Robin Ireland

Guidelines for the diagnosis and management of adult aplastic anaemia

Sally B. Killick (Writing Group Chair), Nick Bown, Jamie Cavenagh, Inderjeet Dokal, Theodora Foukaneli, Peter Hillmen, Robin Ireland, Austin Kulasekararaj, Ghulam Mufti, John A Snowden, Sujith Samarasinghe, Anna Wood (BCSH Task Force Member), Judith C.W. Marsh on behalf of the British Society for Standards in Haematology. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Northern Genetics Service, Newcastle upon Tyne, St Bartholomew’s Hospital, Barts Health NHS Trust, London, Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, Addenbrooks Hospital, University of Cambridge, Cambridge, Leeds Teaching Hospitals, Leeds, Kings College Hospital NHS Foundation Trust, London, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Great Ormond Street Hospital for Children NHS Foundation Trust, London, West Hertfordshire NHS Trust, Watford.

Pulmonary tuberculosis complicated by haemophagocytic syndrome and rifampicin-induced tubulointerstitial nephritis

The benign, or infection-associated, haemophagocytic syndrome (IAHS) is a rare bone marrow disorder of macrophage cell proliferation diagnosed most commonly in immune compromised patients who develop herpes type viral infections (Risdall et al. 1979). It has also been reported in association with bacterial infections and rarely with mycobacterial infection (Chandra et al. 1975; Mamoharon & Catovsky 1981; Bultmann et al. 1982). Despite being potentially reversible it may produce a life-threatening pancytopenia (Seligman et al. 1972). We report a further case of the haemophagocytic syndrome associated with Mycobacterium tuberculosis in which thrombocytopenia was the predominant feature. There were unusual features in the clinical presentation and the patients treatment and recovery were subsequently complicated by rifampicin-induced renal failure.

Immunophenotypic analysis of erythroid dysplasia in myelodysplastic syndromes. A report from the IMDSFlow working group

Current recommendations for diagnosing myelodysplastic syndromes endorse flow cytometry as an informative tool. Most flow cytometry protocols focus on the analysis of progenitor cells and the evaluation of the maturing myelomonocytic lineage. However, one of the most frequently observed features of myelodysplastic syndromes is anemia, which may be associated with dyserythropoiesis. Therefore, analysis of changes in flow cytometry features of nucleated erythroid cells may complement current flow cytometry tools. The multicenter study within the IMDSFlow Working Group, reported herein, focused on defining flow cytometry parameters that enable discrimination of dyserythropoiesis associated with myelodysplastic syndromes from non-clonal cytopenias. Data from a learning cohort were compared between myelodysplasia and controls, and results were validated in a separate cohort. The learning cohort comprised 245 myelodysplasia cases, 290 pathological, and 142 normal controls; the validation cohort comprised 129 myelodysplasia cases, 153 pathological, and 49 normal controls. Multivariate logistic regression analysis performed in the learning cohort revealed that analysis of expression of CD36 and CD71 (expressed as coefficient of variation), in combination with CD71 fluorescence intensity and the percentage of CD117+ erythroid progenitors provided the best discrimination between myelodysplastic syndromes and non-clonal cytopenias (specificity 90%; 95% confidence interval: 84–94%). The high specificity of this marker set was confirmed in the validation cohort (92%; 95% confidence interval: 86–97%). This erythroid flow cytometry marker combination may improve the evaluation of cytopenic cases with suspected myelodysplasia, particularly when combined with flow cytometry assessment of the myelomonocytic lineage.

Primary effusion lymphoma in an HIV-negative man

A 55-year-old Caucasian male with cryptogenic cirrhosis of the liver and refractory ascites was referred for consideration of a liver transplant. There was no previous history of opportunistic infections and serological screening for human immunodeficiency virus (HIV), hepatitis B and hepatitis C was negative. Immunoglobulin levels were normal and autoantibodies and tumour markers were not detected. A computed tomography (CT) scan showed hepatomegaly with irregular hepatic architecture, established varices and marked portal enteropathy with splenomegaly and ascites but no nodal enlargement. Ascitic fluid cytology showed abundant atypical cells with hyperchromatic nuclei and many apoptotic cells (top left), macrophages and mesothelial cells. Immunophenotyping was undertaken on ascitic and pleural fluid and cells typed as mature T cells with no excess of blasts or clonally-restricted B cells. These cells expressed CD45, HLA-DR, CD38 and CD7 but no other B, T or myeloid markers. Immunohistochemistry of these cells failed because of background staining and poor preservation of cellular architecture. DNA was extracted from the ascitic fluid and gene rearrangement studies by multiplex polymerase chain reaction confirmed a monoclonal IGH@ rearrangement with a polyclonal T-cell receptor pattern. Peritoneal biopsy proved inconclusive but immunohistochemical analysis of a subsequent ascitic fluid sample showed pleomorphic lymphoid cells with plasmacytoid features, positive for CD38 (top right), CD30, epithelial membrane antigen (EMA) and MUM1/IRF4. There was strong nuclear expression of human herpesvirus 8 (HHV8) latent protein (LANA; bottom left) and Epstein–Barr virus-encoded RNA (EBER; bottom right) by in situ hybridization. A diagnosis of primary effusion lymphoma (PEL) was made. PEL is a rare large B-cell neoplasm and, in the absence of immune suppression, is particularly unusual. Confirmation of B-cell clonality by immunophenotyping may be difficult as PEL usually lacks cytoplasmic and surface immunoglobulin. CD45, HLA-DR, CD30, CD38, Vs38c, CD138 and EMA are often demonstrable. Pan-B markers may not be expressed and there may be aberrant expression of T-cell markers, making it difficult to assign lineage. Immunoglobulin genes are usually clonally rearranged, as in this case. The nuclei of the neoplastic cells are universally positive for HHV8 LANA and this is useful in establishing a diagnosis. If the cytological features are poorly preserved, histochemical staining may fail. The patient was treated with dose-attenuated cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) chemotherapy, but had a poor response and died within 6 months of presentation. Clinical outcomes remain poor for this disease although there are occasional reports of a response to immunomodulatory agents with chemotherapy.

Leukaemia cutis with chronic myelomonocytic leukaemia.

A 95-year-old woman presented with a 4-week history of lethargy, and gradual onset of a florid eruption of asymptomatic red cutaneous nodules on her trunk and legs (top). A full blood count showed: haemoglobin concentration 100 g/l, white blood cell count 59 · 10/l, platelet count 75 · 10/l, neutrophils 40 · 10/l, monocytes 15 · 10/l, basophils 0AE4 · 10/l. The blood film (bottom) was consistent with a diagnosis of chronic myelomonocytic leukaemia. A bone marrow aspirate showed hypercellular particles and trails with a predominant population of monocytes and 11% blast cells, consistent with chronic myelomonocytic leukaemia 2. Immunophenotyping identified a large population of relatively mature myelomonocytic cells: CD13+, CD33+, MPO+, CD14+, lysozyme+. Cytogenetic analysis showed trisomy 8. A skin punch biopsy showed medium to large cells with pleomorphic indented nuclei and abundant granular cytoplasm, consistent with leukaemia cutis. She was commenced on hydroxycarbamide 1 g orally daily but failed to respond. Her white cell count increased within 7 d to 110 · 10/l, with an increase in monocytes and promonocytes but not blast cells (blast cells plus monocytes were <20%). As she was clinically deteriorating transfer for palliative care was initiated. There are limited reports of leukaemia cutis in chronic myelomonocytic leukaemia, usually associated with a more aggressive disease and blastic transformation. There have also been cases, such as this, where the nodular rash is the initial presentation of chronic myelomonocytic leukaemia.

British Committee for Standards in Haematology guidelines for aplastic anemia: Single centre retrospective review finds no compelling evidence for the recommended higher platelet count threshold of 20 × 109/L - RESPONSE to Yan et al

Foukaneli, T., Hill, A., Hillmen, P., Ireland, P., Kulasekararaj, A., Mufti, G., Snowden, J.A., Samarasinghe, S., Wood, A., Marsh, J.C. & British Society for Standards in Haematology. (2016) Guidelines for the diagnosis and management of adult aplastic anaemia patients. British Journal of Haematology, 172, 187–207. Sagmeister, M., Oec, L. & Gmur, J. (1999) A restrictive platelet transfusion policy allowing long-term support of outpatients with severe aplastic anemia. Blood, 93, 3124–3126. Stanworth, S.J., Estcourt, L.J., Powter, G., Kahan, B.C., Dyer, C., Choo, L., Bakrania, L., Llewelyn, C., Littlewood, T., Soutar, R., Norfolk, D., Copplestone, A., Smith, N., Kerr, P., Jones, G., Raj, K., Westerman, D.A., Szer, J., Jackson, N., Bardy, P.G., Plews, D., Lyons, S., Bielby, L., Wood, E.M., Murphy, M.F. & TOPPS Investigators. (2013) A no-prophylaxis platelet-transfusion strategy for hematologic cancers. New England Journal of Medicine, 368, 1771–1780. Wandt, H., Schaefe-Eckart, K., Wendelin, K., Pilz, B., Wilhelm, M., Thalheimer, M., Mahlknecht, U., Ho, A., Schaich, M., Kramer, M., Kaufmann, M., Leimer, L., Schwerdtfeger, R., Conradi, R., Dolken, G., Klenner, A., Hanel, M., Herbst, R., Junghanss, C., Ehninger, G. & Study Alliance Leukemia. (2012) Therapeutic platelet transfusion versus routine prophylactic transfusion in patients with haematological malignancies: an open-labl, multicenter, randomized study. Lancet, 380, 1309–1316. Weber, M., Kroger, N., Langer, F., Hansen, A., Zabelina, T., Eifrig, B., Hossfeld, D.K. & Zander, A.R. (2003) Non-overt disseminated intravascular coagulation in patients during treatment with antithymocyte globulin for unrelated allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplantation, 31, 817–822.

Mott cells in CD20-positive myeloma.

A 63-year-old woman presented with a 2-month history of left thigh pain, no ‘B’ symptoms, no significant past medical illness and normal clinical examination. Her full blood count was normal. The erythrocyte sedimentation rate was elevated at 115 mm/h, total globulins were elevated but the rest of the serum biochemistry was normal. Serum immunoglobulin electrophoresis with immunofixation showed an IgGk paraprotein at a concentration of 22 g/l and elevated IgM at 10Æ4 g/l. Urinary Bence–Jones protein was absent and the serum free light chain ratio was normal. A skeletal survey was normal. A bone marrow aspirate showed a lymphoplasmacytic infiltrate of 30% and cells with large intracytoplasmic inclusions (top right) often in doublets or triplets with the nuclei pushed to the rim of the cell. A bone marrow trephine biopsy showed extensive infiltration by lymphoplasmacytic cells and huge plasma cells (top left). Plasma cells with large Russell body inclusions occupied both paratrabecular and intertrabecular areas and stained positively for CD20, nuclear Cyclin D1 and lambda light chain (bottom right). Flow cytometry initially failed to identify light chain restricted plasma cells. It was recognised that the large sized plasma cells were outside the conventional lymphoid/plasma cell gate. Repeat ungated flow cytometric analysis demonstrated CD45 cytoplasmic kappa+ = 11%; CD45 cytoplasmic lambda+ = 17%; CD19 cytoplasmic kappa+ = 12%; CD19 cytoplasmic lambda+ = 14% and a reversed kappa: lambda ratio of 11:17. Fluorescence in situ hybridisation on separated plasma cells (CD138) was carried out using the IGH/CCND1 dual fusion dual colour probe (Vysis, Berkshire, UK). Of 100 cells analysed, 78 showed a pattern of one fusion signal, which indicated the presence of the t(11;14) translocation (bottom left). The combined clinicopathologic features confirmed the diagnosis of myeloma. The patient remains asymptomatic and no therapeutic options have yet been offered. This case demonstrates an infrequent but impressive morphological appearance of plasma cells with huge intracytoplasmic immunoglobulin inclusions (Mott cells). The presence of t(11;14) is most commonly associated with mantle cell lymphoma but is found in up to 20% of patients with myeloma, using interphase cytogenetics. Lymphoplasmacytoid appearances, high CD20 expression and t(11;14) has been described as a sub-entity in myeloma. This case demonstrates the importance of always reviewing the flow cytometry data in conjunction with morphology.