Bone Marrow Picture Research Articles

Essential Thrombocythemia in Young Women

Background: Essential thrombocythemia (ET) is a rare disease in which there is an increase in the platelet count of more than 450,000/mm3. An increase in the number of platelets occurs due to increased proliferation of megakaryocyte series. Although there is an increase in the number of platelets in ET, it has impaired function. ET clinical manifestations in 50% of cases are asymptomatic, but in symptomatic cases can be vascular occlusive events or microvascular thrombosis.
 Case presentation: A 22-year-old woman with complaints of rash on the hands and feet. Physical examination found an enlarged spleen in Schuffner 1 and ecchymosis on the arms and legs, a platelet count of 811,000/mm3. The peripheral blood smear shows large platelets, the bone marrow picture shows megakaryocytes, which are very easy to find, the size varies with sufficient platelet emission, the JAK2 gene mutation examination shows mutation detection, while the BCR-ABL gene mutation results do not detect gene fusion. Treatment is given cytoreductive therapy in the form of hydroxyurea, while acetylsalicylic acid is not given because there are contraindications for administration.
 Conclusion: Essential thrombocythemia is a neoplastic proliferative disease that occurs in the megakaryocyte series. The diagnosis of ET mostly found mutations in the JAK2 gene. ET management according to risk classification, where acetylsalicylic acid can be given very low and low risk, while intermediate and high risk can be given cytoreductive therapy.

Bilateral central retinal vein occlusion as an initial presentation of Waldenström macroglobulinemia: a case report

BackgroundWaldenström macroglobulinemia is a rare hematological malignancy and is the most common diagnosis in patients with hyperviscosity syndrome. Bilateral central retinal vein occlusion as an initial presentation of hyperviscosity syndrome in Waldenström macroglobulinemia is rare.Case presentationA 42-year-old Nepalese male presented with sudden-onset bilateral painless blurring of vision. Fundus examination revealed bilateral, diffusely dilated, tortuous retinal veins and intraretinal deep blot hemorrhages in all four quadrants of the retina in both eyes; features of bilateral central retinal vein occlusion. Serum electrophoresis showed hypoalbuminemia with an immunoglobulin M kappa monoclonal spike. Bone marrow picture and immunohistochemistry analysis were suggestive of lymphoplasmacytic lymphoma. The patient received systemic therapy for Waldenström macroglobulinemia, along with intravitreal bevacizumab.ConclusionAdequate hydration, plasmapheresis, and a combination of bortezomib, dexamethasone, and rituximab regimen as a systemic therapy may represent an ideal choice for patients with hyperviscosity in Waldenström macroglobulinemia.

Constitutional pericentric inversion of chromosome 16, inv(16)(p13.1q22), mimicking acute myeloid leukemia.

An acquired abnormality, inv(16)(p13q22), is a hallmark of acute myeloid leukemia with eosinophilia (AML M4Eo), which leads to leukemogenesis by forming the CBFB::MYH11 fusion gene [1]. We experienced a case of inv(16)(p13.1q22) discovered incidentally during bone marrow examination without evidence of AML. A 64-year-old woman was referred to our hospital because of hypergammaglobulinemia. She was being treated for rheumatoid arthritis, but had no past and family history of AML. Laboratory examination showed polyclonal gammopathy but no significant abnormalities in complete blood count with differential. Bone marrow picture showed a normocellular marrow and mild increase in plasma cells to 3.8% (reference range, 0.2%–1.7%), but no evidence of hematological malignancy. Surprisingly, chromosome analysis of the bone marrow cells revealed that all 20 cells had inv(16)(p13.1q22) mimicking AML M4Eo (Figure 1A). We therefore performed fluorescence in situ hybridization (FISH) analysis of the bone marrow cells by using the Vysis CBFB Dual Color Break Apart Rearrangement Probe (Abbott Molecular Diagnostics, Des Plaines, IL, USA). The splitting of the red and green signals reflecting truncation of the CBFB locus on chromosome 16q22 was not observed (Figure 1B). In addition, a multiplex reverse transcriptase-polymerase chain reaction assay covering 28 leukemia-specific fusion transcripts including CBFB::MYH11 was performed by using the HemaVision-28Q kit (VERITAS, Tokyo, Japan), but none of them was detected. Therefore, it was suggested that the chromosome inversion of this patient did not disrupt the CBFB gene. High-resolution chromosome analysis of the phytohemagglutinin (PHA)-stimulated peripheral blood lymphocytes also revealed inv(16)(p13.1q22) in all 20 cells, indicating a constitutional abnormality of chromosome 16 (Figure 1C). Thus, this patient was not misdiagnosed as AML M4Eo and has been followed up without treatment. To the best of our knowledge, only a few cases with inv(16)(p13q22) unrelated to AML have been reported [2-5]. All of these were concluded to be constitutional abnormalities, and some cases have been confirmed as familial onset. In these reports, there was no misdiagnosis of AML M4Eo in individuals without hematological malignancy, and in the case of chronic myeloid leukemia with t(9;22)(q34;q11) and inv(16)(p13q22), FISH analysis showed no abnormality of the MYH11 gene and inv(16)(p13q22) was also found in her healthy father, which avoided misdiagnosis as an additional cytogenetic abnormality in chronic phase [4]. Therefore, although extremely rare, we should be aware of the presence of constitutional chromosome abnormalities mimicking hematological malignancies, and it is important to perform further tests such as FISH and genomic analysis for differential diagnosis. We thank Yoshiko Sato, MT (LSI Medience Corporation, Tokyo, Japan), for her technical support. The authors declare that there is no conflict of interest. All procedures in this study were performed in accordance with the principles of the Declaration of Helsinki and the institutional guidelines. Informed consent was obtained from the patient and her family. The data that support the findings of this study are available from the corresponding author upon reasonable request.

276P - Chronic myelod leukemia in chronic phase (CML-CP) with lymphadenopathy at diagnosis: A retrospective analysis

BackgroundLymphadenpathy is a very unusual manifestation of CML-CP with an unclear implication on prognosis. We sought to understand the occurrence of this phenomenon and its effect on prognosis in newly diagnosed cases of CML-CP at a tertiary cancer centre in South India. MethodsA retrospective analysis of all the newly diagnosed cases of CML-CP between January 2016 and December 2018 was undertaken and patients presenting with lymphadenopathy were identified. Data pertaining to CML diagnosis, work up and their clinical outcomes were recorded. Descriptive statistics were used. ResultsFour cases of CML-CP presenting with lymphadenopathy were identified out of 143 cases recorded in this time period (2.8%). The age range is 7-44 years (mean = 25 years) for these cases. All these cases were diagnosed on basis of peripheral smear and bone marrow picture consistent with CML-CP and RT-PCR for BCR-ABL positive for e13a2 (p210). Lymphadenopathy was cervical alone in one case and generalized in the rest of the cases. FNAC of lymph nodes at baseline were suggestive of reactive lymphadenitis. Two out of 4 patients (50%) were high risk according to EUTOS score. All the patients (irrespective of risk group) were started on Imatinib 400mg qDay (250mg/m2 for the paediatric patient). All the four patients progressed to blast crisis, 3 of them being lymphoid blast crisis (75%). The mean time to progression was 14.5 months (range 6-23 months). In contrast, only 1 patient in the rest of 139 patient cohort developed blast crisis in the three years data. ABL kinase domain mutation analysis was done in all the four patients, 2 of them showed Imatinib resistant mutations with both of them more sensitive to Dasatinib. Karyotype at the time of progression to blast crisis was done in 2 patients and it showed isochromosome 17p in one patient.Table 1276P Clinical features and key investigation of patients of CML-CP presenting with lymphadenopathyTable 1Age/sexEUTOS risktime to progression (months)ABL KD mutationKaryotype7/FHigh6not detectedIso17p18/MLow12Not detectedNot done32/MLow14M244VNot done44/MHigh23Y235HNormal ConclusionsLymphadenopathy at diagnosis of CML-CP has a very poor prognosis and heralds early progression to blast crisis. Legal entity responsible for the studyGedala Veni Prasanna. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Etiology of Pancytopenia and its Bone Marrow Picture

Etiology of Pancytopenia and its Bone Marrow Picture

Chloroma of the orbit as a presenting feature of acute myeloid leukemia in a four year old female child

A four year old female child presented with a painless swelling of the right lower lid for 25days, which was progressively increasing in size. On palpation, a firm nodular mass just above the inferior orbital margin was noted. MRI showed homogenous enhancing mass in the orbit. Progressive axial proptosis developed in 8 days, with inability to close the eye. Bone marrow aspiration at this stage revealed Acute Myeloid Leukemia. Chemotherapy was started. Bone marrow picture after 10days showed remission phase. Symptoms and signs began to regress. The child was discharged on maintenance chemotherapy; but was admitted 3weeks later with fever; the child expired after admission 2 days due to secondary infection.

Acquired Amegakaryocytic Thrombocytopenia in a Child: A Very Rare Case

Acquired amegakaryocytic thrombocytopenia (AATP) is a very rare hematological disorder causing severe thrombocytopenia and bleeding. Our patient a two year old girl presented with history of severe bleeding from nose, gums, conjunctive with purpuric and petechial spots all over the body. She had mild hepatosplenomegaly with very low Platelet counts. Bone marrow examination revealed absence of apparent megakaryocytes. Bone marrow biopsy ruled out disorders of marrow suppression. This child was treated with methyl prednisolone, prednisolone and oral cyclosporine for 5 months. On follow up the child has been asymptomatic with complete improvement of the platelet counts and recovery of bone marrow picture.

Neutrophilic - Chronic Myeloid Leukemia : A Case Report

Neutrophilic-chronic myelogenous leukemia (CML-N) is a rare chronic myelogenous leukemia (CML) variant characterized by BCR-ABL1 positive chronic neutrophilia. It has a BCR breakpoint on chromosome 22 between exons 17 and 20 in a region designated as micro-BCR. It is thought to have a more benign course than classical CML. This case report describes a 41-year-old Saudi woman diagnosed with CML-N. The peripheral blood and bone marrow picture for her were dominated by segmented neutrophils and fluorescent in situ hybridization was positive for BCR/ABL fusion of t(9;22). Our patient eventually required a stem cell transplant because of imatinib intolerance and bone marrow failure believed to be induced by nilotinib.

Антиоксидантні властивості кластерних сполук ренію та їх вплив на еритропоез щурівіз карциномою Герена

Biochemical characteristics of kidneys, pe- ripheral blood and bone marrow of rats in model of tumor growth under introduction of cisplatin and cis-tetrachlorodi-μ-isobutyratodirhenium(III), cis-Re2(i-C3H7COO)2Cl4 (I) have been investigated. It was shown that introduction of I alone and together with cisplatin led to decrease of biochemical markers of oxidation of lipids and proteins in tissue homogenates of the kidneys, change of enzyme activity in the urea and tissue homogenates of the kidneys, by a decrease of filtration function of kidneys. Introduction of nanoliposomal forms of the rhenium cluster compound led to a practically normal morphological picture of bone marrow and increase of the RBC (by 60%) with normalization of hematocrit counts, and decrease of quantities of destructed RBC (3.2 times) in comparison with the tumor-bearing animals. A tentative scheme of influence of cluster rhenium compound on erythropoiesis through regulation of synthesis of erythropoietin in kidneys has been proposed.

Bone Marrow Features and Natural History of BCR/ABL-Positive Thrombocythemia and Chronic Myeloid Leukemia Compared to BCR/ABLNegative Thrombocythemia in Essential Thrombocythemia and Polycythemia Vera

The Hannover bone marrow (BM) classification distinguished three phenotypes of BCR/ABL-positive CML: CML of common type (CML.CT), CML with megakaryocyte increase (CML.MI) and CML with megakaryocyte predominance (CML.MP). BCR/ABL-positive essential thrombocythemia (Ph-positive ET) is featured by CML.MP bone marrow picture of small monolobulated megakaryocytes and is part of the CML spectrum as a malignant disease (neoplasia) with an obligate transition into acute leukemia of near to 100% after 10 years follow-up. The Hannover BM classification distinguished three primary prefibrotic BCR/ABL-negative (Ph-negative) myeloproiferative disorders (MPD)s: essential thrombocythemia (ET), polycythemia vera (PV) and chronic or primary megakaryocytic granulocytic myeloproliferation (CMGM/PMGM). The incidence of blasts crisis is low in the Phnegative MPDs ET, PV and CMGM. The risk of myelofibrosis is high in CMGM/PMGM, moderate in PV but low in Ph-negative ET. In BCR/ABL-positive thrombocythemia the platelets are small and indolent (non-reactive) and megakaryocytes are smaller than normal with hypolobulated nuclei caused by BCR/ABL induced maturation defect. BCR/ABL-positive thrombocythemia does not present erythromelalgic thrombotic or bleedings manifestations at increased platelet count in excess of 400 to 1500 × 109/L. The platelets and megakaryocytes in BCR/ABL-negative ET and PV are large due to growth advantage caused by constitutively activated by the JAK2V617F or MPL515 mutation. JAK2 and MPL mutated thrombocythemias are associated with a high risk on aspirin responsive plateletmediated inflammation and thrombosis in the end-arterial circulation (platelet thrombophilia).

P1-31-6 - Synchronous Multiple Neoplasms Consist of Myelodysplastic Syndrome and Colon Cancer

Background: In the last decade, as for the colon cancer, chemotherapies strategy progressed. We nominate result for not only it but also the enlightenment activity of the early diagnosis. It is not unusual for even our dairy practice (hematology fields) to meet with colon cancer.Methods: We investigated myelodyspastic syndrome case who experienced colon cancer. Bone marrow puncture performed and diagnosed by bone marrow picture, cytogenetic study and flow cytometry. The diagnosis of colon cancer performed previous hospital. The patient did not receive adjubant chemotherapy. The definition of multiple neoplasms followed Warren & Gates theory. And as for the definition of synchronous type, a diagnosis interval is less than 6 months, metachronous type interval is more than 6 months.Result: The case is 64-year-old male who was diagnosed and received operation of resection for colon cancer at 2012. Tumor lesion was Sigmoid colon, type I. Pathological findings were papillotubullar adenocarcinoma, clinical stageI, abusolute curable resection, and he did not receive adjubant chemotherapy. During observation period, hematological examination revealed moderate leukocytosis, severe anemia and marked thrombocytopenia. He was preferred to our department and performed bone marrow puncture and biopsy, so we diagnosed myelodysplastic syndrome (Refractory Anemia) in 2012, so this case was synchronous multiple neoplasms, interval is 2 month. He received transfusion 2 times per month as outer-patients.Conclusion: Multiple neoplasms is influenced by each prognosis. This case mostly influenced by myelodysplastic syndrome and up to December 2013, he needed blood transfusion but spends his life ordinary.

Hepatosplenic T-Cell Lymphoma Mimicking Infiltrative Chronic Myelomonocytic Leukemia

Hepatosplenic T cell lymphoma (HSTL) is a rare entity of primary T cell lymphoma, characterized by pancytopenia, hepato-splenomegaly, and sinusoidal or sinusal infiltration of the liver and the spleen. This report describes a rare presentation of a case of HSTL with left shift leukocytosis, thrombocytosis, mild hepatomegaly along with an initial presentation of acute fulminant hepatic failure and bone marrow picture further confusing with chronic myelomonocytic leukemia(CMML). Contrary to the initial suspicion of hepatic infiltration of CMML, ultrasound guided liver biopsy showed leukemic infiltration into hepatic sinusoids with minimal cholestasis. Specific immunostaining of bone marrow revealed predominance of CD3+ T cells with negativity for other cell surface markers. Genetic analysis of bone marrow demonstrated trisomy 8 and isochromosome 7q, thus strongly suggesting hepatosplenic T-cell lymphoma (HSTL). This case report describes the complexity of diagnosing hepatosplenic T-cell lymphoma in a patient presenting with advanced liver disease and bone marrow biopsy finding initially suggestive of CMML.

Acute Fulminant Hepatic Failure Due to Hepatosplenic T-cell Lymphoma Mimicking Infiltrative Chronic Myelomonocytic Leukemia

Background: Hepatosplenic T-cell lymphoma (HSTL) was reported as a distinct lymphoma entity by Farcet et al with poor prognosis and almost 100% mortality within 2 years. HSTL commonly presents with pancytopenia. This report describes a rare presentation of a case of HSTL with leukocytosis, acute fulminant hepatic failure and bone marrow picture further confusing with chronic myelomonocytic leukemia (CMML). Case Report: A 58-year-old Caucassian male with mild mental retardation presented with bilateral swelling of lower extremities. Initial blood work-up showed leukocytosis with left-shift, thrombocytosis and elevated liver enzymes. The patient's previous documented blood picture obtained 4-5 years earlier was normal. Preliminary bone marrow biopsy was hypercellular and suggestive of either myelodysplastic syndrome or CMML with a possible progression to acute leukemia. Contrary to the initial suspicion of hepatic infiltration of CMML, ultrasound guided liver biopsy showed leukemic infiltration (Figure) into hepatic sinusoids with minimal cholestasis. Specific immunostaining of bone marrow revealed predominance of CD3+ T cells with negativity for other cell surface markers. Genetic analysis of bone marrow demonstrated trisomy 8 and isochromosome 7q, thus strongly suggesting HSTL. After discussing the prognosis and treatment options, patient and family members opted for hospice care and comfort measures. Conclusion: Hepatosplenic T cell lymphoma although predominantly presents with pancytopenia and thrombocytopenia, could also present with leucocytosis and thrombocytosis. Sinusoidal infiltration of liver with hypercellular marrow should raise a high suspicion of hepatosplenic T cell lymphoma.Figure. CD3: staining of showing T-cell predominance.

Granulocytic Sarcoma of the Stomach Presenting as Dysphagia during Pregnancy

Granulocytic sarcoma also known as extramedullary myeloid sarcoma or chloroma is an uncommon manifestation of leukemia and presents as a deposit of leukemic cells outside the bone marrow. We report a case of a twenty-five-year-old pregnant woman who presented with progressive dysphagia and recurrent postprandial vomiting. Upper GI endoscopy had shown large flat laterally spread nodular lesions in the cardia and proximal body of stomach. Biopsies from the gastric lesion showed granulocytic sarcoma of the stomach. Concurrent peripheral and bone marrow picture was suggestive of acute myeloid leukemia (AML–M4). There is limited reported literature on granulocytic sarcoma of the stomach. Concurrent gastric granulocytic sarcoma involving cardia and AML in pregnancy has not been reported till date.

Vitamin E and N-Acetylcysteine as Antioxidant Adjuvant Therapy in Children with Acute Lymphoblastic Leukemia

Although cancer therapies have experienced great success nowadays, yet the associated toxic response and free radicals formation have resulted in significant number of treatment-induced deaths rather than disease-induced fatalities. Complications of chemotherapy have forced physicians to study antioxidant use as adjunctive treatment in cancer. This study aimed to evaluate the antioxidant role of vitamin E and N-acetyl cysteine (NAC) in overcoming treatment-induced toxicity in acute lymphoblastic leukaemia (ALL) during the intensive period of chemo-/radiotherapy, almost the first two months of treatment. Forty children newly diagnosed with ALL were enrolled in this study. Twenty children (group I) have taken vitamin E and NAC supplementations with chemotherapy and the other twenty children (group II) have not taken any adjuvant antioxidant therapy. They were evaluated clinically for the occurrence of complications and by the laboratory parameters (blood levels of glutathione peroxidase (Glu.PX) antioxidant enzyme, malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), liver enzymes, and bone marrow picture). Results revealed reduced chemotherapy and radiotherapy toxicity as evidenced by decreasing level of MDA, increasing level of Glu.Px and decreased occurrence of toxic hepatitis, haematological complications, and need for blood and platelet transfusions in group I compared to group II. We can conclude that vitamin E and NAC have been shown to be effective as antioxidant adjuvant therapy in children with ALL to reduce chemo-/radiotherapy-related toxicities during the initial period of treatment.

Identification of Two 7q Genes Encoding Centrosomal Proteins as Myeloid Tumor-Suppressor Candidates.

We previously reported a candidate myeloid tumor-suppressor gene Miki (mitotic kinetic regulator, LOC253012) isolated from a common microdeletion cluster in chromosome subband 7q21.2 that was identified by microarray-based CGH analyses of JMML (ASH Annual Meeting, 2006 and 2007). Deletion of one Miki gene was also detected in 28 % of adult MDS/AML patients by copy-number assessment using real-time quantitative PCR (qPCR). Miki encodes a centrosomal protein: downregulation of Miki by siRNA disturbs the maturation and positioning of centrosomes, as well as spindle formation in mitotic cells, resulting in severe mitotic defects, such as chromosome lagging and proanaphase arrest. This causes abnormal nuclear morphology. When Miki expression levels were constitutively reduced by short-hairpin (sh) RNA in K562 cells, morphology of cells changed drastically: bi- tri- or multiple-nuclear cells with or without micronuclei appeared frequently that strikingly resembled the bone marrow picture of MDS. In addition, FISH analysis revealed widely varying chromosome numbers in these cells, suggesting that Miki-downregulation induces chromosome instability. Six myeloid leukemia cell lines derived from MDS/AML patients with monosomy 7 generally expressed Miki protein at very low (but detectable) levels, suggesting that haploinsufficient effects and/or epigenetic mechanisms reduce Miki expression levels. These six lines harboring monosomy 7 showed severe abnormal mitosis and nuclear morphology, and induction of Miki to these cells using a retroviral vector restored normal mitosis. These findings suggested that loss of Miki gene contributes to myelodysplasia and chromosome instability, which are characteristic of -7/7q- MDS/AML. To elucidate molecular mechanism through which Miki plays roles in centrosomal maturation and spindle formation, we tried to identify proteins associated with Miki using yeast two hybrid assay or mass spectrometry and found that a centrosomal giant scaffold protein CG-NAP (also known as AKAP9/AKAP450/yotiao) binds to Miki in a G2/M specific manner. Intriguingly, CG-NAP gene locates to subband 7q21.2, 1.2 Mb centromeric to Miki gene. qPCR revealed that CG-NAP was also frequently deleted in adult MDS/AML (36 %) and protein expression levels were very low (but detectable) in six cell lines derived from MDS/AML with monosomy 7, raising a possibility that CG-NAP is another candidate for the responsible genes of 7q deletion. CG-NAP is known to promote microtubule nucleation in centrosomes. As expected, downregulation of CG-NAP by siRNA showed abnormal spindle formation and mitotic disturbance (proanaphase arrest and chromosome lagging) similar to those by Miki-downregulation. Moreover, constitutive downregulation of CG-NAP by shRNA transformed K562 cells to bi- tri- or multiple-nuclear with or without micronuclei, indicating that the Miki/CG-NAP protein complex is responsible for the mitotic disturbance and abnormal nuclear morphology. Finally, we found that CG-NAP does not localize to mitotic centrosomes when Miki expression is downregulated by siRNA, suggesting that Miki contributes to organized progression of mitosis by transporting and/or anchoring CG-NAP to mitotic centrosomes. Our data indicate that Miki and CG-NAP in subband 7q21.2 encode centrosomal proteins, which play critical roles in mitosis. Loss of one 7q allele would cause marked reduction of these two gene products, resulting in myelodysplasia and chromosome instability.

Hematological Abnormalities in Copper Deficiency.

Introduction: Copper deficiency can rarely present as anemia and leucopenia. Copper and iron are essential trace elements through their functions as co-factors in numerous biochemical reactions. Hephaestin is a transmembrane copper-dependent ferroxidase necessary for effective iron transport from intestinal enterocyte into the circulation. Copper is hence required for the efficient utilization of iron in the mammalian system. Copper enzymes such as superoxide dismutase and cytochrome oxidase have an essential role in red cell development and heme maturation. We present 4 patients of copper deficiency. The first patient presented with anemia and leucopenia and the bone marrow showed increased vacuolated erythroblasts with and erythroid dysplasia. This patient had a bone marrow picture resembling erythroleukemia. However, as this patient had undergone a gastric bypass, further studies in the form of vitamin B12, red cell folate and copper were performed. Patient was found to have low copper and low ceruloplasmin levels, with normal B12 and red cell folate levels. Three patients had anemia and neutropenia and showed dysplasia in erythroid lineage, ring sideroblasts, and abnormal accumulation of iron granules in plasma cells. In all four cases, repletion of copper resulted in normalization of peripheral counts and bone marrow showed normal trilineage hematopoiesis.Discussion: Copper deficiency is known to present with microcytic anemia. However we report three cases in which patients presented as normocytic anemia and neutropenia.Bone marrow findings in addition to dysplasia, also showed abnormal iron granules in plasma cells as well as ring sideroblasts. Presence of ringed sideroblasts in myelodysplasia is associated with numerous point mutations in mitochondrial DNA. Mutations identified to date involve among others the cytochrome oxidase subunits I and II. Cytochrome c oxidase is involved in oxidizing FE++ to Fe+++ and incorporation into heme. Copper is a component of cytochrome c oxidase and superoxide dismutase and its deficiency leads to low levels of these enzymes. We propose that copper deficiency plays role in causing dysplastic changes in bone marrow and increase in ringed sideroblasts. Any patient presenting with unexplained anemia or leucopenia, with dysplasia and ringed sideroblasts should be evaluated for copper deficiency. Abnormal iron granules in plasma cells have been reported in other conditions like ethanol toxicity, however we report two patients with copper deficiency who were found to have iron granules in plasma cells. We consider copper an important component of the work-up of patients thought to have myelodysplasia especially if they have undergone a gastric bypass and have normal cytogenetics which is not suggestive of clonal hematopoiesis.Hematological abnormalities in patients with copper deficiencypatient 1anemianeutropenianormocyticpatient 2anemianeutropenianormocyticpatient 3anemianeutropeniamicrocyticpatient 4anemianeutropenianormocyticbone marrow findings in patients with copper deficiencyerythroidsmyeloidring sideroblastsiron granules in plama cellspatient 1dysplastichypoplasianoneabnormal iron granules in plama cellspatient 2dysplasticdysplasia15%abnormal iron granules in plasma cellspatient 3dysplastichypoplasianonenonepatient 4dysplasticdysplasianonenone

Downregulation of a Candidate Myeloid Tumor Suppressor Gene Isolated from 7q21 Induces Abnormal Mitosis Due to Insufficient Centrosome Maturation.

To isolate myeloid tumor suppressor gene(s) in 7q, we searched microdeletions in a region spanning 21.7 Mb within 7q21.2–7q31.1 using a microarray-based CGH system. By investigation of 21 childhood myeloid leukemia patients with normal karyotype, we identified a common microdeletion cluster spanning approximately 120 Kb in the 7q21.3 subband. Eight (38%) patients shared this microdeletion, which was not detected in normal individuals. Real-time quantitative PCR revealed that this region is also deleted in 9 (29%) out of 31 adult RAEB and AML patients. Database search revealed that this region contains three hypothetical genes. Among them, we chose one previously uncharacterized gene for further investigation and named Miki (mitotic kinetics regulator) for the function of its gene product, described below. Immunoblot analysis revealed high levels of Miki expression in most lymphoid leukemia cell lines, while half of myeloid leukemia cell lines expressed Miki at reduced levels. In six leukemia lines carrying monosomy 7, expression levels were generally low. Miki co-localized with the Golgi apparatus in the interphase and with centrosomes and spindles in the mitotic phase. To test the function of Miki, we used si-RNAs to downregulate Miki expression in HeLa and K562 cells, both of which show basically normal metaphase and nuclear morphology. Cells expressing Miki at reduced levels showed insufficient maturation and disturbed positioning of centrosomes, resulting in unorganized spindles including loss of spindle tension, curled and fragile spindles, or even completely disturbed spindle formation. Time-lapse observation revealed prometaphase and/or metaphase delay with unaligned or even totally scattered chromosomes in prometaphase in virtually all cells in the mitotic phase. As a result, cells underwent pre-anaphase arrest and exited mitosis in the absence of chromosome segregation or terminated mitosis by cell death. In the interphase, there were many cells with chromatid bridges and/or bi- or tri-nuclear or even multinuclear cells with micronuclei that resembled pathological cells routinely observed in the bone marrow pictures of MDS patients. Interestingly, myeloid cell lines with low Miki expression, including those with monosomy 7, generally showed abnormal mitosis such as scattered chromosomes and abnormal nuclear morphologies (multi-nuclear cells with small nuclei) at higher frequency than cell lines expressing Miki at high levels. Moreover, induction of Miki restores normal mitosis in leukemia cells with monosomy 7. Miki was poly(ADP-ribosyl)ated (PARsylated) in late G2 to M phase by tankyrase-1, one of PAR polymerase (PARP), and tankyrase-1 activity was required for the binding of Miki to spindles and centrosomes. These data suggest that loss of Miki gene contributes to the development and progression of MDS by disturbing mitosis.

Multiorgan involvement due to cytomegalovirus infection in AIDS

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

The Treatment of Delayed Rejection after Boosting of Mononuclear Cells of Her Mother and Chronic Graft Versus Host Disease in Leukemia Recipient Who Underwent Allogeneic Hyplo-Identical Transplantation in Second Remission with Therapeutic Plasma Exchange.

Patient is a Chinese girl of 13 years. She had fever, weakness, headache, and was hospitalized on Feb 20th, 2003. There were 0.89 leukemic monocytes in her bone marrow smear at diagnosis. She was diagnosed acute monoblastic leukemia (M5b) according to FAB classification. The immunophenotyping of bone marrow cells showed CD13 0.579, CD15 0.289, CD33 0.78, cMPO 0.27. After the second remission, she underwent hyplo-identical, ABO-matched combination transplantation of bone marrow and peripheral blood stem cells of her donor mother with T-cell deletion in Aug. 2005. Her hemapoiesis recovered at +10d after transplantation. The while complete blood cell count recovered at +31d when the TCR-PCR DNA gene map was showed the chimera. The rejection appeared at +60d. Her blood picture showed Hb 63g/L, Plt 1.0×109/L, WBC 0.4×109/L. The bone marrow picture showed hypo-cellular as same as in severe aplastic anemia. The TCR-PCR DNA gene map showed the 3/16 locus of recipient. The schedule of treatment of delayed rejection was the combination of Cyclosporin A (CsA), Mycophemolate Mofeil (MMF) and Methylprednisolone (MP). She boosted the G-CSF-primed peripheral mononuclear cells of her mother. The cell dose was 4.3×108/kg without T-deletion. Then she received the stimulation of G-CSF 250 ug daily. One week later, she suffered from Herpes Zoster Virus (HZV) infection. There was characteristic HZV varicella in full right side of head, right face, right eye, and right hand with high fever, malaise. She felt severe postherpetic neuralgia. Only morphine or remain acupuncture can relieve her severe neuralgia. She had also severe pancytopenia, gastrointestinal bleeding. We had to transfuse backed red cell and platelet concentration every week. She received first TPE at +130d and second TPE at +137d after transplantation. Dramatic results were gotten after the two TPE. After TPE she did not need transfusion again. After the third TPE, she was discharged then had treated small dose of CsA for half year. The STR-PCR DNA gene map showed the gene type from her mother. At +311d she suffered from chronic graft versus disease (cGVHD). The skin lesion involved her whole body skin about was about 50% body surface area. The effect had not received after treatment with TPE. The cGVHD had not controlled after the basic treatment with CsA or Sirolimus (FK506), MMF, MP, and Thalidomide 100–400 mg/d. So we added with ultraviolet-B irradiation (UV-B) therapy with dose of narrowbank UV-B, twice a week. The lichenification planum was disappearing. The mechanism of TPE on delayed rejection in ABO-unmatched, allogeneic stem cell transplantation has been clear. But, it is still not clear in ABO-matched and hyplo-identical allogeneic stem cell transplantation. It may be cause humoral rejection as same as ABO-incompatible stem cell or solid organ transplantation. The antibodies have resulted from hyplo-identical allogeneic stem cell of her mother. The mechanism of cGVHD results from donor T-lymphocyte activated and involves skin, liver, gut and so on. It is effective of treatment of cGVHD with immune inhibitor drugs but with TPE. Recently reported ECP is effective because the method result in suppressing the activated T-lymphocyte in recipient.