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Severe congenital neutropenia (SCN) is a rareE primary immunodeficiency disorder characterized by early onset recurrent infections in association with persistent severe agranulocytosis. To identify the clinical, immunohematological, and molecular characteristics of patients with SCN, 18 Iranian patients with the mean age of 8.8 +/- 5.8 years were investigated in this study. All of these patients experienced severe neutropenia; the mean of absolute neutrophil count was 281.4 +/- 137.7 cells/mm3. Bone marrow findings were typified by a myeloid maturation arrest at the promyelocyte-myelocyte stage in these patients. Molecular analysis revealed different mutations in the ELA-2 gene of one patient and in the HAX-1 gene of another three patients. The most common presenting complaints in these patients were superficial abscesses, oral ulcers, cutaneous infections, omphalitis, and pneumonia. During the course of illness, all patients developed mucocutaneous manifestations, and 16 cases had respiratory infections. The most commonly manifestations were abscesses, oral ulcers, pneumonia, periodontitis, otitis media, cutaneous infections, mucocutaneous candidiasis, and acute diarrhea. Three patients died because of a severe infection. Although SCN is a rare disorder, early onset of severe and recurrent infections should always raise a suspicion, which deserves further evaluation for detecting such disorder.

We studied 325 thalassemia intermedia patients from Iran, India, Pakistan, Thailand, Mauritius and Cyprus to examine factors which influence the phenotype. The beta-thalassemia (thal) mutations were determined for 219 beta-thal/beta-thal and 106 beta-thal/Hb E [beta26(B8)Glu-->Lys, GAG-->AAG] thalassemia intermedia patients. Thirty-one different mutations were identified, and their combination gave rise to more than 44 different genotypes, of which 14 (31.8%) had the beta(0)/beta(0), 21 (47.7%) the beta(0)/beta(+) and nine (20.5%) the beta(+)/beta(+) types. Thus, the beta(+)-thal mutations were present in 68.2% of patients. alpha-Thalassemia mutations were present in frequencies higher than in the general population of all ethnic groups studied, as 45% of the patients carried alpha-thal mutations. Correlation of alpha-thal mutations with beta-globin mutations showed that the alpha-thal mutations were mainly co-inherited with the beta(+)-thal mutations. The XmnI (G)gamma polymorphic site at -158 (C-->T) was positive (T) in nine (8.8%) of 102 patients of the beta(+)/beta(+) genotype, and the percentage of both XmnI (G)gamma polymorphism [+/-] (T/C) and [+/+] (T/T) genotypes increased to 42.9 and 87.3, respectively, in the beta(0)/beta(+) and beta(0)/beta(0) patients. This polymorphism was found in the majority of beta(+)-thal/Hb E compound heterozygote patients (88.6%), and beta(0)-thal/Hb E patients (84.8%), suggesting that it could be linked to the Hb E chromosome. Therefore, the XmnI (G)gamma polymorphism at -158 (C-->T) was associated with beta(0)-thal mutations as well as the Hb E chromosome. The present study demonstrates that in cases of thalassemia intermedia with beta(+) mutations, the common ameliorating factor is the presence of alpha-thal mutations, while in cases with beta(0) mutations, the common ameliorating factor is the presence of the XmnI (G)gamma polymorphism at -158 (C-->T).

Iron deposition in liver is a major finding in thalassemic patients and because of direct iron toxicity to liver it is associated with several consequences for example liver fibrosis. Liver biopsies from 63 patients were evaluated, 40 (63.5%) were male and 20 (36.5%) were female. The mean age of the patients was 8.01 ± 3.7 and the age range was from 1.8 to 15 years. Histologic grading and staging was performed for each case according to modified HAI (Hepatitis Activity Index) system. Iron scoring was performed according to Sindram & Marx and MTK1-3 scoring systems. The mean (SD) dry weight (dw) of liver specimens was 1.34 (0.11) mg (range 0.20 to 3.80 mg). The mean (SD) of hepatic iron concentration was 230.9 (121.2)μmol/g dry weight. The relationship between the variables HIC, HII (hepatic iron index) and all histological gradings of iron (S&M and MTK1-3) was very strong. The relationship between the HIC and staging by HAI method was good. Significant differences were identified between the mean HIC in scores 1&2 of all histological iron scorings (S&M and MTK1-3), but no significant differences identified between mean HIC in other adjacent scores in all histological iron scorings (S&M and MTK1, 2 and 3). New scoring system introduced by us in this study which considered size and density of iron granules as well as zone of iron deposition was very much the same as simple Sindram and Marx classification.

Inherited neutropenia is characterized by a decrease in the absolute number of circulating neutrophils and an increased susceptibility to infections. The current study was performed to determine the clinical and laboratory findings of Iranian patients with inherited neutropenias. Records of 26 patients (14 male, 12 female) with inherited neutropenia were reviewed in this study. The patients had been referred to Children's Medical Center, a referral center for immunodeficiency disorders in Iran, during a 22-year period (1981-2003). Primary immunodeficiency disorders of these patients were as follows: cyclic neutropenia (8 patients), Shwachman-Diamond syndrome (7 patients), Kostmann syndrome (6 patients), and Chediak-Higashi syndrome (5 patients). The mean absolute neutrophil count of patients was 398.2 +/- 259.3 cells/mm (range 74-1,152/mm) at the first visit. Twenty-one patients showed severe, four moderate, and one mild neutropenia. Sixteen of these patients had leukopenia, seven anemia, two thrombocytopenia, and one monocytosis. The most common presenting complaints in these patients were oral ulcer, otitis, pneumonia, diarrhea, cutaneous abscess, and oral candidiasis. The patients first manifested symptoms of infection suggesting neutropenia at a median age of 7.5 months (range 1 month to 10 years). During follow-up, respiratory infections developed in 24 cases, oral manifestations in 20 patients. The most common infections, in descending order of frequency, were otitis media, abscesses, pneumonia, oral ulcers, acute diarrhea, cutaneous infections, oral candidiasis, and periodontitis. Less frequent infections were sinusitis, cystitis, conjunctivitis, meningitis, and osteomyelitis. Nonspecific symptoms (hepatomegaly and splenomegaly) were also detected in 10 patients and 1 patient, respectively. Three patients died of recurrent infections. The infectious manifestations both at presentation and during follow-up in inherited neutropenia were similar. Although inherited neutropenias are rare, recurrent infections always deserves further evaluation for detecting such disorders.

Background X-linked lymphoproliferative disease (XLP) is an often fatal inherited immunodeficiency disorder characterised by fulminant infectious mononucleosis, acquired haemophagocytic lymphohistiocytosis, dysgammaglobulinaemia and malignant lymphoma. Given the paucity of data on the genetic stratification of XLP gene mutations in paediatric patients diagnosed with B-cell lymphoma, we sought to determine the existence of such association in the present study. Methods We studied 20 male subjects diagnosed with non-Hodgkin B-cell lymphoma. Results Eleven patients had laboratory evidence of EBV infection by serology and quantitative PCR. The SH2D1A gene analysis was negative in all patients. Conclusions This is the first study to analyse the SH2D1A gene mutations in Iranian paediatric patients diagnosed with lymphoma. Although we could not demonstrate such an association in our cohort of patients, larger, multi-centre studies are required to extend and confirm our early findings.

Neutropenia is a reduction of the absolute neutrophil count (ANC), which could be seen in different conditions, while its association with a number of primary immunodeficiency diseases has been reported. This study was performed in all neutropenic patients who were admitted in a referral pediatric hospital during a 6-year period (2006-2011). One hundred and forty patients with ANC of below 1500/mm(3) were investigated in this study. The most common causes of neutropenia were severe congenital neutropenia (41%), aplastic anemia (19%), cyclic neutropenia (11%), hyperimmunoglobulin M syndrome (9%), and fanconi anemia (7%). The patients experienced their first manifestation at a median age of 1 year, while the median diagnostic age was 21 months. Parental consanguinity was present in about half of the cases. The most common clinical manifestations of the patients were sinusitis (62 cases), periodontitis (51 cases), acute diarrhea (39 cases), pneumonia (38 cases), abscess (36 cases), skin rashes (35 cases), and otitis media (31 cases). Twenty two patients (16%) died during the study period. Considering the differential diagnosis of neutropenia, making the diagnosis and appropriate treatments are the keys in management of patients with neutropenia to avoid further complications.

Metabolic bone disease represents a major cause of morbidity in patients with thalassaemia major. The aim of our study was to assess the prevalence and underlying contributory factors of osteopenia/osteoporosis in a randomly selected population of adult patients with thalassaemia major.The study population was selected using the random sampling method from the patients' database of our thalassaemia clinic. Only transfusion-dependent beta-thalassaemia patients aged over 17 and with no history of treatment with bisphosphonates were included. BMD of lumbar spine and right femoral neck were measured by means of the calibrated dual energy X-ray absorption method. Independent factors likely to be associated with low bone mass were determined and included in the analysis to ascertain possible associations.Our study included 40 patients (19 female and 21 male; mean age: 23.0 ± 4.1). The mean Z score of the right femoral neck was -1.2 (95% CI: -0.9 to -1.5) and for lumbar spine was -2.1 (95% CI: -1.7 to -2.5). The prevalences of osteopenia and osteoporosis involving the right femoral neck were 37.5%, and 12.5%, respectively. The respective prevalence rates for lumbar spine were 47.5% and 37.5%. Our study showed patient's weight, age, duration of the disease and history of hypogonadism or concurrent hypothyroidism are significant contributory factors or predictors of bone mineral loss.Regarding the high prevalence of osteopenia/osteoporosis in patients with thalassaemia major, all patients should be screened periodically for bone disease. The uncertainty and disagreements as to the possible role of different factors indicate the necessity for further studies in order to recognise the pathophysiologic fundamentals of this serious complication of thalassaemia major.

Dear Editor, More than 900 hemoglobin (Hb) variants have been reported, and most variants are caused by mutations in the αor β-globin gene clusters [1]. Clinically, most of hemoglobin variants are asymptomatic, but some variants are unstable, with altered oxygen affinity, or have a thalassemic phenotype (Hb Var database—http://globin. cse.psu.edu/globin/hbvar). Hemoglobin Fairfax is a rare Hb variant, which has been reported only in an African-American child. This hemoglobin results from 15-base-pair tandem duplication of GAGCTGCACTGTGAC sequences inserted between codons 94 and 95, coding an additional Glu-Leu-His-CysAsp amino acids [2, 3]. We report on the hematological and molecular features of hemoglobin Fairfax for the first time in two members (mother and her daughter) of an Iranian family. This family was referred for prenatal diagnosis for β-thalassemia mutations. Red blood cell indices and Hb analysis were carried out according to standard methods. Tests for unstable Hb using isopropanol precipitation showed positive results in both patients. After obtaining a written informed consent, molecular studies were conducted on genomic DNA isolated from peripheral blood cells by a salting out procedure [4]. For identifying αthalassemia genotype, common deletional mutations were studied as previously described [5] with no mutation in αthalassemia genotype. Triplication of α-globin genes was also excluded. Moreover, the entire β-globin gene was amplified and the DNA sequenced with the use of a primer set encompassing exons 1 and 2 (for fragment A: Beta1F 5′-GGGCCAAGAGATA TATCTTAG-3′, Beta1R 5' AATGACATGAACTTA ACCATAG-3′) and another encompassing exon 3 (fragment B: Beta2F 5′-GCAC CATTCTAAAGAATAACAG-3′, Beta2R 5′-GTTTGAAC TAGCTCTTCATTTC-3′). The sequencing reactions were performed by the chain termination method on ABI 3730 XL sequencer (Primm, Milan, Italy), as described elsewhere [6, 7]. The nucleotide numbering is based on GenBank accession number U01317. The hematological and molecular features of hemoglobin Fairfax in the index patient and her mother aged 5 and 29 years old, respectively, are summarized in Table 1. The index case with severe hemolytic anemia, marked splenomegaly, and blood transfusion dependency (every 20 days) receives iron chelating therapy (Desferal) four times a week. She had no other thalassemic features. M. T. Akbari Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14115-111, Iran

Idiopathic CD4+ Lymphocytopenia is a rare combined immunodeficiency disease, characterized by low CD4+ T-cell count and increased susceptibility to opportunistic infections, autoimmunity and malignancies after exclusion of secondary forms of CD4 lymphocytopenia. Here we present a 13-year old boy who was referred to our center because of destructive ulceration of soft and hard palates with extension to nose and maxillary sinus starting at 6 months of age. He had a history of recurrent otitis media, chronic diarrhea, arthritis and herpetic lesions of eyes and mouth since the age of 5 years. Laboratory studies revealed very low number of CD4+ T-cells (100 cells/mm(3)). Secondary causes of CD4 lymphocytopenia, including HIV infection, were ruled out. Immunohistological studies of destructive lesions in oral and nasal cavity revealed angiocentric T-cell lymphoma. Unfortunately, the patient died in spite of treatment with a combination of irradiation and chemotherapy. This patient is the first reported case of lethal midline granuloma with origin T-cell lymphoma in idiopathic CD4+ lymphocytopenia.

Acute lymphoblastic leukemia (ALL) is the most common type of leukemia in children and accounts for 80% to 85% of cases. Hypercalcemia-associated pulmonary calcification has been observed in ALL, but overall it is a rare condition. Hereby, we wanted to report a case of pulmonary metastatic calcification in a 4-year-old girl with diagnosis of ALL in our center, who died 1 year after diagnosis of leukemia. Pulmonary infiltrates were seen 2 months after diagnosis of leukemia, which was proved to be the flecks of calcium in alveolar spaces after open-lung biopsy performed 4 months after diagnosis of ALL, but elevated serum calcium was detected late in the course of the disease (7 mo after lung biopsy), this late occurrence of hypercalcemia is not reported yet.

Early detection of myocardial iron overload is crucial for optimal management of patients with beta thalassemia major, which could lead to intensification of iron chelating therapy. In this study, we evaluate the conventional echocardiography and tissue Doppler imaging measurements in patients with beta thalassemia major and further introduce the assessment of atrial ejection force as a feasible price-saving approach for early detection of myocardial iron overload. During a 1-year period, 42 cases of beta thalassemia major aged

Thalassemia intermedia shows considerable heterogenity in phenotype and molecular basis. The aim of this study was to evaluate the prevalence and effect of different beta-globin mutations, alpha-globin defects and (G)gamma XmnI polymorphisms in Iranian patients. Forty-five Iranian patients with clinical criteria of thalassemia intermedia were studied. The molecular background of the diseases was investigated. The mean age of onset varied from 1.5 to 30 years. Only 22.2% of cases received occasional blood transfusions. The hemoglobin (Hb) level in more than half of the cases was stable (10-12 g/dL) with no need for blood transfusions. In most cases (88.9%) the Hb F level was more than 50%. Sixty-eight point nine percent of patients were homozygous for beta(0)-thalassemia (beta-thal) mutations. The positive XmnI polymorphism with the capability of enhancing Hb F production was seen in 60% of the studied chromosomes. Co-inheritance of alpha-globin gene defects was seen in 22.2% of cases. Only 8.9% of patients had beta(+) or beta(++) mutations. We concluded that the main molecular basis of the thalassemia intermedia phenotype in Iranian cases is co-inheritance of a positive XmnI polymorphism with beta-globin mutations, which can enhance the capability of Hb F production. Co-inheritance of alpha-globin defects and mild beta-globin mutations are second and third causes of thalassemia intermedia phenotypes respectively. These factors must be considered in genetic counseling, prediction of disease prognosis and treatment and prenatal diagnosis.

Chediak - Higashi Syndrome (CHS) is a rare, primary Immunodeficiency disorder with an autosomal recessive (AR) inheritance and characterized by re¬current infection, partial occulocutaneous albinism and an accelerated phase. In this report we describe clinical and laboratory findings from 6 CHS pa¬tients. Clinical and laboratory information of six patients who were referred to our center during the last 20 years (from 1983 - 2003) were reviewed. Onset age of disease was between 3 months to 10 years. All patients had history of consanguineous parents and two patients were siblings. All patients had oculocutaneous albinism, nystagmus, recurrent infections which included upper and lower respiratory tract (U&LRT) infections, stomatitis, thrush, and skin ab¬scesses and hepatitis. In laboratory findings, all patients had neutropenia and normal immunoglobulins and normal CD3, CD4, CD8and CD 19 lymphocyte by flowcytometry and three of the four patients had chemotatic defect. Five patients certainly had giant granule in bone marrow neutrophil and in one patient it was equiovocal. Three patients had an accelerated phase, and for one patient bone marrow transplantation was done that was tolerated well and had been well after 7 years. We emphasize the need for early diagnosis on basis of characteristic facies and diagnostic laboratory examinations and early bone marrow transplantation (BMT) in patients.

We report a 6-year-old Iranian boy with silvery-gray hair, eyelashes and the eyebrows who was admitted because of seizures and subsequent stupor. He had previous history of acute hemiparesis at 1 year of age and hepatitis-like syndrome 3 months ago. Microscopic examination of the patient's hair shaft revealed different sized clumps of melanin seen in the center of the shafts. Bone marrow aspiration revealed erythroid hyperplasia and erythrophagocytic cells. Bilateral frontal cortical and subcortical high signal lesions, dirty white matter, high signal areas in the upper pons and in both caudates and lentiform nuclei in T2 WI were the brain MRI findings of the patient. He died in the accelerated phase of Griscelli Syndrome (GS) type 2. To our knowledge we report the first case of GS from Iran.

Abstract 2061 Introduction: Hydroxyurea(HU) is an antimetabolite agent that also promotes production of fetal hemoglobin (HbF). Reports on the use of HU in patients with thalassemia major (TM) have revealed a reduction in blood transfusion dependency. Due to lesser α/β globin imbalance in thalassemia intermedia (TI) compared with TM, better clinical responses are expected in patients with TI. This study was undertaken to evaluate hematological and clinical responses of patients with β-thalassemia to HU therapy as well as adverse effects of HU and Beta globin gene mutations of patients in a period of thirteen years in southern Iran. Methods: Two hundred patients; mean age of 21±7, ranged from 5 to 40 years enrolled in this study. Patients divided into two groups. Group 1 consisted of 143 transfusion-dependent thalassemia patients after age of two. Group 2 consisted of 57 TI patients without any history of blood transfusion or long interval transfusion. Mean dose of HU was 9.9±2 mg/kg/day, range of 8–15mg/kg/day. Response to HU was defined as increasing Hb level at least 1g/dl after 3 months of starting HU and/or decrease or cessation of the need for blood transfusion. Investigated variables included Hb, MCV, MCH, HbF, and HbA1 in laboratory results as well as spleen size, energy state, facial changes (head circumference), and the need for blood transfusion in clinical findings. The patients were followed by Hb electrophoresis, Complete Blood Count, serum ferritin and chemistry panel in appropriate intervals. The assessment of adverse effects in patients was conducted by pediatric hematologists. Genomic DNA extracted from peripheral leukocyte by Giagen DNA extraction kit. Beta globin gene mutations were determined by ARMS based PCR and confirmed by sequencing. XmnI polymorphism at -153 gG after PCR, was characterized by RFLP method and electrophoresis on 2% agarose. Statistical analysis was done by SPSS v. 15 using student’ t-test, paired t-test, and chi square test. Results: Of the 143 patients in group 1who were transfusion-dependent, 101 patients became transfusion-free and 28of them needed 1–4 transfusions per year. In this group, 14 patients had no response to HU and excluded from the study. All of the patients in group 2 were completely transfusion-free with acceptable Hb level at the end of study. Overall the mean Hb level of the patients after HU therapy was (9.4± 1.3). Exercise tolerance increased in 97% of the patients. No significant facial changes were observed in the patients at the end of study. From 73 non splenectomized patients, 83% had no change in spleen size. Adverse effects of HU were recorded in 44 of 200 patients. The most common side effects were dermatologic adverse effects followed by neurological and gastrointestinal side effects. Hematological malignancy and toxicity or any sign of bone marrow suppression were not observed in the patients during HU therapy. The presence of adverse effects in patients significantly increased by increasing age (p0.05). Up to now, the frequency of beta globin gene mutations and XmnI polymorphism in 150 patients has been characterized (Tables 1 and Table 2). The most frequent beta globin gene mutation and XmnI polymorphism in our patients were homo IVS II-1(40.6%) and +/+ (59%) respectively. Conclusion: In our study HU was effective for decreasing or cessation the need of regular blood transfusion as well as increasing Hb level in β-thalassemia patients. Also all of the patients could tolerate low-dose treatment with HU in this period without any major side effects. So HU could be a safe alternative to blood transfusion in transfusion-dependent β-thalassemia patients after age of 2 or help to increase Hb level in untransfused TI patients. Disclosures: No relevant conflicts of interest to declare.