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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 6 | Issue 2
Page Nos. 29-97

Online since Monday, October 9, 2017

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EDITORIAL  

Is it obligatory to interfere warfarin therapy during dental procedure? p. 29
Ujwala Rohan Newadkar
DOI:10.4103/ijh.ijh_13_17  
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REVIEW ARTICLE Top

Inherited thrombophilia: Diagnostic approach p. 31
Rahem Mahdy Rahem, Rehab Abdul Sahb Al-Waeli
DOI:10.4103/ijh.ijh_26_17  
Hemostatic abnormalities include both bleeding and thrombosis disorders. Adherence to most common guidelines for the diagnosis of thrombophilia is recommended especially in some developing countries. High level of orientation to thrombophilic disorders needs wide spectrum of knowledge about the causes, primary or secondary, investigations to most common risk factors, selecting candidates to investigations, in addition to covering the possibility of multifactorial background of disease. Limited data are available that focus on the thrombophilic disorders with imperfect diagnostic cooperation between clinical and laboratory aspects to reach the full picture of these hemostatic abnormalities. In this short review of literature, we considered the most important publications that assessed the inherited thrombophilia at levels of presentation, diagnosis, and management with focus on the practical side. The aim of this review is to summarize the most important aspects of the thrombophilia presentation, inherited causes, indications for testing, and investigations required for thrombophilic patients.
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ORIGINAL ARTICLES Top

Plateletpheresis adverse events in relation to donor and plateletpheresis session profile p. 38
Rajni Bassi, Kusum K Thakur, Kanchan Bhardwaj
DOI:10.4103/ijh.ijh_14_17  
Introduction: Increasing demand of platelet transfusions for patients has led to a trend in the increased use of automated blood collections. These share many of the same reactions and injuries seen with pooled platelets obtained from whole blood donation but also have unique complications. Aims And Objectives: To study the adverse events (AEs) of plateletpheresis procedure and their relationship with donor and plateletpheresis procedure session profiles. Materials And Methods: This is a retrospective observational study conducted from January 2016 to December 2016. A two-hundred and thirteen (213) plateletpheresis procedures were performed after taking informed and written consent from the donor. All the donors were male and selected according to the guidelines laid down by Director General of Health Services. The AEs were classified into donor related, kit/equipment related and technique related. Results: A total of 13 AEs were noted; of which, 8 (61.53 %) events were associated with donors, 3 (23.07 %) were owed to fault in kit/equipment and 2 (15.384 %) were due to technical aberrations. Donor related AEs included vascular injuries [n = 3 (1.40%)], vasovagal reactions [n = 2 (0.938%)] and perioral tingling sensation [n = 3 (1.40%)]. Technique related AEs [n = 2 (0.938%)] and kit/equipment related AEs [n = 3 (1.40%)] were due to faulty technique and defective kits respectively. Conclusion: Apheresis donations performed on cell separators are safe. Meticulous donor vigilance, superior technical personnel training and experienced transfusion medicine specialist's supervision will make donor's experience more pleasant.
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Is there a need to phase out replacement blood donors by voluntary blood donors in hospital based blood transfusion services? p. 43
Praneeta Jaswant Singh, Hitesh Bhatt
DOI:10.4103/ijh.ijh_15_17  
Background: Providing safe blood for transfusion is a responsibility of every blood bank. Screening for transfusion-transmissible infections (TTI) is one of the ways to ensure safety of blood and its products. Prevalence of TTI varies in different countries. It is low in developed countries whereas it is higher in developing countries. Aims And Objectives: This study was carried out to access percentage of blood collected from the first-time voluntary blood donors (VBD) and family/replacement donors (RD) and to access safety of RD by comparing seroprevalence of TTI among voluntary and RD. Materials And Methods: Over 1 year, donors were studied for the type of donation (voluntary or replacement) made at our blood bank. All donors were screened for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis, and malaria. Comparison of the prevalence of TTI among voluntary and RD was done by entering data into Microsoft Excel 2007 software and using Chi-square tests. Results: Out of total 850 first-time donors, voluntary donors were 109 (12.82%) and RD were 741 (87.18%). Overall seroprevalence of HIV, HBV, HCV, syphilis, and malaria was 0, 23 (2.70%), 12 (1.41%), 7 (0.82%), and 0, respectively. Prevalence of TTI among voluntary donors was very low. All donors were seronegative HIV and malaria. Prevalence of HBV, HCV, and syphilis was higher in RD. Conclusion: Data highlight that RD contributed major source of blood supply in hospital-based blood transfusion services and the prevalence of TTI was higher among them in comparison to first-time voluntary donors. Thus, efforts should be made to increase the number of VBD.
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The frequency of aberrant lymphoid antigens expression in 202 Iraqi patients with de novo acute myeloid leukemia p. 49
Wafaa Mohammed Al-Anizi, Mohammed Abdul Rassoul Al-Mashta
DOI:10.4103/ijh.ijh_17_17  
Background: Immunophenotyping improves both accuracy and reproducibility of acute leukemia classification and is considered, particularly useful for identifying acute myeloid leukemia (AML) with lymphoid marker expression. The incidence of the aberrant phenotypes in AML is still controversial; incidences as high as 88% have been reported. Objectives: To evaluate the occurrence of aberrant lymphoid phenotypes and to correlate their presence with various French-American-British classification (FAB subtypes), 202 cases of newly diagnosed AML were analyzed for lymphoid markers CD1a, CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD19, CD20, and CD79a. Materials And Methods: Whole blood or bone marrow aspirate of 202 patients with de novo AML was collected in ethylenediaminetetraacetic acid tube and analyzed by flow cytometry using a large panel of fluorochrome-labeled monoclonal antibodies. Identification of blast cells was performed using forward scatter versus side scatter (SSC) parameters and CD45 intensity versus SSC dot plots. An antigen was considered positively expressed when at least 20% of the gated cells expressed that antigen. Results: Eighty-five patients (42%) with de novo AML expressed lymphoid-associated antigens. All AML subtypes demonstrated lymphoid-associated antigens except M7. T-cell aberrancy was the most common comprising 32.2% of the total aberrancy. The most frequently lymphoid antigen aberrantly expressed was CD7 (25.7%), followed by CD4 (22.4%) and CD19 (7.9%). Conclusion: A large number of AML cases showed aberrant lymphoid phenotypes. These lymphoid phenotypes might be associated with different leukemia subtypes. T-cell markers are more common than B-cell markers. CD7 was the most common lymphoid marker aberrantly expressed in AML.
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Expressions of immunoglobulin M and immunoglobulin D heavy chain in B-chronic lymphocytic leukemia and their correlation with CD38 expression p. 55
Ghid Nahd Abdul Muhssen, Hind Shaker AL-Mamoori, Majid Hameed Ahmed
DOI:10.4103/ijh.ijh_18_17  
Background: B-chronic lymphocytic leukemia (CLL) is a monoclonal malignancy characterized by an accumulation of small mature-looking B lymphocytes in the blood, bone marrow, and other tissues. It is typically characterized by CD5+, CD23+, CD22−, and CD79b−, with weak expression of surface immunoglobulin (Ig). Objectives: The aim of the study was to assess the expression of IgM and IgD heavy chain by flow cytometry in untreated newly diagnosed B-cell CLL and correlate the heavy chain isotopes expression with CD38 expression. Materials And Methods: A prospective cross-sectional study was conducted on thirty patients with new diagnosis of B-CLL. The study was conducted at nursing home teaching laboratory in medical city hospital in Baghdad for the period from November 2016 to March 2017. Five milliliter of venous blood in ethylenediaminetetraacetic acid was collected from thirty patients for detection of expression of IgM, IgD, and CD38 by flow cytometry. The patients were randomly selected regarding the age, sex, and stage of the disease. Results: The mean age of all included patients was (61.73 ± 6.92) with more disease predominant in male than female. The most common presenting feature of the patients was lymphadenopathy found in 16 patients (43%). Regarding staging system, six (20%) patients were in with Binet Stage C and five patients (17%) were in modified Rai Stage 4. CD38 and IgM expression showed a significant relation to hemoglobin and platelets (P < 0.05). There was a significant positive correlation between IgM and CD38 while it was negative between IgD and CD38. Conclusions: The current study showed that the expression of CD38 had a significant correlation with IgM expression as well as there was positive correlation with the stage of the disease which may point out to inferior prognosis for those patients with CLL.
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The impact of Helicobacter pylori infection on iron deficiency anemia in pregnancy p. 60
Miami Abdul Hassan Ali, Eaman Marouf Muhammad, Ban Hadi Hameed, Hala Hashim Hasoobe
DOI:10.4103/ijh.ijh_19_17  
Background: Anemia in pregnancy has different adverse effects on pregnancy outcome, and iron deficiency anemia (IDA) is the most common cause of anemia during pregnancy. Recent studies have suggested an association between Helicobacter pylori and IDA during pregnancy. Objective: The aim of this study was to evaluate the impact of H. pylori infection on IDA in pregnancy. Patients And Methods: This was a case–control study carried out at Al-Yarmouk Teaching Hospital between January 1 and August 1, 2016. The study included 100 pregnant women divided into two groups: control group with normal hemoglobin (Hb) and a study group with IDA. Both groups were subjected to H. Pylori test. Results: The mean Hb level of the patients was 9.4 ± 0.8 g/dl. Fifty cases had an Hb level <11 g/dl and fifty cases with Hb ≥11 gm/dl. Thirty-two percentage of the study group were seropositive for anti-H. pylori IgA compared to 4% of the control group, and this difference was statistically significant at P < 0.001. Conclusion: There was a positive correlation between IDA during pregnancy and H. pylori-positive cases.
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Cytokines profiling as prognostic markers in newly diagnosed acute myeloid leukemia p. 65
Hiba Shakir Ahmed, Noor Thair Tahir, Fatma Abdalhamza Obed
DOI:10.4103/ijh.ijh_20_17  
Background: Acute myeloid leukemia (AML) is a common acute leukemia in adult. Recent studies have shown that cytokine systems influence leukemic cell biology and clinical investigations. Among various cytokines, interleukin-6 and interleukin-10 (IL-6 and IL-10) participate an essential function in progression of the disease. Objective: The aim of this study is to quantify of IL-6 and IL-10 levels in AML patients who are newly diagnosed and evaluate lipid profile to assess the relationship between lipid profile level and body mass index (BMI) in myeloid leukemic patients. Materials And Methods: Samples were collected from 45 patients with AML from AL-Yarmouk Teaching Hospital in addition to another 45 healthy individuals were served as a control group during a period from October 2015 to October 2016. Patients ages ranged from 40 to 60 years. IL-6 and IL-10 were measured in all patients before any treatments and compared with control group. Results: There was an increase in age, white blood cell, and hemoglobin in AML patients as compared to control, but it was not significant. There was a significant increase in neutrophils and lymphocyte count, (P = 0.001). Furthermore, there was an increase in BMI, fasting blood sugar, and lipid profile except high-density lipoprotein cholesterol for AML patients as compared to control, but it was not significant. There was a significant increase in serum IL-6 and IL-10 for AML patients compared to controls (P = 0.001). Conclusions: The present study refers that AML patients were associated with high concentration of IL-6 and IL-10 in comparing to the control group.
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Bacterial profiling of healthy bone marrow using polymerase chain reaction technique p. 69
Vidyut Prakash, Deepak Kumar, Saurabh Singh, Gopal Nath
DOI:10.4103/ijh.ijh_21_17  
Background: The bone marrow of healthy individuals is conventionally considered sterile like other body fluids, but recently the scientists found genetic material from the bacteria inside their stem cells. The findings raise the possibility that other infectious agents may also reside in the bone marrow. Objectives: The study was planned to look for the presence of all type of bacteria by amplifying 16S rDNA sequences using eubacterial universal primers. Materials and Methods: A total of 18 bone marrow samples of apparently healthy individuals were collected from patients admitted having closed bone fractures. The DNA was isolated and was subjected to nested polymerase chain reaction (PCR) using Universal eubacterial 16S rDNA primers. The samples positive by universal PCR was further checked for the presence of Salmonella Typhi, Salmonella Paratyphi A, and/or Mycobacterium tuberculosis (Mtb) if any using a second nested PCR reaction. Results: A total of 16 (89%) samples could yield the desired amplicon through universal PCR. The secondary PCR of 16 samples, the desired amplicons were detected 3 (18.8%) for Mtb, 4 (25%) for S. Typhi, and 1 (6.2%) for S. Paratyphi A. Conclusions: Even in asymptomatic cases, other infectious agents such as Mtb, Salmonella spp., and many other microorganisms may be present as commensal.
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Immunomodulation of cyproheptadine hydrochloride on albino mice blood lymphocytes p. 74
Zainab Yaseen Mohammed Hasan, Ruqaya M Al-Ezzy, Jasim Mohammed Abdullah, Bashar Sabri AL-Hamdi
DOI:10.4103/ijh.ijh_23_17  
Background: Cyproheptadine hydrochloride (HCl) is antihistaminic drug which used widely in our country as an appetizer and for weight gain especially for low weight children. Objective: The aims of this study were to assess the effects of cyproheptadine HCl on blood picture including white blood cells count, lymphocytes count, and its effect on the level of different cytokines. Materials And Methods: This is an experimental study conducted at Biotechnology Research Center Laboratory in Alnahrain University from November 2016 to April 2017. It included five groups of albino male mice, these groups were treated separately with four doses of the cyproheptadine drug and fifth as control group; the doses were selected according to the British National Formulary (BNF) 2010 calculated on the base of mice/human deference's in body weight: These are (0.065, 0.092, 0.120, 0.24) mg/mice/day, respectively, with fifth untreated mice group considered as control. Results: The untreated mice (control) lymphocyte count was (4000) cell/ml and the total lymphocytes count increased up to (7014) cell/ml than the normal leading changes in interleukins (ILs) level in different manner, such as decreasing in both IL-6 and IL-10 levels with increasing in IL-12 level and no change in IL-4 level. Conclusion: The current study showed that cyproheptadine HCl may have unwanted side effects, and its abuse may lead to disturbances in white blood cell especially lymphocyte which in turn will affect the immunity of persons taking it, especially in children, since the immune system modulates ILs secretion to face the irritability of drug behavior, that will lead abnormalities in human immune system.
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Magnitude of arthropathy in patients with hemophilia: A single-center experience p. 78
Rawand Polus Shamoon
DOI:10.4103/ijh.ijh_24_17  
Background: Hemophilia is a sex-linked bleeding disorder. Affected patients suffer spontaneous or post-traumatic bleeding into various sites of the body, mainly into joints, depending on the level of coagulation factor deficiency. Aims: This descriptive study is designed to assess the prevalence and extent of arthropathy and evaluate the functional status of hemophiliacs in Erbil, Northern Iraq. Settings And Design: A descriptive study of all registered hemophiliacs at Nanakali Hemato-Oncology Teaching Centre, Erbil, Iraq. Patients And Methods: Over 15 months (October 2015 to February 2017), a total of 133 hemophilia patients were studied. Their hospital records were used to retrieve clinical and laboratory data, mainly their coagulation profile. All patients were clinically examined at the daycare center; plain radiography was used to evaluate the degree of joint damage based on Petterson score. The magnitude of joint disease was assessed, and patients' functional status was evaluated depending on Functional Independence Score in Hemophilia (FISH). Statistical Analysis Used: Statistical analysis used MS Excel 2010. Results: Hemophiliacs mean age was 12.9 years. Patients with severe hemophilia presented earlier and had more bleeding episodes. At least one bout of hemarthrosis was recorded in 103/133 patients during the course of their disease with knee joint most frequently involved (in eighty patients) followed by elbow, ankle, wrist, and shoulder. The Petterson score related significantly to age of the patient, number of bleeds, and severity of hemophilia. Majority, 67%, of hemophiliacs found to have the limitation of movement. FISH score significantly related with factor activity level. Functional disability was encountered in 9.7% of cases; majority had severe hemophilia. Conclusions: The incidence and severity of joint bleeding and functional disability were high. The FISH and Pettersson scoring systems are very useful tools in assessing patients with hemophilic arthropathy.
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Characteristics of splenic marginal zone lymphoma: Clinical, hematologic, and flow cytometry findings of 34 cases p. 84
Wafaa Mohammed Al-Anizi, Mohammed Abdul Rassoul Al-Mashta
DOI:10.4103/ijh.ijh_25_17  
Background: Splenic marginal zone lymphoma (SMZL) is a low-grade disorder that regularly presents with peripheral blood (PB) involvement. A precise description of clinical, laboratory features and immunophenotypic characterization of SMZL are still lacking. Here, we reviewed 34 patients presenting with SMZL to describe the clinical, hematologic features, and flow cytometry immunophenotypic findings of this type of lymphoma at diagnosis. Objectives: The aim of this study is to confirm that SMZL has a specific immunologic profile which enables the hematopathologist and clinician to differentiate this low-grade B-cell lymphoma from other B-cell lymphoproliferative disorder, especially chronic lymphocytic leukemia and hairy cell leukemia, which could sometimes stimulate SMZL morphologically and to emphasize that a correlation of immunophenotypic findings, clinical, and hematologic features of patients plus careful morphological examination of PB and/or bone marrow (BM) aspirate can lead confidently to the correct diagnosis. Materials And Methods: Flow cytometry immunophenotypic findings of 34 cases of SMZL were reviewed. The analysis was performed by BD FACS Calibur™ and FACSCanto II flow cytometers. B lymphocytes were identified according to their Side-Scattered (SSC)/CD19 distribution. A marker was considered positive when expressed in more than 20% of cells above the control. Results: Median age was 60 years, range (35–84 years), both sexes were affected equally. All patients presented with splenomegaly, 71% of patients had absolute lymphocytosis and 88% of patients showed PB involvement. Seventy-four percent of patients had anemia and (53%) of them had thrombocytopenia. Cells from all cases expressed pan B-cell antigens (CD19, CD20), 74% of cases expressed CD79b and Human Leukocyte Antigen – antigen D Related (HLA-DR) expressed in nearly almost all cases (97%). Half of the patients expressed CD11c and SIgD, 41% expressed CD5 and FMC7 while CD25 and CD103 showed positivity in less than 5% of cases. Preferential expression of Kappa light chain was demonstrated, CD10 and CD38, SIgG were negative. Conclusion: SMZL has a distinct immunologic profile which if correlated with morphologic findings of PB or BM aspirates, clinical and hematologic features can help to make the accurate diagnosis and lessens the need of further invasive diagnostic procedure.
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Prevalence of hemoglobinopathies among marrying couples in Erbil province of Iraq p. 90
Ranan Kardagh Polus
DOI:10.4103/ijh.ijh_27_17  
Background: Thalassemia is the most common genetic disorders worldwide, widely spread throughout the Mediterranean region including Iraq. One effective method to reduce incidence of thalassemias and sickle cell disease is premarital screening. Objective: The aim of this study was to determine the prevalence of β-thalassemia trait and other hemoglobinopathies among subjects attending the premarital screening center in Erbil. Materials And Methods: Over a period of 1 year, 6224 couples were screened for hemoglobinopathies. Screened subjects were categorized according to the result of complete blood count, serum ferritin, and hemoglobin (Hb) electrophoresis into six groups, namely, normal, β-thalassemia carriers, α-thalassemia carriers, sickle cell carriers, Hb-H (HbH) disease, and iron deficiency anemia. Results: The prevalence of β-thalassemia trait was 6.94% (864/12448) with nearly equal proportions between male and female (male to female ratio = 1:1.1). HbH disease and sickle cell trait were less common. Iron deficiency anemia was reported in 52 subjects (0.4%). Conclusion: We found a relatively high prevalence rate of heterozygous β-thalassemia among the studied sample in comparison to prevalence figures from reports in the nearby geographic locations.
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CASE REPORT Top

A case report of a young female with plasma cells leukemia p. 94
Nawshirwan Gafoor Rashid, Sana Dlawar Jalal
DOI:10.4103/ijh.ijh_22_17  
Plasma cell leukemia (PCL) is a rare and aggressive variant of plasma cell dyscrasias that can occur either de novo (primary) or as a leukemic transformation of end-stage multiple myeloma (MM). PCL is known with a poor prognosis and with a different biologic background, clinical, and laboratory features. Primary PCL presents more often with extramedullary involvement, anemia, thrombocytopenia, hypercalcemia, elevated serum 2-microglobulin, and lactate dehydrogenase levels, in addition to impaired renal function in comparison with MM. Here, we report a case of a young female who was admitted with excessive thirst, polyuria, lower backache, fever, and weight loss over 2 months. Peripheral blood smear showed numerous atypical looking plasma cells, and immunophenotyping on bone marrow (BM) aspirate demonstrated the presence of clonal plasma cells. She was admitted to adult hematology ward in Hiwa Hemato-Oncology Hospital, Sulaimani, Kurdistan, Iraq and received four cycles of bortezomib, thalidomide, and dexamethasone chemotherapy, followed by two more cycles of dexamethasone, cyclophosphamide, etoposide, and cisplatin, and later, she proceeded to autologous BM transplantation. More details of the case are presented below.
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LETTER TO EDITOR Top

Behavior of red blood cells indices in iron deficiency anemia and β-thalassemia trait p. 97
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijh.ijh_12_17  
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