Open Access Case Study

Manual Exchange Blood Transfusion with Cytoreduction in the Management of Chronic Myelocytic Leukemia with Hyperleukocytosis: A Case Report

Ayuba Zakari, Ezra Danjuma Jatau, Adeyemi Ayobola Olusegun, Akor Akoyi Emmanuel, Dauda Yohanna Bangalu

Asian Hematology Research Journal, Page 18-23

Chronic Myelocytic Leukaemia (CML) is a haematological malignancy characterized by granulocytic leukocytosis, splenomegaly, and weight loss. Hyperleukocytosis can lead to leukostasis and hyperviscosity syndrome. Leukapheresis is used to manage hyperleukocytosis, but apheresis machines are expensive and unavailable in most health facilities across Nigeria and other resource-limited countries. Manual Exchange blood transfusion (EBT) can be an alternative to leukapheresis in managing hyperleukocytosis and associated metabolic derangement.

We report a case of a 53-year-old woman who presented to the Jos University Teaching Hospital with granulocytic leukocytosis and massive splenomegaly. Full Blood Count and Bone Marrow Aspiration cytology showed features of CML in the accelerated phase. The patient was commenced on cytoreduction with hydroxyurea but defaulted treatment and re-presented one year after with features of CML in blastic transformation and pulmonary leukostasis. Recommencement of Hydroxyurea and Manual EBT achieved cytoreduction and improvement of pulmonary symptom, while the eventual introduction of imatinib mesylate resulted in the attainment of haematological remission.

Our report found that Manual EBT, combined with cytoreduction, is a reliable alternative to automated leukapheresis in managing hyperleukocytosis in resource-limited settings.

Open Access Original Research Article

The Relation between Glutathione S Transferase (GSTM1, GSTP1 and GSTT1) Polymorphisms and Clinical Diversity of Sickle Cell Disease among Pediatric Sudanese Patients

Naif Taleb Ali, Ozaz Yagoup Mohammed Ahmed, Fayad Osman Mohammed, Huda Mohammed Haroun

Asian Hematology Research Journal, Page 1-17

Background: Sickle cell disease (SCD) is a highly variable condition, with some patients being asymptomatic and others frequently admitted to hospital. Impairment of the glutathione system due to genetic polymorphisms of glutathione S-transferase (GST) genes is expected to influence on the severity of SCD manifestations.

Objectives: This study aimed to investigate the possible association between the presence of GSTM1, GSTT1 and GSTP1 gene polymorphisms and SCD severity, diversity and complications.

Study Design: Cross-section hospital based study.

Place and Duration of Study: This study carried out in Khartoum town in Jafar Ibn Auf Pediatric Hospital / Khartoum during the period (June 2017 to June 2020).

Methodology: The total subjects of the confirmed diagnosis were 126 patients, 78 (61.9%) are males and 48 (38.1%) are female.

GSTM1 and GSTT1 genotypes were determined by polymerase chain reaction (PCR), GSTP1 genotyping was conducted with a PCR-RFLP, and the data analyzed by SPSS version 23.

Results: The GSTM1null genotype was found to be present in male more than female (OR=2.6 and p=0.002) and trend to be protective from development of Dactylitis (OR=0.313 and p=0.006) and reduce risk to develop ACS (OR=0.23 and p=0.002) while this polymorphism increase requirement for blood exchange (OR=1.1 and p=0.044), the GSTT1null genotype found to be present in female more than male (OR=2.6 and p=0.012) and this polymorphism reduce requirements for blood transfusion (OR=0. 137 and p< 0.001) and annual hospitalization (OR=0.436 and p=0.029), and reduce risk to development of stroke (OR=0.125 and p=0.008), polymorphism of both GSTM1 and GSTT1 found to be associated with appearance of disease before one year of age (OR=1.43 and p=0.004) and trend to be protective from development of Dactylitis (OR=0.124 and p=0.002),and there are no statistically significance association between GSTP1 gene polymorphism and gender variability and clinical manifestations of SCD.

Conclusion: Some GST genes polymorphisms were significantly associated with increased risk and some trend to have protective effect on clinical manifestations of SCD.

Open Access Original Research Article

Acute Promyelocytic Leukemia: A Decade Long Experience with Evolving Treatment Strategies

Prakash Singh Shekhawat, Prakas Kumar Mandal, Malini Garg, Avriti Baveja, Tuphan Kanti Dolai

Asian Hematology Research Journal, Page 24-32

Aims: To study the characteristics and outcome of Acute promyelocytic leukemia (APL) patients.

Study Design: Retrospective analysis of APL patients (n=106) treated at the Department of Hematology, NRS Medical College, Kolkata over a period of more than 10 years from October 2009 to September 2020 was done.

Methodology: Patients were treated with ATO, ATRA+ATO and ATRA+ Anthracycline depending on their Sanz risk stratification. Presenting symptoms, clinical spectrum, events (relapse, death, dropout, and refractory disease), and response to treatment was analyzed. Overall survival (OS), event free survival (EFS) and relapse free survival (RFS) were calculated.

Results: Median age was 26.5 (range, 2-71) years with M:F ratio of 1.7:1. Majority presented with bleeding (91.3%) followed by anaemia (84.4%) and fever (78%). Median hemoglobin, TLC and platelet count were 95gm/L, 6.15 x 109/L and 52 x 109/L, respectively. As per Sanz risk criteria Low risk (45.3%) was the commonest followed by Intermediate risk (29.2%) and high risk (25.5%). About half of the cases had BCR1, while BCR 3 (41.5%) and BCR 2 (7.55%). ZBTB/RARA t (11;17) was detected in 2 cases (1.9%) and were treated with AML like therapy. Patients with BCR3 transcript was significantly associated with low platelet count(p=0.009), low Hb (p=0.02) and high TLC (p=0.01) at presentation (p<0.05). Induction mortality was 16.9% and it was significantly associated with low Hb and low platelet count (P<0.05). Most common cause of death was hemorrhagic death. Children (≤18yr) had significantly more differentiation syndrome (DS) than adults (>18yr) (p=0.007). Remission was attained in 83% patients. Median OS, EFS and RFS were not reached. At 10-year OS was 79.1%, EFS was 63.5% and RFS was 78.3%. OS in ATRA+ chemotherapy arm was significantly inferior than ATO (p=0.01) and ATRA+ATO arm (p=0.008), while there was non-significant difference in OS between Vesanoid vs generic ATRA, with or without maintenance.

Conclusion: Bleeding was the commonest presentation. Low risk category was commonest.

Low Hemoglobin and low platelet were significantly associated with Induction mortality and BCR3 transcript. OS in ATRA chemotherapy was significantly inferior to ATO and ATRA+ATO arm ; without any significant difference in OS between original ATRA vs generic ATRA, with or without maintenance, risk categories, or children vs adults.

Open Access Original Research Article

Profile of Autoimmune Haemolytic Anaemia: Analysis of 10 Years Data from a Hematology Center in Eastern India

Avriti Baveja, Prakas Kumar Mandal, Arnab Chattopadhyay, Malini Garg, Prakash Singh Shekhawat, Tuphan Kanti Dolai

Asian Hematology Research Journal, Page 33-43

Aims: To study the Clinico-haematological profile and therapy outcome of patients with autoimmune haemolytic anaemia (AIHA)

Study Design: Retrospective analysis through the case records of 69 patient treated at the Department of Hematology, NRS Medical College, Kolkata over a period of 10 years from January 2011 to December 2020.

Methodology: Clinico-haematological profile including baseline characteristics and therapy outcome of patients with autoimmune haemolytic anaemia (AIHA) were noted. Presenting symptoms, clinical spectrum, response to therapy and events (relapse, death, dropouts and refractory disease) was analyzed by standard statistical methods.

Results: This study identified 69 (primary-56 and secondary-13) consecutive patients were with a median age of 49 years. The common presentations included pallor (98.5%) and jaundice (84.5%) with the presence of splenomegaly (56.5%) and hepatomegaly (47.2%).  Direct antiglobulin test was negative in two patients. Oral prednisolone produced remission in 91.04% patients with a median response duration of 28 days. Among responders, 28 patients relapsed after a median period of 269.2 weeks. The relapsed patients received steroid in most patients. Azathioprine, Rituximab and Splenectomy were given in eight, six and two patients respectively with a overall response rate of 62.65%, 66.6% and 100 % respectively.

Conclusion: Kknowledge of clinical and laboratory profile in AIHA help in directing the investigations and HAS effect on the therapy decisions. With the plethora of drugs available as therapeutic options in primary AIHA, steroid still remains the cornerstone of therapy.

Open Access Original Research Article

Validation of Manufacturers Recommended Working Volumes of Fluorochrome-conjugated Monoclonal Antibodies for Flowcytometric Analysis of Lymphocytes

Moses Dabah Lugos, Gwom Irimiya Davou, Tabitha Silas Vem, Venkateswarlu Perikala, Obadiah Dapus Damulak

Asian Hematology Research Journal, Page 44-56

Background: Flow cytometry is a robust and rapidly growing technique used to analyse multiple parameters concurrently on a single cell basis. Cell populations can be characterised using a combination of both surface and intracellular antigens. The act of generating the best research data under given circumstances begins with a well-designed reagent optimisation protocol. Applying flow cytometric analysis to obtain reliable and dependable research data requires establishing the best working volumes of the monoclonal antibodies.

Aim: This study aimed to provide practical illustrations on the approach for determining optimal working volumes (concentrations) of fluorochrome-conjugated monoclonal antibodies for flow cytometry.

Methods: Peripheral blood mononuclear cells (PBMCs) from healthy volunteers were stained using three different volumes of respective fluorochrome-conjugated monoclonal antibodies: one volume below, a volume above and the volume recommended by the manufacturers. The antibodies analysed include CD3-FITC, CD4-APC-Cy7, CD19-Alexa Fluor 700, CD45-AmCyan, CD28-PE, and CD45-AmCyan isotype control.  Depending on the availability of cells, a total of 10,000 to 30,000 events were acquired for analysis. Combinations of the mean fluorescence intensity (MFI), the number of events in the population of interest, and the clearance of the Isotype control histogram peak from the positive population were used to determine the best working volumes of the mAbs used.

Results: The study reported optimum working volumes of 10µL for CD45-Amcyn, 20µL for CD3-FITC, 10µL for CD4-APC-Cy7, 10µL for CD19-Alexa Fluor 700, 20µL for CD28-PE. We confirmed the recommended volumes provided by the manufacturer for CD3-FITC and CD28-PE. However, higher volumes of CD45-Amcyn, CD4-APC-Cy7 and CD19-Alexa Fluor 700 were found more optimal than the recommended volumes supplied by manufacturers.

Conclusion: The application of a simple validation experiment for the working volumes (concentrations) of fluorochrome-conjugated monoclonal antibodies, like the one described here, is recommended as an integral part of the optimisation protocol for flow cytometry.