Characterization of the mutation spectrum in a Pakistani cohort of type 3 von Willebrand disease.

INTRODUCTION: Type 3 von Willebrand disease (VWD), a severe autosomal recessive hereditary bleeding disorder, is described by the virtual absence of von Willebrand factor (VWF). In consanguineous populations, for example Pakistan, the disease is reported with a higher incidence rate than the worldwide prevalence. AIMS: This study aims to characterize molecular pathology and clinical profile of type 3 VWD cohort of Pakistani origin. METHODS: In total, 48 patients were enrolled in the current study. Initially, the index patients (IPs) were evaluated by a standardized questionnaire for recording bleeding manifestations and by performing conventional coagulation tests. The diagnosis of VWD type 3 was confirmed by VWF antigens less than 5 IU/dL. Direct sequencing of VWF gene (VWF) was carried out to identify causative gene variations. We evaluated the potential consequence of novel splice site and missense variations by predictive computational programs and in silico structural analysis. RESULTS: VWF mutations were detected in 46 out of 48 IPs (95.8%), predominantly as homozygous variants. In total, twenty-nine different gene defects were characterized in this cohort from which 10 (34.5%) are novel. The majority of the mutations were null alleles (66%; including gene conversions, nonsense, splice site variations, small deletions and insertions), and 34% of them were missense substitutions. CONCLUSION: Herein, we reported for the first time, the pattern of gene defects in Pakistani type 3 VWD cohort. We identified a wide heterogeneous mutation spectrum along with variability in the type of bleeding episodes.

Co-existing iron deficiency/overload in beta-thalassemia trait.

OBJECTIVE: To identify the co-existence of iron deficiency and iron overload in individuals with beta thalassaemia trait. METHODS: The cross-sectional study was conducted at Rehman Medical Institute and Khyber Medical University, Peshawar, Pakistan, September 1, 2015, to December 31, 2017, and comprised individuals with hypochromic microcytic blood picture. Haemoglobin electrophoresis was performed on their blood samples. Serum ferritin levels of subjects with Haemoglobin Subunit Alpha 2 levels between 3.5% and 7% were checked. Data were analysed using analysed using GraphPad Prism v6. RESULTS: Of the 292 subjects, 159(54.5%) were males and 133(45.5%) were females. Of these, 240 (82.2%) were anaemic and 52 (17.8%) had haemoglobin within the normal range. Serum ferritin level of 55(18.8%) subjects was low and 207(70.9%) were iron-replete. Notably, 30(10.3%) subjects had serum ferritin levels higher than the reference range, and this was more common among adults (p<0.001). CONCLUSIONS: Ferritin levels in beta thalassaemia trait can be low, normal or higher than the normal values..

Reactive Plasmacytosis: A Diagnostic Conundrum In Acute Myeloid Leukaemia.

Bone-marrow being a home to various kinds of normal hematopoietic cells, sometime becomes overcrowded by abnormal cell population in malignancies like in acute myeloid leukaemia. One such dilemma in diagnosis betides when two abnormal cell populations in bone-marrow occur at the same time. A prime example is when reactive plasmacytosis in bone-marrow eventuate in relation with acute myeloid leukaemia (AML). Due to scarce amount of such cases reported, it is imperative to understand the difference between reactive plasmacytosis which arises after induction of chemotherapy and the one which is diagnosed along with AML, during initial diagnosis due to other causes, like infections and IL-6 production by the leukemic blast population. To substantiate these erstwhile arguments, the brief case history of a 45 years old female patient diagnosed with acute myeloid leukaemia with coincident reactive plasmacytosis having no previous history of chemotherapy is presented along with review of past published literature.

Beta-thalassaemia trait: haematological parameters.

BACKGROUND: Beta-Thalassaemia syndromes are a group of hereditary disorders characterised by a genetic deficiency in the synthesis of beta-globin chains due to a defect in beta-globin genes. The objective of this study was to determine the haematological features of beta-thalassaemia trait (BTT). and to determine the sensitivity of Mean Corpuscular Volume (MCV), Mean Corpuscular Haemoglobin (MCH) and Mentzer Index (ML) as a screening tool for beta-thalassaemia trait. METHODS: A descriptive study was conducted in Hayatabad Medical Complex, Peshawar from May 2009 to May 2010 with 203 subjects having BTT. Blood samples were collected in EDTA anti-coagulated tubes. RBC indices were taken as part of complete blood count (CBC) by haematology analyser, and Haemoglobin (Hb) electrophoresis was done to determine the HbA2 percentage. The data was collected and analysed on statistical software for demographic details, RBC indices and HbA2 levels. RESULTS: Out of 203 patients, 92 (45%) were males and 111 (55%) were females. Most patients tested were in the 15-45 year age group. One-hundred-sixty (79%) patients had anaemia. MCV was lower than 76 fl in all the cases. Mean MCV was 59.1 fl. MCH was low, the mean MCH being 19.3 g/dl. MCH < 26 gave sensitivity of 99% in detecting BTT. We calculated MI for these cases and found out that it was < 12 in 75% of cases and < 15 in 197 (97%). CONCLUSION: Beta-thalassaemia traits present with a microcytic hypochromic blood picture, detected on simple haematology analysers as low MCV and MCH and MI which provide a useful screening tool for beta-thalassaemia trait.

Correlation Of Serum Ferritin With Haemoglobin A2 Level In Beta Thalassemia Traits.

BACKGROUND: Haemoglobin-A2 is considered as a paramount diagnostic parameter for the detection of beta-thalassemia trait which may vary with the fluctuation of body iron stores. The current study aims to evaluate the correlation of serum ferritin as a parameter of body iron stores with haemoglobin-A2 level in beta-thalassemia traits. METHODS: This cross-sectional study was conducted on total 134 known beta-thalassemia traits in Rehman Medical Institute-Peshawar, Pakistan from October 2018 to June 2019. Blood samples from the contributors were drawn in EDTA and plain tubes for complete blood counts, haemoglobin-A2 and serum ferritin estimation. Participants were categorized into 3 groups on the basis of iron status; beta-thalassemia traits with low ferritin (Group A), normal ferritin (Group B) and high ferritin levels (Group C). Pearson correlation was applied to analyse the correlation between the variables. RESULTS: Out of total 134 known beta-thalassemia traits, 73 (54.5 %) were males and 61 (45.5%) were females. Participants of group A with low ferritin were 22 (16.4%), group B with normal ferritin were 96 (71.6%) and group C with high ferritin were 16 (11.9%). Group A shows lowest mean haemoglobin-A2 level comparatively to Group B and Group C, with some effect of serum ferritin on haemoglobin-A2 level. CONCLUSIONS: Haemoglobin-A2 value decreases when there is a decrease in serum ferritin and show slightly increase with high ferritin level as compared to normal ferritin level or body iron stores in beta-thalassemia traits. However, this correlation is not significant enough to mask the actual diagnosis of the disease.

Autosomal recessive inherited bleeding disorders in Pakistan: a cross-sectional study from selected regions.

BACKGROUND: Autosomal recessive bleeding disorders (ARBDs) include deficiencies of clotting factors I, II, V, VII, X, XI, XIII, vitamin K dependent clotting factors, combined factor V & VIII, Von Willebrand Disease (vWD) type 3, Glanzmann's thrombasthenia (GT) and Bernard-Soulier syndrome. Patients with primary bleeding disorders from all the major provincial capitals of Pakistan were screened for ARBDs. Prothrombin (PT), activated partial thromboplastin time (APTT), bleeding time (BT) and fibrinogen levels were measured. Cases with isolated prolonged APTT were tested for factors VIII and IX using factor assays This was followed by FXI:C level assessment in cases with normal FVIII and FIX levels. vWD was screened in patients with low FVIII levels. Factors II, V and X were tested in patients with simultaneous prolongation of PT and APTT. Peripheral blood film examination and platelet aggregation studies were performed to assess platelet disorders. Urea clot solubility testing was done to detect Factor XIII levels where platelet function tests were normal. Descriptive analysis was done using SPSS version 16. RESULTS: Of the 429 suspected bleeding disorder patients, 148 (35%) were diagnosed with hemophilia A and 211 (49.1%) patients had ARBDs. 70 patients (16.3%) remained undiagnosed. Out of 211 patients with ARBD; 95 (33.8%) had vWD type 3. Fibrinogen deficiency was found in 34 patients (12%), GT in 27 (9.6%), factor XIII deficiency in 13 (4.6%), factor VII deficiency in 12 (4.3%), factor V deficiency in 9 (3.2%). Eight patients (2.8%) had vitamin K-dependent clotting factor deficiency, Bernard-Soulier syndrome was diagnosed in seven patients (2.5%), factor X deficiency in 2 (0.7%), factor II deficiency in 2 (0.7%), factor XI deficiency and combined factor V and VIII deficiency in 1 (0.4%) patient each. CONCLUSION: vWD type 3 was the most common ARBD found in our sample of patients in Pakistan, followed by fibrinogen deficiency and GT in respective order.