetic variants in patients with low and high titre inhibitors. A3, A2 and C2 were the most common domains involved in inversion-negative patients with inhibitors. However, there was no significant difference in domain involvement among inversion-negative patients with and without inhibitors. Seven novel-variants were identified, including three large deletions, one large duplication and two nonsense variants in inhibitor-positive patients, and one frameshift variant in inhibitor-negative patient. After adjusting for clinical risk-factors, large deletions were independently associated with the presence of inhibitors [aOR:6.1 (1.41-56.3)]. CONCLUSION: Intron 22 inversions are the commonest variant in Indian patients with severe-HA. Large deletions predispose to inhibitor development independent of clinical risk factors.

Impact of ABO blood group antigens on residual factor VIII levels and risk of inhibitor development in hemophilia A.

Background: The clinical phenotype of hemophilia A (HA) does not always correlate with severity. Similarly, the presence of inhibitors does not necessarily increase the risk of bleeding. This paradox between clinical and laboratory findings may be partially attributed to non-modifiable factors, such as blood group, which is known to influence FVIII levels in healthy individuals. Our aim was to assess the effect of ABO blood group antigens on FVIII levels across the severity spectrum of HA and risk of inhibitor development. Methods: Data of consecutive patients with HA who visited the coagulation unit of a northern Indian tertiary care hospital between 2010‒2021 were reviewed. Patients with missing blood group data, transfusion histories, or baseline FVIII levels were excluded. Results: Mild, moderate, and severe HA was present in 41 (6.9%), 72 (12.2%), and 479 (80.9%) patients, respectively. There were no differences in the FVIII levels among the various blood groups across the HA severity spectrum. Inhibitors were administered to 35 patients (5.9%). In the multivariate analysis, blood group A was an independent risk factor for the development of inhibitors (adjusted odds ratio 2.70, P=0.04) after adjusting for age at onset of bleeding, FVIII transfusion, age at first FVIII transfusion, and severity of HA. Conclusion: Unlike what is observed in healthy individuals, blood group did not influence residual FVIII levels across the severity spectrum of HA. Patients in group A had a higher risk of developing inhibitors.

An Enigmatic Case of Jaundice and Photosensitivity in an Adolescent.

Erythropoietic protoporphyria (EPP) presents with nonblistering photosensitivity. Hepatobiliary manifestations are seen in around 5% cases and include cholelithiasis, elevations in liver enzymes, progressive jaundice, and end-stage liver disease. The diagnosis is suspected based on clinical features and elevated erythrocyte metal-free protoporphyrin and confirmed by genetic analysis showing loss-of-function mutations in the ferrochelatase (FECH) gene. We present an adolescent boy who presented with jaundice and photosensitivity with the liver biopsy showing deposition of brown pigments within the canaliculi and hepatocytes. This pigment showed Maltese cross birefringence on polarizing microscopy and Medusa-head appearance on electron microscopy. Genetic analysis revealed loss-of-function mutations in FECH. Introduction of EPP is an inborn error of heme biosynthesis caused by mutations in FECH with a prevalence of 1:75,000 to 1:200,000. We present a case of a 16-year-old adolescent boy with photosensitivity, abdominal pain, and jaundice with protoporphyrin deposition in the liver who was ultimately diagnosed with EPP based on genetic analysis.

Tumor infiltrating lymphocytes profile and response in neoadjuvant chemotherapy-treated triple-negative breast carcinoma patients.

Background: Triple negative breast carcinoma (TNBC) has the highest mortality among all the breast carcinoma subtypes, but paradoxically, it shows the best response to neoadjuvant chemotherapy (NACT). Tumor infiltrating lymphocytes (TIL) density has been shown to have prognostic significance in TNBC. However, there are limited data on TIL subpopulation and their association with response to NACT in TNBC. Materials and Methods: The study included 80 consecutive patients with TNBC prospectively diagnosed for two and half years, who underwent tru-cut biopsy before NACT, followed by subsequent definite surgical procedures. Global TIL profile and immunohistochemistry (IHC) analysis of CD3, CD4, CD8, CD20, and CD56 were done on all baseline tru-cut biopsies and post-NACT surgical specimens. Results: Almost half the patients were postmenopausal with a mean age of 45.89 ± 4.62 years. The majority had low CD3, low CD4, low CD56, low CD20, and high CD8 positivity in both pre- and post-NACT specimens. On multivariate analysis, low CD3, CD4, CD56 and CD 20 were established as independent predictor of poor pathologic response (PR). Low CD4 (adjusted odds ratio [OR]: 228.46) was associated with the highest OR for poor PR. Low CD8 was associated with significantly decreased odds of poor PR on univariate analysis (OR: 0.26), but it was not been established as an independent predictor of PR on multivariate logistic regression. NACT did not significantly alter the profile of TILs. Conclusions: TIL profile with low CD3, CD4, CD20, and CD56 expression predicts PR to NACT in TNBC and may thus help in prognostication of these patients.

Inhibitor; An Uncommon But Vexing Challenge In North Indian Patients With Hemophilia A.

Factor VIII replacement is the mainstay of treatment in hemophilia A but may lead to the development of inhibitors. While a vexing clinical problem, some observations suggest that the presence of inhibitors may not necessarily portend a higher bleeding risk. Our aim was to assess the prevalence and clinicopathological correlates of inhibitors in a well characterized cohort of Indian patients with HA patients. We retrospectively reviewed the clinical details and laboratory findings of consecutive hemophilia A patients attending a north-Indian tertiary-care center from 2010 to 2020. Among 592 patients with HA, inhibitors were detected in 35 patients (5.9%). Prevalence of inhibitors in moderate and severe hemophilia was 4.2% and 6.7%, respectively. Most patients with inhibitors had history of transfusion with factor VIII alone (54.3%) or a combination of factor VIII concentrate and other blood-products (42.9%). Intracranial bleed was significantly more frequent in patients with inhibitors compared to those without inhibitors (20% vs. 4.1%; p-0.001). Time dependent and immediately acting inhibitors were seen in 60% and 40% patients, respectively. High-titre (> 5 BU) and low-titre inhibitors (< 5 BU) were detected in 28 (80%) and 7 (20%) patients, respectively. Prevalence of inhibitors in our cohort was 5.9% and most had high-titre, time dependent inhibitors. These patients may have a higher risk of intracranial bleeding.

A case of amoebic liver abscess complicated by bilhaemia and venous thrombosis.

Amoebic liver abscess is the most common extra-intestinal manifestation of amoebiasis. It usually responds well to treatment with metronidazole together with drainage, if indicated. Uncommonly, the abscess may rupture into the pleura, peritoneum or pericardium, bile duct at its hilum, or produce septic emboli. We present a patient with two rare complications: venous thrombosis and jaundice secondary to bilhaemia.

Hepatic osteodystrophy and fracture risk prediction using FRAX tool in Indian patients with cirrhosis.

BACKGROUND AND AIM: The main clinical relevance of hepatic osteodystrophy is the increased risk of fractures. Dual-energy X ray absorptiometry (DEXA)-based assessment of bone mineral density, the current gold standard for diagnosing osteoporosis, is not the sole determinant of fracture risk. Other clinical risk factors also play an important role. This study was carried out to assess the prevalence and risk factors of hepatic osteodystrophy and estimate the entailed fracture risk by using the FRAX tool in a cohort of Indian cirrhotics. METHODS: Consecutive patients with cirrhosis (n = 120) were recruited. Etiologic workup, liver function tests, serum calcium, phosphate, 25(OH)D, HbA1c, and DEXA scan were performed. Hepatic osteodystrophy was defined as a T score of < -1. FRAX scores were calculated using the Indian calculator. RESULTS: The study cohort was predominantly male (86.7%) with a median age of 49 (40-65) years. Alcohol was the most common etiology (80%). All patients had Child-Turcotte-Pugh class B (63.3%) or class B (36.7%) cirrhosis. Hepatic osteodystrophy was present in 83.3% patients. On multivariate analysis, smoking (odds ratio [OR]: 3.1 [1.76-4.7], P < 0.001) and serum 25(OH)D (OR: 0.23 [0.09-0.94]; P = 0.03) showed significant association with hepatic osteodystrophy. The 10-year probability of major osteoporotic fracture and hip fracture was 5.7% (2.1-28.9) and 2.5% (1.4-7.4), respectively. Using a FRAX probability cut-off of 20% for major osteoporotic fracture and 3% for hip fracture, 30% patients qualified for osteoporosis treatment. CONCLUSION: Hepatic osteodystrophy is widely prevalent among Indian patients with cirrhosis and entails a high risk of fractures. Approximately one-third of patients with cirrhosis need treatment to reduce the risk of osteoporotic fractures.