An immune window of opportunity to prevent spontaneous abortion: prepregnancy peripheral leukocytes and subsets were associated with a decreased risk of spontaneous abortion

STUDY QUESTION

Do prepregnancy peripheral leukocytes (PPLs) and their subsets influence the risk of spontaneous abortion (SAB)?

SUMMARY ANSWER

PPLs and their subsets are associated with the risk of SAB.

WHAT IS KNOWN ALREADY

Compelling studies have revealed the crucial role of maternal peripheral leukocytes in embryo implantation and pregnancy maintenance. Adaptive changes are made by PPLs and their subsets after conception.

STUDY DESIGN, SIZE, DURATION

This population-based retrospective cohort study was based on data from the National Free Pre-pregnancy Check-up Project (NFPCP) in mainland China. Couples preparing for pregnancy within the next six months were provided with free prepregnancy health examinations and counseling services for reproductive health. The current study was based on 1 310 494 female NFPCP participants aged 20-49 who became pregnant in 2016. After sequentially excluding 235 456 participants lost to follow-up, with multiple births, and who failed to complete blood tests, a total of 1 075 038 participants were included in the primary analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

PPLs and their subset counts and ratios were measured. The main outcome was SAB. A multivariable logistic regression model was used to estimate the odds ratio (OR) and 95% CI of SAB associated with PPLs and their subsets, and restricted cubic spline (RCS) was used to estimate the nonlinear exposure-response relationship.

MAIN RESULTS AND ROLE OF CHANCE

Of the included pregnant participants, a total of 35 529 SAB events (3.30%) were recorded. Compared to participants with reference values of PPLs, the ORs (95% CIs) of leukopenia and leukocytosis for SAB were 1.14 (1.09-1.20) and 0.74 (0.69-0.79), respectively. The RCS result revealed a monotonous decreasing trend (Pnonlinear < 0.05). Similar relationships were observed for the neutrophil count and ratio, monocyte count, and middle-sized cell count and ratio. The lymphocyte ratio showed a positive and nonlinear relationship with the risk of SAB (Pnonlinear < 0.05). Both eosinophils and basophils showed positive relationships with the risk of SAB (eosinophil Pnonlinear > 0.05 and basophil Pnonlinear < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Chemical abortion events and the cause of SAB were not collected at follow-up. Whether women with abnormal PPLs had recovered during periconception was not determined.

WIDER IMPLICATIONS OF THE FINDINGS

PPLs and their subsets are associated with the risk of SAB. Leukopenia and neutropenia screening in women preparing for pregnancy and developing a feasible PPL stimulation approach should be emphasized to utilize the immune window of opportunity to prevent SAB.

STUDY FUNDING/COMPETING INTEREST(S)

This study was approved by the Institutional Research Review Board of the National Health and Family Planning Commission. This study was supported by the National Key Research and Development Program of China (grants 2021YFC2700705 [Y.Y.] and 2016YFC100307 [X.M.]) and the National Natural Science Foundation of China (grant no. 82003472 [L.W.]). The funding source was not involved in the study design, data collection, analysis and interpretation of the data, writing the report, or the decision to submit this article for publication. No competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Aggressive multi-combination therapy for anti-MDA5 antibody-positive dermatomyositis-rapidly progressive interstitial lung disease

OBJECTIVES

To elucidate the efficacy and safety of aggressive multi-combination therapy with mycophenolate mofetil, rituximab, and plasma exchange or polymyxin B immobilized fiber column direct hemoperfusion followed by conventional therapy with corticosteroids, calcineurin inhibitors, and intravenous pulse cyclophosphamide in patients with rapidly progressive interstitial lung disease (RPILD) with anti-melanoma differentiation-associated gene 5 (MDA5)-antibody-positive dermatomyositis (DM).

METHODS

A total of 23 patients with anti-MDA5 antibody-positive DM-RPILD were enrolled, with nine patients in Group A (treated conventionally before March 2015) and 14 patients in Group B (received aggressive treatment after April 2015).

RESULTS

Pretreatment severity of interstitial lung disease (ILD) did not differ between the two groups. However, Group B exhibited a higher cumulative survival rate at 48 weeks than Group A (64.3% vs. 33.3%). The corticosteroid dose, divided by the initial dose at 3 months and 12 months, was significantly lower in Group B than in Group A (p = .046 and .026, respectively). Among the ILD-related deaths in Group B, there was a tendency toward a higher proportion of males and more severe ILD. The incidence of infection did not differ between the groups, but leukopenia was more common in Group B.

CONCLUSION

This aggressive multi-combination therapy may improve the survival outcome of patients with anti-MDA5 antibody-positive DM-RPILD. However, careful management of complications, such as opportunistic infections and leukopenia, is essential. Future refinement through longitudinal investigations tracking the long-term efficacy, safety, and cost-effectiveness of this treatment strategy is needed.

Thrombocytopenia Caused by Iron Infusion in a Patient with End-Stage Kidney Disease

Null.

Severe thrombocytopenia is associated with high mortality in systemic lupus erythematosus-analysis from Indian SLE Inception cohort for Research (INSPIRE)

Thrombocytopenia in patients with systemic lupus erythematosus (SLE) is associated with higher morbidity and mortality. We report frequency, associations and short-term outcome of moderate-severe thrombocytopenia in a prospective inception cohort from India (INSPIRE). We evaluated consecutive SLE patients classified per SLICC2012 for the occurrence of thrombocytopenia and its associations. The outcomes assessed included bleeding manifestations, kinetics of thrombocytopenia recovery, mortality and recurrence of thrombocytopenia. Among a total of 2210 patients in the cohort, 230 (10.4%) had incident thrombocytopenia, of whom moderate (platelet count [PC] 20-50 × 109/L) and severe thrombocytopenia (PC < 20 × 109/L) were noted in 61 (26.5%) and 22 (9.5%), respectively. Bleeding manifestations were generally limited to the skin. Compared to controls, cases had a higher proportion of autoimmune haemolytic anaemia (p < 0.001), leukopenia (p < 0.001), lymphopenia (p < 0.001), low complement (p < 0.05), lupus anticoagulant (p < 0.001), higher median SLEDAI 2 K (p < 0.001) and lower proportion of anti-RNP antibody (p < 0.05). There was no significant difference in these variables between moderate and severe thrombocytopenia. There was a sharp rise in PC by 1 week that was sustained in the majority through the period of observation. There was three times higher mortality in the severe thrombocytopenia group as compared to moderate thrombocytopenia and controls. The thrombocytopenia relapse and lupus flare rates were similar across categories. We report a low occurrence of major bleeds and higher mortality in those with severe thrombocytopenia as compared to moderate thrombocytopenia and controls. Key Points • Severe thrombocytopenia occurs in 1% of patients with SLE; however, major bleeds are uncommon. • Thrombocytopenia has a strong association with other lineage cytopenias and lupus anticoagulants. • Response to initial glucocorticoids therapy is quick and is well sustained with additional immunosuppressants. • Severe thrombocytopenia increases mortality threefold in SLE.

Prevalence of Leukopenia and Associated Outcomes in Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

This case series compares the factors, comorbidities, and complications associated with leukopenia between patients with and without leukopenia on hospital admission.

[Lymphocytic leukopenia in two patients affected by polycystic kidney disease waiting for renal transplantation]

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, responsible for 10% of patients on renal replacement therapy. The disease is well known to be associated with many extrarenal manifestations. Leukopenia may also be present, even if it is not commonly identified as a typical extrarenal manifestation. Herein we describe two case reports of ADPKD patients with leukopenia. The first case is about a 47-year-old patient affected by ADPKD, regularly treated with peritoneal dialysis, who showed a progressive reduction of white blood cell count, mostly of lymphocytes. Lymphocytic leukopenia was so severe that, when he was called for transplantation from a deceased donor, he was considered temporarily not eligible. We then describe a second ADPKD patient regularly treated with peritoneal dialysis, who had stable lymphopenia for years. Six years after starting PD, it was necessary to perform bone marrow aspirate to investigate the simultaneous presence of hypogammaglobulinemia together with M-protein and to exclude monoclonal gammopathy. All the exams performed did not show any significant results, the patients were re-included in the waiting list and one of them was transplanted. Given our experience and what is reported in the literature, there seems to be enough evidence to consider leukopenia as an extrarenal manifestation of ADPKD. However, the clinical significance of leukopenia in ADPKD patients is not known. It could be interesting to investigate the leucocytes' function and if ADPKD patients with leukopenia are more susceptible to infection, or not. Moreover, it would be very useful to analyze the relationship between such manifestation and genotype/phenotype.

Clinical Implications of Hematologic and Hemostatic Abnormalities in Children With COVID-19

Leukopenia, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time are considered poor prognostic factors in adults with acute Coronavirus Disease 2019. The prognostic significance of these abnormalities among pediatric patients remains underreported in the literature. This retrospective cohort study evaluates the prognostic implications of hematologic and hemostatic derangements in patients younger than 22-years-of-age who were admitted to a tertiary-care referral institution for management of acute Coronavirus Disease 2019 infection. Leukopenia and thrombocytopenia were identified as independent prognostic factors of disease severity. Although the majority of children, with available results, had elevated D-dimer or prolonged prothrombin time upon initial presentation, these markers were not found to be associated with the development of severe clinical complications.

Differential diagnosis of leukocytosis and leukopenia

The blood cell count is often examined in routine clinical praxis. Physiologic leucocyte count is in range 4-10 × 109 in liter of blood. Abnormal values of leukocytes and subtypes of leukocytes in differential count are often present. Changes in leukocytes counts are caused by variety of benignant or malignant conditions. It is important in clinical praxis to interpret changes in blood cell count correctly and choose adequate approach in investigation process. In general, leukocytosis and leukocytopenia may present in primary hematologic disorder or secondary/reactive states, caused by reaction of hematopoiesis to underlying condition. This article review common causes of leukocytosis or leucopenia and give basic advice how to investigate patients with changes in leukocytes count.

The prevalence of thrombocytopenia and leucopenia among people living with HIV/AIDS in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Thrombocytopenia and leucopenia are frequently encountered hematological disorders among people living with HIV/AIDS. This systematic review and meta-analysis were aimed to indicate the national prevalence of thrombocytopenia and leucopenia among HIV/AIDS patients.

METHODS

This systematic review and meta-analysis was conducted following the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. A systematic search was conducted from February 01, 2021 to April 02, 2021 using electronic databases Google Scholar, PubMed, Web of Sciences, Google, EMBASE, SCOPUS and ResearchGate. The quality of the included studies was assessed using Newcastle-Ottawa Quality Assessment Scale (NOS) adapted for cross-sectional studies. Data analysis was done using STATA version 14 using metan commands. Random effect meta-analysis was used to estimate the pooled prevalence of thrombocytopenia and leucopenia among people living with HIV/AIDS in Ethiopia.

RESULT

Of the 349 initially searched articles, 90 were assessed for eligibility and only 13 articles published from 2014 to 2020 were included in the final meta-analysis. A total of 3854 participants were involved in the included studies. The pooled prevalence of thrombocytopenia was 9.69% (95%CI; 7.40-11.97%). Significant heterogeneity was observed with I2 value of 84.7%. Thrombocytopenia was 11.91% and 5.95% prevalent among HAART naive and HAART exposed HIV/AIDS patients, respectively. The pooled prevalence of leucopenia among HIV/AIDS patients was 17.31% (95%CI: 12.37-22.25%).

CONCLUSION

This study showed a high prevalence of thrombocytopenia and leucopenia among people living with HIV/AIDS, indicating the necessity of regular screening of HIV seropositive patients for different hematological parameters and providing treatment.

Appendectomy and Cholecystectomy Outcomes for Pediatric Cancer Patients with Leukopenia: A NSQIP-pediatric Study

BACKGROUND

Children with cancer often develop leukopenia which may impair wound healing and increase surgical complication rates. When leukopenic children with cancer develop an acute surgical condition, the optimal management strategy remains unclear. This study examined the effect of preoperative leukopenia on postoperative outcomes in children with cancer who underwent an appendectomy or cholecystectomy.

METHODS

We retrospectively identified cancer patients undergoing an appendectomy or cholecystectomy from the National Surgical Quality Improvement Program-Pediatric database from 2012-2018. Demographics and perioperative characteristics were compared by leukopenia status (WBC <4 vs. ≥4 × 10^3/mL). Postoperative length of stay (LOS) and 30-day composite complications, including infections, reoperations, and readmissions, were analyzed for each procedure using multivariate regression.

RESULTS

There were 227 children who underwent an appendectomy and 101 children who underwent a cholecystectomy. Leukopenia was seen in 93 (41.0%) appendectomy and 57 (56.4%) cholecystectomy cases. Nineteen (8.4%) appendectomy patients and six (5.9%) cholecystectomy patients developed a postoperative complication. The median postoperative LOS was 2 days (IQR 1-6 days) for appendectomy and 1 day (IQR 1-2.5 days) for cholecystectomy cases. After multivariate analyses, leukopenia was not associated with increased postoperative complications after an appendectomy (OR 0.55, P = 0.36) or cholecystectomy (OR 0.39, P = 0.37). There was no significant difference in postoperative LOS based on leukopenia status for children who underwent an appendectomy (P = 0.82) or cholecystectomy (P = 0.37).

CONCLUSION

In pediatric cancer patients, leukopenia was not associated with increased short-term postoperative complications or longer postoperative LOS after either an appendectomy or cholecystectomy. These results support that operative management can be performed safely in pediatric appendicitis and cholecystitis in leukopenic cancer patients.

Hematological Manifestations among Patients with Rheumatic Diseases

BACKGROUND

Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias.

SUMMARY

The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.

Prevalence of HIV indicator conditions in late presenting patients with HIV: a missed opportunity for diagnosis?

AIM

To evaluate prior prevalence of HIV indicator conditions in late-presenters with HIV infection.

DESIGN

Retrospective cohort study between 2000 and 2014 in a healthcare network in Melbourne, Australia comparing patients presenting with late diagnosis of HIV infection (CD4 < 350 cells/ml) to those patients who had a CD greater than or equal to 350 cells/ml at presentation.

METHOD

The European AIDS Clinical Society guidelines on HIV indicator guided testing were used to assess for any indicator conditions in their prior medical history which may have represented a missed opportunity for earlier diagnosis. Main outcome measures: Descriptive statistics and prevalence of HIV indicator conditions.

RESULTS

Of 436 patients with HIV infection, 82 were late presenters. Late presenters were more commonly male (83% vs. 75%, P = 0.11), older (mean age 45 vs. 39 years), born overseas (61% vs. 58%, P = 0.68) and report heterosexual transmission as their exposure risk (51% vs. 31%, P < 0.001). Of 80 patients with late presentation of HIV infection, 54 (55%) had at least one, 29 (36%) at least 2, 12 (15%) at least 3 and 5 (6%) had 4 or more previous HIV indicator conditions which would have triggered HIV testing according to guidelines. The most common indicator conditions were: unexplained loss of weight (31%), herpes zoster (10%), thrombocytopenia or leukopenia (10%), oral or oesophageal candidiasis (10%) and community acquired pneumonia (9%). Twenty patients (25%) had HIV indicator conditions diagnosed at least 12 months before the eventual diagnosis of HIV infection.

DISCUSSION/ CONCLUSION

Patients diagnosed with late-presenting HIV often had an HIV indicator condition prior to presentation, presenting a missed opportunity for earlier diagnosis.

Granulocyte-colony stimulating factor in neonatal sepsis with leukopenia: A prospective cohort study

OBJECTIVE

To observe the duration for normalization of the Total Leucocyte Count (TLC) with adjuvant Granulocyte-Colony Stimulating Factor (G-CSF) treatment in leukopenic neonatal sepsis, and to compare the neutrophilic response to G-CSF in neutropenic vs non-neutropenic subgroups.

METHODS

This prospective cohort study was carried out at the Neonatal Intensive Care Unit at Military Hospital Rawalpindi (NICU) from 1st August 2015 to 25th January 2017. Fifty one newborns with sepsis and leucopenia were sampled judgmentally from a population of 5666 admitted to NICU during the study period. The sample was then divided into neutropenic (exposed) and non-neutropenic (non-exposed) subgroups on basis of the absolute neutrophil count (ANC). Adjuvant G-CSF was given to all subjects and stopped once TLC normalized. SPSS v22 was used to calculate mean G-CSF treatment duration and rise in ANC. A Pearson correlation coefficient and simple linear regression were computed to assess the relationship between pre-GCSF ANC and the duration of treatment with GCSF. Comparison of subgroups with respect to rise in ANC was done using independent samples T-test.

RESULTS

The mean duration of G-CSF treatment was 1.82±0.81 days (1.0 - 4.0). Neutropenic neonates constituted 49% (n=25). The Pearson correlation coefficient showed a positive but negligible and non-significant correlation between the two variables, r = 0.070, n = 51, p = 0.625. A non-significant regression equation was found (F(1,49) = 0.242,p=0.625) with an R2 of 0.005. There was a 7.06±4.5 fold rise in ANC in the neutropenic subgroup compared to the 4.5±3.1 fold rise in the non-neutropenic subgroup (p=0.04).

CONCLUSIONS

The mean duration for recovery from leukopenia with G-CSF treatment in neonatal sepsis was less than 2 days and had no significant relationship with pre-GCSF absolute neutrophil count. The neutrophilic response was significantly higher in neutropenic compared to non-neutropenic neonates. As GCSF made no difference to the outcome in terms of mortality, its routine use is not recommended in leukopenic neonatal sepsis. .

Estimation of the incidence of severe fever with thrombocytopenia syndrome in high endemic areas in China: an inpatient-based retrospective study

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is a severe viral disease caused by SFTSV. It is important to estimate the rate of missed SFTS diagnosis and to further understand the actual incidence in high endemic areas in China.

METHODS

This study was conducted in two high SFTS endemic provinces in 2015. Patients hospitalized in 2014 or within 1 year before investigation were selected after considering their clinical manifestations, specifically, fever, platelet, and white blood cell. During retrospective investigation, sera were collected to detect SFTSV antibodies to assess SFTSV infection. To further understand SFTSV infection, acute phase sera were detected; SFTSV infection rate among a healthy population was also investigated to determine the basic infection level.

RESULTS

In total, 246 hospitalized cases were included, including 83 cases (33.7%) with fever, thrombocytopenia and leukopenia, 38 cases (15.4%) with fever and thrombocytopenia but without leukopenia, and 125 cases (50.8%) without fever but with thrombocytopenia and leukopenia. In total, 13 patients (5.3%) were SFTSV IgM antibody-positive, 48 (19.5%) were IgG-positive. Of the 13 IgM-positive cases, 11 (84.6%) were IgG-positive (9 with titres ≥1:400). Seropositive rates of antibodies were high (8.4% for IgM and 30.1% for IgG) in patients with fever, thrombocytopenia and leukopenia. Furthermore, among IgG-positive cases in this group, 76% (19/25) of patients' IgG antibody titres were ≥1:400. Additionally, 28 of 246 cases were initially diagnosed with suspected SFTS and were then excluded, and 218 patients were never diagnosed with SFTS; the seropositive rates of IgM and IgG in these two groups were 25% and 67.9% and 2.8% and 13.3%, respectively. These rates were 64.3% and 21.4% in 14 sera collected during acute phase of the 28 cases mentioned above. Seropositive rate of SFTSV IgG was only 1.3% in the patient-matched healthy group, and no IgM antibody was detected. A preliminary estimate of 8.3% of SFTS cases were missed in SFTS high endemic provinces.

CONCLUSIONS

The actual SFTS incidence was underestimated. Effective measures such as adding a new SFTS case category - "SFTS clinical diagnosis cases" or using serological detection methods during acute phase should be considered to avoid missed diagnoses.

A Rare Case of Emberger Syndrome Caused By a De Novo Mutation in the GATA2 Gene

Emberger syndrome, or primary lymphedema with myelodysplasia, is a severe rare disease characterized by early primary lymphedema and blood anomalies including acute childhood leukemia. The syndrome is associated with heterozygous mutations in the GATA2 gene. We report on a 13-year-old boy who developed lymphedema of the right lower limb at age 6 years which was accompanied by severe panleukopenia and repeated episodes of erysipelas. The suspicion of Emberger syndrome was confirmed by detection of a new germinal line GATA2 mutation c.414_417del, p.Ser139Cysfs*78. Clinical treatment included a bone marrow transplant from the father.This case is one of a very limited number of Emberger syndrome cases documented in the literature, and genetic testing proved fundamental for definition of the condition and its association with a de novo mutation in the GATA2 which is reported here for the first time.

Heterogeneity in recent-onset type 1 diabetes - a clinical trial perspective

BACKGROUND

Type 1 diabetes (T1D) TrialNet is a National Institutes of Health-sponsored clinical trial network aimed at altering the disease course of T1D. The purpose of this study is to evaluate age-dependent heterogeneity in clinical, metabolic and immunologic characteristics of individuals with recent-onset T1D, to identify cohorts of interest and to aid in planning of future studies.

METHODS

Eight hundred eighty-three individuals with recent-onset T1D involved in five TrialNet studies were categorized by age as follows: ≥18 years, 12-17 years, 8-12 years and <8 years. Data were compared with healthy age-matched subjects in the National Health and Nutrition Examination Survey.

RESULTS

Only 2.0% of the individuals overall were excluded from trial participation because of insufficient C-peptide values (<0.2 pmol/mL). A disproportionate number of these subjects were <8 years old. Leukopenia was present in 21.2% of individuals and lymphopenia in 11.6%; these frequencies were markedly higher than age-matched healthy National Health and Nutrition Examination Survey population. Of the cohort, 24.5% were overweight or obese. Neither high-risk human leukocyte antigen type DR3 nor DR4 was present in 31% of adults and 21% of children.

CONCLUSIONS

The ability of recent-onset T1D patients to meet key entry criteria for TrialNet studies, including C-peptide >0.2 pmol/mL, varies by age. Lower C-peptide level requirements for younger participants and other aspects of heterogeneity of recent-onset T1D patients, such as white blood cell count abnormalities and body mass index should be considered in the design of future clinical studies.

Clinical picture of late-onset systemic lupus erythematosus in a group of Polish patients

INTRODUCTION

The prevalence of late-onset systemic lupus erythematosus (SLE) diagnosed in patients over the age of 50 years is estimated at 10% to 20%. SLE in elderly patients has specific features with misleading signs and symptoms, but its clinical course seems milder compared with that in younger patients.

OBJECTIVES

The aim of the study was to assess clinical manifestations of late-onset SLE in a group of patients treated in Poland.

PATIENTS AND METHODS

From a group of 230 consecutive patients with SLE, individuals with late-onset disease were selected. We retrospectively analyzed the incidence of clinical features of SLE, concomitant diseases, and treatment. The incidence of clinical features in late-onset patients was compared with that in a group of 108 patients with early-onset SLE.

RESULTS

Late-onset SLE was confirmed in 20 patients (8.7%) including 16 women (80%) and 4 men (20%). A delay in diagnosis was 31.7 months (0-144). The most common SLE features were arthritis (50%), rash (40%), nephropathy (40%), photosensitivity (30%), mouth ulcerations (30%), interstitial lung disease (30%), fever (25%), leukopenia (65%), and thrombocytopenia (35%). Kidney involvement was present in all men and in 25% of women. Thrombotic complications were noted in 38.8% of the patients. Concomitant diseases were common in our study group.

CONCLUSIONS

The clinical picture of late-onset SLE differs from that of early-onset SLE. Arthritis, leukopenia, and thrombotic complications are frequent, while skin manifestations, photosensitivity, nephropathy, vasculitis, and central nervous system involvement are less common in late-onset SLE. The diagnosis of late-onset SLE is often delayed, and treatment is determined by the presence of concomitant diseases.

[Secondary acute myeloid leukemia in a lung allograft recipient. Report of one case]

Secondary acute myeloid leukemia is a very rare complication in patients with solid organ transplantation. We report a 62 years old female who received a right single lung allograft for idiopathic pulmonary fibrosis. Her immunosuppression scheme consisted in prednisone, azathioprine, and tacrolimus. Two years after the transplantation, she presented with progressive pancytopenia. Bone marrow aspiration was informed as a M4 acute myeloid leukemia, confirmed by flow cytometry. Cytogenetic study was complex, including alterations in chromosome 5. A secondary acute myeloid leukemia was diagnosed. The patient developed nosocomial pneumonia and died a few days after the diagnosis, without specific treatment. The pathogenesis of acute myeloid leukemia is probably related to the intensive exposure to immunosuppressant, especially azathioprine, in these patients.

The hematologic manifestations of pediatric celiac disease at the time of diagnosis and efficiency of gluten-free diet

BACKGROUND/AIM

To determine the hematologic manifestations at the time of diagnosis of celiac disease in children and the effects of a gluten-free diet on hematologic signs upon follow-up.

MATERIALS AND METHODS

The records ofpatients with celiac disease who received a follow up examination at the Pediatric Gastroenterology Clinic between June 2006 and June 2013 were retrospectively examined.

RESULTS

Ninety-one patients were included in the study. The mean age at diagnosis was 8.1 ± 4.21 years and 59 patients (64.8%) were female. Thirty-two patients (35.2%) had hematologic signs at the time of diagnosis. Anemia (24.2%) was the most common hematologic sign, followed by thrombocytosis (16.5%) and leukopenia (4.4%). The tTG IgA titers were screened in 80 of the 91 patients during diagnosis. Follow-up examinations found that remission for anemia (P = 0.0 17), thrombocytosis (P = 0.039), and decreases in tTG IgA titers (P = 0.034) were more prominent in patients who had followed a strict gluten-free diet.

CONCLUSION

Approximately one-third of the celiac disease patients had hematologic manifestations at the time of diagnosis. Remission in hematologic signs and decrease in tTG IgA titers were more prominent in patients who had adhered to a gluten-free diet.

Are patients with erythema migrans who have leukopenia and/or thrombocytopenia coinfected with Anaplasma phagocytophilum or tick-borne encephalitis virus?

Lyme borreliosis (LB), tick-borne encephalitis (TBE) and human granulocytic anaplasmosis (HGA) are endemic in central part of Slovenia. We tested the hypothesis that patients with erythema migrans (EM) from this region, who have leukopenia and/or thrombocytopenia (typical findings in HGA and in the initial phase of TBE but not in patients with LB) are coinfected with Anaplasma phagocytophilum and/or with TBE virus, i.e. that cytopenia is a result of concomitant HGA or the initial phase of TBE. Comparison of clinical and laboratory findings for 67 patients with EM who disclosed leukopenia/thrombocytopenia with the corresponding results in sex- and age-matched patients with EM and normal blood cell counts revealed no differences. In addition, patients with typical EM and leukopenia and/or thrombocytopenia tested negative for the presence of IgM and IgG antibodies to TBE virus by ELISA as well as for the presence of specific IgG antibodies to A. phagocytophilum antigens by IFA in acute and convalescent serum samples. Thus, none of 67 patients (95% CI: 0 to 5.3%) with typical EM (the presence of this skin lesion attests for early Lyme borreliosis and is the evidence for a recent tick bite) was found to be coinfected with A. phagocytophilum or had a recent primary infection with TBE virus. The findings in the present study indicate that in Slovenia, and probably in other European countries endemic for LB, TBE and HGA, patients with early LB are rarely coinfected with the other tick-transmitted agents.

The Successful Use of Topical Tacrolimus Treatment for a Chronic Actinic Dermatitis Patient with Complications of Idiopathic Leukopenia

Chronic actinic dermatitis (CAD) is a photosensitivity disorder marked by severe eczematous lesions on exposed areas. Although associations with contact dermatitis, atopic dermatitis, and human immunodeficiency virus (HIV) have been suggested, its pathogenesis remains unknown. CAD is often refractory, and systemic administration of cyclosporin A has been the treatment of choice. Recently, topical tacrolimus therapy has been reported to be effective. We report the efficacy of topical tacrolimus treatment in a CAD patient who also had the complication of idiopathic leukopenia. A phototest showed marked suppression of erythema formation in the skin pre-treated with tacrolimus before UVB radiation but not in the skin treated after the irradiation. Therefore, it is suggested that tacrolimus may prevent UV-B induced erythema by suppressing a very early phase of the inflammatory process in CAD.

Clinical forms of canine visceral Leishmaniasis in naturally Leishmania infantum-infected dogs and related myelogram and hemogram changes

Hematological analysis has limited applications for disease diagnosis in Leishmania infantum–infected dogs, but it can be very important in evaluating the clinical forms of the disease and in understanding the evolution of canine visceral leishmaniasis (CVL) pathogenesis. Recently, we demonstrated that alterations in leucopoiesis and erythropoiesis are related to clinical status and bone marrow parasite density in dogs naturally infected by L. infantum. To further characterize these alterations, we evaluated the association between the hematological parameters in bone marrow and peripheral blood alterations in groups of L. infantum–infected dogs: asymptomatic I (AD-I: serum negative/PCR+), asymptomatic II (AD-II: serum positive), oligosymptomatic (OD), and symptomatic (SD). Results were compared with those from noninfected dogs (NID). The SD group was found to present a decrease in erythropoietic lineage with concomitant reductions in erythrocytes, hemoglobin, and hematocrit parameters, resulting in anemia. The SD group also had increased neutrophils and precursors and decreased band eosinophils and eosinophils, leading to peripheral blood leucopenia. In the AD-II group, lymphocytosis occurred in both the peripheral blood and the bone marrow compartments. The SD group exhibited lymphocytosis in the bone marrow, with lymphopenia in the peripheral blood. In contrast, the AD-I group, showed no significant changes suggestive of CVL, presenting normal counts in bone marrow and peripheral blood. Our results showed for the first time that important changes in hematopoiesis and hematological parameters occur during ongoing CVL in naturally infected dogs, mainly in symptomatic disease. Taken together, our results based on myelogram and hemogram parameters enable better understanding of the pathogenesis of the anemia, lymphocytosis, and lymphopenia, as well as the leucopenia (eosinopenia and monocytopenia), that contribute to CVL prognosis.

Pathogenesis, prevalence, and prognostic significance of cytopenias in chronic lymphocytic leukemia (CLL): a retrospective comparative study of 213 patients from a national CLL database of 1,518 cases

Utilizing the database of the Israeli CLL Study Group, we investigated the prevalence and prognostic significance of anemia and thrombocytopenia in patients with chronic lymphocytic leukemia (CLL). Of 1,477 patients, 113 had anemia and thrombocytopenia associated with "infiltrative" marrow failure, median survival of 41 and 86 months, respectively. Autoimmune cytopenias were diagnosed in 100 patients, autoimmune hemolytic anemia (AIHA) in 80, and immune thrombocytopenia (ITP) in 31, while 11 had both co-existent. Median survival of patients with AIHA and ITP, from CLL diagnosis, was 96 and 137 months, respectively, but 29 and 75 months from onset of cytopenia. Patients with AIHA from the time of CLL diagnosis had a significantly shorter survival than those without anemia (p < .0001). Survival was similar for patients with AIHA or anemia due to "infiltrative" bone marrow failure (p = .44). The presence of positive antiglobulin test even without hemolysis was associated with worse outcome. Overall survival of patients with ITP and those without cytopenias (p = 0.94) were similar. In conclusion, laboratory or clinical evidence of AIHA has a significant negative impact on the survival of patients with CLL. Outcome for cases with ITP and patients without cytopenias was similar.