Challenges in the diagnosis and management of autoimmune hemolytic anemia: A case-based approach. Experience from a tertiary care hospital in the Haryana region.

BACKGROUND: Autoimmune hemolytic anemia (AIHA) is a rare immune disorder which occurs when antibodies are directed against self red blood cells (RBCs) leading to hemolysis. AIHA is widely classified as warm autoimmune hemolytic anemia, cold agglutinin syndrome, mixed AIHA, paroxysmal cold hemoglobinuria and rarely drug induced AIHA. The pathogenesis of AIHA is complex interplay between genetic predisposition, immune dysregulation and enviornmental triggers. A direct antiglobulin test can be used to assess the immunological origin of the hemolysis in order to diagnose AIHA after identifying laboratory and clinical symptoms of hemolysis. OBJECTIVE: The objective is to understand underlying mechanism in AIHAs, and usage of targeted therapies to modulate specific components of the immune response. MATERIALS AND METHODS: We are hereby presenting a case series of 11 clinically suspected cases of AIHA in collaboration with their clinical features, immuno-hematological and other laboratory parameters, Flow cytometric analysis of lymphocyte subset in relevant cases, underlying etiology as well as serological subtype are also included. RESULTS: Majority of the patients were categorized as secondary AIHA (7/11, 63.63%). Out of 11 cases 7 were serologically subtyped as warm AIHA (7/11, 63.63%) ,2 cases were DaaT negative AIHA (2/11;18.18%), 2 cases were characterized as mixed AIHA subtype (2/11, 18.18%). CONCLUSION: Accurate subtyping of AIHA requires a systematic immunohematological approach coupled with comprehensive evaluations of clinical, hematological, and biochemical parameters.

A rare case of complicated malaria presenting as warm autoimmune hemolytic anemia.

Autoimmune hemolytic anemia (AIHA) has been rarely reported worldwide or from India as the underlying cause of anemia in malaria. We hereby present a case of complicated Plasmodium falciparum malaria with concomitant warm AIHA in a 31-year-old male. Direct Antiglobulin Test (DAT) was positive and elution studies showed pan-agglutination reaction. Clinico-hematological and serological follow-up of the patient was done post artesunate treatment until day 9. We suggest that it is important to establish the immune basis of anemia in malaria patients for guiding the treatment plan for the clinicians and providing packed red blood cell transfusion if required.

Correlation of T-regulatory Cells and Iron Status in ß-Thalassemia Major Patients.

Background The increased risk of infections in transfusion-dependent ß-thalassemia major (TDT) patients is mainly due to underlying immune dysfunction; however, its cause is largely unidentified. There is sufficient evidence to suggest immune changes due to iron deficiency; however, similar studies demonstrating the effects of iron excess on immune cells in these cases are limited. Aim and objectives To analyze the correlation between T-regulatory cells and iron stores in ß-thalassemia major patients. Methods In this study, 20 ß-thalassemia major cases and 20 healthy controls were studied for complete hemogram, iron profile, and flow cytometric immunophenotyping for CD3+, CD4+, CD8+, and T-regulatory cells markers (CD4+CD25+ and CD4+CD25+FOXP3+). Result Significantly higher levels of serum iron, ferritin, transferrin saturation, and CD4+ cell percentage were observed in cases than in controls. In 70% of cases with serum ferritin cut-off levels of less than 1000 µg/L, the T-regulatory cell marker CD4+CD25+ and serum ferritin revealed a significant moderate positive correlation (p=0.031, r=0.627). These same 70% cases also demonstrated a moderately significant positive correlation between serum iron and absolute lymphocyte count (r=0.529, p=0.042). Conclusion The results suggest that serum ferritin in excess amounts can increase T-regulatory cells, which may further alter the immune status of TDT patients; however, the absence of such a correlation in cases with serum ferritin of more than 1000 µg/L remains unanswered. It is important to understand immune system alterations as this will help provide new modalities for managing thalassemia patients in the form of immunoregulatory therapies.

Giant Cell Tumor of Clavicle in an Elderly: Rare Presentation of a Common Tumor with Review of Literature; 1980-2020.

Giant cell tumor (GCT), also known as osteoclastoma, is a locally aggressive benign tumor arising in the epiphysis of bone. It accounts for 3%-8% of all bone tumors. About 75%-90% of GCTs occur in long tubular bones with more than 50% arising in the distal femur and proximal tibia. Flat bone involvements such as ribs, skull, patella, sternum, and clavicle are rare. Sixty-seventy percent of patients with GCT are between 20 and 40 years of age, rarely affecting too young or too old. We present here an unusual case of GCT of the clavicle in a 62-year-old female.

Screening peripheral blood smear: A tale of the "TAIL".

Examining a well-stained slide in a systematic manner is the key to being a good pathologist. For a blood smear, it involves examining first at low power (40× or 100×) for broader details and then going on to high power (400×) for finer details, from the tail end to the body of the slide. The 'tail end' is the key to early diagnosis.

Microfilaria: not always associated with eosinophilia.

Filariasis is a parasitic infection seen predominantly in tropical and subtropical countries including India. In clinically suspected cases, examining a thick wet mount smear or a buffy coat film is most informative. In unsuspected cases, however, eosinophilia in a peripheral blood smear (PBS) may be the sole indicator of parasitaemia. A few cases of tissue microfilaria with the absence of peripheral blood eosinophilia (PBE) have been reported. Here, we report two cases of microfilaria in PBS in the absence of PBE. A routine screening of the tail end of all PBS at low power magnification is also advised as it may facilitate the detection of asymptomatic cases when there is a normal eosinophil count.