Vimarsh Raina

Speed of sample transportation by a pneumatic tube system can influence the degree of hemolysis

Abstract Background: The objective of the study was to find the incidence of hemolysis in samples transported through a pneumatic tube system (PTS) at different speeds. Methods: This prospective observational study was done in three phases: “short distance and high speed (115 m at 3 m/s)”, “long distance and high speed (225 m at 3 m/s)” and “short distance and slow speed (115 at 2 m/s)”. Fifty-two, 215 and 45 serum tube pairs, respectively, were evaluated in these three phases. A set of tubes was sent by PTS while the other was hand-carried. Samples were analyzed for supernatant hemoglobin (Hb), potassium (K+) and lactate dehydrogenase (LD). Results: Mean transit time of samples through the PTS was much shorter as compared to human courier in all three phases. LD was elevated in PTS arm in the “short distance and high speed” phase and in the “long distance and high speed” phase, all three indices of hemolysis – Hb, K+ and LD – showed elevation in the PTS arm. However, at “short distance and slow speed” phase, there was no hemolysis in the PTS arm. Conclusions: Hospitals should validate their PTS before use and, by altering speed of sample transportation, hemolysis may be obliterated.

Establishing biological reference intervals for novel platelet parameters (immature platelet fraction, high immature platelet fraction, platelet distribution width, platelet large cell ratio, platelet-X, plateletcrit, and platelet distribution width) and their correlations among each other.

AIMS This study aims to establish biological reference interval for novel platelet parameters. SETTINGS AND DESIGN A total of 945 healthy individuals, age ranges from 18 to 64 years (881 males and 64 females) coming for voluntary blood donation from June to August 2012 (3 months) were enrolled after exclusion of rejection criteria. MATERIALS AND METHODS The samples were assayed by running in complete blood count + reticulocyte mode on the Sysmex XE-2100 hematology analyzer and the reference interval for the population was calculated using Clinical and Laboratory Standards Institute guidelines. STATISTICAL ANALYSIS USED Tests were performed using SPSS (Statistical Product and Service Solutions, developed by IBM corporation), version 13. Student t test and pearsons correlation analysis were also used. RESULTS The normal range for various parameters was platelet count: 150-520 × 10(3)/cu mm, immature platelet fraction (IPF): 0.3-8.7%, platelet distribution width (PDW): 8.3-25.0 fL, mean platelet volume (MPV): 8.6-15.5 fL, plateletcrit (PCT): 0.15-0.62%, high immature platelet fraction (H-IPF): 0.1-2.7%, platelet large cell ratio (P-LCR): 11.9-66.9% and platelet-X (PLT-X) (ch): 11.0-22.0. Negative correlation was observed between platelet count (r = -0.468 to r = -0.531; P < 0.001) and PCT (r = -0.080 to r = -0.235; P < 0.05 to P < 0.001) with IPF, PDW, MPV, H-IPF, P-LCR, and platelet-X. IPF/H-IPF showed a positive correlation among them and also with PDW, MPV, P-LCR, platelet-X (r = +0.662 to r = +0.925; P < 0.001). CONCLUSIONS These novel platelet parameters offer newer avenues in research and clinical use. Establishing biological reference interval for different platelet parameters would help determine true high and low values and help guide treatment decisions.

Cascade plasmapheresis (CP) as a preconditioning regime in ABO-incompatible live related donor liver transplants (ABOi-LDLT)

BackgroundABO-incompatible live donor liver transplant (ABOi-LDLT) is being widely done to bridge the gap of demand and supply of organs. Different desensitization regimes are being used to reduce titer of blood group antibodies for successful transplant and accommodation of graft. The authors used cascade plasmapheresis (CP) to bring down titer of naturally occurring blood group antibody to 16 or lower.Material and methodsFour recipients of ABOi-LDLT were of blood groups O, O, B, and B while donors were of blood groups B, A, AB, and AB, respectively. Desensitization protocol included immunosuppressive drugs and plasmapheresis. CP consisted of separating patient’s plasma as the first step and passing it through pore size based filter column as the second step. The first step was performed using disposable kit (PL1, Fresenius Kabi, Germany) with minor modification on apheresis equipment COM.TEC (Fresenius Kabi, Germany). Pore size based filter column used was 2A column (Evaflux, Kawasumi Laboratories, Japan). Blood group antibody titer (immunoglobulin G (IgG)) was done by column agglutination technology (Ortho-Clinical Diagnostics).ResultsCases 1, 2, 3, and 4 with pre-CP titer of 1,024, 512, 32, and 64 required four, three, one, and one CP procedures, respectively. No signs of antibody-mediated rejection were exhibited on histopathological evaluation by any of the patients. Successful organ engraftment occurred as documented by post-operative liver function tests and liver biopsy.ConclusionCascade plasmapheresis offers a cost-effective and efficient way to decrease blood group antibody titer and helps in successful transplant.

Extraoral Plasmablastic Lymphoma Detected Using Ascitic Fluid Cytology and Flow Cytometry: A Case Report with a Review of the Literature

Background: Plasmablastic lymphoma (PL) is a relatively new category of lymphoma, which has been considered to be found predominantly in the oral cavity and has a strong association with HIV. Case: We report a case of extraoral/mesenteric PL detected using cytological examination of ascitic fluid assisted by flow cytometric (FC) analysis. The cells were positive for CD38, CD138, CD10, CD45 and CD56 and negative for CD3, CD19, CD20 and CD79a, with cytoplasmic lambda light-chain restriction. We also reviewed 67 cases of extraoral PL from the available literature and found them to be less often associated with HIV (than oral PL), occurring mostly in males aged 30-60 years, with the most common extraoral site being the anorectal region. Conclusion: A high index of suspicion at the level of the cytopathologist is imperative for identifying lymphoma cells in a body fluid. A rare entity like PL can also be diagnosed on cytology assisted by ancillary techniques (like FC), without the need for a biopsy. We also suggest that the minimum panel to diagnose PLs should include CD138, MUM-1, Ki-67, ALK-1, CD3, immunoglobulin light-chains, CD20 and PAX5.

Increasing Role of Cytogenetics in Pediatric Practice

Karyotyping was done in 100 children suspected of having chromosomal abnormalities of genetically uncertain syndromes, multiple congenital anomalies, short stature, dysmorphic features, unclassified mental retardation, and Down syndrome. A total of 56 patients had an abnormal karyotype: ring chromosome of 13 was seen in 1 patient (1.78%), and trisomy 21 was seen in 29 patients (51.78%) who were diagnosed as Down syndrome patients. Among them, 9 were male patients (31.03%) (47,XY+21) and 18 were female patients (47,XX+21) (62.06%); 2 patients showed 47,XY+21/46,XY (mosaicism) (6.89%). Chromosomal rearrangements involving chromosome numbers 13, 14, and 21 were seen in three patients. Among them, one patient had t(13;21) [45,XX,t(13;21)] and two patients had 45,XY,t(14;21). Trisomy 22 was seen in three patients (5.3%), marker chromosome was seen in two patients (3.57%), 46,XY,16qh variant was seen in one patient (1.78%), 46,XX,der(2) was seen in one patient (1.78%), 46,XX,14ps+ was seen in two patients (3.57%), and 46,XY,r(18) was seen in three patients (5.37%). Apart from this, 11 patients (19.64%) had sex chromosome aberrations: 45,XO was seen in 3 patients (27.7%), 4 patients were mosaic for Turner syndrome (45,XO/46,XX) (36.36%), and 4 patients had 46,Xi(Xp) (36.36%), and the remaining 44 patients had normal karyotypes. All of them showed phenotypic-cytogenetic heterogeneity. These findings suggest that cytogenetic analysis is useful in the investigation of children with genetic disorders of unknown origin to confirm clinical diagnosis and to allow for proper genetic counseling.

Expression of CD71 by flow cytometry in acute leukemias: More often seen in acute myeloid leukemia

Background: CD71 is a marker that has been usually used for identifying dysplasia in the erythroid series. We have tried to evaluate the expression of CD71 in various types of acute leukemias. Materials and Methods: We studied 48 patients of acute leukemia, of which 25 were acute myeloid leukemia (AML), 13 were precursor B-acute lymphoblastic leukemia (B-ALL), 8 were T-ALL, and 2 were mixed phenotype acute leukemia (T/myeloid) as per the WHO classification. Results: We found that the expression of CD71 was most prevalent in AMLs (84%), followed by T-ALL (50%) and least in B-ALL (30%). Conclusion: This finding clearly shows the higher expression of CD71 in AMLs compared to other common type of leukemias, such as B- and T-ALL. We suggest that the high expression of CD71 in AMLs could be used as a diagnostic marker and may also be used for minimal residual disease analysis after further studies in posttreatment scenario. This study is the first of its kind in the South Asian population.

Disseminated Histoplasmosis in an Immunocompetent Host Presenting as Pancytopenia with Bilateral Adrenal Masses

A 44-year-old male presented with fever, progressive weight loss, and anorexia for 6 months. The laboratory results showed deranged renal function tests. Serum adrenocorticotropic hormone was high at 252 pg/mL (normal limit: <46 pg/mL), suggestive of primary adrenal insufficiency. Serum free light chains were elevated, kappa at 87.97 mg/L (reference range: 3.30-19.40 mg/L) and lambda at 91.77 mg/L (reference range: 5.71-26.30). Ultrasonography of the abdomen showed hepatosplenomegaly with space-occupying lesions in bilateral suprarenal regions, while endoscopy ultrasound-guided fine-needle aspiration showed necrotizing granulomatous inflammation. Work-up for tuberculosis and human immunodeficiency virus was negative. The hematological parameters showed pancytopenia. The bone marrow aspiration revealed round to oval organisms with crescent-shaped eccentric nuclei both extracellularly and intracellularly, inside the macrophages and osteoclastic giant cells (Figure 1A). Bone marrow biopsy showed the presence of intracellular and extracellular oval capsulated globose organisms spread throughout the marrow spaces (Figure 1B). Periodic acid-Schiff (PAS) staining showed these organisms as bright eosinophilic structures with clear halos around them (Figure 1C). Gomori methenamine silver (GMS) staining showed clusters of fungal yeasts, morphologically compatible with Histoplasma capsulatum (Figure 1D). The patient was started with intravenous amphotericin B followed by oral itraconazole. His condition improved with recovery of counts and improvement of renal function; he is currently doing well. Informed consent was obtained. Figure 1 A) Bone marrow aspirate showing numerous Histoplasma capsulatum inside the osteoclastic giant cell and macrophage (inset) (Giemsa, 100x), B) bone marrow biopsy showing Histoplasma (H&E, 100x), C) PAS staining showed yeast-like cells with bright ... Histoplasmosis is a fungal infectious disease caused by inhalation of spores of Histoplasma capsulatum. It may present as a self-limiting form or progressive disseminated disease. Disseminated histoplasmosis may affect almost all systems, including the reticuloendothelial system, lungs, gastrointestinal tract, renal tract, central nervous system, visual system, bone marrow, and adrenal glands [1]. Histoplasmosis presenting as a bilateral adrenal mass in an immunocompetent patient is rare. A high index of suspicion is required for the diagnosis of disseminated histoplasmosis in a patient with unexplained fever, as it may mimic other chronic illnesses or a neoplasm. The differential diagnoses that should be considered are tuberculosis, sarcoidosis, adrenal hemorrhage, metastatic carcinoma, and lymphoma. Despite extensive imaging, positron emission tomography scanning, and fine-needle aspiration biopsy, a definite diagnosis may not be reached [2]. Bone marrow examination is a useful diagnostic test to establish a diagnosis of disseminated histoplasmosis. In our case, a middle-aged immunocompetent patient presented with nonspecific symptoms and bilateral adrenal mass with insufficiency, the diagnosis of which was only possible with bone marrow examination. Conflict of Interest Statement The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included.

Prompt diagnosis and management of Epstein-Barr virus-associated post-transplant lymphoproliferative disorder and hemophagocytosis: A dreaded complication in a post-liver transplant child.

EBV‐associated PTLD is increasingly recognized as an important cause of morbidity and mortality in both solid organ and hematopoietic stem cell transplant recipients. Mortality rates due to PTLD and virus‐induced HLH are reported to be quite high. We report a case of EBV‐associated PTLD and HLH in a child after liver transplantation who was successfully managed due to timely intervention. This case highlights that measurement of EBV load by quantitative polymerase chain reaction assays is an important aid in the surveillance and diagnosis of PTLD and early detection of EBV‐induced PTLD, and aggressive treatment with rituximab is a key to survival in patients who have undergone liver transplantation.

Picking up myelodysplastic syndromes and megaloblastic anemias on peripheral blood: use of NEUT-X and NEUT-Y in guiding smear reviews.

Sir, Diagnosing myelodysplastic syndrome (MDS) poses a peculiar challenge as they mainly present as cytopenia(s), which can occur due to a myriad of hematological and nonhematological factors. On a routine complete blood count (CBC) flagged for cytopenia(s), evaluating neutrophilic dysplasia on light microscopy suffers from a multitude of problems such as pH of the stain, quality of staining, time gap in preparation of smear, interobserver variation, and morphological alterations encountered due to secondary causes such as drugs, nutritional, toxin. There is no single parameter or test available to diagnose MDS, and so an extensive workup is required. Apart from battery of tests required, there are other morphologic overlaps present which may further complicate the problem such as megaloblastic anemia (MA) and few subtypes of myeloproliferative neoplasm (MPN). MA cases can present with pancytopenic blood picture with dyspoiesis noted in one or more lineages, similar to that noted in early MDS patients, making the early diagnosis of MDS cases difficult. The macrocytosis in MA can be obscured by concomitant disorders that in themselves cause microcytosis although the leukocyte abnormalities are preserved, resulting in masked MA [1]. Another differential of macrocytosis is MDS, which can be suspected by the presence of hypogranular neutrophils and monocytosis. Thus, in such cases, peripheral smear alone is not of much help, and further invasive tests such as bone marrow examination and cytogenetics needs to be carried out. MPN, on the other hand, usually can be differentiated from MDS and MA cases morphologically, however, with few overlaps, as in cases of primary myelofibrosis in fibrotic phase, MDS/MPN group which includes chronic myelomonocytic leukemia (CMML), atypical CML, juvenile myelomonocytic leukemia, and MDS/MPNU. They may have some clinical, laboratory, or morphologic findings at the time of initial presentation that support a diagnosis of MDS more than MPN. One or more of the other lineages may exhibit ineffective proliferation so that such cases may present with cytopenia(s) as well [2]. Such cases can present as a challenge and need to be differentiated from early cases of MDS. Neutrophil dysplasia is a feature seen in MDS as well as in CMML, thus making it difficult for NEUT-X and NEUT-Y values to differentiate them [3]. As MA is also associated with structural abnormalities in RBC and WBC as seen in MDS, they were also included in the study to evaluate its possible role in NEUT-X and NEUT-Y We evaluated the role of parameters NEUT-X and NEUT-Y (Sysmex XE-2100; Sysmex corporation, Kobe, Japan) in detecting neutrophil dysplasia in suspected MDS, MA, and MPN cases. NEUT-X and NEUT-Y are the latest parameters for neutrophil structural and maturation, NEUT-X is the direct measurement of side scatter diffraction, corresponding to channel number, and is representative of the internal structure of the neutrophils. It correlates with hypogranularity of neutrophils and when taken into consideration with anemia is suggestive of an underlying MDS. NEUT-Y is the direct measurement of the fluorescence intensity [1]. This study included four groups: control, MDS, MPN, and MA group with the aim to compare the NEUT-X and NEUT-Y values among each group as well as to record whether these two parameters have any relationship between each other in individual groups. The control group includes 66 cases which came for routine check up with no complaints or comorbidities, 30 cases diagnosed as MDS, 56 cases of MPN, and 16 cases of MA. The cases were collected over a period of one and a half years (March 2012–August 2013). Inclusion criteria in the study were as follows: • All the cases were diagnosed using multiparametric approach

Aberrant NK cell associated marker (CD56 and CD57) expression in chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is one of the commonest leukemias that has been reported extensively throughout the literature. The characteristic phenotype includes co‐expression of CD5 and CD23, along with dim expression of light chain and CD22/CD79b, with lack of FMC7. The immunophenotypic scoring system given by Matutes has been used to differentiate CLL from non‐CLL chronic lymphoproliferative disorders. Various aberrancies have been described in CLL cases, including abnormal (dim or bright) expression of B cell markers and lineage infidel T cell, myelomonocytic, or rarely Natural killer (NK) cells markers. However, the aberrant co‐expression of CD56 and CD57 has not yet been reported.