Primary renal leukaemia in a young adult male as an extramedullary presentation of T cell acute lymphoblastic leukaemia.

Primary renal involvement by T lymphoblasts is rare among adults with T acute lymphoblastic leukaemia. We report a 28-year-old man presenting with acute renal failure due to infiltration by T lymphoblasts and his response to paediatric-inspired modified BFM-90 protocol. The patient achieved an initial complete remission (CR) but developed central nervous system relapse. He achieved CR2 with cranial irradiation and intrathecal chemotherapy. He underwent a haploidentical transplant in CR2 and remains in remission post-transplant day 330. An early kidney biopsy helped confirm the diagnosis. Such presentations remain responsive to modified BFM-90. An early allotransplant in CR2 remains the standard of care.

Rapid Detection of Plasmodium vivax by the Hematology Analyzer for Population Screening.

In India, where malaria is endemic, the prompt and accurate detection of infections is crucial for disease management and vector control. Our study aimed to evaluate the "iRBC" flag, a novel parameter developed for routine hematology analyzers, for its sensitivity and specificity in detecting Plasmodium vivax (P. vivax) infections. We used residual blood samples from patients with suspected malaria and compared the iRBC flag results with microscopy, which serves as the gold standard. Additionally, we compared the results with rapid immuno-chromatographic tests (RDTs) commonly used in the field. Our study included 575 samples, of which 187 were positive for P. vivax. The iRBC flag demonstrated a high sensitivity of 88.7% and 86.1% on the XN and XN-L hematology analyzers, respectively, and a clinical specificity of 100% on both analyzers. Furthermore, the scattergram derived from each positive dataset exhibited distinct patterns, which facilitated rapid confirmation by laboratory specialists. Notably, the iRBC flag remained effective even in the presence of interfering conditions. Overall, our results indicate that the iRBC flag is a reliable and rapid screening tool for identifying P. vivax in routine blood testing. Our findings have significant implications for malaria detection and control in endemic regions like India.

Changing outcomes of stem cell transplantation in primary immunodeficiencies: Results from a tertiary-care charitable trust hospital in Mumbai.

Background: Hematopoietic stem cell transplantation in primary immunodeficiency disorders has come a long way since the first transplant in 1968. In India, pediatric stem cell transplantation long-term survival outcomes range from 62.5% to 75%, compared to 90% in high-income countries. Objective: We present single-center data of primary immunodeficiency transplants with immune-reconstitution evaluation after transplantation from a charitable trust hospital. Methods: Retrospective data of children transplanted for primary immunodeficiency disorders from March 2019 to March 2022 in a newly established transplant unit were collected. Data of pretransplant infections and comorbidities, surveillance for carbapenem-resistant Enterobacteriaceae, transplant characteristics, donor source, graft-versus-host disease, posttransplant infections, immune reconstitution, overall survival at 1 year, and immunodeficiency-free survival were collated. Results: Twenty-one patients underwent transplantation for primary immunodeficiency disorders. The median age at transplantation was 3 years and 5 months (range, 7 months to 17 years). Seventy-five percent of the cohort had organ involvement, with lung being the most common organ involved, followed by central nervous system. Fifty-two percent of children had peritransplant infections, with most of them recognized at the pretransplant assessment. Among 20 of 21 children with engraftment, 94% had complete chimerism initially, with 33% developing mixed chimerism over time. The median duration of immunosuppression was 3 months after transplantation, and only 1 child required systemic graft-versus-host disease treatment for more than a year. Immune-reconstitution showed good T-cell recovery at 3 months and naive T-cell production at 6 months. There was no regimen-related or sepsis-related mortality. Overall survival of the cohort was 95% at 1-year follow-up. Immunodeficiency-free survival was 86% after a median follow-up of 20 months. Conclusions: Immunodeficiency-free and graft-versus-host disease-free survival can be achieved in the majority of children with primary immunodeficiencies using enhanced supportive care and the latest transplantation algorithms.

Utility of FLAER and CD157 in a five-color single-tube high sensitivity assay, for diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH)-A standalone flow cytometry laboratory experience.

BACKGROUND: FLAER-based flow cytometry assay is considered the gold standard for diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). CD157 is a recently reported marker for GPI-anchored protein found both on neutrophils and monocytes. This study highlights the robustness of FLAER and CD157 combination to identify PNH clones in a high sensitivity assay. Though rare, the data shown highlight the presence of CD157 negativity in few cases re-emphasizing the importance of FLAER for PNH diagnosis. METHODS: A single 5-color tube-FLAER Alexa488/ CD157PE/ CD15PECy5/ CD64PE-Cy7 & CD45APCH7-was used for a high sensitivity PNH assay. RESULTS: Of 364 cases, 59(16.2%) cases had PNH clone in both granulocytes and monocytes. PNH clone sizes ranged from 0.02% to 96.6% in granulocytes and 0.07% to 96.3% in monocytes based on their FLAER-negative, CD157-negative phenotype. Twenty-two of the 59 PNH cases (37.3%) had WBC clone size of <1%. In addition, there were 10 cases which showed absence of CD 157 expression on both granulocytes and monocytes but on FLAER staining showed normal staining patterns. Three of these ten cases also showed a PNH clone based on absence of FLAER expression on both granulocytes and monocytes. CONCLUSION: FLAER and CD157 is a robust combination for diagnosis of clinical and subclinical PNH. Absence of CD157 expression in normal WBCs, though rare, should be kept in mind and re-emphasizes the importance of FLAER for the high sensitivity PNH assay.

Size of atrial septal defect after balloon atrial septostomy does not correlate with immediate improvement in oxygenation.

Objective: Transposition of great arteries is a common cyanotic heart defect. Balloon atrial septostomy aims to improve circulatory mixing and oxygenation. Previous studies have combined infants with intact ventricular septum and those with ventricular septal defect. Additionally, the septostomy was performed much later after birth. The objectives were to ascertain any correlation between the atrial septal defect size and oxygenation, before and after septostomy, as well the change in parameters pre-post procedure. Methods: We performed an audit of the last 10 years of clinical and echocardiographic data (2010-2020) for infants with transposition of great arteries with intact ventricular septum. A pediatric cardiologist, masked to clinical data, reviewed the images. Results: Our study of 25 infants with transposition of great arteries with intact ventricular septum noted that the procedure was performed at a median [interquartile range (IQR)] of 3 (2, 4) hours after birth. Prostaglandin was administered to the majority of infants [20/25 (80%)]. While significant increases in partial pressure of oxygen (24±5 vs 40±6 mmHg, p<0.001) and preductal oxygen saturations (67%±18% vs 81%±11%, p=0.003) were noted, and while the atrial septal defect increased in size from 1.8±0.6 vs 4.8±0.7 mm (p<0.001), no correlation was noted between atrial septal defect size and oxygen saturations. Conclusions: In our study of infants with transposition of great arteries and intact ventricular septum managed with balloon atrial septostomy, no correlation was noted between the atrial septal defect size and oxygen saturations. Pulmonary vascular resistance and pulmonary blood flow may be important physiological variables determining oxygenation.

Multiplexed quantitative proteomics provides mechanistic cues for malaria severity and complexity.

Management of severe malaria remains a critical global challenge. In this study, using a multiplexed quantitative proteomics pipeline we systematically investigated the plasma proteome alterations in non-severe and severe malaria patients. We identified a few parasite proteins in severe malaria patients, which could be promising from a diagnostic perspective. Further, from host proteome analysis we observed substantial modulations in many crucial physiological pathways, including lipid metabolism, cytokine signaling, complement, and coagulation cascades in severe malaria. We propose that severe manifestations of malaria are possibly underpinned by modulations of the host physiology and defense machinery, which is evidently reflected in the plasma proteome alterations. Importantly, we identified multiple blood markers that can effectively define different complications of severe falciparum malaria, including cerebral syndromes and severe anemia. The ability of our identified blood markers to distinguish different severe complications of malaria may aid in developing new clinical tests for monitoring malaria severity.

Diuretic use in infants with developing or established chronic lung disease: A practice looking for evidence.

AIM: The objective was to assess respiratory efficacy of hydrochlorothiazide and spironolactone and ascertain any adverse effects. METHODS: Data from 2014 to 2018 was analysed for infants <28 weeks' gestational age (GA) administered oral diuretics. Impact on respiratory support, weight gain and electrolyte status was assessed as a pre-post intervention study. RESULTS: Of 491 infants, 117 (24%) were administered diuretics for evolving or established bronchopulmonary dysplasia. GA and birthweight of the cohort were 25.7 ± 1.1 weeks and 779 ± 172 g, respectively. Median (interquartile range) chronological age and GA at the start of diuretics was 45 (22, 62) days and 32.1 (30.1, 35.1) weeks, respectively. In 71/117 (61%) infants, diuretics were started at <36 weeks GA. Of them 63 (88.7%) went on to develop bronchopulmonary dysplasia. Median duration of diuretics was 38 (18-52) days. Modest improvement was noted in respiratory parameters (ventilator pressure (cm of H2 O), 8.8 ± 0.4 vs. 8.8 ± 0.5, P = 0.39, oxygen requirement (%), 32 ± 1 vs. 30 ± 1, P = 0.07 and pO2 (mm Hg) 34.5 ± 1.3 vs. 36.6 ± 1, P = 0.04. Ninety-eight (84%) infants developed hyponatraemia (<135 mmol/L); sodium supplements were administered in 58/98 (59%) infants. In one third infants, phosphate levels dropped below 1.8 mmol/L, needing supplementation. Weight gain (g/kg/day) slowed down significantly (18.2 ± 2.1 to 10 ± 2.9, P = <0.001). CONCLUSIONS: Use of diuretics was associated with modest improvements in respiratory support requirements but was associated with significant electrolyte abnormalities and slowdown in weight gain (or weight loss).

Clinicopathological Analysis and Multipronged Quantitative Proteomics Reveal Oxidative Stress and Cytoskeletal Proteins as Possible Markers for Severe Vivax Malaria.

In Plasmodium vivax malaria, mechanisms that trigger transition from uncomplicated to fatal severe infections are obscure. In this multi-disciplinary study we have performed a comprehensive analysis of clinicopathological parameters and serum proteome profiles of vivax malaria patients with different severity levels of infection to investigate pathogenesis of severe malaria and identify surrogate markers of severity. Clinicopathological analysis and proteomics profiling has provided evidences for the modulation of diverse physiological pathways including oxidative stress, cytoskeletal regulation, lipid metabolism and complement cascades in severe malaria. Strikingly, unlike severe falciparum malaria the blood coagulation cascade was not found to be affected adversely in acute P. vivax infection. To the best of our knowledge, this is the first comprehensive proteomics study, which identified some possible cues for severe P. vivax infection. Our results suggest that Superoxide dismutase, Vitronectin, Titin, Apolipoprotein E, Serum amyloid A, and Haptoglobin are potential predictive markers for malaria severity.

Sehgal index: A new index and its comparison with other complete blood count-based indices for screening of beta thalassemia trait in a tertiary care hospital.

INTRODUCTION: Beta thalassemia trait (BTT) must be differentiated from iron deficiency anemia to avoid unnecessary iron therapy and for the prevention of thalassemia major by genetic counseling. In a tertiary care hospital, it is vital that the screening tool is not only sensitive but also specific so as to be cost effective and save time. AIM: The aim of this study was to evaluate the new Sehgal index and compare it to existing complete blood count-based indices for the best combination of sensitivity and specificity to predict BTT. MATERIALS AND METHODS: Study was done in 2 phases - Phase 1: A retrospective analysis of 1022 consecutive high-performance liquid chromatography (HPLC) cases from July 2008 to June 2011. Phase 2: A prospective analysis of 973 consecutive HPLC cases from July 1, 2011 to June 10, 2013 was done to confirm the results of Phase 1 and the applicability of the new Sehgal index. RESULTS: Prevalence of BTT was 28.8% (294/1022) and 25.39% (247/973) in Phase 1 and Phase 2, respectively. Receiver operating characteristic-area under the curve and Youden index was highest for new Sehgal index, followed by Mentzers index <14. The prospective study shows results similar to those in Phase 1 confirming the superiority of the above two indices. CONCLUSION: Sehgal index and Mentzers index <14 showed the best combination of sensitivity and specificity in predicting BTT. The best indices or combination can be used as a "validated flag rule" in the analyzer middleware program in a hospital for identifying suspected cases of BTT.

Unusual immunophenotype of T-cell large granular lymphocytic leukemia: report of two cases.

Large granular lymphocytes (LGL) leukemias are commonly of the T-cell or NK-cell type. T-cell LGL leukemia is typically a disorder of mature CD3, CD8 and T-cell receptor TCR (TCR - T cell receptor)-αß positive cytotoxic T-cells. Rare variants include TCRγδ+ variants and CD4 + TCRαß+ cases. We report a case of each of these rare variants. An 83-year-old female presented with anemia and lymphocytosis with LGLs on peripheral smear. Six-color multiparametric flowcytometric analysis showed expression of CD3, heterogeneous CD7, dim CD2 and TCRγδ and lacked expression of CD5, TCRαß, CD56, CD4 and CD8. A final diagnosis of TCRγδ+ T-cell LGL leukemia was made. Differentiation between TCRγδ+ T-cell LGL leukemia and other γδ+ T-cell malignancies is of utmost importance due to the indolent nature of the former as compared to the highly aggressive behavior of the latter. An 85-year-old male diagnosed with liposarcoma was identified to have lymphocytosis during preoperative evaluation. Peripheral smear showed presence of LGLs. Flowcytometric immunophenotyping showed expression of TCRαß, CD3, CD2, CD5, CD4, dim CD8, CD56 with aberrant loss of CD7 expression. Vß repertoire analysis by flowcytometry showed 97% cells with Vß14 clonality. A final diagnosis of TCRαß+ CD4 + T-cell LGL leukemia was made. CD4 + T-cell large granular lymphocytic leukemias have an indolent, less aggressive course when compared to their CD8 + counterparts and are not necessarily associated with cytopenias. However, their association with secondary neoplasia (29% of the cases) warrants a high degree of suspicion in the diagnosis as also noted in the index case. Use of a wide panel of antibodies and newer modalities such as Vß repertoire analysis helps in accurate subtyping of LGL leukemia.

Reference range evaluation of complete blood count parameters with emphasis on newer research parameters on the complete blood count analyzer Sysmex XE-2100.

Since the advent of automation in the field of hematological cell counters there has been a constant refinement of the technology and increase in the number of newer parameters available on CBC analysers. Many novel parameters are being put into routine clinical use and both clinical evaluation and monitoring critically depend on knowledge of laboratory reference ranges. Here, we present reference interval for the Sysmex XE-2100, with emphasis on the novel or newer research parameters. Blood samples from a total of 122 clinically asymptomatic and apparently healthy subjects were evaluated and a final of 100 subjects (54-M, 46-F) were included in the study. A broad spectrum of parameters available with the analyser was assessed and reference ranges for the same evaluated.

Comparison of platelet counts by sysmex XE 2100 and LH-750 with the international flow reference method in thrombocytopenic patients.

BACKGROUND: There are several methods for counting platelets, of which the international flow reference method (IRM) is considered to be the gold standard. We compared the platelet count given by this method to the count given by automated analyzers using other methods, such as optical fluorescence and impedance. AIMS: The aim of this study is to compare the platelet counts obtained by Sysmex XE 2100 by Impedance (Sysmex-I), optical florescence (Sysmex-O) and reported (Sysmex-R) based on the switching algorithm and LH-750 by Impedance (LH-750) with the IRM in thrombocytopenic blood samples. To calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various technologies at the clinically relevant transfusion thresholds of 10 × 10 9 /l and 20 × 10 9 /l. MATERIALS AND METHODS: A total of 118 blood samples with platelet count of <50 × 10 9 /l were selected for the study. Platelet counts of all samples were analyzed by all methods using the Sysmex analyzer, LH-750 and IRM in parallel within 6 h of collection. STATISTICAL ANALYSIS USED: Pearson correlation, bland Altman analysis, sensitivity and specificity, PPV and NPV. RESULTS AND CONCLUSIONS: Sysmex-R had the least Bias and 95% limits of agreement (95%LA) range and thus correlated best with IRM values. LH-750 had a higher Bias compared to Sysmex-O and Sysmex-R, but a strikingly similar 95% LA ensures similar results in all three methods. In fact, in the oncology subset, it had the narrowest 95% LA, which made it the best performer in this subgroup. Of the three Sysmex results, Sysmex-I had the highest bias, widest 95% LA and highest potential risk of over transfusion. Hence, Sysmex-R and LH-750 were found to be reliable tools for estimation of platelet count in thrombocytopenic patients.

Leukemic phase of anaplastic lymphoma kinase positive, anaplastic large cell lymphoma.

Anaplastic large cell lymphoma (ALCL) is a distinct type of CD30+ T/null-cell non-Hodgkin's lymphoma that frequently involves nodal and extranodal sites. The presence of leukemic phase in ALCL is extremely rare and occurs exclusively with ALK1-positive ALCL. We describe two patients with ALK1-positive ALCL who developed a leukemic phase with rapid progression of the disease. Immunophenotypic pattern assessed on peripheral blood by flow cytometry revealed CD45, CD30, and CD25 positivity in both cases but NPM-ALK1 was expressed in only one case. Both patients developed leukemic phase as a terminal event of the disease and we share the immunophenotypic features of both cases.

Immunophenotypic profile of plasma cell leukemia: a retrospective study in a reference cancer center in India and review of literature.

BACKGROUND: Plasma cell leukemia (PCL) is a rare but aggressive subtype of plasma cell dyscrasia. It is known to present with highly variable morphological features and may mimic with other lymphoid neoplasms. Multicolor flow cytometry (MFC) with availability of newer markers is highly useful in the diagnosis of the plasma cell leukemia. We present an immunophenotypic profile in ten cases of PCL along with their clinical and laboratory findings. MATERIALS AND METHODS: We retrospectively studied immunophenotypic profile of 10 cases of plasma cell leukemia (out of 4615 cases of hematolymphoid neoplasms) using five parameter, three color flow cytometric analysis. We also studied their clinical presentation and other laboratory findings. RESULTS: Common clinical features at presentation were weakness, bone pain, anemia, thrombocytopenia and osteolytic lesions. Plasma cell population was identified on strong expression of CD38 and co-expression of CD38 and CD138. CD56 was expressed in 44% cases. CD19 and CD20 were negative in all cases. Surface light chain restriction was seen in 50% cases and in remaining 50% cases revealed cytoplasmic light chain restriction. CD117 was expressed in one out of two cases studied. CONCLUSIONS: MFC immunophenotyping is highly useful to differentiate Plasma cell leukemia from other chronic lymphoproliferative disorders with plasmacytoid morphology as well as from non-neoplastic reactive PC and co-expression of CD38 and CD138 is a best combination to identify the plasma cells by MFC.

Comparison of platelet counts by CellDyn Sapphire (Abbot Diagnostics), LH750 (Beckman Coulter), ReaPanThrombo immunoplatelet method (ReaMetrix), and the international flow reference method, in thrombocytopenic blood samples.

BACKGROUND: We compared the international flow reference method (IRM) platelet counts with those obtained from CellDyn Sapphire (impedance and optical counts), LH750 (impedance counts), and the flowcytometry based ReaPanThrombo Immunoplatelet method (ReaMetrix). We further evaluated the degree of agreement of above methods with the IRM at the transfusion thresholds of 10 x 10(9) l(-1) and 20 x 10(9) l(-1). METHODS: A total of 104 thrombocytopenic blood samples with platelet count of <50 x 10(9) l(-1) were selected for the study. All samples were tested in parallel by various methods within 6 h of blood collection. RESULTS: For bias estimation, a Bland-Altman analysis was done by taking the IRM as the standard method. The bias for CDS-I counts was +6.505 x 10(9) l(-1) (95% LA -2.110 to +15.122), for CDS-O counts the bias was -3.779 x 10(9) l(-1) (95% LA -8.950 to +1.392), for LH750 the bias was +0.111 x 10(9) l(-1) (95% LA -5.862 to +6.084) and that for ReaMetrix was -1.602 x 10(9) l(-1) (95% LA -7.400 to +4.194). The LH750 had the least average bias and it overestimated platelet counts marginally. The ReaMetrix method showed the highest degree of agreement with the IRM, at both the threshold points with a K value of 0.960 (threshold < or = 10 x 10(9) l(-1)) and 0.923 (threshold < or = 20 x 10(9) l(-1)). CONCLUSIONS: Impedance platelet counts from LH750 were more accurate than optical methods in thrombocytopenic patients. ReaMetrix immunoplatelet counts show the maximum degree of agreement with the IRM at clinically relevant transfusion thresholds. We conclude that as current platelet transfusion thresholds are based on results of automated hematology analyzer methods, the true thresholds may be determined using the IRM and CD41/61 based single-platform immunoplatelet methods.

Hypergranular precursor B-cell acute lymphoblastic leukemia in a 16-year-old boy.

Presence of cytoplasmic granules in the blasts is a well known feature of myeloid leukemia. ALL presenting with the numerous cytoplasmic granules in blasts is a rarity and may be misdiagnosed as acute myeloid leukemia. We describe a rare case of hypergranular precursor B-cell acute lymphoblastic leukemia (ALL) in an adolescent male expressing CD10, CD19, CytoCD22, CD34, as well as CD13 and CD117. The blasts were cytochemically negative for myeloperoxidase (MPO), and acid phosphatase (ACP) but were positive for non-specific esterase (NSE). In centers where immunophenotypic panel is usually decided on the basis of morphology with limited antibodies may result in an erroneous typing of such rare diseases. Hence it is important to be aware of this rare entity and to confirm the lineage of acute leukemia by using a comprehensive panel of antibodies for immunophenotypic analysis.

Intracytoplasmic antigen study by flow cytometry in hematolymphoid neoplasm.

Flow cytometric detection of intracellular antigens has become a standard method in establishing proper leukemic cell lineage affiliation. It has a non-debatable contribution to the diagnosis of hematolymphoid neoplasm as well as in minimal residual disease. Combination of analysis of fluorescence labeling and light scatter properties of cells allows rapid and better determination of target cell antigens. Regarding the detection of intracellular antigens, standardization of the procedure remains, however, a real challenge. Detection of intracellular antigens by flow cytometry (FCM) requires effective fixation and permeabilization of the cell membrane. In the available literature, some reports describe methodologies to achieve satisfactory results for detection of either cytoplasmic or nuclear antigens; however, no methodological consensus has yet been achieved among the laboratories. This article is an attempt to describe different approaches to detect intracellular molecules by FCM.

Exflagellated microgametes of Plasmodium vivax in human peripheral blood: a case report and review of the literature.

Peripheral blood smear examination is the most specific as well as the most common test performed for the diagnosis of malaria. Schizonts, ring forms (trophozoites) and gametocytes are the stages of malarial parasite that are commonly seen in the peripheral blood smear of a patient. Here, we report an extremely rare case of a 40-year-old male patient who presented with Plasmodium vivax infection with multiple exflagellated microgametes in the peripheral blood smear with review of the literature. Exflagellation of microgametes in malarial parasites is only seen in the definitive host, mosquito, and is very unusual to see during the developmental phases in the intermediate host, human. It is important to recognize these exflagellated microgametes in the peripheral blood smear as they may lead to diagnostic confusion with organisms such as spirochetes and trypanosomes.