Normocytic Normochromic Anemia Research Articles

HEMORRHAGIC SHOCK: WHERE IS THE BLEED?

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meckel diverticulum(MD), characterized as a common congenital malformation and is well studied in the pediatric population but less so in adults. Our case emphasizes MD as one of the possible diagnoses of gastrointestinal bleeding in adults when CT scans and endoscopic evaluations are unremarkable. Also, if the suspicion is high, the technetium 99m pertechnetate is also not often adequate to exclude the diagnosis. CASE PRESENTATION: 28 year old male with a history of Inflammatory bowel syndrome presented to the emergency department with lightheadedness and palpitations. Soon after, he experienced a large melanotic stool and was transferred to the ICU with hypovolemic shock. His labs were notable for normocytic normochromic anemia for which he was transfused with packed red blood cells. CTA abdomen and pelvis demonstrated no evidence for active extravasation. The patient continued to have massive melenic bowel movements requiring repetitive blood transfusion for his hemorrhagic shock. Bedside double endoscopy showed non-bleeding internal hemorrhoids with no obvious source of bleeding. Subsequently, workup was broadened to a tagged RBC scan which was positive in the mid to distal small bowel prompting small ileal branch embolization. However, bleeding persisted for which Meckel's scan was ordered and found to be suggestive of Meckel's diverticulum. Subsequently, he had a laparoscopic small bowel resection which led to the resolution of symptoms. DISCUSSION: Meckel's Diverticulum is a rare entity in adults with only 17 cases reported in literature in the last year. It usually presents in childhood with more than half of the patients being less than 10 years old.MD usually presents with intestinal obstruction, hemorrhage and inflammation ofthe diverticulum with or without perforation. Bleeding usually occurs from an ulcer due to ectopic gastric mucosa producing acid and damaging the intestinal mucosa. Clinical features are comparable to any other inflammatory condition and can be confused with more prevalent conditions like acute appendicitis. Meckel's nuclear scan proves to be the standard test in case of high suspicion with a sensitivity of 89.6% and specificity of 97.1%. Other testing modalities include X-ray, CT scan or an MRI in case of an obstruction. Mesenteric arteriography in case of GI bleeding, double-balloon enteroscopy or capsule endoscopy can be used in order to directly visualize the MD, or abdominal exploration can be done as required if the diagnosis remains unclear with high index of suspicion.The standard of treatment in case of a symptomatic patient is surgical resection by performing a diverticulectomy that our patient underwent and was discharged to medical floor after stabilization. CONCLUSIONS: Meckel's Diverticulum remains a diagnosis associated with pediatric population although should not be forgotten in cases of adults with unexplained gastrointestinal bleeding. REFERENCE #1: Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A. Meckel's diverticulum in the adult. J Visc Surg. (2017) 154:253–9. 10.1016/j.jviscsurg.2017.06.006 [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel's diverticulum and its complications. J Med Imaging Radiat Oncol. (2017) 61:225–31. 10.1111/1754-9485.12505 [PubMed] [CrossRef] [Google Scholar] REFERENCE #3: Stone PA, Hofeldt MJ, Campbell JE, et al. Meckel diverticulum: ten-year experience in adults. South Med J 2004;97:1038-41. [PubMed] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Anneris Estevez, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

S3631 The Milky Way

Introduction: Chylous ascites is a rare clinical finding indicative of peritoneal fluid containing lymphatic drainage. It is characterized by having a milky appearance that is rich in triglycerides, surpassing 110 mg/dL. This condition develops after disruption of the lymphatic system, usually secondary to trauma after abdominal surgery, malignancy, or cirrhosis. Chylous ascites accounts for less than 0.5% of cases of ascites in cirrhotic patients, presenting as progressive and painless abdominal distention. Case Description/Methods: Case of a 71 year-old male with history of cirrhosis due to hepatitis C on remission treated with elbasvir/grazoprevir, hypertension and end stage renal disease (ESRD) on hemodialysis (HD) who came to our institution after developing worsening abdominal distention with associated shortness of breath since 2 weeks prior. He denied fever, chills, cough, palpitations, chest pain, abdominal pain, hematemesis, hematochezia, or melena. Vitals signs were stable and physical exam was remarkable for a distended, tense and painless abdomen. Laboratories showed leukocytes in 7.8 x 103/uL, normocytic-normochromic anemia of 9.0 g/dL and platelets in 262 x103/ uL. Chemistry showed renal function consistent with his ESRD, without electrolyte disturbances. SGPT at 13 U/L and SGOT at 22 U/L. Anti-HBS, HBS ag and HIV ag/ab combo is nonreactive. Abd/pelvic CT scan revealed a nodular liver contour with hypertrophic changes of the left lobe compatible with chronic hepatocellular disease. The patient’s symptoms and findings were consistent with decompensated liver disease with tension ascites, for which a large-volume paracentesis was performed, removing 9L of white-milky fluid with subsequent placement of 50 g of IV albumin. The calculated serum-ascites albumin gradient (SAAG) was 2.4 g/dL consistent with portal hypertension. Ascitic fluid analysis revealed 40 cell count, 2 neutrophils, 916 mg/dL triglycerides and 90 mg/dL cholesterol, indicative of chylous ascites. Discussion: Abdominal paracentesis and analysis of the ascitic fluid are essential for the evaluation and management of chylous ascites. Management should focus on treatment of the underlying disease; however supportive measures may alleviate symptoms. These measures may include repeated paracentesis, diuretic therapy, salt and water restriction and dietary measures. It is imperative to be aware of this unusual manifestation, requiring prompt evaluation and appropriate management of the underlying pathology.Figure 1.: Ascitic fluid obtained after performing abdominal paracentesis.

Comparison of peripheral blood smear examination with automated haematology analyzer for diagnosing different types of anemia.

Objective: This study aims to determine diagnostic accuracy of peripheral blood smear and automated haematology analyzer and to determine frequency of different types of anemia diagnosed by peripheral blood smear and automated hematology analyzer. Study Design: Cross Sectional study. Setting: Department of Pathology, Rawal Institute of Health Sciences, Islamabad. Period: November 2015 to April 2016. Material & Methods: Sample size of 149 suspected anemia patients was calculated using WHO calculator with 95% confidence interval. Research approval was taken from hospital ethical board. Patients were approached through non probability consecutive sampling method. Both peripheral blood smear examination and automated haematology analysis of each sample was performed. Diagnostic accuracy and frequency of anemia types was measured. Data analysis was done with the help of SPSS version 25. Chi-square and fissure exact test and ROC curve analysis was applied and significant (p<0.05) results were reported. Results: Total 149 patients were included in study. There were 42(28.2%) male and 107(71.8%) female. Mean age of patients was 35.1±2.1SD. Peripheral blood smear and automated haematology analyzer showed sensitivity (68% vs 92%), specificity (59% vs 88%), PPV (72% vs 92%), NPV (55% vs 88%) and diagnostic accuracy (64% vs 91) respectively. Most common type of anemia diagnosed with peripheral blood smear was microcytic hypochromic anemia with raised RDW 36.7% followed by normocytic normochromic anemia with raised RDW 13.3% and macrocytic anemia (p=0.001) while in automated haematology analyzer microc ytic hypochromic anemia with raised RDW54.4% followed by normochromic normocytic anemoia with normal RDW 11.1% (p=0.000). Conclusion: Automated haematyology analyzer had high diagnostic accuracy for diagnosis of anemia. Microcytic hypochromic anemia and normocytic normochromic are most common anemias diagnosed by peripheral blood smear and automated hematology analyzer and peripheral blood smear cannot be completely replaced by automated haemolytic analyzer. However, if both methods are used simultaneously, more accurate results can be obtained.

SARS-CoV-2 infection in a child with Fanconi anemia and determined immunosuppressed status

Introduction. SARS-CoV-2 virus infection affects all age groups. In children, the infection mainly causes asymptomatic or mildly symptomatic forms of the disease, regardless of their immune status. Case presentation. We describe the case of a 7-year-old male child, known to have Fanconi anemia, scheduled for bone marrow transplantation. The patient comes from a family outbreak of COVID-19, which is why he was tested for SARS-CoV-2 infection. He is asymptomatic at the time of admission to our clinic. The clinical examination performed at the time of admission shows a patient in good general condition, afebrile, with pale skin and mucous membranes, without respiratory changes. Paraclinically, severe neutropenia, severe normochromic normocytic anemia and severe thrombocytopenia are detected, for which transfusions of erythrocyte mass and platelet mass are performed. Due to the immunocompromised status, antibiotic therapy is instituted. If necessary, symptomatic treatment is administered. The evolution is favorable, and the SARS-CoV-2 RT-PCR control test is negative on the eighth day of hospitalization. Conclusions. Immunocompromised status is not a major risk factor for severe COVID-19 in children.

Beneficial effects of empagliflozin on hematocrit levels in a patient with severe anemia

IntroductionSodium-glucose cotransporter (SGLT2) inhibitors may additionally benefit patients with diabetes by improving their erythropoiesis followed by the elevation of hemoglobin and hematocrit levels.Reason for the reportIn the case described, severe normocytic normochromic anemia was resolved when empagliflozin had been introduced to the therapy.Case summaryA 78-year-old male patient was admitted to our hospital with a non-ST-segment elevation myocardial infarction. His past medical history included diabetes, right coronary artery angioplasty, myocardial infarction and paroxysmal atrial fibrillation which required anticoagulant treatment. When examined, severe normocytic normochromic anemia was also diagnosed. About two years prior to his admission, the patient began suffering from persistent anemia despite the modification of his anticoagulant therapy with warfarin, rivaroxaban and dabigatran. An extensive evaluation failed to provide an explanation for his anemia.OutcomeEventually, only the introduction of empagliflozin successfully increased the values of hemoglobin and hematocrit. Therefore, it transpires that SGLT2 enhances erythropoietin (EPO) secretion which subsequently raises hematocrit levels in patients with severe anemia.Graphic abstract

Study of Spectrum of anemia in various age groups

: Anemia is major health problem world-wide especially in developing countries. Globally 1.62 billion persons are affected. It has grave consequences on human health. The present study evaluates the severity and morphology of anemia in various age groups in rural population. : 1): To study degree and severity of anemia in study population; 2): To study distribution of anemia in various age groups; 3): To study morphological spectrum of anemia in study population. s: The study includes 792 patients having low concentration of hemoglobin for their age & sex. The other hematological parameters and morphology were analyzed. : In our study, females constituted 72.6% (575/792) of study population and male constituted 27.4% (217/792) of population. Pediatric patients (up to 15 years of age) constituted 10% of study population. Out of 792 anemic patients, 439 (55.4%) were having moderate anemia, 228 (28.7%) were having mild anemia & 125 (15.78%) were having severe anemia. Out of 792 anemic patients, 384 (48.4%) were having microcytic hypochromic anemia, 296 (37.37%) were having normocytic normochromic anemia, 84 (10.6%) were having macrocytic anemia and 3.5% were having hemolytic anemia. Out of 792 anemic patients, 439 (55.4%) were having moderate anemia, 228 (28.7%) were having mild anemia & 125 (15.78%) were having severe anemia. In our study anemia was more common in females as compared to males constituting majority of study population which is in concordance with other studies also. Moderate anemia was more common in study population as well as in various sub-groups being in concordance with other studies too. Morphologically microcytic hypochromic anemia was the most common type of anemia especially in adult females. Pregnant females were found to have normocytic normochromic anemia predominantly. Most of the cases of hemolytic anemia was found in children <15years. Similarly macrocytic anemia was found more commonly in adult males. Anemia is the most hematological abnormality found in daily practice, though found in all age groups but quite higher in females. The main objective for diagnosing anemia is to make clinician aware so that they can take measures to prevent and control anemia.

Gestational Anemia and its effects on neonatal outcome, in the population of Hyderabad, Sindh, Pakistan

BackgroundAnemia in pregnancy is a globally health-related issue, that affects both mothers and their newborn. Anemia during pregnancy across the world involves approximately 38% of the world population. To evaluate the effect of gestational anemia on perinatal outcome in the population. The aim of present study is to evaluate the effect of gestational anemia on perinatal outcome in the population of Hyderabad, Sindh, Pakistan.MethodsA cross-sectional comparative analysis was conducted among pregnant mothers who were listed to give birth at Liaquat University of medical and health sciences Jamshoro/Hyderabad during the period of September 2018 to September 2019. The study population 400 were selected by convenient random sampling, and grouped into 2 on the basis of their Hb levels, with Hb < 11 gm% they were classified as anemic mothers, Hb ≥ 11 gm% were termed as non-anemic mothers, data was collected on the preformed questionnaire, and was analyzed on SPSS 21.ResultsThe prevalence of anemia was 51.5% in in total population out of which, the incidence of normocytic normochromic anemia was highest 52.4 %microcytic hypochromic anemia was found in 19.4%, Overall, extremely low Apgar was found in 53 anemics, and 8 non. anemic mother’s infants, LBW incidence was 47.5 %; in anemic mothers, and 15.4 % in non-anemic group, the term, small for gestational age infants were 14.5% in anemic mothers, and 3.6% in non-anemic mothers, there were 36 preterm births to anemic mothers and 10 in non-anemic mothers. The incidence of caesarian section is 53.3% in anemic mothers compared to 30.9% in non-anemic mothers.ConclusionsAnemia in pregnancy significantly increases risks of low Apgar, LBW, term SGA, preterm birth, and an increase incidence of caesarian section.

&#x0D; Meningoencefalitis bacteriana secundaria a una vaginitis en un canino: Relato de un caso

The bacterial meningoencephalitis is a neurological disorder that affects dogs and cats, and develops on migration of bacteria from infectious focus, near or far from the central nervous system through the bloodstream, breaking the hemato-encephalic barrier and reaching the brain and meninges. in that context, this work has by objective report a case of meningoencephalitis concomitant with vaginitis in a canine, female, without race defined, 3 years old, attend at Dr. Vicente Borelli's Veterinary Hospital located in Aracaju-SE. The animal had motor incoordination, inclination of the head for the right side and walked in circles. Physical examination, blood count, renal profile, liver profile and protein fraction, cystocentesis guided by ultrasound, physical-chemical analysis, urine culture, CSF collection for cytology and bacterial culture and collection of vaginal secretion for bacterial culture and antibiogram were performed. Finally, exploratory laparotomy was performed to discard uterine stump on physical examination, bilateral horizontal nystagmus, cervical stiffness, lack of response to deep pain, absence of cranial tibial reflex, proprioceptive deficit in the right posterior limb, and blackened vulvar secretion were found. The hemogram showed mild normochromic normocytic anemia, thrombocytopenia and monocytopenia. Renal and hepatic profiles and protein fraction showed no changes. Urinalysis showed a cloudy appearance, alkaline pH, presence of red blood cells and leukocytes, in addition to crystals such as amorphous and triple phosphate. In urine culture, growth, isolation and identification of the microorganism Streptococcus spp. The results found in the cytological examination of the CSF were a small amount of eosinophilic, amorphous, finely granular protein material, density and little increased proteins. Ultrasonography and exploratory laparotomy did not show any noteworthy changes, but they did help to rule out differential diagnoses of vaginitis. As for the microbiological exams of CSF samples and vaginal secretion, both genera of gram-positive bacteria Staphylococcus grew. Thus, the present report allowed us to conclude that vaginitis can trigger meningoencephalitis due to bacterial translocation through the bloodstream.

Association between Thyroid Function and Erythrocyte Indices in General Population from the Asir Region of Saudi Arabia: A Cross-Sectional Study

The purpose of the current investigation is to evaluate the relationship between erythrocyte indices and thyroid function in a general population from the southern region of Saudi Arabia. In a cross-sectional study conducted on 3,007 subjects examined associations among erythrocyte indices, thyroid-stimulating hormone, and free thyroxine. The average age of the population was 48.40±0.261 years, ranging from 13 years to 90 years, and the most represented age group was &lt;50 years. Thyroid dysfunction was observed in 8.41% of the study population, and the most common thyroid dysfunction was subclinical hypothyroidism followed by clinical hyperthyroidism. Most erythrocyte indices were significantly lower in the hypothyroidism group (both primary and subclinical) in comparison to the euthyroid group stratified by gender. According to our investigation, microcytic hypochromic anemia and normocytic normochromic anemia were detected in patients with hypothyroidism. Furthermore, females with subclinical hypothyroidism had a significantly higher prevalence of anemia than male population.

Molecular detection of Theileria species, Anaplasma species, Candidatus Mycoplasma haemobos, Trypanosoma evansi and first evidence of Theileria sinensis-associated bovine anaemia in crossbred Kedah-Kelantan x Brahman cattle

BackgroundSerious disease outbreaks in cattle are usually associated with blood pathogens. This study aims to detect blood pathogens namely Theileria species, Anaplasma species, Candidatus Mycoplasma haemobos and Trypanosoma evansi, and determine their phylogenetic relationships and haemato-biochemical abnormalities in naturally infected cattle.MethodsMolecular analysis was achieved by PCR amplification and sequencing of PCR amplicons of 18SrRNA gene of Theileria species, 16SrRNA genes of Anaplasma and Mycoplasma species, MPSP genes of T. orientalis and T. sinensis, MSP4 gene of A. marginale, 16SrRNA gene of Candidatus Mycoplasma haemobos, and RoTat1.2 VSG gene of Trypanosoma evansi, in sixty-one (61) clinically ill Kedah-Kelantan x Brahman cattle in Pahang, Malaysia.ResultsA total of 44 (72.13%) cattle were infected with more than one blood pathogen. Theileria species was the blood pathogen with the highest molecular detection rate (72.13, 95% CI 59.83–81.81%). Nucleotide blast analyses of all sequences demonstrated high degree of molecular similarity (98–100%) in comparison with their respective reference sequences. Analysis of 18SrRNA gene sequences of Theileria species and 16SrRNA gene sequences of Anaplasma species revealed Theileria sinensis and Anaplasma platys respectively as additional species detected in these cattle. MPSP-PCR analysis was conducted for further confirmation of T. sinensis. The blood picture of eight infected cattle groups revealed poikilocytosis, anisocytosis, rouleaux formation and degenerative left shift. High mean erythrocyte fragility values were common in infected cattle groups. Anaemia of the macrocytic normochromic type and spherocytes were observed in the T. evansi and Anaplasma platys + Theileria sinensis double species co-infected cattle group. Normocytic normochromic anaemia was observed in the T. sinensis infected cattle group. Significant (p < 0.05) increases in serum liver and kidney parameters, total protein, globulin, total and unconjugated bilirubin and decreased albumin values were observed in the T. evansi infected cattle when compared to clinically healthy cattle.ConclusionWe present the first evidence of Theileria sinensis-associated bovine anaemia (TSABA) in Malaysian cattle. Because of the high occurrence of bovine theileriosis and detection of A. platys, there is an urgent need for appropriate preventive and control measures against these blood pathogens.

Human immunodeficiency virus transmission from a 24-year-old woman to her 78-year-old grandmother: a case report

IntroductionSince its debut recognition in 1981, human immunodeficiency virus/acquired immunodeficiency syndrome has affected over 77 million people and has resulted in premature cessation of 35.4 million lives worldwide. Commonly, human immunodeficiency virus is transmitted by sexual contact across mucosal surfaces, by sharing of injecting equipment, through contaminated blood transfusions, and by maternal–infant exposure. Nevertheless, accidental transmission incidences involving family members are rare but possible.Case presentationA 78-year-old woman of African descent from Mtwara Region south of Tanzania was referred to us for further evaluation and treatment. She is 30 years postmenopausal and has a 35-year history of hypertension. Her last attendance to our institute was 11 months prior the index visit and she tested negative for human immunodeficiency virus. She came with complaints of weight loss, recurrent fevers, and cough. Her hematological tests revealed leukopenia with lymphocytosis, together with a normocytic normochromic anemia. Enzyme-linked immunosorbent assay for human immunodeficiency virus was positive, and she had a CD4 count of 177 cells/µL. We went back to history taking to identify the potential source of infection. We were informed that for the past 6 months, the 78-year-old lady has been living with her unwell 24-year-old granddaughter who has been divorced. The granddaughter had a history of recurrent fevers, significant weight loss, and a suppurative skin condition. As a way to show love and care, the old lady was puncturing the suppurative lesions with bare hands; then she would suck them to clear away the discharge. We requested to see the young lady, and she tested positive for human immunodeficiency virus. Both were started on tenofovir/lamivudine/dolutegravir combination plus cotrimoxazole 960 mg. The family was in total disarray following these findings. The patient was discharged through infectious diseases department and died of Pneumocystis jirovecii pneumonia 12 weeks later.ConclusionsCertain sociocultural norms that are believed to express love, care, and togetherness in developing rural communities, particularly Sub-Saharan Africa, have a potential of spreading human immunodeficiency virus, thus warranting prompt transformation.

Rheumatoid arthritis in a sickle cell patient: a dangerous association?

Introduction - The diagnosis of rheumatoid arthritis remains a challenge because sickle cell disease can result in various rheumatological manifestations, including joint and bone pain. The concomitant presence of rheumatoid arthritis and sickle cell disease makes the therapeutic management of both conditions problematic.&#x0D; Observation - A 24-year-old man, a nurse by profession, has been followed for 10 years for homozygous sickle cell disease at the Sickle Cell Disease Research Center (CRLD) of Bamako, Mali. He has presented for 8 months symmetrical polyarthritis with morning stiffness of 3 hours, distinct from the usual vaso-occlusive crisis. The Analog Visual Scale was estimated at 80/100. He reported unquantified weight loss and asthenia. The physical examination showed a deformity in bilateral ulnar deviation, flexion of the right elbow, twelve painful joints, and five swollen joints. Normochromic normocytic anemia (hemoglobin 8.3g/dl), inflammatory syndrome with C - Reactive Protein (CRP) 130.91 mg, and Sedimentation Rate (ESR) 72mm at the first hour were noted. Rheumatoid Factor was weakly positive at 21.3 IU and Anti Citrullinated Peptide Antibodies at 385.2 IU. The radiography discovered bilateral erosive carpets without associated tarsitis and osteonecrosis of both femoral heads. The diagnosis of a very active immunopositive erosive rheumatoid arthritis meeting the criteria of ACR / EULAR 2010 was retained. A treatment based on prednisone 10 mg per day was initiated, associated with methotrexate at a dosage of 15 mg weekly in single-dose, folic acid, calcium, and vitamin D.&#x0D; Conclusion - The coexistence of rheumatoid arthritis in sickle cell patients makes the diagnosis of polyarthritis difficult.

Haemobartonellosis in a Domestic Cat in Indonesia: a Case Study

Haemobartonellosis is a disease caused by Haemobartonella felis or Mycoplasma haemofelis, which attacks red blood cells. Ctenocephalides felis could transmit Haemobartonellosis. Further, vertical transmission from mother to offspring and blood transfusion from infected animals could transfer the disease to other animals. This report aimed to describe the diagnosis and medical treatment of haemobartonellosis in a domestic cat in Indonesia. Physical examinations and blood analysis were carried out. The cat weighed 1,4 kg with 39,3°C temperature, CRT was three seconds, mucosa looked pale, and many Ctenocephalides felis fleas were found. The clinical symptoms detected were weakness, loss of appetite, and hair loss. A blood test indicated normocytic normochromic anemia. The rod-like formation within erythrocytes in blood smear was observed. Infection with Hemobartonella felis was diagnosed based on the blood test and the presence of numerous Ctenocephalides felis. Doxycycline was administrated at 10 mg/kg BW once a day for 21 days. The cat recovered clinically after 21 days, with a good appetite, normal mucosal color, and normal temperature

Identification of Adverse Risk Factors for Survival in Acquired Pure Red Cell Aplasia Receiving Immunosuppressive Therapy By the Japan PRCA2004/2006 Study and Introduction to the New Cohort Study PRCA2016

Pure red cell aplasia (PRCA) is characterized by normocytic normochromic anemia associated with reticulocytopenia and erythroid hypoplasia in otherwise normal bone marrow. The acquired chronic PRCA may present as a primary hematological disorder in the absence of any other diseases or develop associated with certain conditions such as thymoma, lymphoproliferative disorders, infections, collagen vascular diseases, or after exposure to a wide variety of drugs. Idiopathic PRCA and secondary PRCA not responding to the treatment of the underlying diseases are generally treated by immunosuppressive therapy and the most patients require long-term treatment. Glucocorticoids, cyclosporine and cyclophosphamide are commonly used for initial treatment as monotherapy or combination therapy and majority of the patients respond to immunosuppression. However, most patients treated with these medications relapse during tapering of the treatment. Because of the extreme rarity of this disease, the long-term outcome of chronic PRCA following immunosuppression remains unclear and the adverse risk factors for survival have to be elucidated.In order to identify the adverse risk factors for survival in acquired chronic PRCA following immunosuppression and improve the prognosis, we have conducted nationwide surveys for adult acquired chronic PRCA in Japan. We conducted the first study for adult chronic PRCA in japan in 2004 and 2006 that had been diagnosed between 1990 and 2006 across 109 institutions, and collected the data on a total of 185 patients (PRCA2004/2006 study). We have also started another cohort study in 2016 in collaboration with the Japanese Society of Hematology (JSH) (PRCA2016 study) that was approved by the institutional review board and the ethical committee of the JSH.In PRCA2004/2006 study 73 patients (39%) were classified as having idiopathic PRCA and 112 patients (61%) as having secondary PRCA, including 42 thymoma- and 14 large granular lymphocyte leukemia (LGL)-associated PRCA. The details on idiopathic, thymoma-associated and LGL-leukemia-associated PRCA have been previously reported (Sawada K, et al. Haematologica 2007;92:1021; Hirokawa M, et al. Haematologica 2008;93:27; Fujishima N, et al. Haematologica 2008;93:1555). The last questionnaires for the patients with these three subtypes of PRCA were sent to the institutions in 2012 for collecting the data on relapse, subsequent treatment and efficacy and outcome.The PRCA2004/2006 study revealed that the median overall survival (OS) has not yet been reached in idiopathic PRCA following immunosuppression and the estimated median OS times in thymoma-associated and LGL leukemia-associated PRCA were 142 and 148 months, respectively. Twenty-two deaths were reported and the major causes of death were infection and organ failure (Hirokawa M, et al. Brit J Haematol 2015;169:879). Poor response to induction therapy and relapse of anemia were demonstrated to be associated with death and this was also confirmed by the Mantel-Byar analysis (p<0.001) (Fig. 1). The efficacy of re-induction therapy for relapsing PRCA was inferior to the initial inductive therapy (p<0.001) (Fig. 2).With the results of this study, we have proposed the clinical guidelines for management of PRCA in 2011 and we conducted another cohort study in 2016 in collaboration with the Japanese Society of Hematology (JSH) (PRCA2016 study). The primary endpoint of this study is the OS in chronic PRCA following immunosuppression and the principal aim is to learn whether or not the prognosis would be improved. Between 2006 and 2014, 554 PRCA patients were registered in the JSH hematological disorder registry and we asked the physicians to participate in this study (Fig. 3). The potential size of patient cohort is 181, including 116 idiopathic and 65 secondary PRCA and these patients will be followed up during the next ten years. The PRCA2016 cohort study is expected to reveal the unbiased results regarding the long-term survival and quality of life in PRCA following immunosuppression. [Display omitted] DisclosuresFujisawa:Bristol myers Squibb: Honoraria; Beckman Coulter: Honoraria; Eisai: Honoraria; Janssen Pharmaceutical: Honoraria; Novartis: Honoraria; Astellas: Honoraria, Research Funding; Nippon Shinyaku: Honoraria, Research Funding; Sumitomo Dainippon Pharma: Honoraria; Otsuka Pharmaceutical: Honoraria, Research Funding; SHIONOGI CO, LTD: Honoraria, Research Funding; Shire plc: Honoraria; Alexion Pharmaceutical: Honoraria; Pfizer: Honoraria, Research Funding; Ono Pharmaceutical: Honoraria, Research Funding; Takeda Pharmaceuticals: Honoraria, Research Funding; Celgene: Honoraria; Chugai Pharmaceutical: Honoraria, Research Funding; Kyowa Hakko Kirin: Research Funding; MSD: Research Funding. Yonemura:Alexion Pharma GK: Honoraria, Research Funding. Kurokawa:Pfizer Inc.: Research Funding; Celgene Corporation: Speakers Bureau; Nippon Shinyaku Co., Ltd.: Other: Scholarship donations for the laboratory, Speakers Bureau; Bristol-Myers Squibb: Speakers Bureau; Takeda Pharmaceutical Company Limited.: Research Funding, Speakers Bureau; Astellas Pharma Inc.: Research Funding.

English

BACKGROUND Chronic liver diseases frequently are associated with haematological abnormalities. Anaemia occurs in about 75% of patients with chronic liver disease. The most common type of anaemia seen in liver cirrhosis is normocytic normochromic anaemia, due to the chronic inflammatory state, blood loss from oesophageal and rectal varices. The purpose of this study was to study the haematological manifestations in patients with chronic liver disease. METHODS A cross-sectional observational study was conducted at Sri Guru Ram Das Institute of Medical Sciences and Research (March 2019 - March 2020). Total of 90 patients with chronic liver disease were included in the study. The population was divided into 2 groups based on the model for end-stage liver disease (MELD) score and the various haematological abnormalities were assessed in these 2 groups. Similarly, haemoglobin (Hb) levels were assessed in 3 groups based on the ChildTurcotte-Pugh (CTP) classification. RESULTS There was a significant correlation between hemoglobina and CTP class (P &lt; 0.001), with the lowest haemoglobin levels in CTP class C group. The correlation coefficient of MELD score and haemoglobin was -0.504 which was significant statistically. Thus, confirming the fact that haemoglobin levels decreases with the progress in the severity of liver cirrhosis. Of 39 patients with haemoglobin &lt; 8 g/dl, 5 (12.8 %) had a MELD score of &lt; 12, whereas 34 patients (87.2 %) had a MELD score of &gt; 12 and was statistically significant (P &lt; 0.0001). Leukocytosis was observed in 41 patients and leucopoenia in 14 patients. The mean prothrombin time was 20.4 seconds and 80 % of the patients had prothrombin time prolonged by more than 6 sec indicating liver damage alters coagulation profile. CONCLUSIONS We found an association between anaemia and indicators of advanced liver disease such as a higher MELD and CPS scores. This study inferred that levels of haemoglobin decrease as the severity of liver disease progresses. Thus, this measure can be used in the initial assessment of cirrhosis patients that needs urgent identification and correction to reduce morbidity and mortality. KEYWORDS Anaemia, Liver Cirrhosis, Model for End-Stage Liver Disease Score, Child-TurcottePugh Class

English

A 45-year-old multiparous female was admitted 1 week back in Bapuji hospital attached to J J M medical college in view of iron deficiency anaemia and had underwent 3 pints of blood transfusion and was discharged with haematinics. Now after 5 days patient noted purpura and ecchymosis over her all four limbs which has increased from past 2 days. Patient also noticed epistaxis, subconjunctival haemorrhage in the last 1 day which brought her to Bapuji hospital in November 2019. Patient had no history of fever, bleeding per rectum, melena, joint pains, headache, blurring of vision, loss of consciousness, seizures. No past history of bleeding manifestations, blood transfusions and medications altering haemostasis in the family. Complete hemogram showed Hb : 11.1 g/dl, total count: 7210 cells/cumm, platelet count: 22000 cells/cumm. Peripheral smear showed normocytic normochromic anaemia with severe thrombocytopenia. LFT showed serum bilirubin: 2.5 mg/dl, indirect bilirubin: 1.9 mg/dl with normal liver enzymes. Coagulation profile and fever profile was done to rule out other causes of thrombocytopenia and was found to be normal. Serum LDH levels were 856 u/l. Direct and indirect coombs test is negative. ANA was negative. USG abdomen shows no splenomegaly. Patient was transfused with 4 pints of platelets and repeat platelet count after 12 hours shows 19000 cells/cumm. This clinical picture with bleeding manifestation with history of blood transfusion suggested post transfusion purpura, patient was transfused with aphaeretic blood and iv immunoglobulins at 500 mg/kg/day for 5 days and corticosteroid prednisolone was given at the dose of 1 mg/kg body weight. Patient platelet count improved significantly to 72,000 cells/cumm on 3rd day of admission. Patient did not have further bleeding manifestation. Patient’s platelet count improved to 1.60 lakhs/cumm at the time of discharge. Patient couldn’t get anti platelet antibodies and HPA genotyping due to financial constraints.

To study and analyze hematological parameters in anaemia in males

Hematological parameters like Hb (haemoglobin), TC (total count), DC (differential count), PCV (packed cell volume), MCV (mean red cell corpuscular volume) done in the automated cell counter and peripheral smear findings were studied. Observational study.Out of 250 cases, 192 i.e. 76.8% cases showed microcytic hypochromic anaemia, 30 cases i.e. 12% had normocytic hypochromic anaemia, 27 cases i.e. 10.6% had normocytic normochromic anaemia and dimorphic anaemia was seen in 02 cases i.e. 0.6% cases.Out of 250 cases, 193 i.e. 77.2% cases showed microcytosis maximally in 0-5 years age group and 57 cases i.e. 22.8% had normocytic picture. The distribution of peripheral smear (RBC size) finding with age varied significantly (p value &amp;#60;0.05). Iron deficiency is almost universal when dealing with this magnitude of anaemia. However, clinically speaking, many technical experts believe that to differentiate severe anaemia, a screening for other causes is desirable, all males are recommended to be screened. In the present study of pediatric cases 0-5 years age group males were most affected and prevalence was more in males as compared to females and the predominant morphological pattern was microcytic hypochromic anaemia.

STUDY OF CLINICALAND HAEMATOLOGICAL PROFILE OF ANEMIA IN GERIATRIC PATIENTS AT A TERTIARY LEVEL CENTRE IN HARYANA

Background: The demographic transition with ageing of population is a global phenomenon and in recent years there has been an increasing international awareness of health issues relating to aging population. Anemia represents an emerging global health problem producing a negative impact in the quality of life among the elderly and requiring greater allocation of health resources. Aims: To identify elderly patients with anemia and study the etiology, clinical parameters, laboratory parameters in these patients. Methods: A total of 100 patients were enrolled in this study. The entire medical history were obtained from each of the cases including previous medical reports and imaging studies. Complete blood counts , RBC indices,total WBC count, differential count, platelet count, haematocrit, ESR, peripheral smears ,reticulocyte count, ferritin, iron and TIBC were recorded for each patient. The data was compiled and analyzed using Statistical Package for social services (SPSS vs 20). Results: Among the etiologies, iron deciency anemia was seen in 43% of patients, anemia of chronic disease in 32%, anemia of chronic kidney disease and unexplained anemia in 11 % patients. Among clinical features the commonest symptom was easy fatiguability and commonest sign was pallor. Peripheral smear study showed that normocytic normochromic anemia was commonest type. Conclusion: This study showed that the commonest cause for anemia among elderly patients is iron deciency anemia followed by anemia due to chronic disease. Geriatric anemia is a disease that often goes unreported hence every effort should be made to identify the disease and evaluate the cause.

Manifestations of Bone Marrow Abnormalities of HIV/AIDS Patients

Background: Human immunodeficiency virus can involve almost any organ system. Anemia is themost common hematological manifestation in HIV/AIDS patients. Bone marrow changes includevarying degrees of dysplasia in one or more cell lines, plasmacytosis, opportunistic infections andhematological malignancies. There are only a few studies where hematological manifestations ofHIV/AIDS patients had been described. Materials and Methods: 100 HIV positive patients, agedbetween 12-65 years were enrolled in this hospital-based cross-sectional study. The study wasconducted from March 2016 to March 2018. A complete blood count, CD4 counts were done, besidesa thorough history and clinical examination. HIV positive patients were classified as those havingAIDS and Non-AIDS, according to NACO criteria. Written informed consent was taken from patientsand bone marrow aspiration was done. Results: Total number of patients included in the study was100. We were able to do a CD4 count of 91 patients. As per criteria, out of 91 patients, 37 cases hadAIDS. The most common hematological abnormality was anemia, seen in 95.45%of patients. Bonemarrow was normocellular in 86.48% of AIDS and 85.18% of non-AIDS, hypocellular in 8.10% ofAIDS and 9.25%o f non- AIDS, hypercellular in 5.40% of AIDS and 5.55% of non-AIDS patients.Dysplasia was statistically and significantly associated with anemia. The commonest dysplasticfeatures are seen in the granulocytic and erythroid series. L.D. bodies were seen in 2 cases andHistoplasma was found in one case. Conclusion: Normocytic normochromic anemia was the mostcommon peripheral smear finding. Hypocellular bone marrow was more common than hypercellularmarrow in an advanced stage of the disease. Dysplastic changes were more common in AIDS thanNon-AIDS. Granulocytic dysplasia was the most common type of dysplasia. There was evidence ofopportunistic infections and gelatinous transformation were detected in our study.

Prevalence of anaemia and its correlation with glycosylated haemoglobin among patients with type 2 diabetes mellitus: an observational study

Background: Anaemia and type 2 diabetes mellitus are two sides of a coin affecting the quality of life of the patients. Anaemia associated with diabetic status of the patients disturbs the exercise capacity, increases fatigue, anorexia, depression, cognitive dysfunction and decreased libido. Hence, we conducted a study to find the prevalence of anaemia among patients with type 2 diabetic patients and its correlation with glycosylated haemoglobin.Methods: An observational study was conducted in the department of medicine in a tertiary care hospital in Maharashtra. The data was collected from patients with type 2 diabetes attending the outpatient department during a span of 5 months (September 2020 to February 2021). The patients with pre-existing hypertension, chronic renal failure, congestive cardiac failure, stroke and other haematological disorders were excluded from the study. Patients on hormonal therapy, pregnant and lactating patients were also excluded from the study. Prior to the start of the study necessary permissions were taken from the institutional ethics committee. Relevant statistics were used to analyse the data.Results: The prevalence of anaemia in the present study was 45 (56.25%). Among these 45 patients 37 patients had normocytic normochromic anaemia, 6 cases of microcytic hypochromic anaemia and 2 cases of macrocytic anaemia. The mean haemoglobin levels among patients with Hba1c more than 7% was 9.7±1.12 and among Hba1c less than 7% was 12. 23±1.08 and this difference was statistically significant.Conclusions: About half of the patients were anaemic in the present study. Normochromic normocytic anaemia was the most common type of anaemia. There was significant association with levels of anaemia with Hb1ac in the present study.