Priyanka Saxena

Parvovirus B19 Associated Hepatitis

Parvovirus B19 infection can present with myriads of clinical diseases and syndromes; liver manifestations and hepatitis are examples of them. Parvovirus B19 hepatitis associated aplastic anemia and its coinfection with other hepatotropic viruses are relatively underrecognized, and there is sufficient evidence in the literature suggesting that B19 infections can cause a spectrum of liver diseases from elevation of transaminases to acute hepatitis to fulminant liver failure and even chronic hepatitis. It can also cause fatal macrophage activation syndrome and fibrosing cholestatic hepatitis. Parvovirus B19 is an erythrovirus that can only be replicate in pronormoblasts and hepatocytes, and other cells which have globosides and glycosphingolipids in their membrane can also be affected by direct virus injury due to nonstructural protein 1 persistence and indirectly by immune mediated injury. The virus infection is suspected in bone marrow aspiration in cases with sudden drop of hemoglobin and onset of transient aplastic anemia in immunosuppressed or immunocompetent patients and is confirmed either by IgM and IgG positive serology, PCR analysis, and in situ hybridization in biopsy specimens or by application of both. There is no specific treatment for parvovirus B19 related liver diseases, but triple therapy regimen may be effective consisting of immunoglobulin, dehydrohydrocortisone, and cyclosporine.

Bone marrow stem cells and their niche components are adversely affected in advanced cirrhosis of the liver.

Bone marrow (BM) is a reservoir for immune and hematopoietic cells and critical for tissue repair and regeneration. All of these functions are severely altered in cirrhosis. We investigated the cellular and functional state of BM in cirrhosis patients. We studied the histological, cellular, and molecular changes in BM of cirrhosis patients (n = 168) and controls (n = 44). Hematopoietic stem cells (HSCs) and associated niche cells, mesenchymal stem cells, Schwann cells, neural fibers, and endothelial cells were evaluated by immunohistochemistry. Cytokines and growth factors were analyzed in peripheral blood and BM plasma. Cirrhotic BM showed an inverse correlation between cluster of differentiation 34+HSCs and Model of End‐Stage Liver Disease (ρ = ‐0.582, P < 0.001) and Childs scores (P < 0.038). BMs of cirrhosis patients with higher Model of End‐Stage Liver Disease (>15) showed significantly decreased HSCs, mesenchymal stem cells, Schwann cells, and neural fibers; increased interleukin‐1β (P = 0.004), tumor necrosis factor‐α (P = 0.040), and interferon‐γ (P = 0.03); and decreased oncostatin M (P = 0.04), stem cell factor (P = 0.05), and stromal cell‐derived factor 1 (P = 0.03) compared to those with lower Model of End‐Stage Liver Disease scores (≤15). The cluster of differentiation 34+ cell population was a predictor for the development of sepsis (P < 0.001), and per unit loss increased the probability of sepsis by 16%. Cirrhosis patients with fewer HSCs had lower hemoglobin (P = 0.05) and platelet counts (P = 0.05) and showed early graft dysfunction. Conclusions: Increasing severity of cirrhosis causes derangement of the hematopoietic niche and loss of HSCs, contributing to the hematological and immunological dysfunctions and reduced potential for regeneration; restoring BM functions could provide new therapeutic options in cirrhosis. (Hepatology 2016;64:1273‐1288)

Sonoclot Signature Analysis in Patients with Liver Disease and Its Correlation with Conventional Coagulation Studies

Introduction. Liver disease patients have complex hemostatic defects leading to a delicate, unstable balance between bleeding and thrombosis. Conventional tests such as PT and APTT are unable to depict these defects completely. Aims. This study aimed at analyzing the abnormal effects of liver disease on sonoclot signature by using sonoclot analyzer (which depicts the entire hemostatic pathway) and assessing the correlations between sonoclot variables and conventional coagulation tests. Material and Methods. Clinical and laboratory data from fifty inpatients of four subgroups of liver disease, including decompensated cirrhosis, chronic hepatitis, cirrhosis with HCC and acute-on-chronic liver failure were analyzed. All patients and controls were subjected to sonoclot analysis and correlated with routine coagulation parameters including platelet count, PT, APTT, fibrinogen, and D-dimer. Results. The sonoclot signatures demonstrated statistically significant abnormalities in patients with liver disease as compared to healthy controls. PT and APTT correlated positively with SONACT (P < 0.008 and <0.0015, resp.) while platelet count and fibrinogen levels depicted significant positive and negative correlations with clot rate and SONACT respectively. Conclusion. Sonoclot analysis may prove to be an efficient tool to assess coagulopathies in liver disease patients. Clot rate could emerge as a potential predictor of hypercoagulability in these patients.

Sickle Cell Trait Causing Splanchnic Venous Thrombosis.

Sickle cell trait is considered as a benign condition as these individuals carry only one defective gene and typically have their life span similar to the normal population without any health problems related to sickle cell. Only under extreme conditions, red cells become sickled and can cause clinical complications including hematuria and splenic infarction. Although twofold increased risk of venous thrombosis has been described in African Americans, there is no data available from Indian population. We here report a case of sickle cell trait from India whose index presentation was thrombosis of unusual vascular territory.

JAK2V617F: Is It Sufficient as a Single Player in Splanchnic Venous Thrombosis?

Splanchnic venous thrombosis (SVT) includes thrombosis of the hepatic, portal, and mesenteric venous system. Myeloproliferative neoplasms (MPNs) are important factors of SVT in adults. Addition of JAK2V617F mutation in WHO criteria for diagnosis of MPNs has made this test a useful tool for diagnosis. JAK2 is an intracytoplasmic tyrosine kinase that plays a critical role in signal transduction from multiple hematopoietic factor receptors. The mutation is found frequently in patients with SVT; many such patients have no other manifestations of an MPN. Although the correlation of JAK2V617F mutation with thrombotic risk in MPNs has been shown in many studies, the impact of presence of additional thrombophilic factors in these cases is yet not known. As the management of MPNs remains highly dependent on the patients thrombotic risk, it is important to assess the thrombotic risk factors in detail. Here, we report two cases of JAK2V617F positive MPN who also had other thrombophilic conditions and presented with recurrent thrombosis.

Loss of S-100-positive Schwann cells is a feature of JAK2 V617F-positive myeloproliferative neoplasm

Dear Editor, Myeloproliferative neoplasm (MPN) is a distinct group of hematological neoplasm, characterized by chronic persistent cellular proliferation of one or more hematological cell lineages in the blood. The disease process ultimately leads to progressive bone marrow fibrosis. MPN patients are at risk of thrombotic or hemorrhagic events. MPN may also culminate into acute leukemia either as a part of disease process or due to effect of chemotherapeutic agents [1]. Among the MPN, chronic myeloid leukemia is defined by BCR-ABL1 mutation. BCR-ABL1-negative MPNs are associated with JAK2 V617F or C-MPL mutation [2]. Calreticulin has shown to be a sensitive marker of essential thrombocythemia (ET) and primary myelofibrosis (PMF) [2]. JAK2 V617F mutation in hematopoietic stem cells (HSCs) sensitizes uncontrolled proliferation of these cells [3]. HSCs reside in bone marrow in the hematopoietic niche and remain quiescent by coordinated interactions between mesenchymal stem cells (MSCs) and HSCs. Intact MSCs are required for controlled proliferation HSCs. MSCs are innervated and regula ted by sympathetic neural fibers [4]. Sympathetic nerve fibers also support bone marrow Schwann cells [4]. JAK2 V617F-mutated HSCs produce interleukin-1beta, which causes damage to bone marrow neural fibers and ensheathing Schwann cells [5]. In the present study, we aim to look the status of S100 positive Schwann cells in the JAK2+MPNs in comparison to JAK2-negative MPN (CML) and controls. We examined the blood and bone marrow of JAK2 V617F-positive MPN (20) cases, 10 cases of JAK2-negative MPNs (CML) and 10 control cases. JAK2 V617F-positive MPN cases were identified by Sanger sequencing after PCR amplification of desired region. All CML cases had t (9; 22) positive status, detected by fluorescent in-situ hybridization (FISH). For normal control, we included cases, where bone marrow was performed, for diagnostic work up of pyrexia of unknown origin and no pathology noted in the bone marrow. Bone marrow Schwann cells were ascertained by S-100-positive cells in bone marrow biopsy by immunohistochemistry, using mouse monoclonal antibody for S-100 (ready-to-use, clone 15E2E2, Biogenex, CA, USA). Schwann cells were determined by both nuclear and cytoplasmic S-100 positivity in polygonal-shaped cells with the presence of cytoplasmic fibrils. Positive-stained cells with typical morphology were counted in minimum of 10 high power fields (×200), average number was calculated and documented for every case. The mean age in JAK2+ MPN was 52±9.1, JAK2CML 49±8.7, and control group 51±9.8 years, respectively. In JAK2+ MPN cases, hemoglobin (Hb) was 12.3±2.5 g/dl, total leukocyte count (TLC) was 17.6 * Chhagan Bihari drcbsharma@gmail.com

The imbalance of procoagulant and anticoagulant factors in patients with chronic liver diseases in North India

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Atypical Presentation of Childhood Leukemia.

To, The Editor, Leukemia is the most common childhood cancer worldwide [1]. Acute lymphoblastic leukemia (ALL) usually manifests with pallor, hepatosplenomegaly, lymphadenopathy, fever, bone pain, and bleeding [2]. Presence of frank osteolytic lesions with hypercalcemia is infrequent [3].We describes here a case of paediatric ALL who presented with multiple lytic lesions, hypercalcemia and absence of blasts in the peripheral blood film. A 10-year-old boy presents with generalised weakness, pain in right hypochondriac region which was non radiating, aggravated by coughing, associated with vomiting which was non bilious and non projectile for last 15 days. On examination, mild pallor was present with no icterus and lymphadenopathy. Liver was palpable 2 cm below the right costal margin. On investigations, complete hemogram showed Hb of 9.2g/ dl, WBC count of 8.0×109 /L with neutrophils 54%, lymphocyte 36%, monocyte 7%, eosinophil 2%, myelocyte 1% and platelet count 271 ×109 /L. Peripheral blood film showed mild anisocytosis with microcytes and hypochromia. His serum biochemistry studies were as follows: sodium: 134.8 mmol/L, potassium: 4.2 mmol/L, Crealinium: 0.93mg/dl, Calcium: 14.2 mg/dl, Phosphorous 6.4 mg/dl, uric acid: 7.6 mg/dl, LDH: 654 IU/L, Alkaline phosphatase: 110U/L, Albumin: 3.6g/dl. His ESR was 100 mm/h. Serum vitamin D3 level was 16.3 (15-30ng/ml). His serum parathyroid hormone (PTH) level was 7.2 (13.7-77.2 pg/ml). His abdominal ultrasound was normal except for hepatomegaly. The skeletal survey showed multiple lytic lesions in skull [Table/Fig-1] and ill defined translucent areas in pelvic bone. In view of anemia and multiple lytic lesions, bone marrow examination was done. Bone marrow examination revealed hypercellular marrow with 55% blasts which were positive for CD 10, CD 19, CD 22 and negative for myeloperoxidase confirming to diagnosis of precursor B acute lymphoblastic leukemia. Cytogenetic analysis of bone marrow showed 46XY karyotype. Molecular analysis for t (9; 22), t (12; 21), t (1; 19), and t (4; 11) using PCR method were negative. Patient was started on aggressive hydration, bisphosphonate and frusemide with monitoring of tumour lysis markers. For ALL, he was started with chemotherapy as per BFM 2002 protocol. His serum calcium levels decreased to 11.0 mg/dl after 48 hrs. Currently he is undergoing chemotherapy and his Day +15 marrow was hypocellular with 3% blasts (M1 marrow). Hypercalcemia is a rare finding in paediatric ALL ranging in frequency from 0.6- 4.8% [4]. Hypercalcemia of malignancy can occur due to two mechanisms. First is localized bone destruction by invasive cancer cells and second mechanism involves osteoclastic bone resorption after the release of humoral derived factors from tumour cells. Although hypercalcemia is assumed to be linked with high tumour bulk, a series of 22 patients showed no difference in event free survival in children with hypercalcemia at presentation. It has been reported that t (17;19), which is associated with poor prognosis, is frequently seen in patients with hypercalcemia due to humoral factors [5]. In our patient, hypercalcemia was due to direct bone invasion and cytogenetics was normal. The presence of multiple lytic lesions and hypercalcemia with no blasts in the peripheral blood are uncommon findings in ALL, which has prompted us to report this case. [Table/Fig-1]: X-ray Skull showing multiple lytic lesions

New approaches for cholestasis in hemoglobinopathies.

TO THE EDITOR: With approximately 7% of the worldwide population being carriers, hemoglobinopathies are the most common monogenic diseases [1]. The cumulative gene frequency of hemoglobinopathies in India is 4.2% [2]. Although liver involvement in the forms of intrahepatic cholestasis, hepatic crisis and cholelithiasis are common findings in patients with sickle cell disease [3], cholestasis is not a well-studied condition in non-transfusion dependent hemoglobinopathies. Herein, we report two cases of hemoglobin variants that presented with recurrent cholestasis and were managed with new therapeutic interventions.

Procoagulant abnormalities in cirrhosis with portal vein thrombosis

Dear Editor, Chronic liver disease patients remain in a delicately rebalanced hemostatic state which can tilt either in the direction of bleeding or thrombosis. Prothrombotic predominance in cirrhotic patients can lead to various vascular complications, of which portal vein thrombosis (PVT) is the most frequent. This study was undertaken to find out the incidence and to assess the procoagulant abnormalities in cirrhotic patients with PVT. A retrospective study was carried out wherein data of consecutive liver cirrhosis cases (from June 2009 to June 2013) was analyzed. Noncirrhotic PVT and hepatocellular carcinoma were excluded. PVT diagnosis was based on an ultrasound with Doppler, CT angiography, or magnetic resonance imaging. Non-PVT cirrhosis was taken as control group. A retrospective analysis of recorded coagulation profile was done. A total of 3,170 patients with cirrhosis were identified; out of these, 151 (4.7 %) were found to be positive for PVT. Underlying etiologies for cirrhosis were mainly the following: cryptogenic (n=56, 37.08 %), alcohol (n=48, 32 %), HBV (n=18, 11.9 %), and HCV (n=13, 8.6 %). A significantly higher mean age was seen among PVT cases as compared to non-PVT cases. Partial thrombi noted in 79.1 % cases and mainly in portal trunk and intrahepatic portal vein (78.5 %). Majority of the PVT cases were of Child–Turcotte– Pugh (CTP) B and C status. A significantly low prothrombin time (PT) and international normalized ratio (INR) were detected among PVT cases. Platelets were significantly lower in PVT group; however, 5 % PVT cases with platelet counts of >500×10/L were identified. The mean values of natural anticoagulants were well below the normal range, and most of these cases had low anticoagulant levels including the following: antithrombin III (83 %), protein C (85.7 %), and protein S (58.6 %). Protein C levels were also significantly lower in PVT group. Factor VIII levels for cirrhotic with PVT were found to be elevated in 88 % cases and median value was 210.6 % with a range of 90.5 % to 413.4 % (normal range, 70 % to 150 %). Prothrombotic mutational polymorphism details were available in limited number of cases. Mutational polymorphism was detected in methyl tetrahydrofolate reductase (MTHFR) in 11/24 (45.8 %) and Factor V Leiden mutation (FVL) in 1/24 (4.1 %). JAK2 V617 (0/25) and prothrombin mutation (PTM) (0/26) were not detected. CTP and model for end-stage liver diseases (MELD) for PVT cases were not significantly different from the non-PVT cases (results are summarized in Table 1). The prevalence of PVT was found to be 0.6 % to 16 % in different studies; this variation may be due to different patient groups, disease characteristics, and mode of diagnosis, and many of the PVT cases are usually asymptomatic [1]. A significantly low PT and INR have been noted in the PVT group which suggests tilting of hemostatic balance toward prothrombotic state [1]. The classical Virchow’s triad of venous stasis, endothelial injury, and hypercoagulability has been extended to the pathogenesis of PVT in cirrhosis. Hypercoagulability in these patients has been attributed to the reduction of natural anticoagulants and increased C. Bihari (*) : P. Saxena Department of Hematology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, Delhi 110 070, India e-mail: drcbsharma@gmail.com