Infantile pyknocytosis, a neonatal hemolytic anemia with Heinz bodies: A cohort study.

Infantile pyknocytosis (IP) is a rare, probably misestimated, cause of non-immune neonatal hemolytic anemia evolving in two phases: an initial phase with severe jaundice, followed by a second phase with hemolytic anemia, which may require neonatal intensive care. The diagnosis of IP is based on the transient presence on blood smear of hyperdense, contracted, and/or spiculated red blood cells (pyknocytes), associated with the spontaneous resolution of clinico-biological features and the exclusion of other causes. If the etiology remains undetermined, some contributing factors, such as oxidative stress, have been proposed. We report the description of 16 patients with IP aiming at clarifying the circumstances associated with the development of this acquired disorder. In the acute phase, the mean hemoglobin nadir and pyknocyte count were 7.8 g/dL and 11%, respectively, and strikingly, Heinz bodies were evident in 50% of the newborns, but in 100% after prolonged incubation (4 hours). A high proportion of Mediterranean or African ancestry was noted in newborns, as well as a significant number of peripartum events, such as respiratory distress. If the etiology of IP is certainly multifactorial, our series reinforces the role of oxidative stress, which may, at least in part, find origin in desaturation episodes in newborns.

An Additional Case of Hb Saint Nazaire [ß103(G5)Phe→Ile; HBB: c.310T>A] Leading to Moderate Erythrocytosis in a French Family.

We report two members of a French family who are carriers of a rare hemoglobin (Hb) variant leading to erythrocytosis: Hb Saint Nazaire [ß103(G5)Phe→Ile; HBB: c.310T>A]. The proband is a 38-year-old woman referred to our institution for a moderate but persistent polycythemia without any clinical consequence. As her mother had a similar blood count, a diagnosis of a Hb variant with high oxygen affinity was proposed. The variant was difficult to detect by capillary electrophoresis (CE) and not distinguishable by high performance liquid chromatography (HPLC) and isoelectric focusing. Finally, a heterozygous mutation on the HBB gene corresponding to Hb Saint Nazaire was identified. This case report illustrates that this rare cause of erythrocytosis can be easily under or misdiagnosed unless several Hb separation techniques are used.

Diagnostic Value of Antigen-Specific Immunoglobulin E Immunoassays against Ara h 2 and Ara h 8 Peanut Components in Child Food Allergy.

BACKGROUND: Peanut allergy is one of the most severe food allergies in children. The diagnostic gold standard is the oral food challenge (OFC). However, OFC has inherent risks and is time consuming. The measurement of specific immunoglobulin E (sIgE) to peanut components in blood detects peanut sensitization, but the decision point predicting allergy is still unclear. The aim of this study was to determine the diagnostic value of these tests for the evaluation of child peanut allergy. METHODS: In this retrospective study, 81 children were referred for peanut allergy. The diagnosis of peanut allergy was based on the clinical context and a positive OFC. Levels of sIgE against whole peanuts or peanut components (Ara h 2 and Ara h 8) were determined by immunoassay. RESULTS: The Ara h 2 sIgE assay has the best negative predictive value (0.93) and positive predictive value (1) at a cutoff of 0.1 kU/l. Ara h 2 sIgE titers can predict the risk of anaphylaxis (<0.44 kU/l, low risk; >14 kU/l, high risk). The Ara h 8 sIgE assay is not able to discriminate peanut-allergic patients but can be used to evaluate possible cross-reactions to birch pollen with a low risk of anaphylaxis. The best diagnostic strategy is to first determine the Ara h 2 sIgE level and, if negative, evaluate Ara h 8 sIgE. CONCLUSIONS: We propose an algorithm for a better use of peanut component sIgE immunoassays that should improve their diagnostic value and avoid unnecessary OFC.

Analysis of immunoglobulin/T-cell receptor repertoires by high-throughput RNA sequencing reveals a continuous dynamic of positive clonal selection in follicular lymphoma.

Follicular lymphoma (FL) course is highly variable, making its clinical management challenging. In this incurable and recurring pathology, the interval between relapses tends to decrease while aggressiveness increases, sometimes resulting in the transformation to higher-grade lymphoma. These evolutions are particularly difficult to anticipate, resulting from complex clonal evolutions where multiple subclones compete and thrive due to their capacity to proliferate and resist therapies. Here, to apprehend further these processes, we used a high-throughput RNA sequencing approach to address simultaneously the B-cell immunoglobulin repertoires and T-cell immunoglobulin repertoires repertoires of lymphoma cells and their lymphoid microenvironment in a large cohort of 131 FL1/2-3A patients. Our data confirm the existence of a high degree of intra-clonal heterogeneity in this pathology, resulting from ongoing somatic hyper-mutation and class switch recombination. Through the evaluation of the Simpson ecological-diversity index, we show that the contribution of the cancerous cells increases during the course of the disease to the detriment of the reactive compartment, a phenomenon accompanied by a concomitant decrease in the diversity of the tumoral population. Clonal evolution in FL thus contrasts with many tumors, where clonal heterogeneity steadily increases over time and participates in treatment evasion. In this pathology, the selection of lymphoma subclones with proliferative advantages progressively outweighs clonal diversification, ultimately leading in extreme cases to transformation to high-grade lymphoma resulting from the rapid emergence of homogeneous subpopulations.

[Hemolytic anemia in a two-year-old child: A case of multiple red blood cell abnormalities]. / Anémie hémolytique chez un enfant de deux ans : Un cas d'anomalies multiples du globule rouge.

The discovery of hemolytic anemia requires a meticulous investigation to determine its etiology. Among patients of African origin, it is not uncommon to find multiple constitutional red blood cell abnormalities, which can complicate diagnosis. We herein describe the case of a two-year-old child presenting with acute hemolytic anemia. A G6PD deficiency, hereditary spherocytosis, and a sickle cell trait A/S were simultaneously identified, all within the context of a primary infection with Parvovirus B19. This virus commonly triggers acute anemia in children exhibiting constitutional red blood cell abnormalities and need to be considered in such cases.

[Severe thrombopenia with iron deficiency anemia: about a case and literature review]. / Thrombopénie sévère d'origine ferriprive : à propos d'un cas et revue de la littérature.

Iron deficiency is the leading cause of anemia worldwide, affecting approximately 600 million individuals. Once established, it typically manifests as a hypochromic microcytic anemia, the severity of which varies depending on the degree of deficiency. This anemia is frequently associated with thrombocytosis, but the presence of associated thrombocytopenia is much rarer. Here, we report a case of severe iron deficiency with an atypical presentation of bicytopenia, involving both severe anemia and profound thrombocytopenia, which rapidly resolved following iron supplementation. We then discuss the hypotheses that exist to explain the link between iron deficiency and regulation of thrombopoiesis.

Germline JAK2 E846D Substitution as the Cause of Erythrocytosis?

The discovery in 2005 of the JAK2 V617F gain-of-function mutation in myeloproliferative neoplasms and more particularly in polycythemia vera has deeply changed the diagnostic and therapeutic approaches to polycythemia. More recently, the use of NGS in routine practice has revealed a large number of variants, although it is not always possible to classify them as pathogenic. This is notably the case for the JAK2 E846D variant for which for which questions remain unanswered. In a large French national cohort of 650 patients with well-characterized erythrocytosis, an isolated germline heterozygous JAK2 E846D substitution was observed in only two cases. For one of the patients, a family study could be performed, without segregation of the variant with the erythrocytosis phenotype. On the other hand, based on the large UK Biobank resource cohort including more than half a million UK participants, the JAK2 E846D variant was found in 760 individuals, associated with a moderate increase in hemoglobin and hematocrit values, but with no significant difference to the mean values of the rest of the studied population. Altogether, our data as well as UK Biobank cohort analyses suggest that the occurrence of an absolute polycythemia cannot be attributed to the sole demonstration of an isolated JAK2 E846D variant. However, it must be accompanied by other stimuli or favoring factors in order to generate absolute erythrocytosis.

G6PD: a homozygous deficiency revealed by macrocytosis after acute alcoholism / G6PD : un déficit homozygote révélé par une macrocytose au décours d'un épisode d'éthylisme aigu

G6PD deficiency is one of the most common genetic disorders in the world, affecting more than 400 million people. The large majority of patients do not have anemia of chronic hemolysis but are subject to acute haemolytic anemia after exposure to triggering factor, usually eating fava beans, exposure to oxidative drugs or acidosis. We report the case of a 53-year-old woman that had an acute haemolytic anemia revealed by abnormally rapid increase of MCV that eventually led to discover G6PD deficiency. As investigation did not identify any common triggering factor, we discuss the involvement of the patient's acute alcohol consumption in this haemolytic event.

Le déficit en G6PD est l'une des affections génétiques les plus fréquentes dans le monde, touchant plus de 400 millions de personnes. La majorité des patients n'ont pas d'anémie ni d'hémolyse chronique, mais sont sujets à la survenue d'accès d'hémolyse aigue après exposition à un facteur déclenchant : consommation de fèves, médicaments oxydants, acidose le plus souvent. Nous rapportons ici un cas d'accès d'hémolyse chez une patiente de 53 ans révélé par une augmentation rapide du VGM et qui a permis la mise en évidence d'un déficit en G6PD homozygote. L'enquête étiologique n'ayant pas retrouvé de facteur déclenchant habituel, nous discutons l'implication de la consommation aigue d'alcool de la patiente dans cet accès d'hémolyse.

Integrative diagnosis of primary cutaneous large B-cell lymphomas supports the relevance of cell of origin profiling.

Primary cutaneous large B-cell lymphomas (PCLBCL) represent a diagnostic challenge because they are classified as PCLBCL, leg type (PCLBCL, LT) or primary cutaneous follicle centre lymphoma, large cell (PCFCL, LC), which differ by prognosis and therapeutic requirement. Unclassified cases with discordant clinical presentations, morphologies, and immunophenotypes may be classified into the not otherwise specified (PCLBCL, NOS) category based on ancillary molecular analyses. Cell-of-origin profiling as germinal centre (GC) type or non-GC type by immunohistochemistry is not considered reproducible because of variable CD10 expression. In a series of 55 PCLBCL cases with > 80% large cells, we reported 21 PCFCL, LC cases as GC-type and 27 PCLBCL, LT as non-GC-type; 7 cases were considered PCLBCL, NOS. Here, we demonstrate the accuracy of molecular profiling of PCLBCL as GC or non-GC type using a reverse transcriptase multiplex ligation assay (RT-MLPA). RT-MLPA classified the seven PCLBCL, NOS cases in accordance with their mutational profile. An integrative principal component analysis confirmed the main criteria and the relevance of genomic profiling of PCFCL, LC as GC-derived, and PCLBCL, LT as non-GC-derived. Both the cell-of-origin classification of PCLBCL and the integrative analysis identified two clinically relevant subgroups according to overall survival, which may help to standardize PCLBCL diagnosis and patient management.

Concomitant occurrence of genetically distinct Hodgkin lymphoma and primary mediastinal lymphoma.

Synchronous Hodgkin Lymphoma and Primary Mediastinal B-cell Lymphoma is possible, with molecular analyses proving the absence of clonal filiation between both entities. This suggests a common etiology but the existence of two divergent clones.

Erythrocyte hemighosts in a patient with tumor lysis syndrome: One train may hide another.

Rasburicase was introduced to treat hyperuricemia secondary to tumor lysis syndrome. Because of severe hemolytic anemia, a blood smear was requested and showed hemighosts, revealing G6PD deficiency. Erythrocyte morphology is a key tool in laboratory hematology.

[Benefit of Howell-Jolly bodies detection: finding of an acquired hyposplenism in a patient with Goodpasture syndrome]. / Intérêt de la détection des corps de Howell-Jolly : hyposplénisme acquis dans le cadre d'un syndrome de Goodpasture.

Howell-Jolly bodies are intraerythrocytic inclusions corresponding to a small portion of chromatin. Red blood cells that contain these nuclear remnants are removed from the circulation by the spleen. In most cases, presence of Howell-Jolly bodies on a blood smear is the result of functional asplenia and splenectomy. Observation. We report incidental finding of numerous Howell-Jolly bodies in a patient followed by the nephrology department. This microscopic observation of blood smear led to a diagnostic imaging and to the evidence of a reduced spleen, possibly favoured by a history of Goodpasture syndrome in this renal transplant patient without splenectomy. Vaccination and antibioprophylaxy were proposed to prevent infectious risk linked to this splenic hypoplasia. Conclusion. Seeking of Howell-Jolly bodies could be made in every condition associated with a risk of splenic hypoplasia to prevent infectious risk.

Combining gene expression profiling and machine learning to diagnose B-cell non-Hodgkin lymphoma.

Non-Hodgkin B-cell lymphomas (B-NHLs) are a highly heterogeneous group of mature B-cell malignancies. Their classification thus requires skillful evaluation by expert hematopathologists, but the risk of error remains higher in these tumors than in many other areas of pathology. To facilitate diagnosis, we have thus developed a gene expression assay able to discriminate the seven most frequent B-cell NHL categories. This assay relies on the combination of ligation-dependent RT-PCR and next-generation sequencing, and addresses the expression of more than 130 genetic markers. It was designed to retrieve the main gene expression signatures of B-NHL cells and their microenvironment. The classification is handled by a random forest algorithm which we trained and validated on a large cohort of more than 400 annotated cases of different histology. Its clinical relevance was verified through its capacity to prevent important misclassification in low grade lymphomas and to retrieve clinically important characteristics in high grade lymphomas including the cell-of-origin signatures and the MYC and BCL2 expression levels. This accurate pan-B-NHL predictor, which allows a systematic evaluation of numerous diagnostic and prognostic markers, could thus be proposed as a complement to conventional histology to guide the management of patients and facilitate their stratification into clinical trials.

Screening of hereditary spherocytosis and pyruvate kinase deficiency by automated blood count using erythrocytic and reticulocytic parameters.

INTRODUCTION: Development of additional parameters for complete blood count has emerged in recent hematology analyzers, leading to many publications. However, few studies have been conducted on advanced RBC parameters and hemolytic anemias. We investigated the interest of Sysmex unique parameters, MicroR and HypoHe, as well as the immature fraction of reticulocytes (IRF) in combination with complete blood and reticulocyte count, for screening hereditary spherocytosis (HS) and pyruvate kinase deficiency. METHODS: We analyzed 182 samples using Sysmex XE-5000 analyzers from a cohort of red cell disorder patients from the Rouen University Hospital. These included 47 HS, 17 pyruvate kinase deficiencies, sickle cell diseases and trait, ß-thalassemia minor, iron deficiencies, and 489 samples from a routine group. RESULTS: Combining five parameters (hemoglobin level, reticulocyte count, IRF, MicroR, and %HypoHe), we developed a specific screening tool for HS allowing a sensitivity of 100% and a specificity of 92.1% and a specific screening tool for pyruvate kinase deficiencies allowing a sensitivity of 100% and a specificity of 96.5%. These parameters were also found accurate in infants and in HS without anemia. CONCLUSION: We propose a costless, easy-to-use, and efficient approach to detect HS and pyruvate kinase deficiencies using Sysmex analyzers. These screening tools may help diagnosis of these disorders, help prevent complications, and result in a better management of these patients.

Authors' Reply.

Authors' Reply to the Letter to the Editor by Y. Lynn Wang (MYD88 mutations and sensitivity to ibrutinib therapy).