Normal Blood Count Research Articles

What is the origin of the normal ranges of blood cell counts? An evolutionary perspective

AbstractBackgroundThe normal values of the complete blood count are part of the foundational medical knowledge that is seldom questioned due to their well‐established nature. These normal values are critical for optimal physiological function while minimizing the harmful consequences of an excessive number of blood cells. Thus, they represent an evolutionary trade‐off likely shaped by natural selection if they significantly influence individual fitness and exhibit heritability.MethodsOn the basis of the analysis of normal blood count values of 94 mammalian species, we discovered that certain parameters are strongly associated with diet, habitat, and lifespan.ResultsCarnivorous mammals had higher hemoglobin levels than vegetarians, and aquatic mammals displayed red blood cell parameters probably selected to enhance for the diving capacities. Body weight influenced platelet counts and innate immune cells, with lighter animals having higher platelet counts and larger animals showing elevated monocytes and neutrophils.ConclusionsBy treating the history of life as an experiment, we have discerned some evolutionary constraints likely contributing to the selection for optimal trade‐offs in blood cell count.

A Variable Clinical Presentation of Hemoglobin City of Hope.

Hemoglobin City of Hope (Hb-COH), NC_000011.9(NM_000518.5):c.208G > A; NP_000509.1:p.(Gly70Ser), has rarely been described. The presentation ranges from asymptomatic heterozygosity to significant anemia in patients carrying an additional pathogenic variant in β-globin. To elucidate the clinical spectrum of Hb-COH, we analyzed 31 individuals carrying the variant, including, for the first time, homozygous individuals. Seven patients who were compound heterozygous for Hb-COH and an additional variant in β-globin, presented with mild-to-severe microcytic anemia and elevated hemoglobin-A2. Three (43%) of these also had elevated fetal hemoglobin, but none required blood transfusions. Seven patients coinherited Hb-COH with an -α3.7-deletion (NG_000006.1:g.34247_38050del), their presentation ranged from mild microcytic anemia to normal blood counts. Three homozygous and 14 heterozygous individuals for Hb-COH had normal blood counts. Most Hb-COH alleles whose origin was traceable were from Ashkenazi Jews (70.4%). To conclude, while isolated Hb-COH appears asymptomatic even in the homozygous state, it may cause significant anemia when coinherited with an additional pathogenic variant in β-globin. Understanding the full impact of Hb-COH is crucial for optimal patient management and for genetic counseling.

“Unmasking the Uncommon”: A case series of multi-drug resistant Elizabethkingia meningoseptica causing late-onset sepsis and meningitis in preterm neonates

Elizabethkingia meningoseptica is an uncommon nosocomial pathogen that causes meningitis, pneumonia, and sepsis in neonates and in immunocompromised individuals. It exhibits resistance to many commonly employed first-line antibiotics used to treat gram-negative pathogens. Herein, we present three cases of late-onset sepsis with multi-drug resistant (MDR) Elizabethkingia meningoseptica in high-risk neonates. Case 1 was a one-day-old preterm low-birth-weight infant who presented with respiratory distress syndrome and septic shock. The patient was intubated and administered empirical broad-spectrum antibiotics and antifungal agents. Blood culture grew Candida krusei, hence Amphotericin B was initiated. Repeat blood culture on day 27 showed gram-negative bacilli, identified as Elizabethkingia meningoseptica by MALDI-TOF . Antibiotic susceptibility testing (AST) revealed resistance to Piperacillin/Tazobactam, but sensitivity to Vancomycin, Levofloxacin, and Minocycline. IV Vancomycin was administered, which resulted in clinical improvement and negative blood culture results. Case 2 was an eleven-day-old preterm, low-birth-weight baby who presented with fever. Initial investigations revealed normal complete blood counts (CBC) parameters and elevated CRP levels. Blood and CSF cultures isolated Elizabethkingia meningoseptica with a similar AST pattern. Intravenous Ciprofloxacin was initiated with clinical improvement and negative follow-up blood cultures. Case 3 was a one-day-old preterm baby, appropriate-to-gestational age, presenting with respiratory distress syndrome. The infant was intubated and started on inotropic support and intravenous antibiotics. Blood cultures on day 4 showed Elizabethkingia meningoseptica and Vancomycin was started. Follow-up cultures on days 6 and 14 grew Acinetobacter baumannii. A combination of Levofloxacin and Colistin was added, and blood cultures were negative after seven days, with clinical improvement. Elizabethkingia meningoseptica is a significant cause of hospital-acquired infections, especially in Neonatal Intensive Care Unit (NICU), leading to outbreaks. Clinicians must have a high degree of suspicion of E. meningoseptica for gram-negative bacilli causing sepsis and meningitis in high-risk patients. Recent technological advances have enabled accurate speciation to guide therapy and reduce morbidity and mortality rates.

Chronic appendicitis misdiagnosed as a periappendiceal orifice polyp: a case report

BackgroundUnlike acute appendicitis, chronic appendicitis is characterized by nonspecific abdominal pain and intermittent course. This may lead to late diagnosis or misdiagnosis, with the possibility of serious complications.Case reportA male patient of Arab origin aged 55 years had a 2-year history of recurrent episodes of mild pain in the right lower quadrant of the abdomen. The episodes were associated with nausea, chills, and abdominal bloating but no vomiting, rectal bleeding, or weight loss. On examination, the patient showed soft and lax abdomen with mild tenderness in the right lower quadrant, with no organomegaly or abdominal masses. Laboratory findings showed normal complete blood count and C-reactive protein. The patient underwent colonoscopy to rule out malignancy, which showed appendiceal orifice polyp that required resection. The computed tomography scan showed an enlarged appendix with multiple intraluminal dense appendicoliths. The largest stone at the appendiceal orifice measured 1.5 cm × 0.9 cm and was partially protruding within the cecal lumen. The diagnosis of chronic appendicitis was confirmed. The patient underwent appendectomy and was asymptomatic a few days after discharge.ConclusionsWe are reporting a patient with chronic appendicitis presented with multiple appendicoliths. The patient was initially misdiagnosed as periappendiceal orifice polyp. The current finding highlights the importance of imaging, especially computed tomography in confirming the diagnosis in patients with atypical appendicitis presentation.

DDX41 dissolves G-quadruplexes to maintain erythroid genome integrity and prevent cGAS-mediated cell death.

Deleterious germline DDX41 variants constitute the most common inherited predisposition disorder linked to myeloid neoplasms (MNs). The role of DDX41 in hematopoiesis and how its germline and somatic mutations contribute to MNs remain unclear. Here we show that DDX41 is essential for erythropoiesis but dispensable for the development of other hematopoietic lineages. Using stage-specific Cre models for erythropoiesis, we reveal that Ddx41 knockout in early erythropoiesis is embryonically lethal, while knockout in late-stage terminal erythropoiesis allows mice to survive with normal blood counts. DDX41 deficiency induces a significant upregulation of G-quadruplexes (G4), noncanonical DNA structures that tend to accumulate in the early stages of erythroid precursors. We show that DDX41 co-localizes with G4 on the erythroid genome. DDX41 directly binds to and dissolves G4, which is significantly compromised in MN-associated DDX41 mutants. Accumulation of G4 by DDX41 deficiency induces erythroid genome instability, defects in ribosomal biogenesis, and upregulation of p53. However, p53 deficiency does not rescue the embryonic death of Ddx41 hematopoietic-specific knockout mice. In parallel, genome instability also activates the cGas-Sting pathway, which is detrimental to survival since cGas-deficient and hematopoietic-specific Ddx41 knockout mice are viable without detectable hematologic phenotypes, although these mice continue to show erythroid ribosomal defects and upregulation of p53. These findings are further supported by data from a DDX41 mutated MN patient and human iPSC-derived bone marrow organoids. Our study establishes DDX41 as a G4 dissolver, essential for erythroid genome stability and suppressing the cGAS-STING pathway.

Treatment of the blood cancer polycythemia vera with ruxolitinib in the MAJIC-PV study: a plain language summary.

[Figure: see text].

First-line treatment of severe aplastic anemia: immunosuppressive therapy plus eltrombopag versus haploidentical hematopoietic stem cell transplantation, a multicenter prospective study.

Matched-related donor hematopoietic stem cell transplantation (HSCT) remains the preferred first-line option for severe aplastic anemia (SAA) patients aged <40 years even in the era of eltrombopag (EPAG). However, there has not been any direct comparison between immunosuppressive therapy (IST) plus EPAG (IST + EPAG) and haploidentical HSCT (Haplo-HSCT) as first-line therapy. This study prospectively compared the efficacy, safety and health-related quality of life (HRQoL) of Haplo-HSCT (n = 147) and IST + EPAG (n = 121) as first-line treatment for patients with SAA. The results showed that 86.3% of patients in the Haplo-HSCT group and 24.1% of patients in the IST + EPAG group achieved normal complete blood count (CBC) (P < 0.001) after 6 months of treatment. The time to achieve transfusion independence and absolute neutrophil count ≥ 1.0 × 109/L were shorter in the Haplo-HSCT group than in the IST + EPAG group (P < 0.05). In the IST + EPAG and Haplo-HSCT, 3-year overall survival (OS) was 92.4 ± 2.4% and 82.8 ± 3.1% (P = 0.017), whereas 3-year failure-free survival (FFS) was 69.4 ± 4.2% and 81.6 ± 3.2% (P = 0.002), respectively. Similar results were observed in patients with <40 years of age. Among patients with ≥40 years of age, there was no difference in 3-year OS (88.6 ± 4.8% vs. 82.4 ± 8.1%, P = 0.517) between the IST + EPAG and Haplo-HSCT groups, whereas 3-year FFS was lower in the IST + EPAG (58.7 ± 7.5% vs. 82.4 ± 8.1%, P = 0.043). Subgroup analysis for populations aged <40 years indicated that SAA benefited more from IST + EPAG, and very SAA (vSAA) benefited more from Haplo-HSCT. Patients treated with haplo-HSCT scored significantly better in the HRQoL than treated with IST + EPAG (P < 0.0001). Multivariate analysis showed that first-line Haplo-HSCT was associated with normal CBC at 6 months, better FFS and led to a better HRQoL (P < 0.001). In summary, the IST + EPAG achieved better OS for <40 years SAA patients, while the Haplo-HSCT accelerated hematopoietic recovery and HRQoL, achieved better FFS even for those <40 years vSAA and ≥40 years patients.

JAK2 Mutation Assessment in Thrombotic Events at Unusual Anatomical Sites: Insights from a High-Altitude Cohort.

Thrombosis stands as a significant contributor to both morbidity and mortality in individuals afflicted with myeloproliferative neoplasms. This retrospective study investigated the association between JAK2 mutations and venous thrombosis at unusual sites, and in young individuals with ischemic stroke, residing at high altitudes in the Aseer region, Saudi Arabia. Data were collected from two high-altitude referral hospitals over three years (2020-2022). Records of all JAK2 mutation tests were reviewed. Those requested as part of evaluation of thrombosis events, without known myeloproliferative neoplasms (MPNs) were analysed. Among the 208 JAK2 tests, 40 (19.2%) were linked to thrombotic event evaluations. The cohort, with a median age of 41, included 17 (42.7%) males and 23 females, with 57.5% having completely normal complete blood counts (CBC). Thrombotic events were divided between splanchnic vein thrombosis (36.6%) and cerebral thrombosis (34.1%), while the remaining cases involved unprovoked deep vein thromboses/pulmonary embolisms and portal vein thrombosis. Only 2 (5%) participants tested positive for JAK2 mutations: a 17-year-old male diagnosed concurrently with polycythemia vera after renal vein thrombosis and a 31-year-old woman with hepatic vein thrombosis and a normal CBC. This study reveals that JAK2 mutations are infrequently found in high-altitude patients with unprovoked DVT, PE, or atypical thrombosis. While JAK2 testing is notably relevant for splanchnic vein thrombosis, its routine use for other thrombotic events, particularly with normal CBC results, remains uncertain. Given the study's limitations, further prospective research with larger cohorts is needed to refine guidelines for JAK2 mutation testing in various thrombotic contexts.

Association of normal levels of both haemoglobin and white blood cells count with normality of complete blood count.

To assess the use of haemoglobin and white blood cell count together in predicting the normality of other complete blood count parameters and blood film. The prospective study was conducted from August to November 2021 at Al-Yarmouk Teaching Hospital, Baghdad, Iraq, and comprised adult individuals of either gender who were advised blood test by physicians in the outpatient department. Patients with normal haemoglobin and white blood cell counts were placed in group A, while those with abnormal counts of the two parameters were placed in group B. Examination of blood smears morphology was done in both groups. Data was analysed using SPSS 26. Of the 200 subjects, 100(50%) were in group A; 58(58%) males and 42(42%) females with mean age 51.09±18.8 years. There were 100(50%) subjects in group B; 52(52%) males and 48(48%) females with mean age 47.58±15.5 years (p>0.05). In group A, 70(70%) cases showed normal complete blood count parameters and abnormal morphology of 1+ grading in 13(13%). The results were significantly different than group B (p<0.05). Normal haemoglobin and white blood cell count was found to a good marker for the normality of other complete blood count parameters.

Emapalumab as a therapeutic intervention for Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis: A case series.

Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH) is characterized by a severe cytokine storm, heightened inflammatory response, and immune-mediated damage to tissues and organs. Standard treatment protocols for hemophagocytic lymphohistiocytosis often fall short in effectively controlling EBV-HLH, leading to a need for novel therapeutic options. Emapalumab, a monoclonal antibody targeting interferon-gamma, has shown promise due to its targeted cytokine modulation capabilities and favorable safety profile. This study aimed to evaluate the efficacy and safety of emapalumab in pediatric patients with EBV-HLH. The case series involved 4 pediatric patients diagnosed with EBV-HLH who did not achieve disease control despite receiving comprehensive treatment. All 4 pediatric patients were diagnosed with EBV-HLH. Emapalumab was introduced as an adjunctive therapeutic intervention alongside the HLH-94 or L-DEP regimens for these patients. Among the 4 patients, 1 experienced severe multiorgan dysfunction and opted to discontinue therapy. The remaining 3 patients showed controlled disease progression with significant clinical improvements following emapalumab administration. These improvements included reduced levels of inflammatory markers, normalization of blood counts and liver function, and decreased Epstein-Barr virus viral load. The findings suggest that emapalumab may be an effective and safe treatment option for pediatric EBV-HLH. However, further research is necessary to confirm these outcomes, especially in critically ill patients.

Haematological features of telomere biology disorders diagnosed in adulthood: A French nationwide study of 127 patients.

Data on haematological features of telomere biology disorders (TBD) remain scarce. We describe haematological, extra-haematological characteristics and prognosis of 127 genetically confirmed TBD patients diagnosed after the age of 15. Ninety-three index cases and 34 affected relatives were included. At diagnosis of TBD, 76.3% of index cases had haematological features, half pulmonary features and a third liver features. At diagnosis, bone marrow failure (BMF) was present in 59 (46.5%), myelodysplastic syndrome (MDS) in 22 (17.3%) and acute myeloid leukaemia (AML) in 2 (1.6%) while 13 (10.2%) developed or worsened bone marrow involvement during follow-up. At diagnosis, compared to MDS/AML patients, BMF patients were younger (median 23.1 years vs. 43.8, p= 0.007), and had a better outcome (4-year overall survival 76.3% vs. 31.8%, p < 0.001). While frequencies and burden of cytogenetical and somatic mutations increased significantly in myeloid malignancies, some abnormalities were also observed in patients with normal blood counts and BMF, notably somatic spliceosome variants. Solid cancers developed in 8.7% patients, mainly human papillomavirus-related cancers and hepatocellular carcinomas. TBD is a multiorgan progressive disease. While BMF is the main haematological disorder, high-risk myeloid malignancies are common, and are, together with age, the only factors associated with a worse outcome.

Complete morphologic response to gilteritinib in ALK-rearranged acute myeloid leukemia

The cytogenetic abnormality inv(2)(p23q13) in acute myeloid leukemia (AML) results in a fusion of RANBP2 with ALK. This fusion makes ALK constitutively active and acts as a driver for the proliferation of AML cell lines. Gilteritinib, a FLT3 inhibitor approved in AML, also can inhibit ALK among other receptor tyrosine kinases. A 75-year-old-woman with a history of essential thrombocythemia (ET) and a presumed germline DDX41 mutation developed ALK-fusion positive AML and despite standard therapies was transfusion-dependent and globally declining. The patient has been on gilteritinib with an ongoing response of more than one year with near normal blood counts and no evidence of AML. The fact that she was found to harbor a presumed germline DDX41 alteration may account for why she developed, and yet survived, two myeloid neoplasms (ET and AML). Additionally, this demonstrates that gilteritinib is clinically active as an ALK inhibitor, and could be considered for use in any AML patient presenting with an inv(2(p23q13)) translocation. Finally, it is an example of using a disease-agnostic, precision medicine approach to arrive at a beneficial treatment.

A Mysterious Foe in a Case of Malaria: Rare Case of Coinfection with Review of the Literature

Parvovirus B19 and Plasmodium vivax coinfections are rarely documented. Parvovirus B19 may cause bone-marrow suppression, reticulocytopenia, and anemia in malaria patients. Here, we describe an 11-year-old boy with fever, jaundice, and anemia who was diagnosed with P. vivax and treated with chloroquine. Jaundice and fever subsided, but anemia persisted. A blood smear showed no malarial parasites after the completion of antimalarial treatment. Because of persisting anemia, a bone-marrow aspiration was requested, which revealed erythroid suppression and giant proerythroblast with nuclear inclusions. Parvovirus B19-specific IgM antibodies are also found in peripheral blood. The patient received supportive treatment and red blood cell transfusions. After 3 months, the patient was asymptomatic and had normal blood counts. Any chronic anemia should be examined for parvovirus B19 infection, even in cases of well-known factors of anemia. To the best of our knowledge, this is an index case of P. vivax and parvovirus B19 coinfection.

Molecular detection of Anaplasma phagocytophilum, Borrelia theileri and Severe fever with thrombocytopenia syndrome virus (SFTSV) in military working dogs and ticks collected from the Republic of Korea Army garrisons in Gangwon Province in 2021–2022

AbstractTick‐borne pathogens (TBPs) are an emerging concern to humans and animals in the Republic of Korea, especially within the military zones of Gangwon Province, a mountainous region abundant with wild fauna and ticks. This study aimed to detect six TBPs in military working dogs (MWDs) and ticks in this region using Nested polymerase chain reaction (nested PCR) and sequencing. The targeted pathogens included Anaplasma phagocytophilum, Bartonella henselae, Borrelia spp., Orientia tsutsugamushi, Severe fever with thrombocytopenia syndrome virus (SFTSV) and tick‐borne encephalitis virus (TBEV). A total of 164 serum samples from MWDs were collected at the Korean Army Military working dog training center and 1418 ticks were collected at various training sites between June 2021 and August 2022. Haemaphysalis longicornis was identified as the predominant species (98.3%, n = 1394), followed by Haemaphysalis flava (1.6%, n = 22) and Ixodes nipponensis (0.1%, n = 2). This study detected A. phagocytophilum and Borrelia theileri in 1.4% (1/72) of the tick pools and detected SFTSV in 0.6% (1/164) of MWD serum samples. The MWD found to be infected with SFTS was a German Shepherd, but showed no significant clinical signs, with a normal complete blood count (CBC). In the phylogenetic analysis, three sequences were acquired. One sequence (OR865211) exhibited 100% homology with 16S rRNA of A. phagocytophilum identified from animals and human patients in the Republic of Korea. Another sequence (OR865152) displayed 99.34%–100% sequence similarity with 16S rRNA of B. theileri fragments. The third sequence (OR865115), which belongs to the SFTS B‐1 genotype, showed 94.7% sequence similarity to a strain identified in the Republic of Korea (KY789441).

Discrepancies between two total IgE assays and difference in reference intervals in healthy adults

ObjectiveTo compare total immunoglobulin (Ig) E assay performance characteristics between Abbott Architect and Siemens Immulite test systems. Reference intervals were also determined for both platforms in an American population of healthy adults. MethodsAgreement of the two total IgE assays was evaluated in a cohort of 331 subjects with normal complete blood count (CBC) and comprehensive metabolic panel (CMP) results. Reference intervals were established in 302 subjects after exclusion of atopic individuals on the Abbott Architect and Siemens Immulite test systems. ResultsWe demonstrated a 32% positive bias for total IgE quantitation on the Siemens Immulite platform compared to the Abbott Architect, despite both methods calibrated against the same WHO international reference material (75/502), Furthermore, the upper limit of the reference interval (95th percentile) was determined to be higher for the Siemens Immulite assay compared to the Abbott Architect (132 and 102 IU/mL, respectively). ConclusionDespite the use of a common WHO reference material for total IgE assay calibration, significant differences in quantitation was observed between two FDA-cleared test systems. Given that, it is warranted for clinical laboratories to verify vendor established reference intervals and adjust accordingly based on internal assessment of the normal range.

#3092 Case report: Renal cystic disease caused to heterozygous NEK8 variant in pediatric patient

Abstract Background and Aims Polycystic kidney diseases (PKDs) are the most prevalent inherited kidney disease [1]. They are caused by pathogenic variants in genes encoding for proteins with roles in the functioning of primary cilium, a sensory organelle at the cell surface of almost all cells regulating key signaling pathways. Therefore, they are also classified as Ciliopathy and can occur with isolated renal involvement with/without systemic manifestations. As 1 of the family of “Never in Mitosis A–related kinases” (NEK), NEK8 is a regulator of Hippo pathway that controls cell growth, regulate the renal tubule epithelial cell cytoskeletal structure, and is involved in ciliary biogenesis/function. Biallelic NEK8 mutations are reported as causing a syndromic ciliopathy with multiorgan developmental defects, referred to as renal-hepatic-pancreatic dysplasia [1]. A recent paper [1] analyzed a total of 21 patients from 12 families with heterozygous NEK8 variants and cystic kidney disease and proposed a dominant negative effect for specific heterozygous variants in the NEK8 kinase domain as a new cause of PKD. Method We describe a case report of PKD associated with NEK8 heterozygous mutation. Results 8 years old female patient accessed to Emergency Department with first evidence of isolated macro-hematuria. Previous medical history was unremarkable. The girl was afebrile, in good clinical condition, with elevated blood pressure values (120/82 mmHg) at the physical examination. The laboratory tests showed normal blood count with hemoglobin 11.7 g/dl, serum creatinine 0.42 mg/dl, no inflammatory markers. Urinalysis revealed proteinuria (100 mg/dL), hemoglobinuria, active urinary sediment with microhematuria (3557 red blood cell/microliter) and leukocyturia (535 white blood cells/microliter). An abdominal ultrasound study observed kidneys of increased size (longitudinal diameter of approximately 14 cm) with presence of multiple cystic formations with a maximum diameter of 2 cm and lost cortico-medullary differentiation; other organs were normal. Ultrasound findings were confirmed with MRI. The macrohematuria resolved quickly, however we recorded the persistence of positive urinary sediment. No other concomitant clinical manifestations were recorded and the cardiological evaluation was normal. Suspecting a cystic renal disease, we proposed a genetic analysis by whole exome sequencing (WES): an heterozygous NEK8 variant (c.133C&amp;gt;T, p. Arg45Trp) was found. Due to persistent proteinuria and hypertension we suggested to initiate RAAS inhibitor treatment. Conclusion The patient's clinical history and onset of disease agree with the data described in the literature for the NEK8 variant c.133C&amp;gt;T, p. Arg45Trp. In literature all patients had an early onset of PKD. Enlarged kidney were present in 79%, followed by hypertension in 67% of cases; no patients had liver involvement, as in our patient. Kidney failure occurred before adulthood in non-mosaic case. The absence of a phenotype with systemic involvement, doesn't exclude the possible subsequent appearance of extra-renal manifestations. Therefore, it is necessary to set up a multidisciplinary follow-up, including cardiological evaluation and radiological study of brain structure. An early nephroprotective therapy and behavioral strategy must be established to prevent disease progression. Thus, it is suggested to include NEK8 in the genetic analysis when PKD is suspected.

A preliminary study of roxadustat in the treatment of aplastic anemia patients with inadequate erythroid responses

Some aplastic anemia(AA) patients only have partial hematological responses after immunosuppressive therapy. Failure to achieve complete normalization of blood counts, particularly hemoglobin, will reduce their quality of life. This open-label pilot study was conducted to evaluate the efficacy and safety of roxadustat in this setting. A total of 14 patients with AA who had inadequate erythroid response after immunosuppressive therapy were included in the study. The primary efficacy endpoint was hemoglobin response at week 8 after roxadustat treatment. The median duration of roxadustat therapy was 14 (4–30) weeks, with 12 patients receiving roxadustat for ≥ 8 weeks. At week 8, nine patients (9/14, 64.3%) had their hemoglobin rising for at least 15 g/L, with two patients (2/14, 14.3%) achieving normal hemoglobin levels. By the last follow-up, hemoglobin responses were observed in 10 patients (10/14, 71.4%), with 4 patients(4/14, 28.6%) having normal hemoglobin levels. Roxadustat was tapered or discontinued in four responded patients; one relapsed after 12 weeks of tapering, and three maintained their response. Four patients (4/14, 28.6%) experienced mild adverse effects during therapy. Roxadustat is safe and well tolerated by patients with AA. Treatment with the hypoxia-inducible factor prolyl hydroxylase inhibitor improves hemoglobin levels in AA patients with inadequate erythroid responses.

Seronegative Polyarticular Juvenile Idiopathic Arthritis: A Case Report.

Juvenile idiopathic arthritis (JIA) is a chronic rheumatologic childhood disorder of unknown etiology usually presenting with peripheral arthritis. Usually involving the small joints symmetrically, polyarticular JIA is characterized by involvement of 5 or more peripheral joints and is further categorized depending on RA Factor positivity. We aim to report a case of seronegative polyarticular JIA to increase awareness regarding this disease. A 15-year-old boy presented with 3-month history of bilateral symmetrical joint pains, swelling and morning stiffness lasting 3-4 hours. For his ankle and knee pain, he had consulted a local doctor who suspected Rheumatic Fever and started penicillin and analgesics resulting in minimal improvement. He was a student but was unable to attend school in last 2 months due to this illness and had become bed-bound for last 2 weeks. On examination, there was swelling and tenderness of ankles, knees, elbows, wrists, metacarpophalangeal and proximal interphalangeal joints bilaterally. On investigation, ESR, CRP and serum ferritin were raised with normal complete blood count, urinalysis, liver and renal function tests, ASO test, blood and urine cultures, TSH, serum CPK and serum aldolase. Echocardiography did not reveal any abnormalities. His ANA, RA factor and Anti-CCP antibodies were negative. He was diagnosed with Seronegative Polyarticular Juvenile Idiopathic Arthritis and started on oral prednisolone and methotrexate. Currently the patient is asymptomatic on methotrexate 20mg/week. Our patient with symmetrical polyarthritis had negative ANA, RA Factor and Anti-CCP antibodies leading to a diagnosis of seronegative polyarticular JIA. Early screening and prompt management of JIA is required to improve prognosis and reduce risk of disability. The differential diagnosis of childhood joint pains is wide and variable including diseases of autoimmune, cardiac and haematological systems. For diagnosis of JIA, arthritis persisting for more than 6 weeks with onset of symptoms prior to 16 years of age is required with exclusion of secondary causes of joint inflammation. Keywords: Juvenile Idiopathic Arthritis, ANA, RA Factor, Anti-CCP antibodies, Methotrexate.

Ophthalmic vascular manifestations in eosinophil-associated diseases: a comprehensive analysis of 57 patients from the CEREO and EESG networks and a literature review.

Eosinophils have widespread procoagulant effects. In daily practice, eosinophil-related cardiovascular toxicity consists of endomyocardial damage, eosinophilic vasculitis and arterial or venous thrombosis. Here we aim to report on the clinical features and treatment outcomes of patients with unexplained ophthalmic vascular manifestations and eosinophilia. We conducted a retrospective, multicenter, observational study and a literature review of patients with eosinophilia (≥0.5 x109/L) and concomitant ophthalmic vascular manifestations independent of the underlying eosinophilic disease but with no alternative cause for ophthalmic manifestations. Fifty-seven patients were included (20 from the observational study and 37 from the literature review). Ophthalmic vascular features were the initial manifestation of eosinophil-related disease in 34 (59%) patients and consisted of 29 central retinal artery occlusions, six branch retinal artery occlusions, five central retinal vein occlusions, two branch retinal vein occlusions, seven retinal vasculitides, two retinal vasospasms, 12 Purtscher's retinopathies, 13 anterior ischemic optic neuropathies and two posterior ischemic optic neuropathies. The median [IQR] absolute eosinophil count at onset of ophthalmic vascular manifestations was 3.5 [1.7-7.8] x109/L. Underlying eosinophil-related diseases included eosinophilic granulomatosis with polyangiitis (n=32), clonal hypereosinophilic syndrome (HES) (n=1), idiopathic HES (n=13), lymphocytic HES (n=2), adverse drug reactions (n=3), parasitosis (n=2), polyarteritis nodosa (n=1), IgG4-related disease (n=1), eosinophilic fasciitis (n=1) and primary sclerosing cholangitis (n=1). Other extra-ophthalmologic arterial or venous thromboses related to eosinophilia were reported in four (7%) and nine (16%) patients, respectively. Visual prognosis was poor: only eight (10%) patients achieved full recovery of ophthalmologic symptoms. After a median follow-up of 10.5 [1-18] months, one patient (3%) had a recurrence of an ophthalmic vascular manifestation, and three patients (10%) had a recurrence of other vascular symptoms (deep vein thrombosis in two and pulmonary embolism in one patient). At the time of recurrence, absolute eosinophil counts were above 0.5 x109/L in all cases (n=4). This study broadens the spectrum of vascular manifestations associated with hypereosinophilia by adding ophthalmic vascular manifestations. In patients with ophthalmological vascular manifestations and hypereosinophilia, aggressive treatment of the underlying pathology (and normalization of blood count) should be implemented.

Novel RP-HPLC method for estimation of a newly developed combination of tizanidine and etoricoxib in rat plasma: Eight criteria for greens evaluation.

A novel environmentally friendly reversed-phase high-performance liquid chromatography (RP-HPLC) method has been effectively validated for simultaneously measuring a prospective conjunction of tizanidine (TIZ) and etoricoxib (ETC), the combined medicine, in rat plasma. The technique employs diclofenac potassium as the internal standard, guaranteeing dependable and precise outcomes. This study aimed to assess the impact of the suggested combination therapy on treating inflammation resulting from rheumatoid arthritis (RA) in a rat model. The procedure was performed using an Agilent series 1200 model HPLC apparatus. The chromatographic conditions consist of isocratic elution mode, C18 column with dimensions of 150 mm × 4.6 mm × 5 µm, flow rate of 1.5 mL/min, wavelength of 230 nm, temperature of 50°C, and injection volume of 10 µL. The elution was performed using a mobile phase consisting of a phosphate buffer with a pH of 3.5 and acetonitrile in a ratio of 80:20 v/v. Calibration curves were conducted for TIZ and ETC within the 1-50 µg/mL range, demonstrating linear trends with R2 values over 0.999. The effectiveness and eco-friendliness of the proposed method were evaluated using eight separate environmentally conscious metrics. The addition of TIZ and ETC to arthritic rodents amplified these effects significantly. Furthermore, TIZ and ETC significantly reduced serum levels in arthritic rodents, and safety investigations revealed normal complete blood count, liver, and renal functions. TIZ and ETC appear to have antiarthritic, anti-inflammatory, and safe combinations, making them viable future treatment options for RA that are also safe and efficacious. Following validation by United States Food and Drug Administration(US-FDA) rules, all goods met the criteria.