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For the detection of BCR-ABL1-like ALL cases, two methodologies, specifically Gene expression profiling (GEP) or Next-generation targeted sequencing (NGS) and TaqMan based low-density (TLDA) card, are being used. NGS is very costly and TLDA is not widely commercially available. In this study, we quantified the expression of 8 selected overexpressed genes in 536 B-ALL cases. We identified 26.67% (143/536) BCR-ABL1-like ALLs using hierarchical clustering and principal component analysis. BCR-ABL1-like ALL cases were significantly older at presentation (p = 0.036) and had male preponderance (p = 0.047) compared to BCR-ABL1-negative ALL cases. MRD-positivity and induction failure were more commonest in BCR-ABL1-like ALL cases (30.55 vs.19.35% in BCR-ABL1-negative ALL cases). Lastly, we built a PHi-RACE classifier (sensitivity = 95.2%, specificity= 83.7%, AUC= 0.927) using logistic regression to detect BCR-ABL1-like ALL cases promptly at diagnosis. This classifier is beneficial for hematologists in quick decision making at baseline to start tailored treatment regimes.

Pediatric HIV is a significant contributor to childhood morbidity and mortality. As HIV infects bone marrow CD34-positive progenitor cells, the hematological abnormalities are well-expected. The viral load is much higher in children predisposing them to opportunistic infections and hematopoietic malignancies. The present study aimed to determine the spectrum of hematological abnormalities that may yield clinically useful information in HIV-infected children. This was a retrospective study of 19 HIV-infected children who underwent bone marrow examination. Overall, 20 peripheral blood and bone marrow samples were analyzed for morphological changes in all hematopoietic lineages. Immunohistochemistry was performed on trephine biopsy sections for evaluation of B and T cells and cytomegalovirus inclusions. Anemia was the most common cytopenia (95%), followed by thrombocytopenia (45%) and leukopenia (40%). Myelodysplasia was noted in 70% of cases. Dysmegakaryopoiesis was predominant in 65% of cases, while dyserythropoiesis was noted in 25% of cases. Hemophagocytosis and reactive cellular changes were noted in 20% of cases each. Benign lymphoid aggregates and granulomatous inflammation were observed in 15% and 10% of cases, respectively. Significant myelofibrosis was found in 35% of cases. One case showed infiltration by Burkitt lymphoma. Parvoviral inclusions were identified in 1 case. An interstitial increase and aggregates of CD8 + T cells and reduced CD4 + T cells were noted. CD20 + B cells were normal to mildly increased in the bone marrow. Bone marrow examination provides clinically significant information in pediatric HIV revealing the underlying cause of hematopoietic abnormalities and allows the exclusion of major hematological neoplasms.

Cytogenetic abnormalities (CAs), one of the strongest influencers of therapeutic outcome in pediatric B-cell precursor acute lymphoblastic leukemia (BCP-ALL), can be identified by different techniques. Despite several technological advances, many centers with resource-limited settings continue to use either reverse-transcriptase polymerase chain reaction (RT-PCR) and/or fluorescence in situ hybridization (FISH) to identify prognostically relevant CAs. We evaluated a simple and cost-effective triple-probe FISH strategy on air-dried blood and bone-marrow smears and compared its performance with a multiplex RT-PCR-based approach in the prognostication of pediatric BCP-ALL patients. Three hundred twenty BCP-ALL patients were tested prospectively and in parallel by FISH on air-dried blood or bone-marrow smears and RT-PCR. The FISH strategy correctly diagnosed all genetic abnormalities identified by RT-PCR. Prognostically relevant genetic abnormalities were missed by RT-PCR in 24 (8.1%) patients. In another 20 children (6%), with samples inadequate for RT-PCR testing (dry taps or due to poor sample quality), a successful FISH testing could be performed on bone-marrow aspirate or trephine-imprint smears. In addition, FISH detected ploidy changes, which could be confirmed by FxCycle Violet-based flow-cytometry. FISH testing on air-dried smears identified more prognostically relevant CAs, provided information on the ploidy status, and could be successfully performed in children with difficulty in bone-marrow sampling.

Splanchnic vein thrombosis is an uncommon life-threatening form of venous thrombosis. It is one the common complication among MPN’s. In the western studies the prevalence of JAK2V617F mutation among SVT patient is high and ranges from 7 to 59%. The frequency of this mutation among Indian SVT patients is heterogenous. This was a prospective case control study. A total 52 cases of SVT and 40 controls were screened for JAK2V617F mutation along with other routine thrombophilic risk factors. Out of total 52 cases, 10 had BCS, 2 had MVT and rest 40 were of PVT/EHPVO. The JAK2V617F mutation was seen in two cases and not in controls. Among the thrombophilic markers, heterozygous FVL mutation, PC, PS and presence of APA were seen in 2, 3, 1 and 3 cases respectively. In addition, eight cases also showed deranged risk factors (5 inherited and 3 acquired), however the repeat testing was not performed due to loss of follow up. Among controls, one person showed presence of APA and one person showed multiple thrombophilic risk factor deficiency. JAK2V617F mutation was observed in 3.8% among north Indian SVT patients. The frequency of mutation is on the lower side as compared to the available Indian data. The other thrombophilia markers (both inherited and acquired) are more frequent (18%) and patients should be routinely screened for these thrombophilia markers.

Acute promyelocytic leukemia (APML) patients are prone to thrombosis. However, thrombosis at presentation is rare in APML. Our patient presented with thrombosis and cytopenia, and the clinical diagnosis was of paroxysmal nocturnal hemoglobinuria. However, subsequent peripheral blood smear and bone marrow study confirmed the diagnosis of APML. The patient was successfully managed with anticoagulation, arsenic trioxide, and all-trans retinoic acid.

To study the clinico-haematological and histopathological characteristics of FIP1L1-PDGFRA rearranged hypereosinophilia/hypereosinophilic syndrome (F/P+ve HE/HES), a retrospective analysis of patients with F/P+ve HE diagnosed over a period of 43 months was performed. Peripheral blood smears, bone marrow aspirate (BMA) and biopsies (BMB) were reviewed in each case and; reticulin stain and immunohistochemistry for mast cell tryptase (MCT) and CD117 was performed. F/P+ve HE was diagnosed in a total of ten patients during study period. All patients were males with a median age of 36 years (23–44 years). The median duration of presenting complaints was 7 months (2 months–3 years) which included specific symptoms related to various organs (80% of cases). Anaemia, thrombocytopenia and splenomegaly were seen in 60%, 50% and 90% of the cases respectively. Mastocytosis was not obvious in BMA but identified by MCT on BMB in all cases. Myelofibrosis (grade ≥ 1) was seen in 80% of the cases and includes multifocal paratrabecular fibrosis in 50% of the biopsies. Our study shows that bone marrow mastocytosis and myelofibrosis are very useful morphological indicators to suspect F/P+ve HE and suggests the routine use of reticulin staining and MCT immunohistochemistry in all BMBs performed for the evaluation of HE/HES.

Inherited bleeding disorders are not uncommon in pediatric practice: most of them being chronic, require lifelong replacement therapy. To frame a management policy, it is essential to assess the load and pattern of bleeding disorders in the local population. However, there is paucity of data reporting the clinical spectrum of coagulation and platelet function disorders in Indian children. Hence to find out the exact burden and clinico-investigational profile of these patients we conducted this study. In this retrospective case review, detailed clinical information was extracted from case records in 426 children with a suspected diagnosis of hereditary bleeding disorder registered in the Pediatric Hematology clinic of a tertiary referral centre over a period of 14 years (1998-2011) and pooled for analysis. In our cohort prevalence of hemophilia A, hemophilia B, platelet function disorders, von Willebrand disease and other rare factor deficiencies were 72%, 11%, 7%, 4% and 4% respectively. Common clinical spectrum included skin bleeds, arthropathy, mucosal bleeds. 10% had deeper tissue bleeding and 16% received replacement therapy at the first visit. Nearly 3/4th of cases were lost for follow up after the initial visit. Hemophilia A was the commonest inherited bleeding disorder in our population. Skin bleeds and arthropathy were common clinical presentations. Factor replacement therapy was restricted to a minority. There is an urgent need for establishing centres of excellence with administrative commitment for factor replacement therapy for comprehensive management of such children in resource-limited countries.

Background: Modern automated hematology analyzers provide quantitative data on leukocyte size and structure that may be useful to distinguish reactive from neoplastic cellular proliferations. We compared leukocyte volume, conductivity and scatter (VCS) characteristics of chronic myeloid leukemia (CML), bcr-abl1-positive patients with those of non-neoplastic neutrophilia. Materials and methods: Complete blood counts and VCS data (LH750 hematology analyzers, Beckman Coulter) from 38 newly-diagnosed CML patients, 65 CML on imatinib mesylate therapy, 58 patients with elevated age-specific neutrophil counts due to varied causes, 100 pregnant women and 99 healthy controls were collated and compared. Receiver-operating-characteristic curves, logistic regression models and classification trees were studied for their abilities to distinguish various groups. Results: Untreated CML had higher mean neutrophil volume and mean monocyte volume (MNV and MMV), mean lymphocyte scatter (MLS) and higher standard deviations of the mean neutrophil volume and conductivity (MNV-SD and MNC-SD) over all other groups (p 163.0 AND MNC-SD>12.69 was 89.5% sensitive and 100% specific for CML. Two algorithmic classification-tree approaches using VCS parameters alone (i.e. without the aid of blood count parameters) correctly separated 100% cases of untreated CML from all others. Conclusion: Successful distinction of untreated but not post-imatinib CML patients from subjects who were either normal, pregnant or had reactive neutrophilia by automated analyzer-derived cell-population data opens possibilities for their applications in diagnosing and understanding the pathogenesis of CML. Keywords: Automated hematology analyzers, Cell population data, Cellular analysis, Chronic myeloid leukemia, Laboratory instrumentation, Neutrophilia

Lenalidomide maintenance after frontline chemo-immunotherapy (CIT) in chronic lymphocytic leukemia (CLL) has not been standard due to the availability of novel therapies, though these remain out of reach for most in low-middle income countries. This single-center, open-label study randomized CLL patients (non-deletion 17p) after frontline therapy to lenalidomide maintenance (dose-escalated 2.5-10mg, 20/28 days per cycle for six months) or observation (2:1 allocation). Forty patients were included over 2018-2020. At a median follow-up of 22 months, median progression-free survival (PFS) with lenalidomide was not significantly different than observation (26 vs. 18 months

T cell acute lymphoblastic leukaemia (T-ALL) is a genetically heterogeneous and aggressive form of malignancy. Although a number of recurrent fusion genes are reported in T-ALL, their involvement in disease stratification and therapeutic intervention is still controversial. Considering the prognostic value of STIL-TAL1 fusion and tyrosine kinase inhibitor (TKI) based therapeutic potential of NUP214-ABL1, the present study aimed to investigate their frequency and clinical correlation in pediatric T-ALL cases. Our cohort consisted of 48 T-ALL pediatric cases (age ≤ 12 years) with a median age of 6 years and male to female ratio of 20.5:1. The median TLC of the study group was noted to be 220,000/ cu mm with a range from 26,810/cu mm to 785,430/cu mm. By MLPA and RT-PCR analysis we observed that 11/48 cases (23%) showed STIL-TAL1 fusion and 4/48 cases (8.3%) had NUP214-ABL1 fusion gene. Both of the fusion genes did not show any significant correlation with any of the clinico-hematological or treatment outcome parameters. However, upon analysis of copy number variations (CNVs) with other clinically relevant genes, we found significant correlation between LEF1 (p = 0.024) and PTEN (p = 0.049) gene deletions with STIL/TAL1 fusion in T-ALL patients. NUP214-ABL1 fusion gene did not reveal any association with either CNVs or with survival. Although limited with the small cohort size and follow up, our study supports the similar frequency of these fusions as compared to other Asian and Western studies and also highlights utility of MLPA technique as a good diagnostic modality to screen for both STIL-TAL1 and NUP214-ABL1 fusions in a single assay with additional data on secondary copy number changes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12288-020-01394-6) contains supplementary material, which is available to authorized users.

Background: A number of mutations have been reported to occur in patients with acute myeloid leukemia (AML), of which NPM1 and FLT3 genes mutations are the commonest and have important diagnostic and therapeutic implications. Material and Methods: Molecular testing for NPM1 and FLT3 genes was performed in 92 de-novo AML patients. The frequency and characteristics of NPM1 and FLT3 mutations were analyzed. Results: Nucleophosmin 1(NPM1) and FMS-like tyrosine kinase 3 (FLT3) mutations were seen in 22.8% and 16.3% of patients, respectively. Amongst FLT3 mutations, FLT3-ITD mutation was seen in 8.7% cases, FLT3- TKD in 5.4%, and FLT3-ITD+TKD in 2.2% cases. Certain associations between the gene mutations and clinical characteristics were found, including in NPM1 mutated group- female preponderance, higher incidence in M4/M5 categories and decreased expression of CD34 and HLA-DR; and in FLT3-ITD mutated group- higher age of presentation, higher total leucocyte count and blast percentage. Conclusion- AML patients with NPM1 and FLT3 mutations have differences in clinical and hematological features, which might represent their different molecular mechanism in leukemogenesis. The frequency of NPM1 and FLT3 mutations in this study was comparable to reports from Asian countries but lower than that reported from western countries. However, as the number of patients in the study was less, a larger number of patients need to be studied to corroborate these findings.

Objectives Maternal sepsis is a life-threatening condition. Biomarkers have been found to be useful in early detection of sepsis in the critical care setting. We aimed to determine the diagnostic performance of different biomarkers such as procalcitonin, C-reactive protein (CRP), absolute eosinophil count, and activated partial thromboplastin time (aPTT) in maternal sepsis. Methods A total of 35 patients were enrolled in this prospective observational study. Patients with suspected sepsis were evaluated for multi-organ dysfunction. The blood samples for testing of these biomarker levels were obtained at the time of enrollment in the study (day 1), and on day 3 and day 7. Trends of each marker were followed and correlated with the clinical picture. Results Of 35 enrolled patients, 30 completed the study. Among these, 18 had sepsis and 12 were designated as without sepsis. Sensitivities of procalcitonin, CRP, aPTT, and absolute eosinophil count were 83.33%, 77.78%, 55.56%, and 58.82% whereas their specificities were 66.67%, 75.0%, 100%, and 75%, respectively. Area under the curve was highest for procalcitonin (0.813) followed in decreasing order by CRP (0.778), aPTT (0.731), and eosinophil count (0.642), respectively. Conclusion Procalcitonin and CRP may be used as a valuable adjunct in the clinical stepwise approach for the prompt diagnosis of maternal sepsis.

Both innovator and generic imatinib are approved for the treatment of Chronic Myeloid Leukemia-Chronic phase (CML-CP). Currently, there are no studies on the feasibility of treatment free remission (TFR) with generic imatinib. In a single center prospective Generic Imatinib Free Trial - in -CML-CP (GIFT-in-CML-CP) study, twenty-six patients on generic imatinib for more than 3 years and in sustained deep molecular response (BCR ABLIS

Splanchnic vein thrombosis (SVT) is a rare and lethal form of venous thrombosis. The role of platelet indices (PI’s) is not well studied in SVT. The present study was aimed to assess if the PI’s have a significant association with SVT. This was a prospective case control study from coagulation laboratory of Hematology department. A total 100 cases of SVT and 80 controls were screened for PI’s (MPV, PCT & PDW) and platelet count (PC) along with routine thrombophilic risk factors. The SVT cases were divided into 3 subgroups, that comprised of EHPVO/ PVT (n = 69), BCS (n = 27), and MVT (n = 4). The mean PC and PCT were significantly lower in patients than the controls. The PDW was significantly higher in cases than in the controls and MPV was relatively higher in cases however did not show statistical significance. In addition, 16 patients were found to have deranged thrombophilic risk factors. Among these, 8 cases had inherited risk factors (2: FVL; 5: PC; 1: PS) and 8 cases had acquired risk factors (2: APL; and 5: multiple factors and one case had both FVL mutation and APL positivity). The PDW and PCT together with PC were found to significantly differ in SVT cases than in controls, particularly in idiopathic cases. It may be worthwhile to explore the utility of PI’s as a potential risk factor in SVT. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at (10.1007/s12288-021-01400-5)

To report the efficacy, safety, and quality of life (QoL) on generic and innovator ibrutinib in Indian CLL patients. This was a single centre, prospective study of treatment-naive (TN), and relapsed/refractory (R/R) CLL patients receiving ibrutinib in India. The choice of innovator or generic ibrutinib was as per patient discretion. Response and adverse events were recorded as per the 2018 iwCLL guidelines and CTCAEv4.0. QoL was assessed using the EORTC QLQ-C30 and CLL17 questionnaires. A total of 32 CLL patients (TN, n = 7 and R/R, n = 25) received ibrutinib from 2016–2019. The median age was 60 years (37–84). All TN patients attained partial response without any grade 3/4 adverse events (AE). Ibrutinib was less tolerated in the R/R setting, with 52% patients developing grade 3/4 AE and required dose reduction. Eleven patients (44%) died during follow-up. Grade 3–5 infections were seen in 44% of R/R CLL patients. Generic ibrutinib (n = 8) was comparable to innovator ibrutinib (n = 17) in terms of efficacy, safety, and QoL. Ibrutinib is less well tolerated in Indian R/R CLL patients. Infections are a common cause of morbidity and mortality. This study affirms the safety and efficacy of generic ibrutinib. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12288-020-01378-6) contains supplementary material, which is available to authorized users.

To evaluate Neutrophil Lymphocyte ratio (NLR) as a predictor of disease severity in Nasal Polyposis and Allergic Fungal Rhinosinusitis (AFRS). This was a prospective non-randomized interventional study. Disease severity was graded based on endoscopic and CT scoring. Patients were given pre-operative oral steroids for two weeks and taken up for surgery. The pre-treatment neutrophil lymphocyte ratios were calculated from the differential leucocyte counts and compared with the disease severity and post-operative values. In the interventional arms, the disease severity correlated with the NLR. The mean pre-treatment NLR showed a statistically significant change after the intervention at eight weeks. The NLR normalized in patients with nasal polyposis and continued to be higher in patients with AFRS. NLR correlated to the disease severity and showed a linear correlation with the extent of the disease. NLR could be a potential cost-effective marker for disease severity and prognostication. Level of Evidence: Individual Cohort Study (2b)

Considering conflicting data on CDKN2A/B deletion in ALL, this study to assess its prognostic significance as an independent marker in a total of 96 pediatric B and T-ALL cases was planned. The overall frequency of CDKN2A/B deletion was 44% (n = 43) with 36% (30/83) in B-ALL and 100% (13/13) in T-ALL. CDKN2A/B deletion was significantly associated with high WBC count (p = .002) and National Cancer Institute risk (p = .01) in B-ALL. Importantly, CDKN2A/B deletion cases had poor EFS of 42% at 28 months compared to EFS of 90% in rest (p = .0004). Further, relapse free survival was only 56% for cases with CDKN2A/B deletions (n = 25), compared to 100% in control group (p = .001). Moreover, CDKN2A/B deletion was the only risk factor associated with early relapse (p = .01) compared to IKZF1 deletion (p = .73) or occurrence of BCR-ABL1 fusion transcript (p = .26). Thus our study data highlights potential prognostic role of CDKN2A/B deletions in early disease stratification in pediatric B-ALL.

Copy number abnormalities (CNAs) and recurrent fusion transcripts are important genetic events which define and prognosticate B-Cell Acute Lymphoblastic Leukemia (B-ALL). We evaluated CNAs and fusion transcripts in 67 pediatric B-ALL cases and correlated the data with standard risk factors and early treatment outcome parameters. Common fusion transcripts ETV6-RUNX1, E2A-PBX, BCR-ABL1 and MLL-AF4 were examined by RT-PCR and noted in 15%, 15%, 13% and 1.4% of all cases respectively. CNAs in IKZF1, PAX5, EBF1, BTG1, RB1, CDKN2A/B and genes from PAR1 region viz., CSF2RA, IL3RA,P2RY8, SHOX region and CRLF2 were analyzed by multiplex ligation dependent probe amplification assay and were detected in 70% (47/67) of cases, with predominantly deletions in CDKN2A/B (36%), PAX5 (18%) and IKZF1 (16%). A statistically significant association of intermediate/poor risk CNAs was noted with high WBC count (p = 0.001), NCI group (p = 0.02) and minimal residual disease at Day35 (p 0.0001). IKZF1 and CDKN2A/B deletion revealed poor EFS of 56% at 24 months as compared to EFS of 80% in rest of the cases (p = 0.05) suggesting their potential role in early risk stratification.

Chronic myelogenous leukemia (CML) is a rare disease in children, accounting for approximately 3% of leukemias in children and adolescents, with an annual incidence of 1 case per million children in western countries. This study was conducted, at PGIMER, Chandigarh. Ninety eight patients, 48 in children and adolescents group, and 50 in adult group were included in the study. Their hematological profiles along with the bone marrow findings were analyzed. The diagnosis of CML was confirmed by cytogenetics and/or molecular analysis. The complete hematological response (CHR) was analyzed at 3 months and cytogentic response (CgR) at 12 months after starting imatinib therapy. Compared to adults, pediatric and adolescent patients were more symptomatic at presentation (93.5 vs. 75%). Among symptomatic patients, massive splenomegaly (>10 cm), higher total leucocyte and platelet counts were seen more frequently in pediatric patients. The most common transcript in both groups was e14a2. The distribution of pediatric and adolescent cases in Sokal, Hasford and EUTOS score, showed only statistically significant difference for low risk Sokal group, which had more patients in pediatric group. Compared to adults, pediatric and adolescent patients had similar CHR rate (91.3 vs. 92%), but showed lesser major CgR rate (90.9 vs. 95.5%) however, this was not statistically significant.

The need for prognostication in chronic lymphocytic leukemia (CLL) is felt due to the heterogeneous clinical course of CLL, to counsel the patients, tailor follow-up, and to guide treatment decisio...

Summary Introduction A good bone marrow (BM) sample is essential in evaluating many hematologic disorders. An unsuccessful BM aspiration (BMA) procedure precludes a successful flow cytometric immunophenotyping (FCI) in most hematologic malignancies. Apart from FCI, most ancillary diagnostic techniques in hematology are less informative. We describe the feasibility of FCI in vortex-dislodged cell preparation obtained from unfixed trephine biopsy (TB) specimens. Methods In pancytopenic patients and dry tap cases, routine diagnostic BMA and TB samples were complemented by additional trephine biopsies. These supplementary cores were immediately transferred into sterile tubes filled with phosphate-buffered saline, vortexed, and centrifuged. The cell pellet obtained was used for flow cytometric immunophenotyping. Results Of 7955 BMAs performed in 42 months, 34 dry tap cases were eligible for the study. Vortexing rendered a cell pellet in 94% of the cases (32 of 34), and FCI rendered a rapid diagnosis in 100% of the cases (32 of 32) where cell pellets were available. Conclusion We describe an efficient procedure which could be effectively utilized in resource-limited centers and reduce the frequency of repeat BMA procedures.

Introduction of imatinib has changed the outlook of chronic myeloid leukaemia (CML) patients with overall survival approaching general population. Long term survival in CML patients has provided an opportunity to better study natural history and long term complications of disease as well as the treatment modalities. To study the occurrence and association of other malignancies with their outcomes in patients with CML. This is a single centre retrospective study. All CML patients case records registered with haematology clinic of a tertiary care centre in North India from 2001 to 2014 were perused and evaluated for dual malignancies. Those patients with dual malignancies were personally examined and interviewed if alive. Out of 1677 patients, 15 cases had co-existent malignancies. Four of fifteen cases of dual malignancies had CML as secondary cancer. Three had synchronous and rest 12 patients had metachronous malignancies. Only one patient was in accelerated phase, rest all were in chronic phase. Median age of the dual malignancy cases was 50 years (25–66 years), much younger than reported in west. The initial dose of imatinib was 400 mg OD in all except one. We did not find any causal association between CML or imatinib therapy with development of secondary tumours. Interestingly in this series, incidence of CML as secondary or synchronous malignancy was higher than earlier published studies.

There is controversy about whether 3- or 6-month molecular assessment predicts progression-free and overall survival in those with chronic myeloid leukemia (CML). The factors predicting molecular response at 3, 6, and 12 months have not been studied extensively. The study objective was to study the factors affecting molecular response at 3 and 6 months in patients with CML who are receiving imatinib mesylate.We prospectively enrolled patients with newly diagnosed CML who were receiving imatinib mesylate as the initial therapy for CML. The diagnosis of CML was based on clinical examination, bone marrow, and demonstration of BCR ABL(IS) transcripts by polymerase chain reaction. The molecular response(IS) was assessed at 3, 6, and 12 months by GeneXpert (Cepheid, Sunnyvale, CA) and co-related with various baseline characteristics of patients. We also looked at whether early achievement of a complete hematologic response within 6 weeks predicts molecular response at 3 or 6 months. The study took place at a tertiary care hospital in Northwest India catering to patients belonging to low-middle socioeconomic status.We enrolled 131 patients with CML in the chronic phase from July 1, 2013, to August 31, 2014. The median age of the patients was 40 years (range, 13-67) with a male preponderance (61% were male). Most patients presented with symptoms of low-grade fever (52.7%) and abdominal fullness (26.7%). Spleen was palpable in 84.7% of patients. The median hemoglobin at presentation was 10.8 g/dL (range, 4.8-18.4 g/dL), white cell count was 138.3 × 10(9)/L (4.1-697 × 10(9)/L), and platelet count was 326 × 10(9)/L (85-1819 × 10(9)/L). The median number of peripheral blood basophils was 3% (range, 0%-20%), and blasts were 3% (range, 0%-10%). Myelofibrosis of more than grade 1 was present in 30% of patients. Most patients belonged to intermediate Sokal (45.8%) and Hasford (55%) scores and low EUropean Treatment Outcome Study (78.6%) score. Of 128 evaluable patients at 3 months, 96.9% achieved complete hematologic remission (CHR) and 82.3% achieved BCR ABL(IS) of less than 10%. None of the patients who had BCR ABL(IS)10% at 3 months achieved BCR ABL(IS)1% at 6 months or0.1% at 12 months. Early achievement of CHR (6 weeks), peripheral blood blast count of5%, and lactate dehydrogenase851 U/L were significantly associated with achievement of BCR ABL(IS)10% at 3 months and BCR ABL(IS)1% at 6 months.We found that BCR ABL(IS) assessment at 3 months is superior to assessment at 6 months. Patients with CML in the chronic phase who achieve CHR within 6 weeks are more likely to achieve BCR ABL(IS)10% at 3 months and1% at 6 months than patients who achieve CHR between 7 and 12 weeks.

PURPOSE: To study the thrombotic factors, namely deficiencies of plasma proteins C, S, and antithrombin, factor V Leiden mutation, and positivity for antiphospholipid antibodies in young patients with retinal vein occlusion. METHODS: The thrombophilia parameters listed above were analyzed from the laboratory records of 50 patients with the clinical diagnosis of retinal vein occlusion, aged less than 50 years. RESULTS: A single prothrombotic factor was seen in 2 (4%) cases. The highest positivity was for the antiphospholipid antibodies (lupus anticoagulant in 6%, anticardiolipin antibodies in 2%, and anti-β 2 glycoprotein 1 in 10% cases). Other than one case where antiphospholipid syndrome was confirmed, these were transient. One patient had antithrombin deficiency. Protein C and protein S deficiency and factor V Leiden mutation were not seen in this group. CONCLUSION: Our data suggest that these thrombophilia risk factors are not commonly associated with retinal vein occlusion, and there is a need for studies on other factors that contribute to the development of this condition.

Invasive fungal infection (IFI) in patients with acute promyelocytic leukemia (APL) is a common phenomenon in developing countries. In a systematic study (Dual Inducing Differentiating agents—Indian Trial: DID-IT) using dual differentiating agents (ATO and ATRA) in 98 APL patients at our center we report 18.3% incidence of IFI (n-18). Among all cases of IFI three were definitive, 14 were probable and one was possible IFI. We conclude that incidence of IFI in APL is affected by environmental and therapy related factors and mere usage of dual differentiating agents need not necessarily decrease the incidence of fungal infections.

Automated blood counts revealing lymphocytosis necessitate smear reviews. Even expert morphological evaluation may however, fail to differentiate a benign-versus-malignant etiology without further testing. Automated analyser-derived quantitative data on leukocyte cell populations remain undertested for distinguishing such etiologies. Instrument manufacturers claim that if successful, they may be used to generate software flags that help under-resourced laboratories better triage hemogram specimens requiring further testing. We tested the diagnostic accuracy of volume-conductivity-scatter (VCS) indices together with complete blood count (CBC) parameters in such scenarios. We compared LH780-derived (Beckman Coulter, FL, USA) CBC + VCS parameters from patients with clonal lymphoproliferations (n = 42, including 30 chronic lymphocytic leukemia cases) versus 83 controls with absolute or relative lymphocytosis (derivation cohort). Diagnostic performances of 11 logistic regression equations derived were subsequently evaluated on two specific validation cohorts (n = 130 and n = 1465). Clonal lymphocytoses showed significantly lower hemoglobin and higher leukocyte counts but similar lymphocyte percentages (LY %) vis-à-vis controls. The most significant, albeit overlapping predictor of clonality was the absolute lymphocyte count, LY# (47.8 ± 48.4 × 10(9)/L vs. 2.9 ± 1.4 × 10(9)/L in clonal vs. benign cases). In eleven logistic regression equations constructed using four combinatorial approaches, only the models with LY# (highest sensitivity/specificity of 99.3%/100%) and the lymphocytic VCS parameters alone (highest sensitivity/specificity of 76.2%/90.2%) performed consistently in both validation cohorts. Lymphocytic VCS parameters were moderately successful in distinguishing benign-versus-malignant lymphocytes. Other approaches of CBC-plus-VCS parameters did not sustain their initial excellent performances in the validation cohorts, highlighting a need for careful appraisal and better standardization of automated cellular analysis technologies.

Hypocellular acute leukemia was previously referred to as smoldering leukemia. This is currently defined as having ≥20 % blasts in peripheral blood or bone marrow with cellularity of less than 20 % in bone marrow biopsy at presentation. Hypocellular variants of acute myeloid leukemia (AML) are commoner than that of acute lymphoid leukemia (ALL). They may pose a diagnostic challenge to the treating clinician and pathologist as they can simulate hypoplastic myelodysplastic syndrome and aplastic anemia. It is of utmost importance to distinguish these overlapping disorders as treatment modalities differ. Details of clinical features, complete blood counts, bone marrow aspirate findings, percentage cellularity, pattern of infiltration in trephine biopsies, and immunophenotyping by flow cytometry or immunohistochemistry were analyzed in cases diagnosed as hypocellular acute leukemia. Hypocellular acute leukemia constituted 2.5 % (8/316) of all diagnosed cases of acute leukemia during the study period. Seven of the eight cases of hypocellular acute leukemia were hypocellular AML while one was hypocellular ALL. Median age of patients was 45 years, with a male:female ratio of 1.7:1. Mean duration of symptoms was 1.2 months, with most common presenting feature being fever. None of the patients except one had an antecedent hematologic disorder or chemotherapy or radiotherapy. Hypocellular acute leukemia is important to recognize from other overlapping disorders. Clinical parameters and laboratory data including immunophenotyping can aid in distinguishing them.

We describe a rare case of metastatic prostate cancer to bone marrow and synchronous multiple myeloma as the second malignant disease. Various diagnostic procedures, including cytomorphology and immunohistochemistry analyses together contributed to the detection of metastasis of prostate cancer and synchronous plasma cell proliferation in the bone marrow. The association between these two disorders is poorly understood however, some studies show that bone marrow microenvironment may play a crucial role. The need for further research in this regard is required to unfold this fascinating association.

Bone marrow involvement in neuroblastoma indicates advanced stage of disease. The recent use of autologous bone marrow “rescue”, has provided an additional important reason for accurate assessment of bone marrow status in newly diagnosed patients. In this study, we analyzed 44 cases of neuroblastoma for bone marrow infiltration status and their hematological parameters. Eighty-eight bone marrow aspirate and trephine touch imprint smears and 44 trephine biopsy sections were examined in these 44 patients. Of these, 24 cases (54.5 %) showed marrow infiltration. Leucopenia and bicytopenia were significantly (p

Graft-versus-host disease (GVHD) is a clinical syndrome ascribed to the inflammatory reaction mounted by the donor cells against the host organs [1]. Transfusion associated graft-versus-host disease (TA-GVHD) is a rare and a fatal complication of the transfusion of non-irradiated cellular blood components in susceptible recipients [2]. It has low incidence of 0.1–1 % in susceptible recipients with an extremely high mortality rate of 87–100 % [3]. The underlying pathogenesis of this dreaded condition is due to the donor T-cells that engraft, proliferate and mediate a cellular immune response against host tissues, resulting in damage to skin, liver, gastrointestinal tract and bone marrow [2]. The existence of an atypical TA-GVHD, which does not follow a fatal course and exhibit all the manifestations of GVHD, has been suggested. English literature describes only two such published cases [4, 5]. The relative rarity of atypical TA-GVHD interested us to present this case report.

INTRODUCTION: Despite advances in diagnostic techniques, many cases of acute myeloid leukemia (AML) remain underdiagnosed in remote centers unequipped with these technologies. We hypothesized that the automated cellular indices with scatter plots and flags may aid in rapid and cost‐effective screening of AML. METHODS: Cell population data (CPD) parameters from 100 de novo AML samples were analyzed by Coulter LH 780 automated analyzer and were compared with 100 age‐matched controls. Similar parameters were also compared with 100 and 50 reactive cases of neutrophilia and monocytosis, respectively. System‐generated flags and scatter plot patterns were also analyzed. RESULTS: Results were compared between AML cases and normal controls; AML FAB M2, M3, M4 vs reactive neutrophilia; AML FAB M4, M5 vs reactive monocytosis. Significant parameters were selected from all comparison groups. Using appropriate statistical tools, we calculated the cutoff values of these parameters and were able to screen out AML cases with 94% sensitivity and 95% specificity. Three statistical equations were generated using two of the most significant parameters which improved the sensitivity to 98% and specificity to 99%. Five hypothetical scatter plot patterns were devised and were classified according to FAB categories of AML. Most common pattern was selected in AML which was seen in 56% of the cases. Output was analyzed combining these patterns and flags with CPD parameters. CONCLUSION: CPD either alone or in the form of statistical equations along with scatter plots and flags can provide rapid and economic tool in preliminary diagnosis of AML in cost‐constrained settings.

Objective: To determine the frequency, etiological spectrum and treatment outcome of hypereosinophilia (HE) and hypereosinophilic syndrome (HES) in a tropical setting.Methods: A retrospective analysis of hospital data of five years and a comprehensive prospective evaluation of patients presenting with HE/HES over a period of 33 months was performed.Results: HE/HES was diagnosed in total of 125 patients during study period with an estimated prevalence of 0.5-1 case per one lakh population in our hospital settings. Infections, especially helminthes were the commonest cause (34%) followed by primary/clonal HE/HES (24%) and reactive HE/HES secondary to various clonal disorders (14.3%). Lymphocytic variant of HES and FIP1L1-PDGFRA positive HES were diagnosed in 3.6% each. Imatinib responsive BCR-ABL1 negative HE/HES constitute 7.1% in our patients.Conclusions: None of the clinical or routine laboratory features including the age of patients, duration of HE, presence or absence of organomegaly, hemoglobin levels, eosinophil %, absolute eosinophil count, total leukocyte count, platelet counts, serum IgE levels or presence of myelofibrosis can be used to predict or exclude malignancy in patients with HE/HES. The absence of blasts in peripheral blood or the absence of >5% blasts in bone marrow does not exclude primary/clonal HES. Clonal disorders (Primary HES and reactive HES secondary to clonal disorders; 38%) are diagnosed with nearly equal frequency compared to infections (34%) in tropical settings necessitating a thorough follow-up and comprehensive work-up in these patients.

BACKGROUND Plasma cell leukemia (PCL) is a rare and aggressive plasma cell neoplasm. In PCL, clonal plasma cells comprise ≥20% of the peripheral blood (PB) leukocytes and/or the absolute clonal PB plasma cell count is ≥2×10(9)/L. Primary PCL (PPCL) originates de novo, whereas, secondary PCL (SPCL) evolves from pre-existing multiple myeloma. METHODS Clinicohematological features, immunophenotypic profile, and survival of PCL patients were analyzed retrospectively. RESULTS Between January 2007 and December 2014, ten PPCL and four SPCL patients were investigated (8 PPCLs and 3 SPCLs had complete clinical data). All were North Indians, sharing common geography and ethnicity. Our cohort showed less frequent renal failure, more frequent hepatomegaly, and non-secretory type disease. In contrast to western literature, flow cytometric immunophenotyping of our cohort revealed altered expression of CD138 (67%), CD56 (33%), and CD20 (0%). With novel therapeutic agents, these PPCL patients had a median overall survival of 15 months. CONCLUSION We highlight that our PPCL patients from North India had distinct clinicohematological and immunophenotypic profiles. The significance of our findings must be tested in a larger patient cohort and must be supported by molecular and cytogenetic investigations to unmask possible significant effects on pathogenesis.

Celiac disease or gluten-sensitive enteropathy is characterized by malabsorption, chronic inflammation of the small intestine mucosa, villous atrophy and crypt hyperplasia. Association of auto-immunity has been reported to be almost threefold higher in patients with celiac disease. While there are several reports of celiac disease in association with autoimmune diseases, there is paucity of literature on its association with antiphospholipid antibodies. We report here an 8-year-old girl child with celiac disease who was found to have lupus anticoagulant positivity, an extremely uncommon association. This child is perhaps the youngest ever patient of celiac disease in association with lupus anticoagulant.

In a community-based cluster randomized controlled trial, we randomly assigned clusters of anemic women and adolescent girls to either “directly observed home-based daily iron therapy” (DOHBIT; n = 524 in 16 villages) or unsupervised self-treatment at home (n = 535 in 16 villages) for a period of 90 days. Those in the DOHBIT group, when compared with those in the unsupervised self-treatment group, had significantly lower relative risk (RR) of anemia (16.8% vs 35.3%, RR = 0.47 [95% confidence interval (CI) = 0.33-0.65]; P < .0001), higher hemoglobin (Hb) rise of ≥2 g/dL (70.2% vs 42.2%, RR = 1.56 [95% CI = 1.31-1.87]; P

Plasma cell leukemia is an unusual manifestation of multiple myeloma, reported to occur in 2% of newly diagnosed patients. It may either present at the time of diagnosis (primary) or evolve as a late feature in the course of multiple myeloma (secondary). Most clinical signs of myeloma are observed in plasma cell leukemia, although osteolytic lesions and bone pain are less frequent and lymphadenopathy, organomegaly and renal failure are more often present. The immunophenotype of plasma cell leukemia differs typically from that of myeloma by lack of aberrant CD56 expression. An abnormal karyotype is more frequently found in plasma cell leukemia and there is higher incidence of unfavourable cytogenetics. Plasma cell leukemia is an aggressive disease, characterized by a fulminant course and a short survival. We are reporting cases of this rare condition which presented at our center over 3 years along with review of literature.

We have previously shown that children with pediatric systemic lupus erythematosus (pSLE) have high incidence of anti-phospholipid antibodies (APLA) and reports suggest that presence of APLA can modify disease expression. While the frequency of APLA has been studied previously in adults with SLE, there is paucity of literature in children especially with regard to long-term follow-up. In the earlier study, we analyzed 27 pSLE patients for the prevalence of APLA; in the present study, we further reviewed the APLA status and its relation with clinical outcome of this cohort of patients over a further 7 year follow-up period. Out of the initial cohort of 27 patients, follow-up APLA testing was available in 21 patients who were tested for APLA at least once during this time. Seven (33.3 %) of these 21 patients were never positive for any of the APLA; 1 (4.8 %) was persistently positive; and 13 (61.9 %) were positive for APLA intermittently or at least once. Overall, APLA positivity for IgG, IgM anticardiolipin antibodies (ACA) and lupus anticoagulant (LA) was comparable, with positivity seen in 10 (47.6 %), 9 (42.9 %) and 9 (42.9 %) cases, respectively. Anti-β2 GP1 antibodies were tested in 11 patients on follow-up, of which 3 (27.3 %) showed positivity. In all, 10 (47.6 %) patients showed positivity for more than 1 APLA. Two (9.5 %) patients showed varying degrees of positivity for LA, ACA, and anti-β2 GP1 antibodies at different times, thereby showing the importance of checking for all APLAs at each time of testing. Out of these 21 patients, 3 (14.3 %) patients had thrombosis, and all 3 patients were positive for APLA. There were 2 (9.5 %) fatalities—both of these had thrombosis and were positive for APLA. Our study shows that pSLE patients on treatment frequently test positive for APLA. Thrombosis was infrequent in this cohort. However, when present it was associated with APLA positivity and high fatality in our experience. On the other hand, presence or persistence of these antibodies was not always associated with thrombosis. Our study suggests that pSLE children should be tested routinely for APLA, as this would identify patients with an increased risk of thrombotic complications. However, the frequency of repeat testing for APLA in those who test negative initially needs to be determined on a case-to-case basis.

A 29-year-old female presented with 15-day history of fever and headache along with sudden onset of altered sensorium and hematuria from 3 days prior to admission. On examination, she exhibited pallor and splenomegaly. Complete blood counts showed pancytopenia with hemoglobin = 68 g/L, TLC = 2.6 9 10/L and platelet count = 16 9 10/L. Peripheral blood film showed a large number of schistocytes, spherocytes, polychromasia, and nucleated red blood cells (Fig. 1). Reticulocyte count was 4.4 %. Screening coagulogram was normal with prothrombin time = 13 s (control = 13 s), activated partial thromboplastin time = 25 s (control = 23–38 s), fibrinogen levels = 3.6 gm/L (normal = 2–4 gm/L) and D-dimer was negative. Lactate dehydrogenase (LDH) and serum ferritin were increased, being 1,735 IU/L (105–333 IU/L) and 1,934 ng/mL (12–150 ng/mL), respectively. Serum creatinine was also elevated at 2.2 mg/dL (0.7–1.2 mg/dL). Workup for infective etiology, including serology for leptospirosis, dengue, malaria, and typhoid fever, and polymerase chain reaction for Weil–Felix antigen and scrub typhus were negative. Clinical diagnosis of thrombotic thrombocytopenic purpura was considered, but in view of the pancytopenia, bone marrow examination was performed. Bone marrow aspirate revealed an increase in histiocytes with hemophagocytosis (Fig. 2). In addition, trephine biopsy showed intravascular thrombi (Fig. 3). The patient was treated with intravenous immunoglobulin and therapeutic plasma exchange (TPE) with fresh frozen plasma. Following eight cycles of TPE, she improved clinically, and her LDH values and platelet count at Fig. 1 Peripheral blood film showing large number of schistocytes and spherocytes (May Grunwald Giemsa, 9400)