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Introduction Coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV2 can present from mild flu‐like symptoms to acute respiratory distress syndrome. There is multi‐organ involvement; particularly, hematopoietic system can be associated with morphological changes in blood cells of COVID‐19 patients. Method We conducted a cross‐sectional study on a cohort of 50 COVID‐19 patients, confirmed on RT‐PCR with documented cycle threshold (Ct) value. Peripheral blood sample of these patients was collected and examined for complete blood counts (CBC) on automated haematological analyser as well as Leishman‐stained blood smears to look for morphological changes in blood cells. Morphological changes were evaluated with reference to clinical severity and Ct value. Additionally, association between Ct value and clinical severity was also performed. Statistical tests were performed, and P value

ObjectiveLarge data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma.DesignSecondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease.Setting39 public and private hospitals across India during the study period from 22 April to 14 July 2020.ParticipantsOf the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed.Primary outcome measureFactors associated with all-cause mortality at 28 days after enrolment.ResultsThe mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3–7) and non-survivors (4 days; IQR 3–6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p2/FiO2 ratio 10 (9.97, 3.65–27.13, p1.0 mg/L (2.50, 1.14–5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44–4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60–5.45, p=0.001) were significantly associated with death.ConclusionIn this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death.Trial registration numberCTRI/2020/04/024775.

Background: Serological tests for anti-SARS-CoV-2 antibodies can provide valuable information in epidemiologic and public health research. However, the data is limited on serological response post COVID-19 infection. Objective: To investigate the use of ARCHITECT SARS CoV-2 IgG II Quantitative assay to quantify the IgG antibodies in recovered COVID-19 infections. Methods: Abbott SARS-CoV-2 IgG assays were performed using the ARCHITECT Quantitative chemiluminescent microparticle immunoassay to detect IgG against SARS-CoV-2 S1 receptor binding domain (RBD) in serum and plasma. Patients having IgG concentrations above ≥50 AU/mL were defined as positive. We analyzed 333 COVID-19 patients who were tested negative by RT-PCR not more than three months after testing positive. Results: The mean age of the population was 34.3 years and 95% were male. About 93% of the patients had mild disease and rest had moderate disease. The mean IgG levels in the entire cohort was 1860.27 AU/mL, the lowest and highest value detected by ARCHITECT SARS CoV-2 IgG II Quantitative Assay (Abbott Laboratories, USA) were 39.8 AU/mL and 43657.4 AU/mL, respectively. While patients with moderate COVID-19 disease had numerically higher IgG levels than patients with mild disease, the difference was not statistically significant (1787.7 AU/mL vs. 2865.39 AU/mL, p=0.21). In 97% of the patients, IgG antibodies could be detected up to 95 days after testing negative on RT-PCR. Conclusion: Patients with moderate COVID-19 disease may develop higher IgG antibodies than in patients with mild disease. Antibodies can be detected in majority of recovered individuals for more than 90 days which may be valuable in developing future vaccination strategy.

ObjectivesConvalescent plasma (CP) as a passive source of neutralizing antibodies and immunomodulators is a century-old therapeutic option used for the management of viral diseases. We investigated its effectiveness for the treatment of COVID-19.DesignOpen-label, parallel-arm, phase II, multicentre, randomized controlled trial.SettingThirty-nine public and private hospitals across India.ParticipantsHospitalized, moderately ill confirmed COVID-19 patients (PaO2/FiO2: 200-300 or respiratory rate > 24/min and SpO2 ≤ 93% on room air).InterventionParticipants were randomized to either control (best standard of care (BSC)) or intervention (CP + BSC) arm. Two doses of 200 mL CP was transfused 24 hours apart in the intervention arm.Main Outcome MeasureComposite of progression to severe disease (PaO2/FiO2< 100) or all-cause mortality at 28 days post-enrolment.ResultsBetween 22ndApril to 14thJuly 2020, 464 participants were enrolled; 235 and 229 in intervention and control arm, respectively. Composite primary outcome was achieved in 44 (18.7%) participants in the intervention arm and 41 (17.9%) in the control arm [aOR: 1.09; 95% CI: 0.67, 1.77]. Mortality was documented in 34 (13.6%) and 31 (14.6%) participants in intervention and control arm, respectively [aOR) 1.06 95% CI: −0.61 to 1.83].InterpretationCP was not associated with reduction in mortality or progression to severe COVID-19. This trial has high generalizability and approximates real-life setting of CP therapy in settings with limited laboratory capacity. A priori measurement of neutralizing antibody titres in donors and participants may further clarify the role of CP in management of COVID-19.Trial registrationThe trial was registered with Clinical Trial Registry of India (CTRI); CTRI/2020/04/024775.

INTRODUCTION: Tuberculosis is a rare cause of liver abscess in the Indian subcontinent even though the disease itself has high prevalance rates here. Isolated tubercular liver abscess presenting without any other foci of infection is a rare presentation with a documented prevalence of 0.34%. In an adult immune competent patient diagnosis can be challenging as it is likely to be confused with pyogenic and amoebic liver abscess or hepatoma. CASE HISTORY: A 30 year old female patient presented with complaints of low grade fever, vague abdominal pain of 4 months duration, breathlessness and loss of appetite for 1 month. Past or family history was non-contributory. Ultrasonography abdomen revealed a small hypoechoic lesion in sub-hepatic region of size 49x20mm suggestive of a liver abscess. Computerized Tomographic scan images confirmed loculated irregular collections in and around left lobe of liver and Reidel’s lobe. Fine needle aspiration cytology from the lesion revealed ill formed granulomas on a necrotic background. Zeihl Neelson staining was positive for acid fast bacilli CONCLUSION: Isolated tubercular liver abscess is a rare entity, particularly in immunocompetent individuals.Symptomatology and radiologic findings may not be contributory. Diagnosis of this entity rests on the demonstration of acid fast bacilli in material obtained. FNAC is a simple minimally invasive, cost effective procedure which helps attain the same. DOI: 10.21276/APALM.1382

Background: Thyroid cancer presenting with cervical lymphadenopathy as a sole occurrence is uncommon. It usually presents as a palpable thyroid mass or nodule. Isolated cervical lymphadenopathy is rare and hence poses a diagnostic challenge. Fine needle aspiration- cytology (FNAC) or biopsy are important modalities which help establish the origin. Case Report: Two cases of lateral cervical lymphadenopathy with no other specific clinical findings were encountered within a span of two weeks with different clinical backgrounds. First to present was a 28 year old young male with a months’ history of lateral cervical swelling. Later a 58 year old male also presented without any history of overt primary thyroid carcinoma. FNAC in both the cases confirmed presence of metastasis from occult primary papillary cancer thyroid. Following this ultrasonography neck was performed which revealed a solid-cystic mass in both the cases. In the younger male an ill-defined solid nodule with microcacifications was identified in the left thyroid lobe while in the case of elderly male; thyroid gland was normal. Subsequently both underwent total thyroidectomy with left neck dissection and histologically proven primary papillary thyroid cancer was found. Conclusion: Posterior cervical lymphadenopathy occurring primarily as a result of papillary carcinoma thyroid is rare. DOI: 10.21276/APALM.1149

Sclerosing polycystic adenosis (SPA) is a rare benign neoplasm of the salivary gland which resembles the fibrocystic disease of the breast clinically as well as morphologically. This entity has varied morphological presentation on fine needle aspiration. Only a few case reports and occasional case series are found in the literature describing its cytology. Here we are presenting a case of SPA in the parotid gland in a 13-year-old male patient who presented with a slow growing infra-auricular mass since one year without any other symptoms. Radiological investigation suggested a possibility of matted level II cervical lymph nodes. Fine needle aspiration of the same showed only crystalloids in a dirty background. Hence, a possibility of retention cyst was given and excision was advised. On histopathological examination, the mass was diagnosed as Sclerosing polycystic adenosis of the parotid gland. Since SPA is a rare entity with diverse morphological features, it is more likely to be misdiagnosed on cytology. Recognition of this benign entity is important since the differential diagnosis includes other more common benign and malignant salivary gland neoplasm particularly mucoepidermoid carcinoma and other tumors with cystic and oncocytic features. Repeat aspiration from multiple sites should be considered in cystic lesions of the salivary gland so that its varied cytological components can be yielded to help with the diagnosis. Diagn. Cytopathol. 2017;45:640-644. © 2017 Wiley Periodicals, Inc.

Sclerosing polycystic adenosis (SPA) is a rare benign neoplasm of the salivary gland which resembles the fibrocystic disease of the breast clinically as well as morphologically. This entity has varied morphological presentation on fine needle aspiration. Only a few case reports and occasional case series are found in the literature describing its cytology. Here we are presenting a case of SPA in the parotid gland in a 13-year-old male patient who presented with a slow growing infra-auricular mass since one year without any other symptoms. Radiological investigation suggested a possibility of matted level II cervical lymph nodes. Fine needle aspiration of the same showed only crystalloids in a dirty background. Hence, a possibility of retention cyst was given and excision was advised. On histopathological examination, the mass was diagnosed as Sclerosing polycystic adenosis of the parotid gland. Since SPA is a rare entity with diverse morphological features, it is more likely to be misdiagnosed on cytology. Recognition of this benign entity is important since the differential diagnosis includes other more common benign and malignant salivary gland neoplasm particularly mucoepidermoid carcinoma and other tumors with cystic and oncocytic features. Repeat aspiration from multiple sites should be considered in cystic lesions of the salivary gland so that its varied cytological components can be yielded to help with the diagnosis. Diagn. Cytopathol. 2017;45:640-644. © 2017 Wiley Periodicals, Inc.

To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in pediatric population. The present study, conducted over a period of 3 mo analyzed all the episodes of transfusions and divided them into appropriate and inappropriate according to the type of blood components, the requesting departments and the clinical indication of transfusion. Data was reviewed according to the British Committee for Standards in Hematology and American Association of Blood Bank guidelines. A total of 2,145 units of hemocomponents were transfused to children, including 1,181 units of red cell concentrates, 566 units of platelet concentrates/platelet rich plasma, 118 units of whole blood and 280 units of fresh frozen plasma in 1,819 episodes. Appropriate usage of blood components was 59.65 %. Whole blood was most appropriately transfused (82.9 %). Appropriate indications outnumbered inappropriate requisitions in Department of Pediatric Medicine (70.38 %), Nursery (82.54 %) and Thalassemia day care centre (55.63 %). Red cell concentrate was most appropriately indicated in anemias (73.14 %) and inappropriately in cases of surgeries (53.6 %). Platelets were used more appropriately in all clinical indications. Whole blood was transfused most appropriately (100 %) in double venous exchange therapy. Most appropriate indication of fresh frozen plasma usage was coagulopathy (42.57 %). As the appropriate usage (59.65 %) of blood components was low in the present study, regular auditing of transfusion practices from time to time is indicated. This not only helps guide their judicious use but also serves to evaluate and decrease their inappropriate usage.

Giant cell tumor (GCT) of the bone is a benign locally aggressive neoplasm which accounts for 3–8 % of all primary bone tumors. 60–70 % of the patients with giant cell tumor of the bone occur in the age group of 20–40 years. Patients older than 55 years of age very rarely develop GCT. Although many case series have been published on giant cell tumor of the bone, even on extensive search of literature, we found only a single series of 10 cases focusing exclusively on giant cell tumors in elderly. They observed that there was no difference in behavior of GCT in elderly and younger patients in terms of location of tumor, radiographic features and clinical course. We present a case of GCT of tibia in an elderly male without any evidence of malignant transformation or dedifferentiation, despite magnetic resonance imaging revealing features of a malignant lesion.

Background: The minimum hemoglobin cutoff for blood donation in India is 12.5 gm% for both male and female donors and the minimum donation interval is 3 months. Donation of one unit of blood results in decrease in hemoglobin by 1 gm% and loss of 200-250 mg of iron. Donor deferral due to anemia is one of the major reasons of temporary rejection of blood donors. In the absence of further workup or advise, it results in loss of valuable donor base. Aim and Objective: To provide baseline information regarding the prevalence and spectrum of anemia in prospective blood donors to help plan a future strategy for donor management. Materials and Methods: Hemoglobin testing of donors was performed using Hemocue and Copper sulfate specific gravity method. Ethylene diamine tetraacetic acid sample of all the donors who failed either or both the screening tests was tested on automated analyzer for evaluation of hemoglobin and red blood cell indices. Results: Of all the donors, 15.5% were deferred due to anemia. Prevalence of anemia in prospective blood donors was 1.8%. It was significantly higher in female donors compared with male donors (34.2% vs 1.2%). The most common type of anemia was normocytic normochromic.

Background: The demand for plateletpheresis is increasing day by day due to its many merits over random donor platelets. However, in our country, there is a dearth of apheresis donors due to greater devotion and time required for the procedure and lack of awareness. Aim: The aim of the present study is to analyse the reasons for deferral of apheresis donors at a tertiary care center. Materials and Methods: This retrospective analysis was conducted to study the causes, frequency and the type of plateletpheresis donor deferral at regional blood transfusion center, Lady Hardinge Medical College and associated Shrimati Sucheta Kriplani Hospital and Kalawati Saran Childrens’ Hospital. The study was undertaken over a period of two years (from January 2010 to December 2011. Results: Out of a total of 343 donors screened, 87 donors were deferred, the overall deferral rate being 25.36%. The most frequent cause of deferral was a low platelet count accounting for 43.5% of all the causes followed by a low hemoglobin level (27.05%). Among the donors deferred for anaemia, 15 out of 23 (65.2%) had hemoglobin in the range of 11.5-12.4gm%, representing 17.2% of all deferrals. Conclusion: Based on these findings and the scarcity of apheresis donors in our country, we are of the opinion that the selection criteria for plateletpheresis donors should be revised to accommodate more donors and reduce deferral rate without compromising on the health of the donors.

Pure mucinous carcinoma of the breast accounts for about 2% of all breast carcinomas and is associated with a favourable prognosis due to its lower nuclear grade and infrequent axillary or hematogenous metastases. Micropapillary variant of mucinous carcinoma breast has recently received attention as a unique form of invasive carcinoma of the breast exhibiting dual differentiation towards mucinous as well as micropapillary. The characteristic features for labeling a tumor as mucinous micropapillary carcinoma are micropapillary pattern, nuclear pleomorphism, hobnail cells and psammoma bodies in addition to the predominant mucinous component. Micropapillary mucinous carcinoma (MUMPC) when compared to pure mucinous carcinoma tends to have a higher nuclear grade, axillary lymph node metastases, lymphovascular invasion and overexpression of Her 2, p53 and Ki-67, thereby displaying an aggressive clinical behaviour. We present a rare case of micropapillary mucinous carcinoma to highlight the fact that this being a unique and rare variant of mucinous carcinoma should be recognized and reported as a separate category by the pathologists owing to its aggressive clinical behaviour and its influence on the nature of therapy.

Hemoglobin estimation is an integral part of donor screening in blood banks. Various methods are available for hemoglobin estimation and each one of them has its advantages and limitations. Hemocue as a hemoglobinometer is gaining widespread popularity not only for donor screening but also as a bedside hemoglobinometer. We conducted a study involving 535 donors with an aim to assess the accuracy of hemocue readings and compared it with cell counter values. We also compared the hemocue readings using capillary blood with the venous blood.

Blood donors are deferred from donating blood for several reasons, either permanently or temporarily. Losses related to disease marker rates are well established. Donor and donation losses for other reasons, however, have not been extensively quantified. This study quantified the rate of and reasons for donor deferral among Delhi donors. A retrospective study was conducted by reviewing the deferral donor records from 1 January 2007 to 31 December 2008. The percentage of deferred donors was 9% with majority of them (91.0%) being deferred for temporary reasons. Anemia was the most frequent cause for donor rejection (32.8%). Permanent deferral accounted for 9.1% with hypertension being the most common cause (29.4%) in this category.

Large cell lung carcinoma (LCLC), rhabdoid phenotype (RP) is a rare entity, accounting for 0.1-1% of all lung tumors. It is characterized by presence of more than 10% cells with rhabdoid morphology-large cells with abundant cytoplasm, eccentric nuclei, prominent nucleoli and eosinophilic cytoplasmic inclusions. We report a case of rhabdoid variant of large cell carcinoma in a 65-year-old female. Patient presented with a lump in the right axilla. Computed tomography showed a large mass lesion in right lung with involvement of the chest wall. Tru-cut biopsy from the lung lesion was performed and histopathology was compatible with LCLC. A RP was considered due to the presence of tumor cells with eosinophilic cytoplasmic globules and eccentric nuclei. Cytokeratin and vimentin were diffusely positive while thyroid transcription factor was focally positive. INI-1, desmin, calretinin, HMB-45, and neuroendocrine markers were negative. This case highlights that recognition of large cell carcinoma lung, RP is very important because of its aggressive nature and adverse outcome.

Tuberculous infection is highly prevalent in India, however, hydatid disease is relatively uncommon. Frequent sites of predilection of hydatid disease are the liver and lungs. Other unusual sites of infliction are the peritoneum, thyroid, breast, pancreas, and mediastinum. Hydatid disease in the axilla is quite uncommon. We hereby report a case of coexistent axillary hydatid disease with tuberculous lymphadenitis. To the best of our knowledge, even after extensive search of the literature we did not come across any such case. Fine needle aspiration cytology (FNAC) is a cost-effective procedure performed on an outpatient basis and helped clinch a prompt diagnosis, with minimum discomfort or complications. The role of FNAC in early diagnosis cannot be overemphasized.

Sir, As we all are aware, transfusion-transmitted malaria is emerging as a major problem especially in developing countries, which fall in the zone of endemicity. Transmission of malaria by blood transfusion was one of the fi rst recorded incidents of transfusion-transmitted infection.[1] The frequency of transfusion-transmitted malaria varies from 0.2 cases per million in nonendemic countries to 50 or more cases per million in endemic areas.[2] Although it was in 1971 that screening of donated blood for viral infections was begun, but there are no defi nite guidelines to the choice of the test. Testing of blood for malarial parasite is mandatory as per the drugs and cosmetic act part X11 B of Schedule F, but there are no clear guidelines to date. Microscopic detection of blood though considered the gold standard for malaria diagnosis for decades is quite labor-intensive and requires adequate technical skill and manpower. This has spurred the development of several nonmicroscopic malaria rapid detection tests (RDT) based on the detection of malaria parasite antigen in whole blood. We at our blood bank, Regional Blood Transfusion Centre, have been routinely screening all donated units of blood for malaria using RDT, based on immunochromatographic methods detecting antigens, histidine-rich protein 2 (HRP2-P. falciparum), and p-lactate dehydrogenase (pLDH-P. vivax) (Paraview, First Sign; Diagnova Pvt. Ltd. New Delhi, India Ltd.) since March 2008. Thick and thin smears were made of all positive cases to corroborate the results of RDT. Total of 11,736 units of donated blood were screened between March 2008 and September, 2009. Three (0.03%) units were found to be positive, 2 for P. vivax, and 1 for P. falciparum. All the three cases were found positive microscopically. None of the donor had given a history of fever/malaria during predonation screening [Table 1]. Table 1 Comparison of rapid detection tests and peripheral smear screening of positive cases The RDT works through lateral flow/immuno chromatographic strip method and signifi es the presence of antigens by a color change on the absorbing nitrocellulose strip. Three main types of antigens are being detected by the commercially available RDTs. Falade et al. in 2009 conducted a study on 391 consecutive potential blood donors in malaria endemic area of South-West Nigeria using 3 methods’ microscopy, OptiMAL RDT (pLDH), and Clinotech Malaria cassette (detects surface protein of merozoites and sporozoites). Microscopy revealed parasitemia in 79 (20.0%) of potential donors, mean level of parasitemia being 445/μl. The corresponding prevalence of malarial parasitemia detected using RDT were 3.8% for OptiMAL and 57.8% for Clinotech, with the results for microscopy being the gold standard.[3] Bharti et al. in 2008 evaluated the usefulness of a new RDT, pLDH/HRP2 malaria card test (First Response Combo Malaria Antigen Test, New Delhi, India) for malaria diagnosis in the forested belt of central India. Analysis revealed that RDT was 93% sensitive, 85% specifi c with a positive predictive value of 79%, and a negative predictive value of 95% (microscopy being used as the gold standard).[4] Kyabayize et al. studied the operational accuracy and persistent antigenicity of HRP2 RDTs for Plasmodium falciparum malaria in a hyperendemic region of Uganda. Using a cross-sectional study design, a total of 357 febrile patients of all ages were tested using RDT out of which 40% (139) had positive blood smears for P. falciparum. RDT had overall sensitivity of 98%, specifi city of 72%, positive predictive value of 69%, and a negative predictive value of 98%. In the children followed-up after successful antimalarial treatment, the mean duration of persistent antigenicity was 32 days, this duration varied signifi cantly depending on pre-treatment parasitemia.[5] Therefore, a donor who is deferred for 12 weeks following completion of treatment will not give a false positive test for malaria by RDT. Importance of recognizing transfusion-transmitted malaria lies in the fact that it can lead to febrile transfusion reaction which can falsely simulate a hemolytic transfusion reaction. It can lead to the widespread dissemination and spread of drug-resistant malarial parasite. The utmost importance is derived from the presumption that the screened blood units are transfused to patients ranging from newborns (requiring exchange transfusions) to the geriatric group. These along with the immune-suppressed (cancer and leukemia therapy) patients are at a higher risk of falling prey to units not effectively screened for malarial parasite. Thus clinicians will waste valuable time manage on lines of hemolytic transfusion reaction. Nonetheless, no matter what strategy is adopted, it is likely that cases of transfusion-transmitted malaria may still occur, so malaria must always be considered in any patient with a febrile illness post-transfusion. Thus we would like to recommend that use of rapid detection devices with peripheral smear screening of positive cases is reasonably reliable method to prevent transfusion-transmitted malaria in India.