Khaliqur Rahman

Role of CD200 in differential diagnosis of mature B-cell neoplasm

CD 200 is a type I immunoglobulin super family membrane glycoprotein, which is expressed in various mature B‐cell neoplasm (MBN). This study aimed at analyzing the expression pattern of CD200 by flow cytometry immunophenotyping (FCI) and to evaluate its utility in narrowing down the differential diagnosis of MBN, particularly in low‐grade lymphomas.

Fluorescent Aerolysin (FLAER)‐based paroxysmal nocturnal hemoglobinuria (PNH) screening: a single center experience from India

Fluorescent aerolysin (FLAER) has been recommended as an important part of antibody panel used for flow cytometric detection of paroxysmal nocturnal hemoglobinuria (PNH) clone. This study was aimed to observe the frequency of PNH‐positive clones and their sizes in patients screened for various indications.

Co-existence of AML1-ETO and BCR-ABL1 transcripts in a relapsed patient of acute myeloid leukemia with favorable risk group: A coincidence or clonal evolution?

Prognosis of acute myeloid leukemia relies heavily on the cytogenetic and molecular abnormalities. AML1-ETO fusion protein resulting from t(8;21), a recurring cytogenetic abnormality, is known to be associated with favorable prognosis. Additional molecular defects may, however, co-operate with the fusion proteins and alter the course of the disease. Among the additional cytogenetic defects, presence of Philadelphia (Ph) chromosome has rarely been documented in this subtype. Little is known about the consequences of its interactions with AML1-ETO, and its effect on morphological and clinical picture. Moreover, Ph+ clones or subclones may appear at any point during the disease course. We herein report one such unusual case of a 26-year-old female, who was diagnosed to have t(8;21) and managed accordingly. During disease relapse after 2.5years, the bone marrow showed extensive eosinophilia and basophilia. Subsequent molecular testing showed the presence of BCR-ABL in addition to the AML1-ETO fusion product.

Mixed phenotypic acute leukemia with two immunophenotypically distinct blast populations: Report of an unusual case

Mixed phenotypic acute leukemia (MPAL) is a rare disorder with an incidence of less than 2% of all acute leukemia using the recent 2008 WHO criteria. Common subtypes encountered are the B/myeloid and T/myeloid; B/T or trilineage MPAL being an exception. We discuss here a case of 20‐year‐male patient who presented with pallor and generalised lymphadenopathy. Peripheral blood smear examination showed presence of 61% blasts of lymphoid morphology. Immunophenotyping by multicolor flow cytometry showed two distinct populations of blasts with T and B phenotype respectively. He was diagnosed as MPAL with two distinct blast lineages. Conventional karyotyping done on bone marrow sample showed t(9;22)(q34;q11)(Ph +). Induction was started using ALL based protocol. The patient is on follow up with post induction marrow being in morphological remission.

Auer rods in polymorphs in a case of acute myeloid leukemia

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Plasma cell myeloma with unusual morphology–A series of 6 cases

Morphological variants of plasma cells have been described in cases of Plasma cell neoplasm. Presence of these atypical forms poses difficulty in morphological diagnosis and demands the use of ancillary techniques to ascertain the nature of these atypical cells. We hereby report a series of 6 such cases where the bone marrow examination showed plasma cells with atypical morphology, leading to varied differential diagnosis; however immunophenotyping by flow cytometry in adjunct to serum electrophoresis, immunofixation and free light chain assays confirmed the diagnosis.

Rare BCR-ABL1 transcript in a RUNX1-RUNX1T1-positive de novo acute myeloid leukemia: The chicken and egg tale.

To the Editor, Philadelphia chromosome (Ph) is the hallmark of chronic myeloid leukemia (CML) and is frequently reported in patients with acute lymphoblastic leukemia (ALL). There is enough accumulating evidence for the existence of de novo Ph+ acute myeloid leukemia (Ph+ AML) after excluding the biphenotypic leukemias.1-3 Diagnostic, clinical, and morphological features favoring Ph+ AML over a myeloid blast crisis in CML (MyBC) include a short clinical course, absence of organomegaly, basophilia, and reduced proliferation of megakaryocytic lineage. Cytogenetically, a restricted presence of Ph chromosome in some metaphases and a normal karyotype after induction chemotherapy supports the possibility of Ph+ AML,4 and in the molecular front, the presence of nucleophosmin (NPM1) mutation, deletion of antigen receptor genes (IGH and TCR), IKZF1, and/or CDKN2A favor the diagnosis of a de novo disease over MyBC.5 Here, we document a rare case of de novo AML with RUNX1RUNX1T1 (AML1ETO) and BCRABL1 mutation; the diagnostic dilemmas and morphological characteristics of these “double hit” leukemia are discussed. A 39yearold female patient, a known case of bronchial asthma, presented to the hematology OPD with progressive fatigue and severe breathlessness of 1month duration. There was no prior history of blood transfusion or steroid intake. Physical examination was notable for pallor and absence of organomegaly or lymphadenopathy. Complete blood counts revealed pancytopenia with the presence of circulating blasts in peripheral blood. Subsequent bone marrow examination revealed proliferation of myeloperoxidase (MPO)positive blasts (60%), many of which showed the presence of long slender Auer rods. In addition, dyspoiesis was appreciated in the maturing myeloid cells and megakaryocytes (Figure 1A,B and inset). Immunophenotypically, the blasts expressed CD33, CD13, CD117, CD34, CD38, HLADR, MPO, and aberrant CD19. Conventional cytogenetic analysis performed on the diagnostic bone marrow aspirate sample showed the presence of t(8;21)(q22;q22) and loss of X chromosome in 55% metaphases and t(1;1)(p36.3;q25) in 5% of the metaphases. No Ph chromosome was detected. The presence of RUNX1RUNX1T1 fusion transcript was also confirmed by nested reverse transcriptase PCR, performed in accordance with the international BIOMED1 protocol.6 NPM1 and FLT3ITD mutation analyses, carried out by capillary electrophoresis (ABI 3500 genetic analyzer; Thermo Fisher Scientific), were found negative. The patient was administered standard 3 + 7 AML chemotherapy protocol consisting of daunorubicin at a dose of 60 mg/m2 once daily for 3 days and 100 mg/m2 cytosine arabinoside for 7 days by continuous infusion. The postinduction day 28 bone marrow performed to assess remission status revealed morphological remission. However, the marrow was hypercellular with the presence of numerous megakaryocytes, some of which simulated dwarf forms of CML (Figure 2C,D). In addition, the presence of mild eosinophilia was noted. Hence, the patient was reinvestigated for the presence of BCRABL1

Clinicopathological profile of paroxysmal nocturnal haemoglobinuria clone-positive aplastic anaemia paediatric patients-A single centre study from North India

There is a paucity of literature related to the prevalence of Paroxysmal Nocturnal haemoglobinuria (PNH) clones in paediatric aplastic anaemia (AA) patients.

The triple-negative (CD34-/HLA-DR-/CD11b-) profile rapidly and specifically identifies an acute promyelocytic leukemia

The genetic testing to confirm or rule out an acute promyelocytic leukemia (APL) typically takes a minimum of 24‐72 hours. Flow cytometric immunophenotyping (FCI) on the other hand provides rapid and objective information to differentiate APL from non‐APL.

Neutrophil Erythrocyte Rosettes: An Unusual Manifestation of Autoimmune Hemolytic Anemia.

Presence of spherocytes and or red cell agglutination in blood smear are pathognomonic of autoimmune haemolytic anemia (AIHA) [1]. An unusual and infrequent manifestation of AIHA is rosetting of leucocytes by red blood cells (RBC’s), more commonly documented with monocytes. Here we describe a case of AIHA on treatment where peripheral blood smear examination showed the presence of numerous neutrophil-erythrocyte rosettes. A 43 year old male presented with complaints of episodes of jaundice, mild fever and generalized body ache of 20 days duration. He also complained of episodic passage of reddish colour urine since 20 days. The patient had a past history of similar complaints 5 years back, when he was diagnosed to have AIHA and was treated with prednisolone at a dose of 35 mg/day, which was gradually tapered off. Examination revealed pallor and icterus with mild hepatosplenomegaly. Investigations showed haemoglobin of 9.9 gm/dl, corrected reticulocyte count of 5.8 %, serum total and conjugated bilirubin of 2.6 and 1.0 mg/dl respectively. Plasma haemoglobin and serum lactate dehydrogenase were elevated measuring 62.8 mg/L and 1296 U/L, respectively. Urine routine examination was positive for protein, bilirubin and blood/haemoglobin (2?), while microscopic examination showed only 2–3 RBC’s per high power field. Peripheral blood smear showed frequent RBC rosettes around neutrophils (Fig. 1). All the rosettes were typically seen with neutrophils and none around monocytes (inset Fig. 1). Direct antiglobulin test was strongly positive for IgG and C3d complement (4?). The patient was re-initiated on prednisolone at a dose of 35 mg/day. Red cell-neutrophil rosettes are rarely described in AIHA [2]. Though the rosettes have been proposed to represent a physiologic intermediate in extravascular RBC destruction and strongly predict clinical AIHA, the exact mechanism behind the rosette formation is unclear. Shaw et al. in 1979, performed in vitro studies utilizing antibody coated RBC’s and clearly demonstrated that the Fc receptors, present on all three cell types namely neutrophils, monocytes and lymphocytes interact with the antibody coated red cells and result in rosette formation. The antibody dependant cell cytotoxicity was found to be much more by monocytes than neutrophils, thereby indicating that neutrophils require a much higher titre of antibody coated target cells to mediate cytotoxicity [3]. The presence of these rosettes in this patient were possibly due to interaction of neutrophil Fc receptors with the IgG decorated RBC’s, though interestingly, no such rosettes could be appreciated with monocytes. Moreover, this rosetting is distinct from the red cell clumping seen in cold antibody disease, which is mediated by the interaction of the pentameric IgM antibody with I/i antigen on the RBC’s [1]. Similar neutrophil erythrocyte rosettes have also been described in EDTA anticoagulated blood samples [4]. The clinical relevance of these rosettes is elusive, yet their presence in peripheral smears can be considered as indicator of an ongoing auto immune process. These interactions may contribute to intravascular hemolysis, & Ruchi Gupta ruchipgi@yahoo.co.in