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The diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH) in the setting of dengue fever is usually challenging but should be kept in mind in patients with persistent fever, pancytopenia, and multiorgan dysfunction. We report a case of severe dengue who had prolonged fever with multiorgan involvement, laboratory features fulfilling the diagnostic criteria of HLH, and had a prompt response with high-dose corticosteroids. Physicians should be aware of this rare clinical syndrome and its variable clinical presentations so that fatal outcomes can be prevented with prompt and appropriate treatment.

Background At onset of coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) was repurposed for treatment of patients based on reports that it had in vitro activity. The aim of this study was to find out if HCQ reduces number of days of hospitalization when given to patients with moderate to severe COVID-19 infections who require hospitalized care. Methods This was an open-label randomized control trial of HCQ administered 400 mg twice on day 1, then 400 mg once daily from day 2 to day 5 in patients with moderate to severe COVID-19 infection. Assessment was not blinded. Standard of care was given to both arms.Primary outcome was number of days of hospitalization till discharge or death. Result One hundred ten patients (55 in each arm) were included. Mean age was 58 years. Baseline characteristics were well matched. There was no difference in the primary outcome (13.67 vs 13.89; p = 0.98). Number of deaths were more in HCQ arm (RR: 1.81; 95% CI: 1.13–2.93; p = 0.03). There was no difference in number of days on oxygen or normalization of oxygen saturation, number who needed ventilator, days to ventilator requirement and days on ventilator. Twenty-nine patients in control arm received remdesivir. When adjusted analysis was done after removal of these patients, there was no difference in primary or secondary outcomes. Number of deaths in adjusted analysis were not significant (RR: 1.28; 95% CI: 0.87–1.88; p = 0.37). Conclusion HCQ does not change the number of days of hospitalization when compared with control.

Tyrosine kinase inhibitors (TKI) (imatinib, dasatinib, and nilotinib) are used for the treatment and long-term control of chronic myeloid leukemia (CML). TKIs rarely cause systemic side effects with atypical presentations, and these must be borne in mind while prescribing these drugs over a prolonged period. Dasatinib-induced cardiopulmonary toxicity should be suspected in patients presenting with new-onset cardiac or pulmonary symptoms, with features of congestive cardiac failure and pulmonary infiltrates. We report a rare presentation of simultaneous occurrence of pleural effusion, interstitial pneumonitis, pulmonary hypertension, and heart failure in a CML patient on dasatinib for >6 years, which was successfully treated with discontinuation of the drug and oral steroids.

In the current era of effective Anti retroviral therapy (ART), and Human Immunodeficiency Virus (HIV) infection becoming a chronic illness, there has been a gradual rise in the prevalence of rheumatic manifestations associated with this disease. These are characterized by a modified clinical course and widened spectrum of a few emerging rheumatic manifestations seen with HIV infection.To assess the type, frequency, prevalence and clinical spectrum of rheumatic manifestations amongmale patients followed at an HIV clinic of a tertiary care defence hospital.All male patients with confirmed HIV infection at the study centre were studied after obtaining informed consent. A detailed history was taken including the date of seropositivity, symptoms of rheumatic disease, family history of rheumatic illness, and treatment history with ART. A detailed general and systemic examination was performed and rheumatic symptoms guided appropriate investigations were carried out on as required basis.879 confirmed HIV cases were evaluated for rheumatic manifestations during the study period. Of these 499 cases were newly detected HIV cases and the rest 380 were old cases on follow up. Rheumatic disorders were diagnosed in 16 cases (1.82%). Spondyloarthropathy was the commonest presentation i.e. 5 out of 16 cases (31.25 % of the rheumatic disorders). Mean age was 37 years (range 27-52 yrs). 2 patients of the study group had the rheumatic illness prior to detection of HIV. Psoriatic Arthritis (0.114 %) was seen in 1 patient who was HLA B-27 negative. Reactive arthritis (0.227 %) was noted in 2 patients. 1 patient had cutaneous small vessel vasculitis (0.114 %), whereas 1 of the patient developed DLE (0.114 %) over neck. HIV related non specific polyarthritis (0.114 %) of the large joints was noted in 1 patient who was RF negative, while polyarthralgia (0.340 %) was noted in 3 patients. 10 patients (60 %) had CD 4 countlt; 200 cells/ µL, whereas 6 patients had a CD 4 count between 200 and 500 cells/µL. 13 out of 16 patients detected to have rheumatic illnesses were on ART.With the advent of ART, the clinical spectrum of HIV infection is changing as a chronic treatable disease. Present study consisting mainly adult males, showed only 1.82 % prevalence of rheumatic disorders in HIV infection. Early diagnosis, availability of ART and prompt treatment of opportunistic infections have changed the clinical profile of HIV patients. Impact of ART in producing and affecting the clinical spectrum of rheumatic disease has to be kept in mind while treating HIV-infected patients.

Introduction: Acute myeloid leukemia (AML) is the commonest leukemia in adults. Mortality in thew first 30-days ranges from 6% to 43%, while infections account for 30–66% of early deaths. We aim to present our experience of infections in newly-diagnosed AML. Method: This prospective, observational study, was undertaken at a tertiary care hospital in Northern India. Patients with confirmed AML (bone marrow morphology and flow cytometry) and who had developed febrile neutropenia (FN), were included. Result: A total of fifty-five patients were included in the study. The median age of the patients was 47.1 years (12–71) and 28 (50.9%) were males. Fever (33, 60%) was the commonest presentation at the time of diagnosis. One or more comorbid conditions were present in 20 patients (36.36%). Infection at presentation was detected in 17 patients (30.9%). The mean duration to develop febrile neutropenia since the start of therapy was 11.24 days. With each ten-thousand increase in white blood cell (WBC) count, the mean number of days of FN development decreased by 0.35 days ( p = 0.029). Clinical and/or radiological localization was possible in 23 patients (41.81%). Thirty-four blood samples (34/242, 14.04%) from 26 patients (26/55, 47.3%) isolated one or more organisms. Gram negative bacilli (GNB) were isolated in 24 (70.58%) samples. Burkholderia cepacia (8/34, 23.52%) was the commonest organism. The number of days required to develop febrile neutropenia was inversely associated with overall survival (OS). However, when compared, there was no statistically significant difference in OS between patients developing fever on day-10 and day-25 ( p = 0.063). Thirteen patients (23.63%) died during the study period. Discussion: Low percentage of blood culture positivity and high incidence of MDR organisms are a matter of concern. Days to develop febrile neutropenia were inversely associated with overall survival (OS), emphasizing the importance of preventive measures against infections. Conclusion: Infections continues to be a major cause of morbidity and mortality among AML patients.

Referrals for evaluation of polycythemia cases have increased since the hemoglobin (Hb) thresholds for diagnosis of Polycythemia Vera (PV) have been lowered by WHO. The current study enrolled patients of age > 18 years from the Indian Armed Forces or their family members with polycythemia from November 2016 to October 2018. After exclusion of secondary causes, 49 patients were diagnosed as Primary Erythrocytosis (PE). The patients were classified into two groups: PV and Idiopathic Erythrocytosis (IE) and a systematic comparison of clinical and laboratory features of the two groups was done. The prevalence of PV in PE was 20.4% (10 of 49) while the rest 39 (79.6%) had IE. Seven PV patients had JAK2(V617F) mutation, one had JAK2(Exon12) mutation, and two were JAK2 negative PV. Nine of 10 (90%) PV patients had Hb > 18.5 g/dl, while only 21 of 39 (53.8%) IE patients had Hb > 18.5 g/dl (p = 0.06). None of the JAK2 mutated patients had Hb 18.5 g/dl. Most patients with Hb between 16.5–18.5 g/dl would still be classified as IE. We advocate the need for further studies evaluating the utility of investigating all patients of PE with the revised WHO Hb threshold as well as studies on genetic profile of IE patients from India.

PaintCopter is an autonomous unmanned aerial vehicle (UAV) capable of spray painting on complex three-dimensional (3D) surfaces. This letter aims to make PaintCopter more user-friendly and to enable more intuitive human–robot interaction. We propose a virtual reality interface that allows the user to immerse in a virtual environment, navigate around the target surface, and paint at desired locations using a virtual spray gun. A realistic paint simulator provides a real-time previsualization of the painting activity that can either be processed right away or stored to a disk for later execution. An efficient optimization based planner uses this information to plan the painting task and execute it. The proposed planner maximizes the paint quality while respecting the spray nozzle constraints and platform dynamics. Our experiments show that the interface allows the user to make precise modifications to the target surface. Finally, we demonstrate the use of virtual reality interface to define a painting mission, and then the PaintCopter carrying out the mission to paint a desired multicolored pattern on a 3D surface.

Background: Immune thrombocytopenia (ITP) is a benign hematological disorder characterized by low platelet counts in peripheral blood and spectrum of various bleeding manifestations. Azathioprine is one of the effective, readily available, and affordable immunosupressants available for ITP management in developing countries. We aimed to study the efficacy and long-term safety profile of our patients with ITP who were treated with azathioprine. Method: This was a retrospective, single-center study conducted at a tertiary care hospital in Northern India. The patients who had received at least one line of therapy before receiving azathioprine were included in this study. All patients received oral azathioprine at a dose of 1 mg/kg/day (50 mg or 100 mg tablet formulations were used), which was increased up to 2 mg/kg/day depending upon the response and adverse effects. Result: Sixty-three patients were analyzed. Their median age was 28 years (range 15-68); 29/63 patients (46.03%) were females. The median duration from diagnosis to azathioprine initiation was 539 days (323 days-980.5 days). The patients included in the study had received a median of 3 (range 1-6) prior lines of therapies; 38/63 patients (60.32%) had received ≥3 prior therapies. Six patients (9.5%) had relapsed after splenectomy, and 16 patients (25.4%) had relapsed after receiving rituximab. The mean baseline platelet count was 10000/μL. The median time to response was 95 days (90 days-not reached) and the cumulative overall response rate (complete and partial response) at day 90 was 38.1%. Only one patient achieved complete response with azathioprine in our study. The cumulative rate of relapse at five years was 21.2%. Twenty-six patients stopped azathioprine after achieving some response (CR/PR) with Azathioprine for a median duration of 1067.5 days (range: 236 days-2465 days). They were followed up for a median of 870 days (range: 392 days-1928 days), and twelve of them relapsed. Twenty-six patients (26/63, 41.27%) reported one or more adverse events while on azathioprine. Leucopenia was the most frequent adverse event, followed by anemia and hepatobiliary laboratory abnormalities. Serious adverse events (grade ≥3 CTCAEv4) were noted in three patients (4.7%). One patient succumbed to severe sepsis multiorgan dysfunction while being on treatment. Conclusion: We conclude that azathioprine has a good response rate in chronic ITP patients. It is well-tolerated with minimal and manageable side effects.

Autologous stem cell transplantation (ASCT) is considered as standard of care in patients with multiple myeloma (MM) patients aged 65 years or younger. We analyzed data of 94 patients of plasma cell dyscrasias who underwent 95 autologous transplants at our institute from October 2003 to Aug 2016. Other than 76 patients of newly diagnosed multiple myeloma, we also transplanted two patients of POEMS syndrome, two patients of plasma cell leukemia, three patients of concurrent light chain deposition disease, three patients of multifocal plasmacytomas, and eight patients of isolated light chain myeloma. One patient underwent transplant twice. The median age of patients was 53 years (range 21–65). The average interval between diagnosis and transplant was 10.51 ± 5.42 months. The predominant stage in the study cohort was ISS-III. IgG kappa was the commonest subtype of plasma cell dyscrasia (27.9%) followed by IgG lambda (16.27%). Renal involvement was seen in 25% patients at the time of transplantation. Following chemotherapy, 42% patients were in CR, 39% in VGPR, 5% had PR and 14% had progressive disease at the time of transplantation. All patients were conditioned with melphalan (dose 120–200 mg/m(2)) except for one who received an additional bortezomib for his second transplant. The mean time to neutrophil and platelet engraftment was 11.09 ± 1.82 and 12.69 ± 4.55 days respectively. Mucositis was noted in all patients (grade 3 in 37.5% patients). The median PFS (biochemical) was 55.8% and PFS (clinical) was 76.7% at 6.5 years. Thirteen percent of the transplanted patients succumbed to their illness of which three patients died within 30 days of transplant. Median OS was 76.7% at 6.5 years. ASCT is a feasible option for MM in India and the results are comparable.

Danazol is an attenuated androgen and is used in the treatment of aplastic anemia (AA) in resource constraint settings. We chose to study the role of CD4+ CD25T-regs' percentages of 25 acquired idiopathic AA patients and 25 healthy controls who completed study protocol were analyzed by performing multicolor flowcytometry on peripheral blood samples.More than one-third (36%) of AA patients in our study received Danazol as monotherapy, whereas less than a third (32%) each received standard doses of IST with equine Anti Thymocyte Globulin (ATG) and Cyclosporine combination, or Cyclosporine and Danazol combination, respectively. Results showed that all AA patients had a significantly lower percentage of T-regs at the time of diagnosis when compared to healthy controls (p 0.0001), implicating their role in the pathophysiology. On treatment, all 25 patients showed a significant rise in the percentage of T-regs when compared to baseline (p 0.0001).The rise in T-regs' percentage was higher in patients treated with Danazol alone when compared to standard IST (ATG with Cyclosporine), or Cyclosporine with Danazol combinations (p = 0.585).We conclude that Danazol also leads to increase in T-regs in acquired idiopathic AA.

Introduction: The outcomes of Philadelphia positive acute lymphoblastic leukemia(Ph-ALL) have improved significantly after the introduction of tyrosine kinase inhibitors (TKI). The presence of Philadelphia positivity once considered as poor prognosis mandating transplantation, now even can be managed with TKI added to steroids. The data is scarce on Ph-ALL from real-world settings with resource constraints. Objective: To study the characteristics and outcomes of Ph+ve ALL from real world settings. Methodology: It is a retrospective observational study wherein the data of all patients of Ph-ALL managed at a tertiary care center in North India over the last 14 years (2004-2018) were analyzed. All case records of the Ph-ALL were perused, digitalized and their survival statistics derived. Results:Amongst a total of 611 ALL case records, 55 (9%) were Ph-ALL. Ph-ALL cases with complete data (n-51) were analysed for overall survival. The mean age of the patients was 31± 2.41 years (range 3-76) (Fig. 1A). Males constituted 74.5% (n-38) and females, 25.4% (n-13) of our cohort. On risk stratification, 11 (21.5%), 5 (9.8%), and 35 (68.6%) patients were classified as standard, intermediate and high risk. Twenty five percent patients had associated complex karyotype in addition to the Ph positivity. Of these 24 patients (47.05%) received adult ALL (GMALL protocol), 15 patients (29.4%) received paediatric BFM protocol, and12 patients (23.5%) received Hyper-CVAD. Week 4 Bone marrow evaluation was in CR in 87.2% of patients. L-Asparaginase was given in only 60% of the patients. An interruption in the therapy of more than 2 weeks for various reasons was present in 23.4% of the patients, mainly secondary to infections. Prophylactic cranial irradiation was given in 34.7% of the patients and high dose methotrexate was given in 30.4% of the patients. Relapse was seen in 22% of the patients. CNS disease was present in 17.6% of the patients. Only 19.6% of the patients were subjected to transplant. All patients received TKI, of which 44% received high dose imatinib and 56% patients received dasatinib. A total of 19.6% patients succumbed to the illness at various stages of the therapy. The cumulative overall survival at 1y (1y-OS) was 95.68% with 3y and 5y OS being 72.09% and 63.07% (Fig. 1B). The survival was not statistically different between patients with and without complex karyotype (p-0.52),based on type of TKI administered (Dasatinib Vs high dose Imatinib) (p-0.76), males and females (p-0.41), risk category (p-0.41) or by the presence of CNS disease (p-0.21) (Fig. 1C-G). The survivals based on the type of protocol was statistically different with the best survival with GMALL protocol and the least survival with Hyper-CVAD therapy (log rank p Conclusion: We have demonstrated in this study the improved outcomes of Ph-ALL who usually present late in resource constraint settings. There was no additional benefit of dasatinib over high dose imatinib in this cohort. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

Introduction: The outcomes of Adolescent and young adult (AYA) have been studied in various hemato-oncology subsets. Patients of AYA-ALL have improved outcomes by paediatric-inspired or fully paediatric protocols. The outcomes published from trials are different from the actual practise, that too in the real-world settings with resource constraints. Objective: To study the characteristics and outcomes of AYA-ALL from real world settings. Methodology: It is a retrospective observational study wherein the data of all patients of AYA-ALL managed at a tertiary care center in North India over the last 14 years (2004-2018) were analyzed. All case records of the AYA-ALL were perused, digitalized and their survival statistics derived. Results:Amongst a total of 611ALL case records, 116 (18.98%) were AYA-ALL. AYA-ALL cases with complete data (n-116) were analysed for overall survival. The mean age of the patients was 26.65 ± 6.61 years (range 16-39) (Fig. A). Males constituted 32.7% (n-78) and females, 67.2% (n-38) of AYA-ALL. On risk stratification, 67 (57.7%), 26 (22.4%), and 23 (19.8%) patients were classified as standard, intermediate and high risk. Phenotypically, 78 patients were B-ALL, 23 were T-ALL and rest were MPAL. Of these 61 patients (52.5%) received adult ALL (GMALL protocol), 26 patients (22.3%) received paediatric BFM protocol, 19 patients (16.3%) received Hyper-CVAD, 8 patients (6.8%) MCP841 protocol and 2 received modified drugs not adhering to any fixed protocol. Week 4 Bone marrow evaluation was in CR in 91.4% of patients. L-Asparaginase was given in only 74.5% of the patients. An interruption in the therapy of more than 2 weeks for various reasons was present in 35% of the patients. Prophylactic cranial irradiation was given in 42.4% of the patients and high dose methotrexate was given in 25.2% of the patients. Relapse was seen in 27.7% of the patients. CNS disease was present in 9.4% of the patients. Only 8% of the patients were subjected to transplant. The cumulative overall survival at 1y (1y-OS) was 86.98% with 3y and 5y OS being 67.9% and 55.6% (Fig. B). The survivalsbased on the type of protocol was statistically different with the best survival with GMALL protocol and the least survival with Hyper-CVAD therapy (log rank p-0.0011) (Fig.C). The survival was also significantly different between different risk groups (p-0.003) (Fig.D). The survival was not statistically different between males and females (p-0.5), B-ALL vs T-ALL (p-0.6) (Fig. E, F). Conclusion: We have demonstrated in this study the improved outcomes of AYA-ALL who usually present in late chronic phase in resource constraint settings. Contrary to the belief, adult GMALL protocol had better survival vis-à-vis pediatric BFM protocol in this cohort of AYA-ALL. Figure. Figure. Disclosures No relevant conflicts of interest to declare.