Ring finger protein 138 inhibits transcription factor C/EBPα protein turnover leading to differentiation arrest in acute myeloid leukemia.

E3 ubiquitin ligase, ring finger protein 138 (RNF138) is involved in several biological processes; however, its role in myeloid differentiation or tumorigenesis remains unclear. RNAseq data from TNMplot showed that RNF138 mRNA levels are highly elevated in acute myeloid leukemia (AML) bone marrow samples as compared with bone marrow of normal volunteers. Here, we show that RNF138 serves as an E3 ligase for the tumor suppressor CCAAT/enhancer binding protein (C/EBPα) and promotes its degradation leading to myeloid differentiation arrest in AML. Wild-type RNF138 physically interacts with C/EBPα and promotes its ubiquitin-dependent proteasome degradation while a mutant RNF-138 deficient in ligase activity though interacts with C/EBPα, fails to down-regulate it. We show that RNF138 depletion enhances endogenous C/EBPα levels in peripheral blood mononuclear cells (PBMCs) isolated from healthy volunteers. Our data further shows that RNF138-mediated degradation of C/EBPα negatively affects its transactivation potential on its target genes. Furthermore, RNF138 overexpression inhibits all-trans-retinoic acid-induced differentiation of HL-60 cells whereas RNF138 RNAi enhances. In line with RNF138 inhibiting C/EBPα protein turnover, we also observed that RNF138 overexpression inhibited ß-estradiol (E2)-induced C/EBPα driven granulocytic differentiation in C/EBPα inducible K562-p42C/EBPα-estrogen receptor cells. Furthermore, we also recapitulated these findings in PBMCs isolated from AML patients where depletion of RNF138 increased the expression of myeloid differentiation marker CD11b. These results suggest that RNF138 inhibits myeloid differentiation by targeting C/EBPα for proteasomal degradation and may provide a plausible mechanism for loss of C/EBPα expression often observed in myeloid leukemia. Also, targeting RNF138 may resolve differentiation arrest by restoring C/EBPα expression in AML.

Cost-effectiveness analysis of emicizumab prophylaxis in patients with haemophilia A in India.

INTRODUCTION: Emicizumab is the initial subcutaneously administered bispecific antibody approved as a prophylactic treatment for patients with haemophilia A (PwHA). AIM: This study assessed the economic evaluation of emicizumab treatment for non-inhibitor severe haemophilia A (HA) patients in India. METHODS: A Markov model evaluated the cost-effectiveness of emicizumab prophylaxis compared to on-demand therapy (ODT), low-dose prophylaxis (LDP; 1565 IU/kg/year), intermediate-dose prophylaxis (IDP; 3915 IU/kg/year) and high-dose prophylaxis (HDP; 7125 IU/kg/year) for HA patients without factor VIII inhibitors. Inputs from HAVEN-1 and HAVEN-3 trials included transition probabilities of different bleeding types. Costs and benefits were discounted at a 3.5% annual rate. RESULTS: In the base-case analysis, emicizumab was cost-effective compared to HDP, with an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years (QALY) of Indian rupees (INR) 27,869. Compared to IDP, ODT and LDP, emicizumab prophylaxis could be considered a cost-effective option if the paying threshold is >1 per capita gross domestic product (GDP) with ICER/QALY values of INR 264,592, INR 255,876 and INR 305,398, respectively. One-way sensitivity analysis (OWSA) highlighted emicizumab cost as the parameter with the greatest impact on ICERs. Probabilistic sensitivity analysis (PSA) indicated that emicizumab had a 94.7% and 49.4% probability of being cost-effective at willingness-to-pay (WTP) thresholds of three and two-times per capita GDP. CONCLUSION: Emicizumab prophylaxis is cost-effective compared to HDP and provides value for money compared to ODT, IDP, and LDP for severe non-inhibitor PwHA in India. Its long-term humanistic, clinical and economic benefits outweigh alternative options, making it a valuable choice in resource-constrained settings.

Preinduction Serum Vitamin D3 Levels and Induction Chemotherapy Remission Rates in Patients with Acute Leukemia.

Vitamin D deficiency(<20 ng/mL) is a common condition, associated with an inferior prognosis in some cancers. However, the prognostic significance of vitamin D deficiency in acute leukemia is largely unknown. The present study aimed to assess the baseline status of vitamin D [25-(OH) D3] and find its association with induction remission rate and mortality using standard chemotherapy in patients with acute leukemia. In this prospective observational study, blood samples were collected from 73 newly diagnosed patients before starting induction chemotherapy to measure serum vitamin D [25(OH)D] levels along with routine investigations.44/73 (60.3%) patients were acute lymphoblastic leukemia (ALL), and 29/77 (39.7%) were acute myeloid leukemia (AML) patients. Descriptive statistics and frequency distribution were used in SPSS software, and Pearson's chi-squared test compared the categorical variables. Post-induction remission status (complete and incomplete remission) and induction-related mortality were correlated with vitamin D levels. 44/73 patients (60.3%) included in this study were males, and the remaining were females. The mean age of the participants was 30.32 ± 14.95 years. The mean serum vitamin D level in the cohort was 15.74 ± 28.14 ng/mL. Vitamin D deficiency was observed in 59/73 (80.8%) patients, whereas 14/73 (19.2%) had normal levels (≥20ng/mL) of the vitamin. Vitamin D deficiency is common among acute leukemia patients. Herein, we observed that low vitamin D level is associated with higher rates of incomplete remission in acute leukemia patients (P = 0.016). Vitamin D deficiency is common among acute leukemia patients and is associated with poor short-term outcomes.

Bone marrow metastasis in nonhematological malignancies: A study from tertiary care center.

Introduction: Metastatic cancer presents a treatment challenge to clinicians, particularly for patients with bone marrow infiltration. For tumor staging, therapy selection, and prognosis risk stratification, the status of the bone marrow should be known for the presence or absence of metastasis. The study aimed to evaluate the hematological findings and comprehensive analysis of bone marrow in cases of nonhematological malignancies with bone marrow metastasis. Materials and Methods: This retrospective study comprised a record retrieval of the departmental archives for the past 6 years. A total of 331 patients with nonhematological malignancies were found, of whom 31.42% (104/331) showed bone marrow metastasis. An integrated clinical approach with bone marrow examination findings and immunohistochemistry whenever necessary was used to achieve a definitive diagnosis of bone marrow metastasis. Results: Among the study population, 31.42% (104/331) of patients had nonhematological malignancies that metastasized to the bone marrow. Most of the patients with bone marrow metastasis had anemia, which was found in 77.88% (81/104) of the cases. Leukoerythroblastic reaction was noted in 31.73% (33/104) of the cases, and thrombocytopenia was found in 25% (26/104) of the cases. The most common malignancy with bone marrow metastasis in adults was prostatic adenocarcinoma (28.1%) (9/32) and in pediatric cases, neuroblastoma (53.9%) (52/98). Conclusions: It is essential to diagnose nonhematological malignancies that have metastasized to the bone marrow since this necessitates tumor staging, therapy selection, and prognosis risk stratification. To conclude, not a single hematological parameter is predictive of bone marrow metastasis; however, unexplained anemia, a leukoerythroblastic blood picture, and thrombocytopenia in peripheral blood should raise suspicion for bone marrow metastasis in cases of nonhematological malignancies.

Résumé Introduction: Le cancer métastatique présente un défi de traitement pour les cliniciens, en particulier pour les patients présentant une infiltration de moelle osseuse. Pour la stadification tumorale, la sélection du traitement et la stratification du risque de pronostic, l'état de la moelle osseuse doit être connu pour la présence ou l'absence de métastases. L'étude visait à évaluer les résultats hématologiques et l'analyse complète de la moelle osseuse dans les cas de tumeurs malignes non hématologiques avec métastases de la moelle osseuse. Matériel et méthodes: Cette étude rétrospective comprenait une récupération des archives ministérielles des 6 dernières années. Un total de patients atteints de tumeurs malignes non hématologiques ont été trouvés, dont 31,42% (104/331) présentaient des osmétastases médullaires. Une approche clinique intégrée avec les résultats de l'examen de la moelle osseuse et l'immunohistochimie chaque fois que nécessairea été utilisé pour établir un diagnostic définitif de métastases médullaires. Résultats: Dans la population étudiée, 31,42 % (104/331) des patients présentaient des tumeurs malignes non hématologiques qui se métastasaient à la moelle osseuse. La plupart des patients atteints de métastases de la moelle osseuse présentaient une anémie, qui a été trouvée dans 77,88% (81/104) des cas. Une réaction leucoérythroblastique a été observée dans 31,73 % (33/104) des cas, et une thrombocytopénie a été observée dans 25 % (26/104) des cas. La tumeur maligne la plus fréquente associée aux métastases de la moelle osseuse chez l'adulte était l'adénocarcinome de la prostate (28,1 %) (9/32) et, chez les enfants, le neuroblastome (53,9 %) (52/98). Conclusions: Il est essentiel de diagnostiquer les tumeurs malignes non hématologiques qui ontmétastasé à la moelle osseuse car cela nécessite une stadification tumorale, une sélection thérapeutique et une stratification du risque de pronostic. Pour conclure, pas un seul paramètre hématologique n'est prédictif des métastases de la moelle osseuse; Cependant, une anémie inexpliquée, une image sanguine leucoérythroblastique et une thrombocytopénie dans le sang périphérique devraient faire suspecter des métastases de la moelle osseuse en cas de tumeurs malignes non hématologiques. Mots-clés: Aspiration de moelle osseuse, biopsie de la moelle osseuse, métastases de la moelle osseuse, résultats hématologiques, immunohistochimie, tumeurs malignes non hématologiques, frottis sanguin périphérique.

Targeting CERS6-AS1/FGFR1 axis as synthetic vulnerability to constrain stromal cells supported proliferation in Mantle cell lymphoma.

The interaction between stromal and tumor cells in tumor microenvironment is a crucial factor in Mantle cell lymphoma (MCL) progression and therapy resistance. We have identified a long non-coding RNA, CERS6-AS1, upregulated in MCL and associated with poor overall survival. CERS6-AS1 expression was elevated in primary MCL within stromal microenvironment and in a subset of MCL cells adhered to stromal layer. These stromal-adhered MCL-subsets exhibited cancer stem cell signatures than suspension counterparts. Mechanistically, we found that downregulating CERS6-AS1 in MCL reduced Fibroblast Growth Factor Receptor-1 (FGFR1), expression attributed to loss of its interaction with RNA-binding protein nucleolin. In addition, using in-silico approach, we have discovered a direct interaction between nucleolin and 5'UTR of FGFR1, thereby regulating FGFR1 transcript stability. We discovered a positive association of CERS6-AS1 with cancer stem cell signatures, and Wnt signaling. Building on these, we explored potential therapeutic strategies where combining nucleolin-targeting agent with FGFR1 inhibition significantly contributed to reversing cancer stem cell signatures and abrogated primary MCL cell growth on stromal layer. These findings provide mechanistic insights into regulatory network involving CERS6-AS1, nucleolin, and FGFR1 axis-associated crosstalk between tumor cells and stromal cell interaction and highlights therapeutic potential of targeting a non-coding RNA in MCL.

Cerebral infarction leading to hemiplegia: A rare complication of acute pancreatitis.

Peripancreatic vascular thrombosis is a known complication of acute pancreatitis (AP) and chronic pancreatitis. However, hemiplegia resulting from cerebral infarction due to cerebral arterial thrombosis is a rare complication of AP. Here, we report a case of alcohol related severe AP with multi-organ dysfunction, which was complicated by large left sided middle cerebral artery territory infarct - leading to right sided hemiplegia in a 48-year-old male patient. The neurological and vascular thrombotic complications of pancreatitis, their pathogenesis and management are discussed in brief.

Study of Hemato-morphological Features in Neuroblastoma Infiltrating Marrow.

Objective Neuroblastoma typically affects children within the first 5 years of life and accounts for 10% of all pediatric malignancies. Neuroblastoma at onset may manifest as a localized or metastatic illness. The aim of this study was to identify hematomorphological features in neuroblastoma infiltrating marrow as well as to ascertain the prevalence of bone marrow infiltration in neuroblastoma. Materials and Methods This retrospective study included newly diagnosed 79 cases of neuroblastoma, which were referred for bone marrow examination for the staging of the disease. Medical records were retrieved to acquire hematomorphological findings of peripheral blood and bone marrow smears. Statistical Package for Social Sciences, IBM Inc., USA, version 21.0 was used to analyze the data. Results The interquartile age range of neuroblastoma cases was 24.0 to 72.0 months (median = 48 months) with a male to female ratio of 2.7:1. Also, 55.6% (44/79) of cases in the study population showed evidence of marrow infiltration. The bone marrow infiltration was significantly linked to thrombocytopenia ( p = 0.043) and nucleated red blood cells ( p = 0.003) in peripheral blood. The bone marrow smears of cases with infiltration showed a significant shift to the left in the myeloid series ( p = 0.001) and an increased number of erythroid cells ( p = 0.001). Conclusion For neuroblastoma patients, a diligent, exhaustive search for infiltrating cells in bone marrow is advised if thrombocytopenia or nucleated red blood cells are identified on a peripheral blood smear and bone marrow smears showed myeloid left shift with an increased number of erythroid cells.

Interleukin-6 and interleukin-8 levels in children with aplastic anemia and its correlation with disease severity and response to immunosuppressive therapy.

Background: Aplastic anemia (AA) is an uncommon condition characterized by pancytopenia and hypocellular bone marrow. Interleukin (IL)-6 and IL-8 have been shown to inhibit myelopoiesis and are major mediators of tissue damage. The primary goal of this study was to determine the IL-6 and IL-8 levels in children with AA, as well as their relationship to illness severity and immunosuppressive medication response. Materials and Methods: The IL-6 and IL-8 levels were tested in 50 children aged 3-18 years who had AA. As controls, 50 healthy age and sex matched individuals were used. A sandwich enzyme-linked immunosorbent assay kit (solid-phase) was used to measure IL-6 and IL-8 levels quantitatively. The concentrations of IL-6 and IL-8 in pg/mL were used to represent the results. Immunosuppressive medication was given to the patients in accordance with the British Committee for Standards in Haematology Guidelines 2009. Results: The patients' average age was 11.3 ± 3.7 years. Patients with AA had significantly higher IL-6 and IL-8 levels than controls (278.88 ± 216.03 vs. 4.51 ± 3.26; P < 0.001) and (120.28 ± 94.98 vs. 1.79 ± 0.78; P < 0.001), respectively. The IL-6 and IL-8 levels were also investigated with respect to AA severity, with statistically significant differences (P < 0.01) between different grading strata. Patients with very severe AA (VSAA) had the highest IL-6 levels (499.52 ± 66.19), followed by severe AA (SAA) (201.28 ± 157.77) and non-SAA (NSAA) (22.62 ± 14.63). For IL-8 levels, a similar trend (P < 0.01) was detected, with values of 209.81 ± 38.85, 92.12 ± 78.0, and 9.29 ± 10.68 for VSAA, SAA, and NSAA, respectively. After 6 months of immunosuppressive treatment (IST), mean levels of IL-6 and IL-8 in responders and nonresponders were again assessed. The mean IL-6 level in the responders' group (46.50 ± 45.41) was significantly lower, when compared to the nonresponders' group (145.76 ± 116.32) (P < 0.001). Similarly, the mean IL-8 level in the responder's group (33.57 ± 27.14) was significantly lower, compared to the nonresponder's group (97.49 ± 69.00) (P < 0.001). Conclusions: Children with AA had higher IL-6 and IL-8 levels than normal age- and sex-matched controls. Increased levels were linked to the severity of the condition, suggesting that IL may have a role in AA. IL levels can be monitored in AA patients during IST, which can assist in predicting response to IST.

Résumé Contexte: L'anémie aplastique (AA) est une affection peu fréquente caractérisée par une pancytopénie et une moelle osseuse hypocellulaire. Il a été démontré que l'interleukine (IL)-6 et l'IL-8 inhibent la myélopoïèse et sont des médiateurs majeurs des lésions tissulaires. L'objectif principal de cette étude était de déterminer les niveaux d'IL-6 et d'IL-8 chez les enfants atteints d'AA, ainsi que leur relation avec la gravité de la maladie et la réponse aux médicaments immunosuppresseurs. Matériel et méthodes: Les niveaux d'IL-6 et d'IL-8 ont été testés chez 50 enfants âgés de 3 à 18 ans atteints d'AA. 50 témoins sains appariés par l'âge et le sexe ont été utilisés. Un kit de dosage immuno-enzymatique en sandwich (phase solide) a été utilisé pour mesurer quantitativement les niveaux d'IL-6 et d'IL-8. de manière quantitative. Les concentrations d'IL-6 et d'IL-8 en pg/mL ont été utilisées pour représenter les résultats. Des médicaments immunosuppresseurs ont été administrés aux patients conformément aux directives 2009 du British Committee for Standards in Haematology. Résultats: L'âge moyen des patients était de 11,3 ± 3,7 ans. Les patients atteints d'AA présentaient des taux d'IL-6 et d'IL-8 significativement plus élevés que les témoins (278,88 ± 216,03 contre 4,51 ± 3,26 ; P < 0,001) et (120,28 ± 94,98 contre 1,79 ± 0,78 ; P < 0,001), respectivement. Les taux d'IL-6 et d'IL-8 ont également été étudiés en fonction de la gravité de l'AA, avec des différences statistiquement significatives (P < 0,01) entre les différentes strates de classement. Les patients présentant une AA très sévère (VSAA) avaient les taux d'IL-6 les plus élevés (499,52 ± 66,19), suivis par les patients atteints d'AA sévère (SAA) (201,28 ± 157,77) et les patients non-SAA (NSAA) (22,62 ± 14,63). Pour les niveaux d'IL-8, une tendance similaire (P < 0,01) a été détectée, avec des valeurs de 209,81 ± 38,85, 92,12 ± 78,0, et 9,29 ± 10,68 pour les VSAA, SAA et NSAA, respectivement. Après 6 mois de traitement immunosuppresseur traitement immunosuppresseur (IST), les niveaux moyens d'IL-6 et d'IL-8 chez les répondeurs et les non-répondeurs ont été à nouveau évalués. Le taux moyen d'IL-6 dans le groupe des répondeurs (46,50 ± 45,41) était significativement plus faible, par rapport au groupe des non-répondeurs (145,76 ± 116,32) (P < 0,001). De même, le niveau moyen d'IL-8 dans le groupe des répondeurs (33,57 ± 27,14) était significativement plus faible que dans le groupe des non-répondeurs (97,49 ± 69,00) (P < 0,001). Conclusions: Les enfants atteints d'AA présentaient des niveaux d'IL-6 et d'IL-8 plus élevés que les témoins normaux appariés selon l'âge et le sexe. L'augmentation des taux était liée à la gravité de l'affection, suggérant que l'IL pourrait jouer un rôle dans l'AA. Les niveaux d'IL peuvent être surveillés chez les patients atteints d'AA pendant l'IST, ce qui peut aider à prédire la réponse à l'IST. Mots-clés: Anémie aplastique, traitement immunosuppresseur, interleukine-6, interleukine-8.

Severe COVID-19-associated hyperinflammatory syndrome versus classic hemophagocytic lymphohistiocytosis: similarities, differences, and the way forward.

The hyperinflammatory immune response in severe COVID-19 infection shares features with secondary hemophagocytic lymphohistiocytosis (sHLH) in the form of fever, cytopenia, elevated inflammatory markers, and high mortality. There are contrasting opinions regarding utility of HLH 2004 or HScore in the diagnosis of severe COVID-19-related hyperinflammatory syndrome (COVID-HIS). This was a retrospective study of 47 patients of severe COVID-19 infection, suspected to have COVID-HIS and 22 patients of sHLH to other illnesses, to evaluate the diagnostic utility and limitations of HLH 2004 and/or HScore in context to COVID-HIS and to also evaluate the utility of Temple criteria for predicting severity and outcome in COVID-HIS. Clinical findings, hematological, and biochemical parameters along with the predictor of mortality were compared between two groups. Only 6.4% (3/47) of cases fulfilled ≥5/8 HLH 2004 criteria and only 40.52% (19/47) of patients showed HScore >169 in COVID-HIS group. 65.9% (31/47) satisfied the Temple criteria in COVID-HIS as compared with 40.9% (9/22) in the non-COVID group (p = 0.04). Serum ferritin (p = 0.02), lactate dehydrogenase (p = 0.02), direct bilirubin (p = 0.02), and C-reactive protein (p = 0.03) were associated with mortality in COVID-HIS. Both HScore and HLH-2004 criteria perform poorly for identifying COVID-HIS. Presence of bone marrow hemophagocytosis may help to identify about one-third of COVID-HIS missed by the Temple Criteria.

Reed Sternberg-Like Cells in Non-Hodgkin Lymphoma: A Diagnostic Challenge.

Reed-Sternberg cells are distinguishing features of classical Hodgkin lymphoma. However, they are seen infrequently, in both B and T cells Non-Hodgkin lymphomas with a comparable morphology and immunophenotype. These cells are known as Reed-Sternberg-like cells. The characteristic background milieu of classical Hodgkin lymphoma is typically not present in Non-Hodgkin lymphomas, and Reed-Sternberg-like cells are typically present as dispersed cells or in tiny clusters. They are positive for CD30, show variable expression of B cell lineage markers and are negative for CD45/LCA in Non-Hodgkin lymphomas. Reed-Sternberg-like cells have phenotypes that are remarkably similar to those of conventional Reed-Sternberg cells. In this interesting case report, we discuss a case of disseminated B-cell Non-Hodgkin lymphoma with Reed-Sternberg-like cells that presented as a diagnostic challenge. It is essential to distinguish between classical Hodgkin lymphoma and Non-Hodgkin lymphomas due to distinct therapy protocols and prognosis. The presence of large CD30 positive Reed-Sternberg like cells may mimic Hodgkin's Lymphoma. However, monomorphic background population with CD20 positivity should always raise the suspicious of B-cell Non-Hodgkin lymphoma. Immunohistochemical detection of a panel of targets should always be applied to correctly diagnose these rare cases of B-cell Non-Hodgkin lymphoma with Reed-Sternberg like cells.

Ruxolitinib and tuberculosis: A case report with brief review.

JAK 2 inhibitors are widely used for the treatment of primary myelofibrosis. Ruxolitinib is the most commonly used JAK inhibitor in clinical practice. We report two cases of Primary Myelofibrosis who developed tuberculosis on active treatment with ruxolitinib. Our first case was a 48 year male who developed disseminated tuberculosis during fourth month of treatment and second case was a 50 year male developing tubercular lymphadenitis during second month of treatment respectively. These case reports indicate reactivation of underling tubercular infection as a very dreaded complication of this treatment. The prevalence of tuberculosis is much higher in India compared to the west. A thorough pretreatment evaluation should ideally be done using Mantoux test or interferon gamma release assay (IGRA) to rule out latent tuberculosis. Furthermore, the patients should be counselled regarding the possibility of reactivation of infections including tuberculosis. Also, proper follow up is the need of hour in all patients on any kind of immunomodulators.

The Molecular Role of HIF1α Is Elucidated in Chronic Myeloid Leukemia.

Chronic myeloid leukemia (CML) is potentially fatal blood cancer, but there is an unmet need to discover novel molecular biomarkers. The hypothesis of this study aimed to elucidate the relationship of HIF1α with the redox system, Krebs cycles, notch1, and other regulatory proteins to better understand the pathophysiology and clinical relevance in chronic myeloid leukemia (CML) patients, as the molecular mechanism of this axis is still not clear. This study included CML patient samples (n = 60; 60: blood; 10: bone marrow tissues) and compared them with healthy controls (n = 20; blood). Clinical diagnosis confirmed on bone marrow aspiration, marrow trephine biopsy, and BCR/ABL1 translocation. Cases were subclassified into chronic, accelerated, and blast crises as per WHO guidelines. Molecular experiments included redox parameters, DNA fragmentation, Krebs cycle metabolites, and gene expression by RT-PCR/Western blot/LC-MS, PPI (STRING), Pearson correlation, and ROC curve analysis. Here, our findings show that p210/p190BCR/ABL1 translocation is common in all blast crisis phases of CML. Redox factor/Krebs oncometabolite concentrations were high, leading to upregulation and stabilization of HIF1α. HIF1α leads to the pathogenesis in CML cells by upregulating their downstream genes (Notch 2/4/Ikaros/SIRT1/Foxo-3a/p53, etc.). Whereas, downregulated ubiquitin proteasomal and apoptotic factors in CML pateints, can trigger degradation of HIF1α through proline hydroxylation. However, HIF1α showed a negative corelation with the notch1 pathway. Notch1 plays a tumor-suppressive role in CML and might have the potential to be used as a diagnostic marker along with other factors in CML patients. The outcome also revealed that oxidant treatment could not be effective in augmentation with conventional therapy because CML cells can enhance the levels of antioxidants for their survival. HIF1α might be a novel therapeutic target other than BCR/ABL1 translocation.

Aplastic anemia severity and IL-6 and IL-8 blood levels.

INTRODUCTION AND AIMS: Aplastic anemia is a rare, fatal bone marrow disorder that is presumed to be an autoimmune-mediated illness that actively destroys haematopoietic cells through a T helper type-1 cell response. Different cell types in the bone marrow and peripheral circulation produce chemokines, such as interleukin-6 (IL-6) and interleukin-8 (IL-8). The myelopoiesis that is profoundly impaired in aplastic anemia may be inhibited by these two, as critical and powerful inhibitors. Therefore, it is conceivable that their ongoing overproduction may contribute to aplastic anemia. We performed a quantitative enzyme-linked immunosorbent assay on the peripheral blood plasma to reveal the levels of IL-6 and IL-8 and their correlation to aplastic anaemia. MATERIALS AND METHODS: A total of 80 cases of aplastic anemia were included in this study, diagnosed according to the criteria laid down by the International Agranulocytosis and Aplastic Anemia study group. A total of 10 healthy individuals served as controls in this study. With the help of a commercial ELISA kit and the instructions from the kit's maker, the levels of IL-6 and IL-8 were measured in a quantitative way. RESULTS: Mean serum IL-6 and IL-8 levels in cases were 283.28±220.27 and 122.56±97.79 pg/ml, respectively, as compared to 7.52±1.43 and 3.42±1.73 pg/ml levels in controls. Statistically, mean IL-6, as well as IL-8 levels, were significantly higher in aplastic anemia patients than in controls (p< 0.001). Levels of interleukins were also assessed in relation to the severity of the disease. Patients with very severe aplastic anaemia had significantly higher mean IL-6 and IL-8 levels (516.71±36.73 and 220.50±23.45 pg/ml, respectively), followed by severe aplastic anaemia (198.84±150.39 and 89.82±77.18 pg/ml, respectively) and non-severe aplastic anaemia (26.71±33.40 and 10.29±2.63 pg/ml, respectively) (p<0.001). CONCLUSION: Blood serum levels of IL-6 and IL-8 were increased in aplastic anemia and showed a correlation with the severity of the disease. Hence, IL-6 and IL-8 may play an important role in the immune-mediated pathophysiology of aplastic anemia and their increasing levels are giving alarming signals for timely implementation of the appropriate treatment regimen to stop further progression of the disease. Additional studies are required in order to further investigate the exact involvement and role of IL-6 and IL-8 in aplastic anemia.

ALK-negative primary cutaneous T-cell anaplastic large cell lymphoma, myxoid variant; masquerading as sarcoma: unveiling the diagnostic dilemma.

We present a case of 50-year-old man with history of ulcerative right axillary mass for 6 months. Axillary lymphadenopathy and organomegaly were absent. Microscopic examination showed sheets of pleomorphic cells which were mitotically active. Distinctive myxoid change was seen throughout the tumor. These cells were strongly positive for CD30 and vimentin but were negative for CD3, CD5, CD20, CD15, anaplastic lymphoma kinase protein (ALK), CD56, cytokeratin, melan A, desmin, myogenin, CD68, S100, epithelial membrane antigen and CD34. The final diagnosis of primary cutaneous ALK-negative T-cell anaplastic large cell lymphoma (PCALCL), myxoid variant was made. Work-up revealed no systemic involvement. The patient received eight cycles of cyclophosphamide, doxorubicin, vincristine, prednisone and etoposide chemotherapy with complete resolution of disease. This case report highlights that a high index of suspicion is necessary in patients of PCALCL due to varied clinical presentation, and to discuss in brief the histopathologic and immunophenotypic features of this entity along with its differential diagnosis.

Case reports of chronic myeloid leukemia and tuberculosis: Is imatinib the link between the two?

Current standard of care for treatment of CML is based on tyrosine kinase inhibitors (TKI's). Imatinib is most frequently used first line tyrosine kinase inhibitor. Various side effects of TKI's are known, but some may still be unknown. We are reporting three cases of CML who developed tuberculosis while on treatment with imatinib or dasatinib. Two cases developed CNS tuberculosis and other one was tubercular pleural effusion. These cases indicate that imatinib and other TKI's probably interfere with immunological functions and predispose patients for tuberculosis.

Complicated case of COVID-19 disease with overlapping features of thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis.

Haemophagocytic lymphohistiocytosis has been reported as an uncommon complication of severe COVID-19 disease while thrombotic thrombocytopenic purpura has been rarely reported. Here, we are reporting a 21-year-old man who developed a combination of these complications during the hospital stay in the post-COVID-19 recovery period. He presented with fever and bilateral COVID-19-related pneumonia requiring invasive ventilation. His hospital course was complicated by the development of pneumothorax, ventilator-associated pneumonia, thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. He received remdesivir, IVIG, steroid, fresh frozen plasma and supportive care but had a fatal outcome.

A Cross Sectional Study on T Cells and Subsets in Chronic Lymphocytic Leukemia and their Association with Clinical Phenotype.

T cells in B chronic lymphocytic leukaemia (CLL) have been reported to show qualitative and quantitative alterations, thereby regulating the antitumor immune response. We evaluated the absolute count, percentages of T cells and subsets and their association with disease parameters in Indian patients. 45 treatment naïve CLL cases and 10 healthy controls were evaluated for CD3 + Tcells, CD4 + T cells, CD8 + T cells percentage by flowcytometry. The absolute counts were obtained by multiplication with absolute lymphocyte counts obtained on cell counter. The clinical characteristics (age, sex, Rai stage, B symptoms, CD38 expression) were analysed for any association with alteration of these cells (percentages, absolute counts, ratio with monoclonal B cell count) and CD4: CD8 ratio. The mean absolute count of CD3 + T cell, CD4 + T cell and CD8 + T cells was significantly higher (p < 0.05) in CLL patients as compared to healthy controls. CD4:CD8 ratio was variable (normal, increased and decreased). The mean CD8 + T cells count was higher in advanced disease stage, and CD38 positive cases (p > 0.05). Younger CLL patients (< 55 years) had greater increase in CD8 + T cells (p > 0.05). Significant alterations in T cells and their subsets were observed in CLL. A trend towards advanced stage, CD38 expression, presentation an early age was seen with increase in CD8 + T cell counts.

Association of Interleukin-1ß-31C/T, -511T/C and -3954C/T Single Nucleotide Polymorphism and Their Blood Plasma Level in Acquired Aplastic Anemia.

Aplastic anemia (AA) is an immune-mediated disorder in which hematopoietic stem and progenitor cells are targeted by a number of cellular and molecular pathways. This case control study aims to investigate the association of interleukin-1beta (IL-1ß) gene polymorphisms, (IL-1ß-31, IL-1ß-511 and IL-1ß-3954) and their plasma levels with acquired AA. Genotyping was done by Restricted Fragment Length Polymorphism (PCR-RFLP) method and IL-1ß plasma levels were evaluated in peripheral blood using ELISA. Increased level of IL-1ß was reported to be significant in cases as compared to controls. The susceptibility of developing AA was higher in the cases for IL-1ß-3954 genotype. IL-1ß-511 genotype showed significant association with the severity groups of AA. No significant association was noticed in responder versus non-responder group. Plasma level of IL-1ß gene was found to be significantly higher in severe and very-severe group of AA versus control group. Our findings suggest that IL-1ß gene and its genotypes might be involved in the pathophysiology of AA and play a central role in the etiopathogenesis of AA.

FBW7 Inhibits Myeloid Differentiation in Acute Myeloid Leukemia via GSK3-Dependent Ubiquitination of PU.1.

Glycogen synthase kinase 3ß (GSK3ß), an ubiquitously expressed serine/threonine kinase is reported to be overexpressed and hyperactivated in cancers including acute myeloid leukemia (AML) where it promotes self-renewal, growth, and survival of AML cells. Therefore, GSK3ß inhibition results in AML cell growth inhibition and myeloid differentiation. Here we identified master transcription factor PU.1 of monocyte-macrophage differentiation pathway as potential GSK3ß target. We demonstrate that GSK3ß phosphorylates PU.1 at Ser41 and Ser140 leading to its recognition and subsequent ubiquitin-mediated degradation by E3 ubiquitin ligase FBW7. This GSK3-dependent degradation of PU.1 by FBW7 inhibited monocyte-macrophage differentiation. We further showed that a phospho-deficient PU.1 mutant (PU.1-S41, S140A) neither bound to FBW7 nor was degraded by it. Consequently, PU.1-S41, S140A retained its transactivation, DNA-binding ability and promoted monocyte-macrophage differentiation of U937 cells even without phorbol 12-myristate 13-acetate (PMA) treatment. We further showed that FBW7 overexpression inhibited both PMA as well as M-CSF-induced macrophage differentiation of myeloid cell lines and peripheral blood mononuclear cells (PBMC) from healthy volunteers, respectively. Contrarily, FBW7 depletion promoted differentiation of these cells even without any inducer suggesting for a robust role of GSK3ß-FBW7 axis in negatively regulating myeloid differentiation. Furthermore, we also recapitulated these findings in PBMCs isolated from patients with leukemia where FBW7 overexpression markedly inhibited endogenous PU.1 protein levels. In addition, PBMCs also showed enhanced differentiation when treated with M-CSF and GSK3 inhibitor (SB216763) together compared with M-CSF treatment alone. IMPLICATIONS: Our data demonstrate a plausible mechanism behind PU.1 restoration and induction of myeloid differentiation upon GSK3ß inhibition and further substantiates potential of GSK3ß as a therapeutic target in AML.

Essential Thrombocythemia Presenting with Recurrent Priapism: A Case Report and Review of Literature.

BACKGROUND Priapism is rarely reported as a complication in patients with essential thrombocythemia at presentation. We could find very few such cases of essential thrombocythemia while searching the literature. A combined modality of treatment is used in the form of chemotherapy and procedures like repeated aspiration and instillation of phenylephrine to treat essential thrombocythemia presenting with recurrent priapism. CASE REPORT A 31-year-old man presented to the Urology Department with priapism for the last 24 h. He had previously had multiple similar episodes in the last 20 days and 1 episode of prolonged penile erection 5 months ago. On examination, his penis was erect, swollen, and painful. There was no organomegaly. The priapism was managed with repeated aspiration and instillation of phenylephrine. Routine investigations showed marked thrombocytosis. Subsequent investigations done in the Clinical Hematology Department revealed increased megakaryocytes in bone marrow and presence of JAK2V617F mutation. After confirmation of diagnosis, cytoreductive therapy (hydroxyurea 500 mg twice a day) and acetyl salicylic acid 75 mg once a day was initiated. With this treatment, the platelet count normalized over a period of 2 months and no further episodes of priapism were noted; however, the patient developed erectile dysfunction. CONCLUSIONS Essential thrombocythemia can present with priapism as the first manifestation. Early suspicion, diagnosis, and management is needed to prevent erectile dysfunction. Erectile dysfunction is usually irreversible after long-standing priapism.