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Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia with or without bleeding. Mild to moderate thrombocytopenia can be seen with thyrotoxicosis and hypothyroidism. This study was conducted to assess prevalence of thyroid dysfunction in ITP and impact on treatment and outcomes. This prospective study included patients more than 12 years old, diagnosed as ITP. Serum Thyroxine (T4) and Thyroid Stimulating Hormone levels and anti-thyroid peroxidase (TPO) antibodies were done by electro- chemiluminescence immunoassay. A total of 168 patients were enrolled, with thyroid function tests available in 146 patients. Mean age was 30.6 years, with 67.8% females (n = 114). Sixty percent patients had chronic ITP and 25% had persistent ITP. Overall prevalence of thyroid disease was 25.7% in the study population, with overt hypothyroidism seen in 21 (16.4%) patients, subclinical hypothyroidism in 9 (7.0%) patients and subclinical thyrotoxicosis in 3 (2.3%) patients, while no patient had overt thyrotoxicosis. Thyroid status of the patients did not correlate with duration of ITP or response to treatment. Presence of anti TPO antibodies was associated with abnormal thyroid function and chronic ITP. The prevalence of thyroid dysfunction is increased in ITP patients. Many such cases have anti TPO antibodies, suggesting autoimmune pathology. Role of glucocorticoids, estrogens and systemic illness in these findings must be further studied before firm conclusion can be drawn about their routine inclusion in diagnostic work up.

In COVID 19 pandemic, delivery and access of health care services have become challenging. Telemedicine services can be considered for management of patients with hematological diseases. This study included all patients who enrolled for telemedicine facility for hematology from May 15 to July 15, 2020. Patient’s demographic and disease related parameters were recorded during the teleconsultation call. Overall satisfaction of attending doctor and patients were also recorded. A total of 1187 teleconsultation appointments were taken, of which 944 (79.6%) were successfully attended. Median age of patients was 38 years (range- 0.5–78 years), with 38% females. 55% of successful calls were from patients suffering a malignant hematological disorder. 24% had an active complaint pertaining to their disease or treatment. Of these, 162 (17%) were asked for a physical consultation. A significant association was found between the requirement of physical consultation and diagnosis (p

BackgroundThere is no effective therapy for COVID-19. Hydroxychloroquine (HCQ) and chloroquine (CQ) have been used for its treatment but their safety and efficacy remain uncertain.ObjectiveWe performed a systematic review to synthesize the available data on the efficacy and safety of CQ and HCQ for the treatment of COVID-19.MethodsTwo reviewers searched for published and pre-published relevant articles between December 2019 to 8th June 2020. The data from the selected studies were abstracted and analyzed for efficacy and safety outcomes. Critical appraisal of the evidence was done by Cochrane risk of bias tool and Newcastle Ottawa scale. The quality of evidence was graded as per the GRADE approach.ResultsWe reviewed 12 observational and 3 randomized trials which included 10659 patients of whom 5713 received CQ/HCQ and 4966 received only standard of care. The efficacy of CQ/HCQ for COVID-19 was inconsistent across the studies. Meta-analysis of included studies revealed no significant reduction in mortality with HCQ use [RR 0.98 95% CI 0.66-1.46], time to fever resolution [mean difference −0.54 days (-1.19-011)] or clinical deterioration/development of ARDS with HCQ [RR 0.90 95% CI 0.47-1.71]. There was a higher risk of ECG abnormalities/arrhythmia with HCQ/CQ [RR 1.46 95% CI 1.04 to 2.06]. The quality of evidence was graded as very low for these outcomes.Author’s ConclusionThe available evidence suggests that CQ or HCQ does not improve clinical outcomes in COVID-19. Well-designed randomized trials are required for assessing the efficacy and safety of HCQ and CQ for COVID-19..

Multiple myeloma (MM) is a hematological malignancy marked by uncontrolled proliferation and accumulation of plasma cells in bone marrow. Despite presence of numerous diagnostic markers for MM, their invasive and non-specific nature demands identification of some effective biomarker. Small non-coding RNAs, i.e., microRNAs being secreted out in circulation could depict the change in homeostasis. Earlier, we reported diagnostic potential of a proteoglycan, Versican (VCAN) in MM, hence, VCAN linked cell-free microRNAs have been explored to study their diagnostic involvement in MM. Biopsy proven MM patients and controls were recruited. The relative microRNA expression of VCAN linked microRNAs (miR-143, miR-144, miR-199, and miR-203) along with levels of VCAN have been investigated in bone marrow supernatant fluid (BMSF) and blood serum and their correlation were done with clinico-pathological parameters. The diagnostic potential was assessed using ROC curve. Relative microRNA expression of all microRNAs was found significantly lower in MM patients in both BMSF and serum while VCAN levels were substantially higher in patients. VCAN levels showed positive trend while microRNAs expression showed negative trend with severity of disease. miR-203 showed significant correlation with myeloma-associated parameters and also showed optimum sensitivity and specificity for diagnosis of MM in serum. Downregulation of cell-free microRNAs illustrates their importance in MM. The negative trend of microRNAs with disease progression suggests their diagnostic significance. Correlation of miR-203 with myeloma clinical parameters along with optimum sensitivity and specificity affirms its non-invasive diagnostic potential in MM which could further be validated in larger patient cohort.

Acute graft-versus-host disease (aGVHD) and relapse are major issues for patients undergoing allogenic hematopoietic stem cell transplant (allo-HSCT). T-regulatory (Treg) cells in the donor graft are negatively correlated with the incidence of aGVHD without any impact on relapse. In this study to determine the association of Treg cells with aGVHD in allo-HSCT patients. Thirty-two patients with hematological disorders, who underwent allo-HSCT. Twenty-nine patients who achieved engraftment were enrolled in the study. Treg cells were quantified in donor graft by flowcytometry and were assessed for their association with aGVHD and other clinical outcomes. Fifteen of 29 patients developed aGVHD. According to the occurrence and severity of aGVHD, patients were divided into two groups: 20 (68.9%) patients with grade 0–I aGVHD and 9 (31.1%) patients with grade II–IV aGVHD. Treg cells/CD4 ratio was significantly higher in the grade 0–I aGVHD group than in grade II–IV aGVHD group, (p = 0.0002). We could not find the association of CD34 dose (p = 0.55) or CD3 dose (p = 0.57) with the severity of aGVHD. Higher Treg cells/CD4 ratio in donor graft was associated with less severe aGVHD. Though more studies are needed, Treg cells/CD4 ratio may be used as a predictive marker for severity of aGVHD in post allo-HSCT.

Despite having standard principles of management of hemophilia, treatment differs in various countries depending on available resources. Guideline for management of hemophilia in Indian setting is essential. Indian Academy of Pediatrics conducted a consultative meeting on Hemophilia on 18th September, 2016 in New Delhi, which was attended by experts in the field working across India. Scientific literature was reviewed, and guidelines were drafted. All expert committee members reviewed the final manuscript. To bring out consensus guidelines in diagnosis and management of Hemophilia in India. Specific factor assays confirm diagnosis and classify hemophilia according to residual factor activity (mild 5-40%, moderate 1-5%, severe

To determine the efficacy of zoledronic acid (ZA) in thalassemia major associated low bone mineral density. Prospective, open label, single arm trial. Bone mineral density (BMD) at lumbar, hip and forearm region were performed at baseline and after 1 year of therapy. Initial, 9 patients received a first dose of 4 mg. Due to severe adverse effects, further doses for these patients and all new recruited patients were 1 mg once every 3 months for 4 doses. All patients were receiving 500 mg of calcium carbonate twice daily and 0.25 μg alfacalcidol once daily before and during the entire study period. Dual energy X-ray absoptiometry was performed at baseline and after 1 year. Twenty-seven patients with transfusion dependent thalassemia with a median age 19.5 year (15–38 years) were eligible for ZA treatment. Seven patients had bony pains. Four patients developed grade 4 hypocalcemia (3 developed tetany) and 2 developed infusion related toxicity with initial dose of 4 mg. One mg dose was well tolerated. At the end of 1 year, bone pains had completely resolved. There was significant increase in BMD at lumbar (p = 0.002) and forearm regions (p = 0.04) and intertrochantric area (p = 0.041). The % change in BMD at 1 year was +3.7 ± 3.2%. ZA is an efficacious agent in treatment of low BMD in these patients. ZA produces significant adverse reactions at 4 mg dose but 1 mg dose is well tolerated and is efficacious.

Acute Myeloid Leukemia (AML) as per World Health Organization (WHO 2008) classification is on the basis of the antigenic characterization, enzymes restriction in the neoplastic myeloid cells and the specific translocations/mutations. AML can be assessed and differentiated by flowcytometry (FCM)/immunohistochemistry (IHC)/cytochemistry techniques. Myeloperoxidase (MPO) is an unequivocal marker to differentiate AML from the acute lymphoblastic leukemia. Despite FCM popularity, it has its limitations, in form of ‘dry-tap’, cost, and inability of being performed by retrospective analysis. IHC, though an old technique has overcome these disadvantages of FCM. Cytochemistry, on the other hand has its own advantages in being cost-effective; technically easy to do while its disadvantages are its inability to be carried out in the old samples, ‘dry-tap’ conditions in aleukemic leukemia. There has been non-uniformity in the literature among these techniques especially concerning their sensitivity for MPO. A prospective study was done at All India Institute of Medical Sciences New Delhi from 01 July 2014 to 30 Nov 2015 to include 120 diagnosed acute myeloid leukemia cases. Myeloperoxidase stain was done by cytochemistry, immunohistochemistry and flow cytometry and results were compared. There were 28 cases which showed discrepancies. Out of these 28 cases immunohistochemistry showed positivity in majority (22 cases) followed by flow cytometry (14 cases). Therefore it is important to employ more than one technique and IHC must be included for detection of MPO in all suspected cases of AML especially when negative with FCM .

A comprehensive laboratory diagnosis of hemoglobinopathies forms an integral part in workup of disorders of globin chain synthesis. Clinical findings, complete blood counts, peripheral smear examination along with hemoglobin (Hb) electrophoresis and/or cation exchange high performance liquid chromatography findings and parental study helps to clinch a final diagnosis. Compound heterozygous hemoglobinopathy presents with variable clinical findings and some of them are picked up on screening tests done as part of routine antenatal workup. Here we report a rare double heterozygous hemoglobinopathy of Hb D-Punjab and Hb J-Meerut in a 35 year antenatal female.

Hereditary hypotransferrinemia is a very rare cause of iron deficiency anemia in childhood characterized by microcytic hypochromic anemia refractory to iron therapy and concomitant iron overload. Regular plasma infusion to replace the deficient transferrin molecule is the therapeutic option. We report two cases; both presented with refractory anemia requiring blood transfusions and responded to monthly fresh frozen plasma replacement.

Thrombocytopenia is common in patients with dengue virus (DENV) infections. With a focus on understanding the possible mechanism of thrombocytopenia in DENV infections we described a direct correlation between activation and depletion of platelets in patients. Our data showed a sharp decrease in platelet counts at day 4 of fever in patients. The high DENV genome copies in platelets correlated directly with the elevated platelet activation along with increased binding of complement factor C3 and IgG on their surface at day 4. Recovery in platelet count was observed on day 10 through day 6 and 8 with simultaneous decrease in platelet activation markers. Further, our in vitro data supported the above observations describing a concentration-dependent increase in platelet activation by DENV serotype-2. The high copy number of DENV2 genome in the platelet pellet correlated directly with platelet activation, microparticle generation and clot formation. Furthermore the DENV2-activated platelets were phagocytosed in large numbers by the monocytes. The DENV2-mediated lysis and clearance of platelets were abrogated in presence of platelet activation inhibitor, prostacyclin. These observations collectively suggest that platelet activation status is an important determinant of thrombocytopenia in dengue infections. A careful strategy of inactivation of platelets may rescue them from rapid destruction during DENV infections.

Aplastic anemia (AA) is a life-threatening bone marrow failure disorder, if untreated, is associated with very high mortality. Allogenic bone marrow transplantation (BMT) is the standard of care for severe aplastic anemia (SAA) patients those who are younger than 40 years of age. The development of secondary malignancies in post-BMT setting for AA is a rare, however, well documented phenomenon. Among the secondary malignancies, development of acute myeloid leukemia is even rarer entity. Here we report a case of acute myeloid leukemia following human leucocyte antigen (HLA) matched sibling peripheral blood stem cell transplant (PBSCT) in a case of SAA. The patient achieved complete remission (CR) following chemotherapy and in CR1, a second HLA matched PBSCT from a different donor was offered. The patient is presently in remission at day +180 post-PBSCT.

Forty-five years old male, a known case of T cell acute lymphoblastic leukemia (ALL) on maintenance therapy presented with bilateral painless progressive diminution of vision. Evaluation revealed cytomegalovirus (CMV) retinitis with low CD4 counts. CMV retinitis is usually seen in HIV disease or in post allogenic stem cell transplant recipients. CMV retinitis occurring in ALL maintenance phase is very rare. The disease is aggressive and shows incomplete response to medical therapy.

Pulmonary complications are one of the most common causes of morbidity and mortality in patients undergoing peripheral blood stem cell transplantation. Both infective and non-infective etiologies can involve the lungs during this period and differentiating them clinically is a challenging task and management differs in each case. We present here a case of acute myeloid leukemia, in whom following allogeneic peripheral blood stem cell transplantation, diffuse alveolar hemorrhage developed.

To assess the treatment and outcome of children with acute myeloid leukemia. The Primary objectives were to assess remission rates, treatment related toxicity and disease free survival. Secondary objective was to assess prognostic factors associated with poor outcome. A retrospective analysis of all treated patients with acute myeloid leukemia, less than 18 year of age from Sept 2005 to Aug 2009 was done. Clinical laboratory, treatment and follow up records retrieved to calculate remission rate, treatment related toxicity, disease free survival and poor prognostic factors. This analysis included thirty five patients (male : female; 23:12), twenty seven (77.1%) achieved remission after one 3 + 7 induction and seven required two inductions. High dose cytosine arabinoside consolidation was given in thirty one patients while one underwent allogenic stem cell transplantation. Two patients died during chemotherapy (TRM- 5.7%), two did not complete the therapy, seventeen relapsed (48.5%) with 80% of relapses occurring within first year of remission and no relapse occurred after 2 years. Fourteen patients are in remission (40%, follow up 5–54 months) and cumulative median disease free survival is of 13 months. The present data suggests that 3 + 7 induction, followed by high dose cytarabine consolidation has low treatment related toxicity and resource utilization; however, relapse free survival is inferior to more intensive regimens, highlighting the need to intensify chemotherapy regimen once the treatment related mortality has been minimized.

Dear editor, Priapism, that is, persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation, is a relatively uncommon disorder and is a medical emergency. Typically, only the corpora cavernosa are affected [1]. The term priapism was derived from the Greek god Priapus, son of Aphrodite who was born with oversized genitals [2]. The haematological causes for priapism include Sickle cell anaemia, Leukaemia, Multiple myeloma, Paroxysmal nocturnal haemoglobinuria, Thalassaemia, Thrombocythemia and Henoch–Schonlein purpura [3]. As far as hemoglobinopathies are concerned, priapism is most often encountered in sickle cell disease in 38–42 % of cases followed by sickle/beta thalassemia [4, 5]. Priapism is also noted in patients with sickle cell trait even though the incidence is low as compared with sickle cell anaemia [6–9]. However, so far priapism in Hb E homozygosity is not reported in literature. In this correspondence we intend to bring to notice an unusual association of priapism with Hb E homozygosity. A 27 years old male, resident of North Eastern part of India was referred to our haematology OPD to rule out any underlying haematological disorder as the individual had an episode of priapism 3 months ago. The patient had an episode of unprovoked painful persistent erection for more than 8 h for which he sought medical advice. The surgeon at that medical center had managed with therapeutic needle aspiration from corpora cavernosa combined with flushing of cavernosa with normal saline to clear the sludged blood. The patient’s symptom subsided subsequently with the intervention and was referred to our center for further evaluation. On detailed clinical history, the individual was not on any medication for chronic illnesses; neither was he abusing any psychoactive drugs, alcohol, no history of prior trauma to the perineal region. His physical examination revealed mild pallor. There was no hepatosplenomegaly or lymphadenopathy. Systemic examination did not reveal any abnormality. On USG abdomen, spleen was not reported as enlarged (Span 13 cms). On investigations, haemoglobin, total leucocyte count and platelet count were 9.1 gm/dL, 7.1 9 10/lL and 118 9 10/lL respectively. Peripheral smear examination revealed microcytic hypochromic red cells and target cells with normal differential leucocyte count and reticulocyte count of one percent. There were no sickle cells or atypical cells in peripheral smear and sickling test was also negative. Subsequently Hb HPLC was performed which revealed with Hb A2 ? E of 92.6 % (Retention time3.68 min), Hb A of 6 % (Retention time 2.29 min) and Hb F (Retention time 1.06 min) of 1.6 % (Fig. 1; Table 1). This was followed by parental study which revealed Hb A2 ? E in mother and father of 29 and 27 % respectively suggestive of both parents being heterozygous for Hb E, S. Venkatesan A. Purohit (&) M. Aggarwal P. K. Singh T. Seth H. P. Pati Department of Hematology, All India Institute of Medical Sciences, New Delhi, India e-mail: purohitabhi80@gmail.com

Flow cytometry is the most sensitive and specific diagnostic modality for paroxysmal nocturnal hemoglobinuria (PNH) clone assessment in PNH and other bone marrow failure states. A total of 101 samples included 23 PNH, 46 aplastic anemia (AA), seven myelodysplastic syndrome (MDS) cases, and 25 normal controls. Flow cytometry was performed using CD55, CD59, and stain–lyse–wash method, and the PNH clone size was correlated with the severity of disease. The PNH clone size on granulocytes in PNH patients varied from 7% to 97% detected with a sensitivity of 0.2% and correlated with the clone on monocytes (r = 0.563; p 0.05). PNH clone (0.4–38.7%) was detected in 23 (50%) AA patients. Three (42.9%) of the seven MDS patients showed PNH clone (

Expression of cell surface CD13 in acute B-cell leukemia (ALL-B) is often viewed, as an aberrant expression of a myeloid lineage marker. Here, we attempted to study the stage specific expression of CD13 on ALL-B blasts and understand its role in leukemogenesis as pertaining to stage of B-cell ontogeny. A total of 355 cases of different hematological malignancies were diagnosed by immunophenotyping. Among 68 cases of early B-cell ALL, 22 cases with distinct immunophenotype was identified as immature B-cell ALL. Blasts from these ALL-B patients demonstrated prominent expression of CD10, CD19, CD22, but neither cytoplasmic nor surface IgM receptors. This strongly indicates leukemogenesis at an early stage of B-cell development. We also identified, the existence of a subpopulation of cells with remarkably similar phenotype in non-leukemic marrow from healthy subjects (expressing CD10, CD19, CD22, CD24, Tdt together with the co-expression of CD13). This sub-population of B cells concomitantly expressing CD13 appeared to be a highly proliferating group. By blocking their cell surface CD13 in leukemic blasts with monoclonal antibody we were able to inhibit their proliferation. We hypothesized that neoplastic transformation at this stage may be facilitated by CD13. CD13 may thus be an important target for novel molecular therapy of early stage acute B-cell leukemia.

A young adult diagnosed as T-acute lymphoblastic leukemia presented with unusual complications during chemotherapy. He was diagnosed to have tubercular splenic abscess and had neurologic complaints like vincristine- induced peripheral neuropathy and focal neurologic deficit complicating the course of chemotherapy. Cases of hepatosplenic tuberculosis presenting as abscesses during prolonged neutropenia in patients with acute leukemia during or after chemotherapy are rare but reported. Vincristine induced neuropathy is reported to be higher in Indian children possibly due to co-existent malnutrition. The focal lesions in the brain were intriguing as regards to the symptomatology and exact etiology especially with the limitation of imaging in such patients. This case highlights the difficulty in the course of chemotherapy due to the rare complications encountered.

Dear Editor, Immunosuppressive therapy with antithymocyte globulin (ATG) with ciclosporine is the standard of care in patients with aplastic anaemia who are not eligible for bone marrow transplantation. ATG is an animal protein and its predominant toxicities include allergic reactions and serum sickness. Acute renal failure attributable to ATG has rarely been described. We report two patients with aplastic anaemia who developed acute renal failure during ATG therapy. Both patients developed oliguric acute renal failure with temporal relation to ATG administration and absence of other etiological factors. One of the patients had complete recovery of renal function with supportive treatment while the other died of sepsis and multi-organ dysfunction.

Pleural effusions in acute myeloid leukemia (AML) can have wide differential diagnosis, however AML presenting as pleural effusion with leukemic infiltration is rarely documented. A 22 year old male presented with pleural effusion for 3 months and subsequently diagnosed as AML M2, which prompted us for this communication.

Diagnosis of immune thrombocytopenia (ITP) is based on clinical suspicion and normal peripheral smear except for thrombocytopenia. Bone marrow examination is carried out to rule out leukemia, myelodysplastic syndrome or aplastic anemia. However, in most cases, clinical diagnosis is not altered after the bone marrow reports. Hence, this present study was carried out to evaluate the justification for bone marrow examination in the setting of isolated thrombocytopenia. All patients presenting to the hematology OPD with isolated thrombocytopenia and suspected diagnosis of ITP, between October 2011 and April 2013, were included in the study. Data was collected from bone marrow reports and outpatient records. A total of 353 cases were found. 319 cases had features of typical ITP and the rest had some form of organomegaly and/or lymphadenopathy. Bone marrow examination in all cases revealed normal hematopoietic elements and prominence of megakaryocytes including juvenile forms with no novel diagnosis in any patient. Routine use of bone marrow examination in the diagnostic workup of isolated thrombocytopenia is not required in our center even if steroids are planned as a first line therapy. However, a detailed history, thorough examination with complete hemogram and peripheral smear examination are essential.

Histoplasmosis is a systemic mycosis which has a worldwide distribution.Though common in immunocompromised patients, disseminated histoplasmosis has rarely been reported in patients with aplastic anemia. We report here a case of very severe aplastic anemia who developed disseminated histoplasmosis in the form of hepatic involvement, which proved fatal due to lack of cell mediated immunity.

Dear Editor, Infarcts are commonly seen in spleen, and rarely in myocardium and brain, in patients of chronic myeloid leukemia (CML). Bone infarcts, manifesting as severe debilitating pain as an initial presentation of CML have not been reported. We present a case of CML in chronic phase whose initial presentation was severe bone pains with inability to walk. Tc-99m MDP bone scan revealed heterogenous areas of bone infarct involving long bones of both upper and lower limbs. She was treated with Imatinib and Ecosprin. She became complete pain-free in 4 months. This case highlights the unusual presentation of CML-CP and complete recovery with standard therapy. A 32-years old woman presented with diffuse bony-pains involving bilateral upper and lower limbs for 3 weeks duration. She was not able to perform her daily routine activities because of severe pain (ECOG performance status 3). Clinical examination revealed mild pallor and splenomegaly (spleen size 8 cm below costal margin). Hemogram revealed hemoglobin 9.4 g/dl, total leukocyte count 136 × 109/l, platelet count 588 × 109/l and differential count-neutrophils 16%, lymphocytes 22%, myelocytes 24%, metamyelocytes 34%, basophils 3% and blasts 1% (Sokal, Intermediate risk 0.83). Her biochemical profile revealed blood urea 36 mg/dl, creatinine 1.1 mg/dl, uric acid 4.2 mg/dl, calcium 8.6 mg/dl and bilirubin 0.8 mg/dl. Her leukocyte alkaline phosphatase (LAP) score was low and RT-PCR for BCR-ABL was positive for p210. She was diagnosed as a case of chronic myeloid leukemia- Chronic phase (CML-CP). Radiographs of limb bones were normal. Tc-99m MDP bone scan revealed heterogenous increased radiotracer uptake in limb bones (involving bilateral humeri, forearm bones, femurs), suggestive of multiple bone infarcts. Rest of the skeleton was normal. She was started on hydroxyurea 500 mg thrice daily, allopurinol 100 mg thrice daily, imatinib mesylate 400 mg once daily and ecosprin 75 mg once daily. She was given analgesics (paracetamol and tramadol) for bone pains. Hydroxyurea and allopurinol were stopped after 2 weeks and imatinib and ecosprin continued. Patient achieved complete hematological response after 2 months of imatinib therapy but continued to have limb pains for 4 months though with decreased intensity. Pain completely subsided 5 months later (ECOG performance status 0). Repeat bone scan performed at 5 months revealed completely normal bone scan. Quantitative PCR for BCR-ABL at 15 months revealed major molecular response. CML accounts for approximately 15 to 20% of leukemias in adults. The clinical findings at diagnosis of CML-CP vary among reported series. Twenty to 50% of patients are asymptomatic, with the disease first being suspected from routine blood tests [1, 2]. Among symptomatic patients, systemic symptoms such as fatigue (34%), weight loss (20%), abdominal fullness (15%) and bleeding episodes due to platelet dysfunction (21%) are common [2]. Abdominal pain and discomfort may include left upper quadrant pain and early satiety due to the enlarged spleen with or without perisplenitis and/or splenic infarction. Tenderness over the lower sternum, due to an expanding bone marrow, is sometimes seen. Acute gouty arthritis may also present due to overproduction of uric acid [3]. Other frequent findings include splenomegaly (present in 48–76%), anemia (45–62%), white blood cell count above 100 × 109/l (52–72%) and platelet count above 600 × 109 (15–34%) [1, 2]. Involvement of extramedullary tissues such as the lymph nodes, skin, and soft tissues is generally limited to patients with blast crisis. Although thrombocytosis is common, thrombosis is not seen [2]. Other rare manifestations include splenic rupture [4] and priapism [5]. The radiological changes studied in CML include diffuse osteoporosis, focal osteolytic and osteoblastic lesions, chloromas and arthritis [6]. Bone pains are one of the common presentations of hematological malignancies [7] and are usually due to marrow infiltration by leukemic cells causing expansion of bone marrow. Bone infarction with severe pain as initial presentation has never been reported in CML-CP, though a case of CML developing bone infarction and progressing to myelofiberosis has been documented [8]. Our patient presented with diffuse debilitating bone pains due to multiple bone infarcts which is an unusual presentation of CML-CP. The patient responded to the usual treatment with complete disappearance of bone lesions and complete clinical recovery.

A DOUBLE BLINDED, RANDOMIZED, PLACEBO (P) CONTROLLED PILOT STUDY OF RhGM-CSF(GM) IN LOW BIRTH WEIGHT NEONATES (LBWN). PRELIMINARY RESULTS DEMONSTRATE A SIGNIFICANT REDUCTION IN NOSOCOMIAL INFECTIONS WITH RhuGM-CS