Indian Journal Of Hematology And Blood Bank

1. INDIAN JOURNAL OF HEMATOLOGY AND
BLOOD TRANSFUSION VOLUME 31,
JANUARY-MARCH 2015
PRESENTED BY: DR. NIKITA KHANDELWAL
Department of pathology,
Sri Aurobindo Medical
college , Indore(M.P)

2. UNRELATED UMBILICAL CORD BLOOD TRANSPLANT FOR
CHILDREN WITH B-THALASSEMIA MAJOR
Sandip A. et al GCRI, Ahmedabad

3. ABSTRACT
 Beta thalassemia major, one of the most prevalent
hemoglobinopathy throughout the world, can be cured by
allogenic SCT. Many patients, however, lack a suitably donor.
Unrelated umbilical cord blood can be used as an alternative stem
cell source for these patients.
 Post transplant complications were mild hepatic veno-occlusive
disease,acute GVHD grade 2, and CMV interstitial pneumonia.
 The lack of a marrow donor registry in india makes UCBT from
related and unrelated donors a good alternatives.transplant should
be delayed until the child is at least 18 months of age.

4. INTRODUCTION
 beta thalassemia major, also known as cooley’s anemia or
homozygous b-thalasssemia,is a clinically severe disorder that
results from the inheritance of two beta thalassemia alleles, one
on each copy of chromosome11
 SCT still remains the only cure currently avaiable for patients with
thalassemia. Umbilical cord hematopoietic stem cells are
increasingly used as an alternative to BM, advantages include
ready availability, no risk to the donor, low rate of viral
contamination and low risk of GVHD. Disadvantages include low
stem cell dose for larger patients and lack of stem cells for blood
infusions following the initial procedure.

5. SUPPORTIVE CARE AND POST
TRANSPLANTATION FOLLOW UP
 Blood components were given whenever indicated to maintain
haemoglobin and platelet values.For fungal infection oral
intraconazole was prescribed for the month preceding
transplantation. Oral acyclovir and oral cotrimoxazole were given
to prevent CMV reactivation and pneumocystis jiroveci infection.
 Parenteral nutrition was provided for the duration of anorexia in
form of 25% dextrose,amino acids and albumin.

6. DISCUSSION
 UCB has the advantages of rapid availability, and low risk of severe
GVHD despite donor- recipient HLA disparity.
 After transplantation of cord blood, engraftment usually seems
slower than after transplantation of marrow or peripheral blood .
 Patients with transfusion dependent thalassemia are a high risk of
graft failure, either because of major prior alloimmunisation or an
insufficient amount of UCB stem cells. The conditioning regimens
were generally well tolerated and the median day of neutrophil
engraftment was 17 days after transplantation.
 Transplant should be done after 18 months of age at the
earliest.Dose of stem cells is the importanat factor for engraftment.

8. Improving Outcome of Aplastic Anaemia with
HLA-Matched Sibling Donor Hematopoietic Stem
Cell Transplantation: An Experience of Gujarat
Cancer and Research Institute (GCRI)
Shreeniwas S.Raut Civil hospital,Ahmedabad

9. INTRODUCTION:
Staging of aplastic anaemia is according to criteria of the
International Aplastic Anaemia Study Group, as follows:
 Blood – Neutrophil <500/cumm
Platelet <20000/cumm
Reticulocytes <1% corrected
 Bone Marrow – Severe hypocellularity
Moderate hypocellularity,
with hematopoietic cells representing <30% of residual
cells.
 Severe aplasia is defined as those including any 2 or 3 peripheral
blood criteria and either marrow criterion.
 Very severe aplastic anaemia (VSAA) i.e. The individuals with
neutrophil count lower than 200/cumm are less likely than other to
respond to immunosuppressive therapy.

10.  Human leucocyte antigen (HLA) matched sibiling donor
transplantation is therapy of choice in young patients of sever
aplastic anaemia (SAA).
 Bone marrow transplantation (BMT) and
immunosuppressive therapy are the main therapeutic
modalities currently used to treat both children and adult,
success rates ranging from 60 to 80%.
 The choice between immunosuppression or BMT is largely
based on the availability of a sibiling donor and on age.

11.  For the non-responder with a matched sibling,
immunosuppuressive therapy delays transplantation and
exposes the patient to risks of transfusions, including
allosensitization and iron over load, prolonged neutropenia
and infections and possibly poor performence scores. thus
early Hematopoiteic stem cell transplantation (HSCT) is
justified in SAA.

12. PATIENTS AND METHODS
 All patients who underwent HLA identical allogeneic HSCT for
aplastic anaemia at the GCRI between Dec 2007 and May 2013 were
included in this study.
 All patient had six anitgen HLA matched sibling or family donor.
 Written informed consent was obtained from all patients before HSCT.

13. Mean Range Median
Age in year 22.33 5-46 19
Previous transfusions 24.5 1-192 8
Diagnosis to HSCT
interval in months
17.43 0.5-96 4
Mononuclear cell
volume
5.09 x 108 3.77-5.5 5.1
CD 34 % ( n= 9) 0.6% 0.27-0.76% 0.63%
Donor age 15 7-45 19
Neutrophil engraftment
time in days
14.7 10-125 13.5
Platelet engraftment time
in days
21.78 10-125 13.5
RBC units required till
discharge
4.5 1-10 4
SDP units required till
discharge
8.6 2.5-2.5 6.75
Hospitalisation duration
after stem cell infusion
30 14-114 24
Patient characteristics

14. Variable Males Females
Deaths 3 /12 0 /3
Median survival in
months still date
9.5 14
GVHD 5 / 12 (41%) 2 /3 (66.66%)
Median neutrophil
engraftment time in
days
13 (+ 1 primary
rejection)
14
Median platelet
engraftment time in
days
13 14
Outcome of male and females

15.  High – Risk Patients
High – Risk Patients were identified as those with any of the following
risk factors-
a) Active infection ( bacterial or fungal) at the time of HSCT.
b) Failed previous immuno-supressive therapy.
c) Duration disease >/=6 months.

16. Duration of disease >/=6 month 6
Infection at the time of HSCT 1
Failure on ATG 3(all 3 patients also had duration of
disease >/=6months)
Total 7
Deaths 3/7 (42.86%)
Overall survivble 4/7 (57.14%)
High risk stratification of patients

17. Trasplant
All patients were nursed in HEPA(High-efficiency particulate
arrestance)-filtered rooms. The conditioning regimen used was
cyclophosphamide with antithymocyte globulin (ATG) or a
combination of Fludarabine and cyclophosphamide with or without
ATG.

18. Graft Source
Bone marrow was used in first 3 patients. Peripheral blood stem
cells was the graft source in 11 patients. In one patient a source
combination of bone marrow and peripheral blood stem cells was
used because bone marrow did not yield required amount of cells.
End points
The parameters studied were engraftment, survival, graft failure,
acute/chronic GVHD and relapse.

19. Engraftment-
The date of neutrophil recovery was scored as the first of 3
consecutive days with ANC 500/cumm or greater and
unsupported platelet count > 20,000 on 3 consecutive days
Chimerism Analysis –
 Chimerism Analysis was done using VNTRs (variable number
tandem repeat) when donor and recipient had same sex. It was
done at post-HSCT day 30 (day+30).
 In patients who had a sex mismatched transplant, chimerism was
assesed with FISH for X and Y chromosomes.

20. Graft failure-
 Graft failure was scored as primary failure if ANC was < 500/cumm on
day 28 .
 secondary failure if there was neutrophil recovery followed by an
otherwise unexplained fall to < 500/cumm for 3 or more days.
Anti microbial Prophylaxis –
 No antibactarial or antifungal prophylaxis was used.
 Acyclovir was started on day +1 for herpes prophylaxis.
 Sulfamethoxazole/Trimethoprim for prophylaxis against pneumocystis
carinii was started once the platelet count was >50,000/cmm.
 Prophylaxis with ganciclovir was given in 3 patients .

21. GVHD prophylaxis
GVHD prophylaxis consisted of cyclosporine (CSA) in combination
with short course methotrexate (MTX). CSA was started at a dose
of 5 mg/kg/day intravenously in two divided doses on day-1, and
changed to the oral route once the counts had improved. CSA dose
was adjusted according to drug therapeutic levels, as well as with
renal status of the patient. CSA was continued at full doses for a
period of 12 month and then tapered over a period of 6 months.

22. Statistical Analysis
Descriptive variables were analysed using mean, median, range.
Disease –free survival (DFS) was calculated as survival in the
absence of death or relapse. Overall survival (OS) included all
patients who were alive on the last evaluation. The probability of
OS were estimated using Cox proportional hazards regression
analysis.

23. GVHD:
o Acute GVHD- disease presenting within the first 100 days of
hematopoietic cell transplantation (HCT) with rash, jaundice,
diarrhoea or fever.
o Chronic GVHD – onsets of the disease after first 100 days with
scleroderma like presentation.
o Overlap syndrome – in which diagnostic or distinctive features of
chronic GVHD and acute GVHD appear together.

24. RESULT
 There were 15 patients (12 male and 3 female) including 4 paediatric (age
<14 year) patients,with a median age of 19 years ( range:5-46).
 Median time from diagnosis to HSCT was 4 month ( range: 0.5 to 96) while
median number of transfusion before HSCT was 8(1 -192).
 At the time of HSCT seven patient (46.66%) were considered as high risk.
 Risk factors included active infection in 1, duration of disease >/= 6 month
and hence more transfusions in 6, failed immunosuppression (ATG or CSA) in
3 and no one had a second BMT. All three deaths were in sub group.
 There were three(42.86%) deaths and 57.14% overall survible at the time of
analysis in high risk patients.
 All three deaths were in high risk male . Both the females in high risk group
are in alive and well

25. Engraftment:
 Fourteen (93.33%) engrafted and one patient (6.66%) had primary
graft rejection.
 Post transplant Chimerism data were available for 14 evaluable
patients . The day + 30 chimerism showed 100% donor chimerism
in 11 patient (73.33%), 2 patients showes 99% donor chimerism
while 1 female showed mixed chimerism(95% XY).

26. Survival and deaths:
• Hundred day transplant-related mortality was nil (0%).
• 6 month mortality was 2/15(13%) .
• 1 year mortality was 3/15 (20%).
• At median follow-up of 14 (3-65) months,12(80%) are alive and
well.

27. DISCUSSION
 Though immunosuppressive therapy is most commonly used
therapy for SAA, allogenic HSCT is treatment of choice in patients
with age <40year age when sibling donor is available as it is
curative.
 We have analysis the data of 15 consecutive patients undergoing
matched sibling donor HSCT at our institution and their follow up
till of analysis.
 At a median follow up of 14 months overall survival was 80%.

28.  GVHD as a complication of BMT is positively correlated with
increasing age of the patient.
 Grafts depleted of T cells decrease the risk of GVHD but may
increase the risk of graft rejection .
 In our experience, out of all 4 paediatric patients (<14 years), only
one experienced GVHD.
 While 6 out of 10 (60%) engrafted adults had some form of GVHD.

29. HEREDITARY SPHEROCYTOSIS:EVALUATION OF 68
CHILDREN
Dr. Capan Konca et al, Department of Pediatrics, Manas evleri Uygur
sitesi,Adiyaman, Turkey

30. INTRODUCTION:
 Hereditary Spherocytosis (HS) is a world wide disease.
 In the Northern European population, it is the most-common, inherited
form of anemia, affecting approximately 1 in 1,000 -2,500 individuals.
 In nearly 75% of cases, the inheritance has an autosomal dominant
pattern, and the other 25% of cases present recessive forms and de novo
mutations.

31.  HS syndromes are a group of inherited disorders characterized by the
presence of spherical-shaped erythrocytes on the peripheral blood
smear.
 Clinical findings of HS are variable and include jaundice,
spleenomegaly, gallstones, and haemolytic anaemia, which can be
compensated or severe and sometimes requires exchange transfusion
at birth and/or repeated blood transfusions.
 The primary molecular abnormality of HS may affect several
membrane proteins, such as spectrin, ankyrin, band 3 and, rarely,
protein4.2.

32. Materials and Methods
 In this retrospective study, 68 HS patients were evaluated.
 All were under age 18 at diagnosis and were followed between
march 1997 and March 2007 by the Paediatric Haematology
department of Dicle University, where city hospitals and primary
health centers refer patients.
 HS was diagnosed on the basis of clinical history, physical
examination, and laboratory test results, including complete blood
count, blood smear, reticulocyte count, bilirubin concentration,
positive osmotic fragility test (OFT), and negative direct antiglobulin
(Coombs’) test.

33.  Folate supplements administered to patients with moderate and
severe HS were 2.5 mg/day up to the age of 5 years and 5 mg/day
thereafter.
 Clinical presentation at baseline was classified retrospectively as
mild, moderate, or severe based in the modified criteria of Eber et
al.

34. Statistical analysis
◦ It was performed using the Statistical package for Social Scinence (SPSS)
Version 15.0 (SPSS,Inc., Chicago, IL). Mean, median, minimum, and
maximum values and standard deviations were calculated for numerical
parameters.
◦ The Mann-Whitney U test and the Kruskal-Wallis test were used to
compare groups.
◦ Cross-table statistics were used to compare categorical variables.
◦ A p value less than 0.05 was considered statistically significant. Because
it is retrospective, this study does not conflict with the Declaration of
Helsinki.

35. Result
 The patients comprised 36 males (52.9%) and 32 females (47.1%).
 The median age at diagnosis was 5.6 years (range 3 months to 18
years). The median follow- up time was 5.4 years.
 Predominant clinical manifestation at diagnosis were anaemia in
59 (86.76%) patients, splenomegaly in 49 (72.05%), and jaundice in
33 (48.52%). One patient had gallstones.

36. Clinical feature N %
Anaemia 59 86.7
Splenomegaly 49 72.1
Jaundice 33 48.5
Growth failure 10 14.7
Gallstone 1 1.4
Clinical manifestation of patients at admission

37. N Mean SD
MCV(fl) 68 73.6 15.5
MCHC(g/dl) 68 35.9 4.7
Hb(g/dl) 68 10.2 2.1
HTC(%) 68 19.5 7.5
RDW(%) 68 19.8 4.6
Reticulocytes(
%)
68 6.4 4.8
Spherocytes(%
)
56 8.6 2.2
Unconjugate
Bilirubin(mg/
dl)
36 2.3 0.8
Haematological and biochemical data of HS
patients

38.  When patients were classified Eber criteria and
hematogogic and clinical features, 20 (29.4%),
42(61.7%), and 6 (8.8%) patients were classified as mild,
moderate, and severe, respectively

40. Discussion
 HS is a worldwide disease and the most common cause of
inherited, chronic haemolysis in Northern Europe and North
America, where it affects about one person in 2,000.
 HS often is diagnosed in childhood or young adulthood, it may
be diagnosed at any time in life, including old age. About 75%
of cases have a family history of HS.
 In the current study, median age at diagnosis was 5.6 years
(range 3 months to 18 year), and a positive family history was
recorded for 30 patients (44.1%)

41.  Who had 12 siblings, 8 parents, and 10 distant relative who
were diagnosed with HS.
 20 patients (29.4%) were considered the first cases in their
families. The major complications of HS are aplastic and
megaloblastic crises, hemolytic crisis, severe neonatal
haemolysis, cholecystitis, and cholelithiasis.
 Chronic hemolysis leads to formation of bilirubinate gallstones.
 Another type of crisis is megaloblastic, which occurs when
dietary intake of folic acid is inadequate for the increased needs
of erythroid hyperplasia.

42.  In the current study, the major complications of HS were
haemolytic, aplastic, and megaloblastic crises and cholelithiasis
in 7 (10.2%), 1 (1.4%), 7(10.2%), and 6(8.8%) patients,
respectively.
 Management of patients with HS is supportive. Folate
supplements are recommended in moderate and severe HS but
not necessarily in mild HS if the diet is adequate.
 Red cell trasfusions may be needed in severe cases, but
unnecessary transfusions may lead to iron overload.

43. Conclusion-
 HS should be considered in evaluating possible diagnoses in
patients with haemolytic anaemia.
 In this study, the clinical course of patients with HS was
relatively benign, with a low proportion of patients with
splenectomized and aplastic crises.
 Prospective studies with long-term follow up periods are
needed to determine course of patients with HS.

44. THE PROGNOSTIC SIGNIFICANCE OF HBF IN CHILDHOOD
HAEMATOLOGICAL MALIGNANCIES
Debjani mallick, ESIC Medical college
joka,west Bengal

45. ABSTRACT
The aim of the present study was to quantify HBF levels in various
childhood haematological malignancies and also,to ascertain its
prognostic significance by comparing the results with the already
established standard prognostic factors. Newly diagnosed cases of
haematological malignancies in the paediatric age group were
included in the study.
INTRODUCTION
The causes of elevated HBF production in leukaemia are most
likely multifactorial.The degree of incidence in HBF synthesis may
be associated with the degree of malignancy: the more aggressive
the disease, the more augmented the HBF synthesis and is not
restrictred to any particular type of leukaemia.
According to ICCC, precurssor cell leukaemia were the most
frequent haematological maignancies in children and constituted
60% of all haematological malignancies.

46. MATERIALS AND METHODS
 Clinical history and physical examination was noted in each
case and each one of them was subjected to complete
haemogram and BM aspiration .FNAC as wellas biopsy of
lumph node were done in case of lymphomas.
 HBF levels were estimated in each case of the
study.Estimation wsas done by HPLC .
RESULTS
50 cases of newly diagnosed haematological malignancies were
studied out of which most of the cases were of
ALL(n=30,60%) followed by AML(n=8,16%), HL(n=7,14%),
NHL (n=5,10%)
 Maximum no. of cases were within age group of 10-12 years
comprising 20 cases of ALL,5 cases of HL,4 cases of AML,3
cases of NHL.
 Raised HBF levels were found in 43.3% cases of ALL and
37.5% cases of AML.no significant rise of HBF seen in
lymphomas.

48. DISCUSSION
 HBF levels are often elevated in childhood leukaemias as
compared to childhood lymphomas.The elevated levels being
significantly correlated with poor prognostic factors in cases
of ALL.

49. STUDY OF ADVERSE WHOLE BLOOD DONOR REACTIONS
IN NORMAL HEALTHY BLOOD DONORS: EXPERIENCE OF
TERTIARY HEALTH CARE CENTRE IN JAMMU REGION

50. ABSTRACT
 The aim of the study was to estimate the frequency and type
of adverse events during blood donation.
 Presyncopal reactions are vasovagal reactions of mild
intensity,were the most commonly observed adverse
reactions and accounted for approximately 58/108 all
adverse reactions noted.

51. INTRODUCTION
The adverse reactions that occur in donors can be divided into
(1) Local reactions
(2) Systemic reactions .
 LOCAL REACTIONS occur predominatly because of problems
related to venous access.They are usually hematomas due
to extravastion from veins caused by incorrect placement of
needle during venepuncture.
 Pain ,hyperaemia, and swelling develop
 SYSTEMIC REACTIONS can be divided into mild or severe. In
most of the cases they are vasovagal reactions. It is
characterized by the appearance of pallor,sweating,
dizziness, abdominal cramps, nausea, hypotension, and
bradycardia.

52. MATERIALS AND METHODS
 Strict asepsis was maintained by cleaning the site of
venepuncture using betadine and alcohol.
 Those donors who complaint of adverse reactions like
giddiness,light headedness,pallor are managed by stopping
the donation and raising the legs of the donor.
RESULTS
Presyncopal symptoms,in other words vasovagal reactions of
mild intensity were the most commonly observed adverse
reactions and accounted for approximately 53.70% of all
adverse reactions noted.

55. DISCUSSION
As only 0.365% of whole blood donations were complicated by
adverse events and most of these events were presyncopal
symptoms. In conclusions, blood donations have an
obligations to constantly monitor risks of blood donation and
to make a concerted and commited effort to achieve the
lowest possible rate of complications.

56. MACROTHROMBOCYTOPENIA IN NORTH INDIA:ROLE
OF AUTOMATED PLATELET DATA IN THE DETECTION OF
AN UNDER DIAGNOSED ENTITY
Naveen kakkar,christian medical college
ludhiana,punjab

57. ABSTRACT
• The study was done to assess the occurrence of
macrothrombocytopenia in north india population and the role of
automated platelet parameters in its detection
• INTRODUCTION
• Congenital macrothrombocytopenia is an under diagnosed entity
and is seen in a group of largely inherited disorders characterised
by large sized platelets seen on the blood smears associated with
raised mean platelet volume(MPV) and low to near normal
platelet counts.pateints may be asymptomatic or may have
bleeding of varying severity depending on the inherent genetic
defect responsible
• This study highlights the role of automated platelet data;MPV and
platelet cytogram patterns in the diagnosis of
macrothrombocytopenia

58. MATERIALS AND METHOD
 Blood samples were run on 5 part differential system that
analyses blood cells by flow scatter and enumerates the
differential count using MPO staining. Platelet count is done
by flow cytometry and the volume is plotted on the platelet
cytogram.
RESULTS
 75 patients out of a total of 12,556 samples received for CBC
during the study period were detected to have
macrothrombocytopenia .Of the total of 12,556 blood
samples 7,407 were from males and 46 of them had
macrothrombocytopenia.There were 5,149 blood samples
from female pateints of which 29 had
macrothrombocytopenia. Hence no gender differernce was
noted.

59.  Macrothrombocytopenia was suggested in all the patients in
the absence of
 (1) history of bleeding
 (2) no evident cause of thrombocytopenia
 (3) large platelet on peripheral smear examination
 (4) raised MPV and characteristics dispersed platelet
cytogram pattern

61. DISCUSSION
 Acquired thrombocytopenia can be seen in a variety of
clinical disorders including infections, autoimmune disease,
marrow aplasia,ITP and in patients on drugs or radiation
therapy
 ITP and myelodysplasia are the commonest conditions
leading to acquired trombocytopenia.
 Of the inherited macrothrombocytopenia BSS(bernard
soulier syndrome ) and MHY9 (May Hegglin Gene) related
disease are the commonest.

62. CONCLUSION
 Macrothrombocytopenia is an underdiagnosed condition in
north india and may be initially suspacted on automated
blood counts. Along with a blood smear examination ,
automated data(MPV and platelet cytogram pattern) aids the
diagnosis and can avoid unnecessary investigations and
interventions for these patients

63. Spontaneous Remission of Adult Acute
Lymphoblastic Leukemia: A very Rare Event
Abhishek Purohit et al, Department of Haematology, AIIMS, New
Delhi, India

64.  A 46 year old gentalman presented to us with an unusual
problem when his acute lymphoblastic leukaemia (ALL)
disappeared without any chemotherapy.
 We faced a dilemma whether to go ahead and treat his initial
diagnosis or wait. Eventually he did relapse and was treated,
although with a fatal outcome.
 He came to us with fever, breathlessness and dry cough of 2
weeks duration. On examination, he was pale with no icterus,
lymphadenopathy, organomegaly or skin bleeds.

65.  On systemic examination, there was an ejection systolic murmur
in aortic area radiating to the carotid.
 On investigations, he was pancytopenic (hemoglobin
9.1gm/dl,platelet count 1.1lac/cumm and leucocyte count
1000/cumm with 20% blasts).
 The blood culture grew Acinetobacter spp.
 Echocardiography showed a concentrically hypertrophied left
ventricle with an 8 × 9 mm sized vegetation on a bicuspid,
thickened, calcified aortic valve with moderate stenosis and mild
regurgitation.
 Computed tomography scan of chest showed multiple nodules
with a ground glass haze.

66. Bone marrow aspiration With flow-cytometry revealed 90% blasts
of B lineage.

67.  Bone marrow aspirate was negative for BCR-ABL transcript
and other cytogenetic anomalies.
 We deferred chemotherapy in view of positive blood culture,
infective endocarditis and possible fungal pneumonia.
 After 2 weeks of broad spectrum antibiotics(cefaperazone+
sulbactum, gentamicin and vancomycin) and antifungals
(voriconazole and caspofungin) his blood counts normalized
and blasts disappeared from peripheral blood.

68.  A repeat bone marrow aspirate and biopsy was also normal.

69.  Chemotherapy was deferred and a haemogram was checked
every week for signs of relapse.
 After 9 week, peripheral blood smear showed blasts and
bone marrow aspirate revealed 80% blasts of B lineage.
 He was started on chemotherapy but succumbed to fungal
pnemonia during induction.
 An association of spontaneous remission in acute
leukemias with concomitant bacterial, viral or fungal
infections has been noted.

70.  The cytokine release following infections has been
postulated to cause regression via immune modulation
mechanism.
 Extrapolating from the experience with AML where such
remissions were short lived and as seen in our patient with
ALL, chemotherapy should not perhaps be deferred despite
apparent Spontaneous remission.

71. THANK YOU……