Clinical, Laboratory Profile, Treatment and Outcome Of Primary Amyloidosis in the Era Of Novel Agents: An Experience from a Tertiary Care Hospital

Introduction: Diagnosis of AL amyloidosis requires demonstration of amyloid in affected tissues along with clonal plasma cells in bone marrow or presence of monoclonal light chains in blood. With the availability of serum light chain assay and immunophenotyping by flow cytometry, more cases of AL amyloidosis are being diagnosed. Here we present our experience of AL amyloidosis diagnosis and treatment in the era of modern diagnostics and therapy. Aims & Objectives: We aimed to describe the clinical presentations, laboratory features, treatment and outcomes of patients with AL amyloidosis in a single center using standard diagnostic tests and treatment with novel agents. Material(s) and Method(s): A retrospective analysis of AL amyloidosis patients, diagnosed in our hospital, a tertiary care center from January 2016 to June 2022 was conducted. The data was collected from departmental database. All statistical analyses were done by SPSS version 17. Result(s): Diagnosis of AL amyloidosis was done in 31 patients. Median age of presentation was 61 years. 25 (80.6%) were males. Major symptoms were pedal edema (38.7%) and shortness of breath (32.3%). Twenty four (77.4%) presented with ECOG PS >= 2. Most common systems involved were cardiac (54.8%) and renal (54.8%). Fourteen (45.2%) had two or more systems involvement while 17 (54.8%) had single system involvement. Lambda monoclonal light chain was present in 83.9% and kappa monoclonal light chain in 16.1%. Median M-protein was 0.59 g/dL (range 0-2 g/dL) and median bone marrow plasma cells were 6% (range-1-18%). Eighteen patients were treated;cyclophosphamide, bortezomib and dexamethasone (CyBORD) in 12/18 (66.7%) and bortezomib + dexamethasone in 6/18 (33.3%). Among 18 patients followed up with median follow up of 9 months (range 1-64 months), six expired;three due to COVID, two due to cardiac arrhythmia (during first cycle) and one due to relapse and rest 12 were alive. Among the 12 patients who were alive 6 were in complete hematological response. Conclusion(s): Our study presents the spectrum of clinical manifestations, management and outcomes of primary amyloidosis in Indian context. There is a need to increase the awareness among the physicians about amyloidosis so that early diagnosis can be made and timely treatment can be done with novel agents to improve the dismal historical results.

Clinical Profile and Treatment Outcome of Severe Aplastic Anemia in Adults: An Experience from Tertiary Care Centre in North India

Introduction: Untreated/refractory severe aplastic anemia (SAA) is associated with very high mortality. Allogenic bone marrow transplantation or immunosuppressive therapy remains mainstay of treatment but these treatments are timely available to only a select subset of patients. Recently eltrombopag has been approved for treatment of SAA. Aims & Objectives: We aimed to describe clinical profile and treatment response in patients with SAA from a tertiary care centre. Material(s) and Method(s): A retrospective analysis of patients diagnosed with SAA over a period of 7 years from January 2015-December 2021 was performed. The details of demographic profile, laboratory features, treatment given and response were analyzed. Result(s): Ninety patients were diagnosed with SAA during this period out of which 18 patients went elsewhere for treatment. Seventy-two patients who received treatment in our hospital were included in the analysis. Sixty-two patients were SAA while 10 VSAA. PNH screening was done in 24 patients, out of which 17 (70%) had small clone. The details of treatment and response achieved is shown in Table 1. Eight patients (11.1%) received matched related donor allogenic hemopoietic cell transplant, out of which one had rejection followed by auto recovery while one died 6 months later due to covid 19 disease. Sixty-four patients received immunosuppressive therapy, forty-nine (76%) responded. Recurrence of SAA occurred in two patients who has achieved complete response to ATG therapy;one received second course of horse ATG + CSA + ETP and responded again. Conclusion(s): Timely diagnosis and appropriate treatment selection is of utmost importance to achieve optimal outcome in severe aplastic anemia. Eltrombopag has become an important addition not only in front line but also in relapsed refractory aplastic anemia. Patients lacking donor, or resources for ATG should be treated with cyclosporine and eltrombopag as early as possible. (Table Presented).

CLINICAL, LABORATORY PROFILE, TREATMENT AND OUTCOME OF PRIMARY AMYLOIDOSIS IN THE ERA OF NOVEL AGENTS: AN EXPERIENCE FROM A TERTIARY CARE HOSPITAL IN INDIA

Background: Diagnosis of AL amyloidosis requires demonstration of amyloid in affected tissues along with clonal plasma cells in bone marrow or presence of monoclonal light chains in blood. With increasing awareness among physicians and availability of proper diagnostics, more cases of AL amyloidosis are being diagnosed. Here we present our experience of AL amyloidosis diagnosis and treatment in the era of modern diagnostics and therapy with novel agents. Aims: We aimed to describe the clinical presentations, laboratory features and outcomes of patients with AL amyloidosis in a single center using standard diagnostic tests and treatment with novel agents. Methods: A retrospective analysis of AL amyloidosis patients, diagnosed in our hospital, a tertiary care center in India from January 2016 to December 2021. The data was collected from departmental database. All statistical analyses were done by SPSS version 17. Results: Diagnosis of AL amyloidosis was done in 27 patients. Median age of presentation was 59 years. 22 (81.5%) were males. Major symptoms were pedal edema (37%), shortness of breath (22.2%), frothy urine (11.1%) and fatigue (11.1%). Twenty two (81.5%) presented with ECOG PS ≥ 2. Most common system involved was renal in 16 (59.2%), followed by cardiac in 13 (48.1%) and gastro-intestinal in 9 (33.3%). Fifteen (55.6%) had two or more system involvement while 12 (44.4%) had single system involvement. Lambda monoclonal light chain was present in 22/27 (81.5%) and kappa monoclonal light chain was present in 5/27 (18.5%). Median Hb was 11.6 g/dl (range 6.7- 14.8 g/dl), median M-protein was 0.69 g/dL (range 0-2 g/dL) and median bone marrow plasma cells were 7% (range- 1-18%). Fourteen patients were treated;cyclophosphamide, bortezomib and dexamethasone (CyBORD) in 10/14 (71.4%) and bortezomib + dexamethasone in 4/14 (28.6%). Among 14 patients followed up with median follow up of 13 months (range 6-60 months), 5 expired;3 due to COVID, one due to cardiac arrhythmia (during first cycle) and one due to relapse and rest 9 were alive. Among the 9 patients who were alive 6 were in complete hematological response and 3 were in partial response after 6 cycles of therapy. Summary/Conclusion: Our study presents the spectrum of clinical manifestations, management and outcomes of primary amyloidosis in Indian context. There is a need to increase the awareness among the physicians about amyloidosis so that early diagnosis can be made and timely treatment can be done with novel agents to improve the dismal historical results.

Pilot Study of Lymphocyte Subset Analysis in COVID-19 Patients Presenting to a Tertiary Hospital

Introduction: A reduced absolute lymphocyte count in peripheralblood along with relative increase in neutrophil count has beenobserved consistently in hospitalized COVID-19 patients. The role ofbaseline lymphocyte subsets in COVID-19 is still unknown.Aims &Objectives: We aimed at analyzing the baseline lymphocytesubsets in COVID-19 patients and its impact on the outcome andseverity of the disease.Materials &Methods: Study was conducted retrospectively fromhospital electronic records. Diagnosis of COVID-19 disease wasbased on the RTPCR for SARS-COV-2 virus. Lymphocyte subsetswere determined using flowcytometry in COVID-19 patients onadmission to COVID ward. The variation in the baseline lymphocytesubsets according to the severity and outcome of the disease wasanalyzed.Result: Patients who died of COVID-19 disease had higher mean Blymphocytes and NK cells than the survivors but was not statisticallysignificant. T lymphocyte counts and CD8 + T cell counts showedstatistically significant (p< 0.05) reduction in patients who expiredthan who survived COVID-19 disease.Conclusions: We concluded that low CD8 + T cell counts atadmission may be predictive of patient outcomes in COVID-19.

Mimickers of Hit Antibodies in Critically Ill COVID Patients

Introduction: Infection with SARS CoV2 leads to respiratory failureand can lead to support of extracorporeal oxygenation (ECMO)leading to exposure to heparin. Exposure to heparin and developmentof thrombocytopenia raises the suspicion of HIT. The strong positiveIgG PF4-heparin antigen test by immunochromatography is followedby platelet aggregation test in our center. We present a case of covid-19 in which HIT was strongly positive on gel agglutination butfunctional assay was negative. Review of literature shows that this could be due to circulating platelet immune complexes in critically illcovid patients which simulate HIT antibodies.Aims &Objectives: Materials &Methods: 7 months pregnantfemale, non-vaccinated, asthmatic, COVID 19 positive patient wasadmitted to our hospital. On admission her fetal ultrasound wasnormal and was started on non-invasive ventilation along with supportive care. However she deteriorated and shifted to veno-arterialextracorporeal membrane oxygenation support (ECMO). Her plateletcount dropped by>50% at day 6 of heparin exposure with anintermediate probability for HIT (4Tscore 5). HIT gel agglutinationtest was positive for IgG antibodies for antiheparin/PF4 antibodies butfunctional assay based on heparin-induced platelet aggregation(HIPA) revealed no increase in aggregation of patient serum with0.5U/ml and 1U/ml heparin dosage. Heparin induced thrombocytopenia was ruled out due to PAT and patient continued on ECMO.This could be due to increased platelet activating immune complexesor anti-PF4 antibodies mimicking antiheparin/PF4 antibodies. However, patient deteriorated and succumbed to the disease.Result: Heparin induced thrombocytopenia was ruled out due to PATand patient continued on ECMO. This could be due to increasedplatelet activating immune complexes or anti-PF4 antibodies mimicking antiheparin/PF4 antibodies. However, patient deteriorated andsuccumbed to the disease.Conclusions: Pathophysiology of Covid 19 disease in critical caseshas shown exacerbated immune reactions, increased endothelialinjury, which causes increased release of PF4 leading to plateletactivation.3 A recent work has also shown significantly increasedplatelet apoptosis, secondary to IgG-mediated FccRIIA signaling, incritically ill COVID-19 patients.4 It is also possible that the circulating immune complexes may be formed by corona virus-antibodycomplexes (as seen in H1N1 viral infection) 0.5 A high titre of antiPF4/heparin antibody test may not strongly predict the presence ofclinically relevant HIT antibodies, thus a confirmatory functional testshould be performed.

Sars-cov-2 associated with cmv reactivation-proof of immune dysregulation;''amalgamation of past and present''

Aims & Objectives: To study the immune profile of SARS-CoV-2 patients with recent & active CMV infection. Patients/Materials & Methods: The immune profile of three SARSCoV-2 patients with persistent lymphopenia and increased CMV copy numbers were analysed using single platform flowcytometry, The patients were also evaluated for acute phase reactants such as IL-6, CRP, LDH and Ferritin levels. Other tests like PT, APTT, D-Dimer & Fibrinogen for coagulopathies were also correlated. The patients were exhaustively evaluated for underling comorbities. Results: The lymphocyte subset counts in SARS-CoV-2 patients showed markedly reduced CD4 and CD8 counts with mean CD4 counts 260 cells/microL and CD8 counts of 126 cells/microL. The patients were CMV positive with copy numbers ranging from 149 to 217 AU/mL. The IL-6, CRP, Ferritin values were elevated in all with normal LDH and Procalcitonin values. D-dimer levels were elevated with normal PT, APTT&Fibrinogen levels. The mean of IL-6,CRP and ferritin were : 286.86 pg/mL,112 mg/L,197.35 ng/mL respectively. All our patients had comorbidities like diabetes mellitus, hypertension and cardiovascular disease. These patients were all treated with injection Gancyclovir and patient showed steady improvement clinically and TLC counts reached the normal range within few days of initiating treatment with progressive reduction in CMV copies. Discussion & Conclusion: The common hematological feature of SARS-CoV-2 is leucocytosis with absolute lymphopenia & high neutrophil to lymphocyte ratio. However, studies have shown that persistent leucopenia is associated with secondary and opportunistic infections. The novel corona virus affect the T cell subset especially CD8 + T lymphocytes causing lymphopenia by either excessive recruitment to peripheral pathways, hyper activation by inflammatory cytokines or increased pro-apoptotic signaling by Caspase 3 and CD59. Immune dysregulation in SARS-CoV-2 patients may lead to reactivation of CMV. It has also been speculated that rampant use of anti IL-1 and anti-IL6 and immunomodifying drugs such as Favipravir might be playing an important role in reactivation of CMV virus. Conclusion: A CMV screening in all the high risk patients, persistent or increasing leucopenia and in ICU setting might help in reducing the percentage and degree of mortality and complications the patient might suffer from. A timely diagnosis and treatment with an eyesight for detection of early complication may help in this battle with SARSCoV-2.

Typically ''atypical'': A case series of atypical chronic myeloid leukemia

Aims & Objectives: Atypical Chronic myeloid leukemia (aCML) is a rare subtype of MDS/MPN. The diagnosis of aCML has evolved over years with more evidence from cytogenetic and molecular studies. We report here a case series of three patients with aCML that was picked up based on morphology and molecular workup. Patients/Materials & Methods: Case 1: A 68-year male with incidental detection of leukocytosis on routine hemogram without organomegaly with Hb11.6 g/dL,TLC 35X103/μl,platelets 41X103/ ll,DLC My30MM5N53L8E3Baso1%. Bone marrow was hypercellular with M:E ratio7.7:1, severe dysgranulopoiesis, 07% blasts,and dysmegakaryopoiesis (>50%). His extended MPN reflex panel (BCR-ABL1, JAK2, CALR, MPL) was negative. Provisional diagnosis of aCML was made. NGS panel revealed multiple mutations in ZRSR2, ASXL1, RUNX1, SF3B1, EZH2, TET2 genes. He has completed 6 cycles of Azacytidine and remains stable for 8 months since the diagnosis. Case 2: A 76-year old male with suspected CML presented with mild hepatosplenomegaly with Hb 8.9 g/dL,TLC 46X103/μl, platelets 75X103/μl, DLC Blast3My12MM8 N66Ly8 Mono2Baso1% and 2nRBC/100 WBCs. Bone marrow was hypercellular with M:E 6.3:1, significant dysgranulopoiesis 03% blasts, and dysmegakaryopoiesis. His extended MPN reflex panel was negative. NGS revealed mutations in ASXL1 and KRAS genes. After diagnosing aCML he was started on hydroxyurea and remains stable after 6 months of diagnosis. Case 3: A 71-year old female with suspected CML based on moderate splenomegaly and hemogram showed Hb 8.9 g/dL,TLC 65.94X103/μl, Platelets 45X103/μl with DLC Blast1My29MM22N38Ly5Eo4Baso2% Bone marrow was hypercellular with M:E 5.8:1, prominent left shift in granulocytic series, 01% blasts, no dysgranulopoiesis. There was significant dysmegakaryopoiesis. A provisional diagnosis of CML vs MDS/MPN was kept and was advised molecular workup. BCR-ABL1 and JAK2 mutation were negative. NGS panel revealed ASXL1 and SF3B1 gene mutations. Finally diagnosed as aCML and treated with Hydroxyurea. She developed undiagnosed fever during COVID19 lockdown and succumbed to her illness. Discussion & Conclusion: Atypical CML is a very rare entity with close differential diagnoses of accelerated phase of CML or MDS/ MPN-U. However as more awareness of this entity has emerged, more patients are subjected to NGS evaluation, thus contributing to the knowledge about this under-reported diagnosis from the third world.