Normochromic Research Articles

Case Report: Ehrlichiosis and Anaplasmosis in Timber Wolf Crossbreed (Canis lupus) in Bali, Indonesia

Pathogenic bacteria from the Anaplasmataceae family cause ehrlichiosis and anaplasmosis in animals, including dogs and wild carnivores (wolves, foxes, raccoons, and others). These diseases are emerging vector-borne diseases transmitted through ticks. A six-month-old timber wolf crossbreed (Canis lupus) came to the Veterinary Teaching Hospital, Faculty of Veterinary Medicine, Udayana University, Bali, Indonesia, with a history of weakness, decreased appetite, and excessive salivation. Examination revealed that the timber wolf crossbreed had pale mucosa, lethargy, hypersalivation, normochromic microcytic anemia, thrombocytopenia, gas accumulation in the stomach and intestine, and no foreign bodies in the digestive tract. Rapid test results with the SNAP® 4Dx® Plus Test IDEXX® were positive for Ehrlichia sp. and Anaplasma sp.; however, the blood smear examination was negative. The therapy for this case included sodium chloride 0,9% infusion as fluid therapy, atropine sulfate as symptomatic therapy, hematopoietic, multivitamin, iron supplementation as supportive therapy, and doxycycline antibiotic as causative therapy. The wolf showed decreased salivary excretion and ate 4 h after fluid therapy, atropine sulfate, and hematopoietic administration. The wolf improved their condition through increased appetite and became agile after seven days of treatment. The wolf was declared clinically cured after two weeks of doxycycline treatment.

Correlation of red blood cell parameters and platelet count among adult anemic patients attending Madda Walabu University Goba Referral Hospital, Goba, Southeast Ethiopia: A comparative cross-sectional study.

Anemia is a worldwide public health problem and is associated with platelet disorders. The relationship between anemia and platelets is complex, with the association being either normal platelet count or thrombocytosis. Platelets are significantly decreased in patients with anemia, and thrombocytopenia has been documented in patients with severe anemia. There are few reports in the literature on the correlation between platelet count and red blood cell parameters in anemic patients. Therefore, this study aimed to compare the correlation between red blood cell parameters and platelet count in adult anemic patients attending Madda Walabu University Goba Referral Hospital (MWUGRH): Goba, Southeast Ethiopia, from May 30 to July 30, 2022. A cross-sectional comparative study was conducted among 352 subjects (176 anemic and 176 controls) who attended the hospital during the study period and were recruited using a convenient sampling technique. Sociodemographic and other relevant variables were collected using a structured questionnaire. Four milliliters of venous blood were collected and placed in a K2EDTA tube for analysis of hematologic parameters using the Sysmex XN-550 (Sysmex Corp., Japan) automated hematology analyzer; the hemoglobin value was used to determine anemia status. Data were entered into Epidata Manager, version 4.6.0.2, and analyzed using SPSS Statistical Software, version 25. The independent-sample t-test was used to compare parameters between groups, and correlation statistics was used to correlate parameters between groups. Chi-square was used at a 95% confidence interval, considering P < .05 statistically significant for association among categorical variables. Correlation analysis showed that platelet count was significantly, positively correlated with RBC, and negatively correlated with MCV, MCH, and MCHC (r (P) = 0.168 (.026) and -0.252 (.000), -0.275 (.001), -0.218 (.004), respectively). It was also negatively correlated with HGB and HCT levels in the healthy control (r (P) = -0.266 (.000) and -0.149 (.049) respectively). Morphologically, 44.32% were microcytic hypochromic anemia, 53.98% were normocytic normochromic anemia and 1.70% were macrocytic anemia. The findings showed that platelet count variation correlates well with red cell indices and morphologic types of anemia in adult anemic patients. Such correlation will enable physicians to make diagnoses and administer treatments.

Anaemia in a child with chronical disease and a newly diagnosed hypoparathyreosis

Anemia of chronic patients is a secondary hematological syndrome, and most often accompanies infectious-inflammatory, immunopathological and tumor processes. The introduction discusses the importance of blood testing to assess the response of the immune and hematopoietic systems to various adverse effects. Various mechanisms are involved in the pathogenesis of anemia, among which the main place belongs to the action of proinflammatory cytokines. In many cases, sideropenia develops that is not associated with an absolute iron deficiency, but occurs as a result of the redistribution of iron reserves in the body. In some patients, diagnosis of various types of pathology begins with the detection of anemia. This requires a comprehensive examination of patients, the exclusion of primary hematological pathology and the detection of all concomitant diseases, including foci of infection. This article presents a clinical example of a multidisciplinary approach to the diagnosis of normochromic normocytic anemia, which resulted in the detection of endocrine pathology — hypoparathyroidism, and chronic foci of Epstein–Barr virus and streptococcal infection in a teenage girl. The peculiarity of the case was that the patient initially consulted a hematologist about mild anemia, but during the examination it became obvious that complaints of progressive weakness, fatigue, hand tremors, and dizziness could not be linked to the existing hematological pathology. Spastic disorders and tetany of the limb muscles that arose during the examination period became the reason for diagnosing metabolic disorders: determining creatine phosphokinase, serum myoglobin, blood electrolytes, including calcium and phosphorus, as well as hormones of the thyroid and parathyroid glands. The examination results showed that the severity of the girl’s condition and neurological symptoms were caused by severe metabolic changes, phosphorus-calcium metabolism disorders in the form of hypocalcemia, hyperphosphatemia, increasing levels of creatine phosphokinase, high levels of lactate dehydrogenase, and were due to endocrine pathology. The presence of neurological symptoms, changes in magnetic resonance imaging and electrocardiogram against the background of a significant decrease in parathyroid hormone, hypocalcemia, and increasing levels of creatine phosphokinase required the patient to be referred to the hospital with a diagnosis of “Hypoparathyroidism”. The presented clinical case confirms the need for an individual, multidisciplinary approach to the diagnosis of secondary anemic conditions, which will allow identifying pathology of various organs and systems.

Prevalence of Anemia in Heart Failure Patients Hospitalized in a Cardiology Department in Dakar, Senegal

The objectives of this study were to assess the prevalence of anemia in patients with heart failure, analyze the characteristics of anemia in this population, and identify prognostic factors related to anemia and heart failure. We conducted a descriptive and analytical retrospective study over a period of nine months, from April 1, 2018, to December 31, 2018. The study included patients aged over 18 years who were hospitalized in a cardiology department for heart failure of all causes, with hemoglobin levels strictly below 12 g/dl for women and 13 g/dl for men. Heart failure diagnosis was based on ESC 2016 criteria. The study was approved by the ethics committee of Cheikh Anta Diop University, Dakar. Data analysis was performed using SPSS 18 (Statistical Package for Social Sciences version 18), with a p-value of ≤ 0.05 considered statistically significant. We identified 182 patients with anemia, representing a hospital prevalence of 11.61%. The average age was 58.9 ± 15.93 years, with a female predominance in those under 50 years and a male predominance in those over 50. Most patients (77.1%) had a low socioeconomic status. Major cardiovascular risk factors included physical inactivity (56%) and hypertension (47%). Clinically, 78% of patients had dyspnea, 31.9% had chest pain, 40.7% had cutaneous-mucosal pallor, and 72.2% had global heart failure. Ischemic heart disease was the main cause of heart failure (49.2%). Diagnostic investigations revealed elevated ferritin in 50% of cases, elevated CRP in 88.1%, and elevated creatinine in 37.4%. The mean hemoglobin level was 11.6 ± 7.15 g/dl, with 71.4% of patients having hemoglobin between 10 and 13 g/dl. Normocytic normochromic anemia predominated. The study showed that anemia was more common in patients with an ejection fraction &amp;gt; 50% (48.1%) and those with global heart failure (72.2%). Statistically significant associations with severe and mild anemia were observed in the age groups 20-29 years (p=0.003) and 50-59 years (p=0.014) and with endocarditis (p=0.03). Only women showed severe and very severe anemia (p=0.21). The hospital mortality rate was 15.38%. In conclusion, this study reveals a significant prevalence of anemia among hospitalized patients, with important correlations between anemia and various clinical and socioeconomic factors.

The Erythrocyte Morphology of Pregnant Women with Undernutrition who Live in Archipelago Dry Land, Kupang City, East Indonesia

The prevalence of undernutrition of pregnant women remains high in Indonesia, and also deficiency of micronutrition such as iron, folic acid, or vitamin B which affected low level of hemoglobin. The insufficient hemoglobin levels in erythrocytes could disturb delivery oxygen needed to the tissues and fetus as well. The occurrence of anemia in pregnant women varies depending on diet, infections, lifestyle, environment, and socioeconomic factors. This study aims to describe the erythrocyte morphology of pregnant women in Kupang City, located in a dry island region. The research involved 24 pregnant women living in Kupang City, using a cross-sectional observational method. The results of erythrocyte morphology from peripheral blood smears showed that 12 subjects (50%) had microcytic hypochromic anemia and 1 subject (4.2%) had microcytic normochromic anemia. This indicates that, based on erythrocyte morphology, nutritional deficiencies and the possibility of chronic inflammation among pregnant women are still very high. Geographical background could be a predisposing factor for this anemia. Continuous education about adequate and balanced nutrition for pregnant women and further investigations to determine the etiology of inflammation are greatly needed.

Pyrexia of Unknown Origin in a Patient with Ankylosing Spondylitis: A Rare Case of Concurrent Adult-Onset Still's Disease

Background: Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the axial skeleton, with systemic symptoms such as fever being uncommon. Adult-onset Still’s disease (AOSD) is an autoinflammatory condition characterized by high-grade fever, rash, and polyarthritis. The co-occurrence of AS and AOSD is extremely rare and presents significant diagnostic challenges. This case report outlines the complexities involved in identifying and managing such an overlap. Case Presentation: A 37-year-old male with a history of AS presented with pyrexia of unknown origin (PUO), bilateral asymmetric polyarthritis, and a transient skin rash. Laboratory findings showed elevated inflammatory markers (CRP: 322 mg/L, ESR: 82 mm/hr), hyperferritinemia (&gt;10,000 ng/mL), hyperleukocytosis (16,000/mm³) with neutrophil predominance, and normocytic normochromic anemia (hemoglobin: 9 g/dL). Extensive infectious and immunological investigations were negative, while PET CT revealed metabolically active lymphadenopathy. Biopsies excluded malignancy and macrophage activation syndrome. A diagnosis of AOSD was established based on Fautrel and Yamaguchi criteria. The patient’s treatment was shifted from NSAIDs to corticosteroids (prednisone 1 mg/kg/day), leading to significant improvement, followed by maintenance therapy with DMARDs to sustain remission. Conclusion: This case highlights the importance of considering AOSD in AS patients presenting with PUO and systemic inflammation. Timely diagnosis and appropriate treatment can reduce complications. Further studies are needed to explore the pathophysiological links and optimize management strategies.

Elucidating loss-of-function mechanisms of monoallelic EPAS1 mutations underlying congenital hypoplastic anaemia in a paediatric anaemia cohort.

HIF-2α, encoded by EPAS1, plays a dominant role in regulating erythropoietin (EPO) production, maintaining the dynamic balance of erythropoiesis. Gain-of-function mutations in EPAS1 cause erythrocytosis. However, anaemia caused by EPAS1 loss-of-function mutations has been confined to only one case report, and the underlying mechanism remains unclear. Herein, the reanalysis of high-throughput sequencing data from 311 patients with anaemia identified three monoallelic EPAS1 variants from three unrelated families in a paediatric anaemia cohort. The probands showed highly consistent clinical phenotypes with normocytic and normochromic anaemia, reticulocytopenia and relative deficiency of serum EPO, characterised as congenital hypoplastic anaemia. Invitro studies suggested that defects in steady-state protein abundance, nuclear localisation and binding with co-activator in EPAS1 variants lead to impaired EPO transcriptional activation. Therefore, loss-of-function mutations in EPAS1 can cause erythroid hypoplasia in an EPO-dependent manner. This study identified a new causative gene for congenital hypoplastic anaemia and clarified the molecular aetiology of loss-of-function EPAS1 mutations.

Exploring the Diagnostic Challenges of Pseudotumoral Peritoneal Tuberculosis That Mimics Advanced Ovarian Cancer in Women: The Role of Laparoscopy in a Case Study

This case involves a 63-year-old multiparous woman with no significant medical history and no known exposure to tuberculosis. She presented with chronic abdominal pain and weight loss, anorexia, and subjective fevers. During the clinical examination, the patient was found to have ascites, bilateral pleural effusion, fever, and a general deterioration in her condition. Blood tests revealed normochromic normocytic anemia. The C-reactive protein was elevated, and the erythrocyte sedimentation rate was accelerated. Ferritin levels were raised. Her blood sugar, hepatic and renal functions were normals. The electrolyte panel showed no abnormalities. Serologies for hepatitis B, C, and HIV were negative, and the immunological profile was normal. The ascitic tap yielded a citrine-yellow fluid, and the cytochemical analysis indicated that the ascites were exudative. Analysis of the ascitic fluid revealed that the DNA test for Mycobacterium tuberculosis was negative, but the adenosine deaminase (ADA) level was elevated. Additionally, the CA125 level was significantly elevated, exceeding 600 UI/ml. A pelvic ultrasound identified a cystic pelvic mass with thick septations but without any solid tissue component, measuring 92x69 mm. The complementary CT (Computed Tomography) scan revealed enlarged ovaries, heterogeneous on the left, associated with a moderately abundant peritoneal effusion. The laparoscopic exploration revealed inflammatory peritoneal nodules, parietal adhesions, and serous ascites. Anatomopathology confirmed peritoneal tuberculosis. The peritoneal form, particularly in its pseudotumoral manifestation, can mimic ovarian cancer. Definitive diagnosis often requires invasive procedures.

8252 Central Adrenal Insufficiency Masquerading as Syndrome of Inappropriate Antidiuretic Hormone (SIADH): A Case Report

Abstract Disclosure: J.G. Sazon: None. J.L. Reyes: None. J.V. Chua: None. S.A. Kho: None. Hyponatremia, the most common electrolyte imbalance encountered in clinical practice, has various causes and presentation. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) is a frequent hospital-related cause, potentially leading to misdiagnosis with adrenal insufficiency due to shared clinical features which may cause potential deleterious effect. We present a case of a 41-year-old male hyponatremic patient with a two-month history of progressive generalized body weakness and lightheadedness, initially managed as SIADH. Upon admission, the patient persistently showed low serum sodium level (122mmol/L) (NV: 135-145mmol/L), exhibited signs of euvolemic hyponatremia despite fluid restriction, intravenous furosemide, and sodium chloride tablets. Further work-up revealed normocytic normochromic anemia (Hgb 107 g/L) (NV: 120-160g/L), elevated ESR of (31mm/hr) (NV: 0-15mm/hr), low Ft4 (2.97 pmol/L) (NV: 12-22 pmol/L) and normal TSH (2.2 uIU/mL) (NV: 0.27-4.20 uIU/mL). During hospital stay, he experienced an episode of hypotension at 80/50mmHg and hypoglycemia at 65 mg/dL. Investigation revealed adrenal insufficiency secondary to pituitary macroadenoma with apoplexy as showed in magnetic resonance imaging. Patient was started on Prednisone. Pre-operatively, hydrocortisone 100mg IV every 8 hours preoperatively. He underwent transsphenoidal surgery; excising a 2.5cm soft and grayish suprasellar mass. Post-operatively, he was given Prednisone and Levothyroxine resulting in symptom improvement and normal sodium levels.The occurrence of hyponatremia due to adrenal insufficiency is relatively uncommon, emphasizing the need for heightened suspicion when assessing patients with prolonged or recurring hyponatremia. This paper highlight the need to replace glucocorticoid prior supplementation of thyroid hormone in such cases, averting the occurrence of adrenal crisis. This case indicated a mechanism of persistent hyponatremia attributed to secondary adrenal insufficiency, with added therapeutic benefits observed through the use of glucocorticoids and transsphenoidal surgery. Presentation: 6/1/2024

Managing RS3PE: Diagnostic approach, initial steroid response, and long-term management with DMARDs

Background. RS3PE, or Remitting Seronegative Symmetrical Synovitis with Pitting Edema, is a unique and relatively rare form of inflammatory arthritis that predominantly affects older adults. It is distinguished by its hallmark features: symmetrical swelling of the joints, significant pitting edema in the extremities, and a negative serological profile for common markers associated with rheumatoid arthritis, such as rheumatoid factor (RA factor) and anti-citrullinated protein antibodies (anti-CCP). This condition is often characterized by a remitting course, meaning that symptoms may improve or resolve over time, particularly with appropriate treatment. The condition usually affects older adults and can sometimes be associated with other underlying health issues, such as malignancies or infections. The “remitting” aspect of RS3PE refers to the fact that the symptoms often improve or resolve over time, particularly with appropriate treatment, which usually involves corticosteroids or other anti-inflammatory medications. Case report. This case study details the clinical presentation, diagnosis, and management of a 56-year-old female patient with known hypertension who presented with bilateral dorsal hand swelling, pain, and early morning stiffness over a 15-day period. The patient’s initial examination revealed bilateral pitting edema and active arthritis in the proximal interphalangeal joints, with significant warmth and tenderness. Laboratory tests showed elevated ESR and CRP, normocytic normochromic anemia, and negative rheumatoid factor and anti-CCP antibodies. Imaging studies, including X-ray, ultrasound, and mammogram, showed no erosive changes or malignancy, while a Pap smear and serum CA-125 levels were within normal limits. The clinical picture, combined with the exclusion of other conditions, supported the diagnosis of RS3PE. Treatment commenced with intravenous low-dose dexamethasone, which led to significant symptomatic improvement. This was followed by a transition to oral prednisolone, and the patient initially showed complete resolution of symptoms. However, recurrence of symptoms occurred upon discharge, prompting the introduction of steroid-sparing agents: methotrexate and hydroxychloroquine, alongside continued oral steroid treatment. Over a two-month follow-up period, the patient experienced no signs of relapse. This case fits the clinical and investigative criteria for RS3PE. The patient showed symptomatic improvement after treatment with low-dose steroids.

Assessment of Reticulocyte Count as a Prognostic Indicator for Canine Ehrlichiosis: Implications for Diagnostic and Therapeutic Strategies

Canine ehrlichiosis is increasingly recognized in India, with significant implications for canine health. It is a tick-borne disease, caused by Ehrlichia canis. It is prevalent in various regions, particularly in areas with high tick populations. Anaemia is one of the most common and important manifestation of this disease. Anemia results from the destruction of red blood cells and bone marrow suppression. The prevalence of canine ehrlichiosis correlates with the density of tick vectors and can be exacerbated by environmental factors. Canine anemia can be classified as either regenerative or non-regenerative. Objective of the study was, investigating the prognostic value of reticulocyte counts in dogs with ehrlichiosis. The study involved 212 dogs screened between February 2023 and March 2024. Risk factors such as age, sex, breed, and season were recorded. Canine ehrlichiosis was diagnosed by finding morula stages in monocytes and neutrophils in thin blood smear examination. The pathogen was confirmed through PCR-based molecular examination. Reticulocyte count was performed through supravital stain new methylene blue (NMB). Reticulocytes contain ribosomal RNA, which is less condensed than in mature erythrocytes. NMB has a high affinity for ribosomal RNA, resulting in a blue coloration of these immature cells. This staining reaction makes reticulocytes clearly distinct compared to mature red blood cells under a microscope, facilitating their identification and quantification. The study found that the haematological parameters of infected dogs were significantly lower than healthy dogs. The mean ±SE values of Hb, TEC, PCV, and corrected reticulocyte were significantly lower (p&lt;0.001) in infected dogs compared to healthy dogs. These findings suggest that significantly lower values of Hb, TEC, PCV, MCV, MCH, MCHC, and corrected reticulocyte indicate anaemia, normocytic, normochromic anaemia, and non-regenerative anaemia. It can be concluded than in canine ehrlichiosis, anemia is one of the most common finding accounting aprox 28% of total diagnosed cases. Accurate anemia characterization is key for diagnosing and treating ehrlichiosis.

ANEMIA PATTERN IN PATIENTS WITH CHRONIC KIDNEY DISEASES PRESENTED AT TERTIARY CARE HOSPITAL

Anemia is a common complication in patients with chronic kidney disease (CKD) and contributes significantly to morbidity. Understanding the patterns and severity of anemia within this population can guide more effective management strategies. Objective: To assess the pattern and severity of anemia in patients with chronic kidney disease. Methods: This cross-sectional study was conducted from January 2024 to July 2024, involving 250 anemic CKD patients aged 18 years and above. The study was carried out at a nephrology care facility, with participants selected based on predefined inclusion and exclusion criteria. Data on demographic information, laboratory profiles, and anemia patterns were collected. Anemia was classified into mild, moderate, and severe categories. Statistical analysis was performed using SPSS version 24 to establish associations between the severity of CKD and the type of anemia. Results: Among the patients, 59.2% had normochromic anemia, 18.8% had hypochromic anemia, and 14% had macrocytic anemia. Moderate anemia was the most prevalent severity, observed in 51.2% of cases, followed by mild anemia in 41.6% and severe anemia in 7.2%. A significant association was noted between the severity of CKD and the type of anemia, particularly with normochromic anemia being more prevalent in patients with moderate CKD. Conclusion: The study concludes that normochromic anemia is the most predominant pattern of anemia in CKD patients, followed by hypochromic and macrocytic anemia. These findings underscore the importance of regular monitoring and tailored anemia management in CKD patients to improve overall patient outcomes.

Investigation of Hepatozoon Canis Related Alterations in the Haemato Biochemical Profile of Dogs

Aims: Hepatozoonosis, caused by a protozoan parasite Hepatozoon canis, is important for canine health due to its ability to cause chronic, debilitating disease, and the challenges it presents in terms of diagnosis and management. The present study was conducted to see the effect of H. canis infection on various haematological and biochemical parameters as compared to the normal healthy dogs in order to understand the disease pattern and suspecting the disease. Study Design: The clinically affected dogs that come to the veterinary hospital with symptoms of hepatozoonosis were included in the study. Haematological and biochemical parameters of dogs found positive for hepatozoonosis were analysed. The values of these parameters were subsequently compared to healthy animals in order to identify any significant difference caused by H. canis. Place and Duration of Study: The studied was conducted at Department of Veterinary Medicine, DUVASU Mathura, India. Total 212 blood samples were collected from the dogs that were brought for the treatment in between February 2023 to March 2024. Methodology: Total 212 dogs were included in the present study out of this 46 dogs were found positive with H. canis using PCR based molecular test. These positive animals were subjected to study the changes in biochemical parameters like blood urea nitrogen, creatinine, alkaline phosphatase, alanine transaminase, aspartate amino transferase, total leucocyte count, total erythrocyte count, haemoglobin, haematocrit, erythrocyte indices (MCV, MCH, MCHC), differential leucocyte count, platelet count and platelet indices (MPV, PDW) using autoanalyzer. Student's t-test in Graphpad Prism was used to compare these values to healthy animals. Results: The study confirms that Hepatozoonosis leads to significant haematological and biochemical changes in dogs. Infected dogs have lower Hb, TEC, and PCV than healthy animals, indicating anaemia. Thrombocytopenia and leukocytosis were also observed in the infected animals. Non-significant differences in MCV, MCH, and MCHC indicate normocytic, normochromic anaemia. Anisocytosis and non-regenerative anaemia is indicated by significant RDW-CV increases with decrease in MCV values. Increased liver-specific enzymes like ALT, AST, and ALP and kidney-related enzymes like BUN and CRT suggest hepatic and renal involvement in disease pathophysiology. Conclusion: In hepatozoonosis, haemato- biochemical parameters like non-regenerative anaemia. anisocytosis, thrombocytopenia, leukocytosis, low serum protein concentration and increased ALT, AST, ALP and BUN values may be used as non-specific biomarkers. The results can be used in making clinical decisions and monitoring therapeutic responses in cases of hepatozoonosis.

A Rare Case of Late Onset-Pompe’s Disease: Presented as Heart Failure

Pompe disease is a hereditary lysosomal storage disorder characterized by a deficiency in the acid alpha-glucosidase (GAA) enzyme, leading to glycogen accumulation in muscle and neurons. Clinical manifestations vary from severe infantile-onset with hypertrophic cardiomyopathy and early mortality due to respiratory insufficiency to late-onset with proximal muscle weakness, gross motor delay, and progressive respiratory insufficiency. A case of an 11-year-old boy who reported to the pediatric emergency department with a nine-year history of progressive muscle weakness and a one-month history of anemia symptoms (easy fatigue, shortness of breath, pale appearance) and heart failure (orthopnea, dyspnea). His family history included consanguineous marriages and similar conditions in his brother and maternal uncle. On examination, he appeared pale, malnourished, and exhibited signs of respiratory distress and tachypnea. His cardiovascular examination revealed apex beat displacement, elevated JVP, bilateral pedal edema, mild ascites, positive hepatojugular reflux, and systolic murmurs. Respiratory examination indicated bilateral crepitation and wheezes. Musculoskeletal examination showed decreased muscle mass and power, especially in proximal muscles. Abdominal examination revealed hepatosplenomegaly and mild ascites. Radiological findings included an enlarged cardiac shadow with pleural effusion and bilateral radio-opaque shadows on chest x-ray, while echocardiography showed impaired left ventricular systolic function with mild to moderate mitral and tricuspid regurgitation. Laboratory tests indicated elevated aspartate aminotransferase, LDH, and creatine kinase levels, along with normocytic, normochromic anemia. Muscle biopsy from the hamstring revealed PAS stain positive granules. These clinical, radiological, and laboratory findings strongly suggest late-onset Pompe disease, marking this as potentially the second reported case in Pakistan.

A Comparative Study of Peripheral Smear Findings with RBC Indices and Automated Analyzer Generated RBC Histograms in the Diagnosis of Anemia's

Abstract Introduction The red blood cell (RBC) indices generated by cell counters help in the morphological classification of anemia. The importance of microscopic examination of peripheral blood smears (PBSs) stained by Leishman stain cannot be used alone when it comes to interpretation of the underlying cause of anemia. Hence, all three RBC histograms, indices, and microscopic examination of PBSs are very essential for a complete assessment of anemia. Aims and Objectives To diagnose the type of anemia by examination of PBSs, automated cell-generated RBC histograms, and RBC indices and to compare and correlate the findings of RBC indices and automated cell-generated RBC histograms with PBS examination. Materials and Methods This was a prospective comparative study done on 500 cases of anemia for a period of 5 months from August 2023 to December 2023 in a rural tertiary care teaching hospital and all the patients' RBC indices, RBC histogram findings, and PBS findings were noted and analyzed. Results Among 500 samples, normocytic normochromic anemia consists of the majority of the cases 272 (54.4%), followed by microcytic hypochromic anemia cases 183 (36.6%), macrocytic anemia cases 27 (5.4%), normocytic hypochromic anemia were 10 (2%) cases, and dimorphic were 8 cases (1.6%). When compared with RBC histogram, 265 (53.0%) cases showed normal bell-shaped curve, 188 (37.6%) cases showed left shift, 27 (5.4%) cases showed broad based curve, 10 (2%) cases showed right shift, and 10 (2%) cases showed bimodal curve suggesting normocytic normochromic, microcytic hypochromic, normocytic hypochromic anemia, macrocytic, and dimorphic anemia, respectively. Conclusion This study showed a well correlation in the findings of the automated hematology analyzer with the microscopic examination. Histogram alone could be used as a screening method but when combined with RBC indices and PBS findings, they act as useful supplements and by correlating findings of all three, we could diagnose the majority of anemia.

Multi-Biomarkers' Responses in Gills of Oreochromis niloticus Exposed to Glyphosate and Polyethylene Microplastic, Isolated and in Mixture.

Microplastics (MPs) and glyphosate-based herbicides (GBH) are among the most common contaminants in aquatic environments. In Brazilian rivers, both contaminants were found in elevated levels, leading to a high probability of their association, which can alter their individual effects and potentially intensify their toxicity. This study evaluated the isolated and combined effects of polyethylene microplastics (PE-MPs) and GBH on Oreochromis niloticus using multi-biomarkers of toxicity. The fish were subjected to a 96-h exposure period, with concentrations set based either isolated, PE-MPs group (5 mg L-1), GBH group (5 mg L-1), or in a group of associated contaminants (GAC), PE-MP + GBH (5 mg L-1 + 5 mg L-1). Toxicity effects were evaluated using biochemical, cytogenetic, hematological, and histopathological biomarkers. We observed change in erythrocyte parameters leading to macrocytic normochromic anemia in GAC. Leukocyte parameters indicate a nonspecific immunosuppression caused by the exposure of associated contaminants, besides the attempts to repair damage caused by PE-MPs. Histopathological markers indicate damage to tissues exposed to contaminants. Besides, there were morphophysiological adjustments on gills, with proliferation and hypertrophy of mitochondria-rich cells on GBH and GAC, besides epithelium ruptures, which were mostly present in the exposed groups. Therefore, this study indicates that PE-MPs and GBHs present toxic effects in O. niloticus with the used concentrations, intensified by the association of contaminants. Thus, multi-biomarkers were useful key to verify toxicity, providing data to the investigation of high levels of contaminant's mixture toxicity present in aquatic environments.

RBC histogram: Useful diagnostic tool in evaluating anaemia

: Anaemia is a widespread public health problem, more common in developing countries. Red blood cell histogram is a vital part for evaluation and diagnosis of anaemia. Histogram can be a useful modality for arriving at the probable diagnosis of anaemia reporting in short span of time.: To observe various RBC Histogram on haematology Analyser in anaemia and analyse the usefulness of RBC Histogram to correlate with peripheral smear.: A prospective study was done in Department of Pathology of Secondary Care hospital from January 2024 to March 2024 on 300 anaemia patients. RBC Histogram were observed, analysed and correlated with peripheral smear. Out of total 300 patients, Most common anaemia is Microcytic Hypochromic (60%), Normocytic normochromic (21.33%), Dimorphic anaemia (12.33%) and macrocytic anaemia (6%). 95.5% microcytic hypochromic anaemia showed left shifted curve, 84.3% Normocytic normochromic anaemia showed normal curve, 88% macrocytic anaemia showed right shift curve. Considering the speed, reliability and less inter observer variation of the modern haematological analysers RBC histogram are important diagnostic tool for various types of anaemia and provide accurate morphological typing of anaemia in most cases hence presumptive report can be released based on RBC histogram.

A Middle-Aged Patient Living with HIV (PLHIV), Presented with Persistent Hiccups, Imbalance, and Multifocal Myoclonus Secondary to Disseminated Tuberculosis

AbstractA middle aged male presented with chronic diarrhoea, persistent hiccups and unsteadiness while walking. His illness had subacute onset and progressive course. Clinically patient had cachexia, pallor, oral thrush and hepatosplenomegaly. On neurological examination, he had fine tremors, gait ataxia, and multifocal myoclonus. Investigations revealed normochromic normocytic anemia, transaminitis, hyponatremia and cerebrospinal fluid pleocytosis(lymphocytic predominance). Brain MRI revealed diffuse patchy meningeal enhancement; CECT abdomen showed circumferential bowel wall thickening, hepatosplenomegaly and necrotic lymphadenopathy. CECT chest exhibited mediastinal lymphadenopathy alongwith centrilobular nodular opacities. Sputum GeneXpert® was positive for mycobacterium tuberculosis with sensitivity to rifampicin. His serology for human immunodeficiency virus was positive. He was diagnosed as disseminated tuberculosis with tuberculer meningitis which caused persistent hiccups, gait abnormaliy and multifocal myoclonus. His symptom resolved with anti tubercular therapy. We aim to highlight here that myoclonus is a rare occurrence with tubercular meningitis.

Hypomagnesemia, hypogammaglobulinemia, and chronic normocytic normochromic anemia: random association? An unresolved case report of an elderly patient with remitting seronegative symmetrical synovitis with pitting edema syndrome

Hypomagnesemia, hypogammaglobulinemia, and chronic normocytic normochromic anemia: random association? An unresolved case report of an elderly patient with remitting seronegative symmetrical synovitis with pitting edema syndrome

Iron Metabolism in Pediatric Living related Liver Transplantation

Abstract Introduction Iron deficiency is a frequent cause of anemia in liver transplant recipients, especially children. Rejection and infection are incriminated causes for occurrence of anemia after liver transplantation (LR). Aim of the Work We aimed to assess iron homeostasis in children who have undergone living related LT (LRLT) and its correlation with occurrence of rejection and infection. Patients and Methods The study was conducted on 35 children who have undergone LRLT. The patient characteristics, frequency of infection and rejection episodes, laboratory investigations including complete blood picture (CBC) and Iron profile (total iron binding capacity (TIBC),serum iron and ferritin) during the patient follow up visits were reported. Results Males were 68.58% of the studied patients and females were 31.42%. Their ages ranged from 1.3-15 years at time of LT with mean (SD) of 7.18 (3.8)years. The mean (SD) duration since LT was 4.83 (4.2) years. The commonest indication to LT was highgamma-glutamyl transferase (GGT) cholestasis (34.7%) followed by biliary atresia (21.7 %). Thirteen percent of patients had low hemoglobin (Hb) of whom 4.3% had normocytic normochromic anemia and 8.7% had microcytic hypochromic anemia. Serum iron was normal in 79.6% of patients and low in 20.4%, and ferritin was normal in 58.7% of patients and low in 41.3% while TIBC was normal in 82.6% of patients and low in 17.4%. Only serum iron showed significant negative correlation with white blood cells (WBCs) (P &amp;lt; 0.05). The iron parameters levels were not different in patients with no rejection or only one attack of rejection and the patients with multiple rejection episodes (P &amp;gt; 0.05). Conclusion Anemia is a reported complication after pediatric LT. Further studies are needed to assess the long term effect of post-LT anemia on patient outcome after LT.