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Kelly DL, Glassman M, Wonodi I, Vyas G, Richardson CM, Nwulia E, Wehring HJ, Oduguwa T, Mackowick M, Hipolito MMS, Peters O, Rai N, Park J, Adebayo AO, Gorelick DA, Weiner E, Liu F, Kearns AM, Adams HA, Love RC, Chen S, Olaniyan A, Ambulos N, McKoy D, Nallani MC, Lanzkron S, Mengistab M, Barr B, Davis E, Lawal R, Buchanan RW, Adebayo R. Clozapine and neutrophil response in patients of African descent: A six-month, multinational, prospective, open-label clinical trial. Schizophr Res 2024; 268:312-322. [PMID: 37633776 PMCID: PMC10891303 DOI: 10.1016/j.schres.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION Clozapine is the most effective antipsychotic for treatment-resistant schizophrenia, but it is markedly underutilized, particularly in the US Black population, partly because of concern over clozapine-associated low absolute neutrophil count (ANC). People of African descent have a lower normative ANC range than the White population, which is associated with a specific "ACKR1-null" ("Duffy null") CC genotype (SNP rs2814778) on the ACKR1 gene, termed benign ethnic neutropenia (BEN). The range of ANC variability and safety of clozapine have not been established in people with BEN or examined prospectively in people of African descent. METHODS We completed a multisite, 6-month, prospective, open-label clinical trial of clozapine treatment in people of African descent with schizophrenia spectrum disorders for whom clozapine was clinically indicated, with or without the ACKR1-null genotype. We examined clozapine safety and weekly ANC during clozapine treatment and evaluated ANC variability by ACKR1-null genotype, sex, study site, and clozapine dosing using repeated measures analysis of covariance. Genotype was assayed using TaqMan® technology. RESULTS We enrolled 274 participants, of whom 227 (82.8 %) completed 6 months of clozapine treatment. There was one case of severe neutropenia (<500 cells/mm3) (0.36 %) over 1467.6 person-months of clozapine exposure. This participant recovered without sequelae after discontinuation of clozapine. Of the 249 participants with known genotypes, 199 (79.9 %) had the ACKR1-null genotype. Neutropenia (<1500 cells/mm3) occurred significantly more often in the ACKR1-null group (33 % [65/199]) than in those with the T allele (6 % (3/50); p < 0.001). Fourteen (5 %) patients discontinued due to adverse events. Rates of infection and fever were low and sialorrhea was the commonest side effect (N = 187, 68 %). CONCLUSION To our knowledge, this is the largest prospective clozapine trial in people of African descent. Severe neutropenia was rare, despite the high prevalence (80 %) of the ACKR1-null genotype. Our findings suggest that clozapine can be used safely in Black patients including those with BEN.
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Affiliation(s)
- Deanna L Kelly
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Matthew Glassman
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Ikwunga Wonodi
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; Sheppard Pratt Health System, Baltimore, MD, United States of America
| | - Gopal Vyas
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; Spring Grove Hospital Center, Catonsville, MD, United States of America
| | - Charles M Richardson
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; Spring Grove Hospital Center, Catonsville, MD, United States of America
| | - Evaristus Nwulia
- Howard University Hospital, Washington, DC, United States of America
| | - Heidi J Wehring
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Taiwo Oduguwa
- Federal Neuropsychiatric Hospital Yaba, Lagos, Nigeria
| | - Marie Mackowick
- Clifton T. Perkins Hospital Center, Jessup, MD, United States of America
| | | | | | - Narayan Rai
- Howard University Hospital, Washington, DC, United States of America
| | - Jaeboon Park
- Clifton T. Perkins Hospital Center, Jessup, MD, United States of America
| | | | - David A Gorelick
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Elaine Weiner
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Fang Liu
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Ann Marie Kearns
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Heather A Adams
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; Spring Grove Hospital Center, Catonsville, MD, United States of America
| | - Raymond C Love
- University of Maryland School of Pharmacy, Baltimore, MD, United States of America
| | - Shuo Chen
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | - Nicholas Ambulos
- University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Darius McKoy
- Howard University Hospital, Washington, DC, United States of America
| | - Madhulika C Nallani
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Sophie Lanzkron
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Mulu Mengistab
- Howard University Hospital, Washington, DC, United States of America
| | - Brian Barr
- University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Erica Davis
- University of Maryland School of Pharmacy, Baltimore, MD, United States of America
| | - Rahman Lawal
- Federal Neuropsychiatric Hospital Yaba, Lagos, Nigeria
| | - Robert W Buchanan
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
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Daniels MV, Ramlall S. Clozapine monitoring at a specialised psychiatric hospital: A retrospective chart review. S Afr J Psychiatr 2023; 29:2039. [PMID: 37928939 PMCID: PMC10623633 DOI: 10.4102/sajpsychiatry.v29i0.2039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 09/01/2023] [Indexed: 11/07/2023] Open
Abstract
Background Clozapine is the only Food and Drug Administration (FDA) and National Institute for Care and Excellence (NICE) approved drug for treatment-resistant schizophrenia (TRS). Its potentially life-threatening haematological side effects of neutropaenia and agranulocytosis mandate rigorous monitoring of neutrophil counts, presenting unique, Third-World population challenges. Aim To describe the Clozapine white blood cell monitoring practice and outcomes in a local psychiatric hospital. Setting At a specialist Psychiatry unit in Durban, KwaZulu-Natal, which follows a modified algorithm of the South African Standard Treatment Guidelines for Clozapine monitoring. Methods A retrospective chart review composed of 120 patients on Clozapine treatment from 01 July 2018-31 December 2020. Demographic and clinical information was captured in a Redcap database. Descriptive statistics using categorical variables were used. Results The study population was from a low socioeconomic background, with low levels of education and employment. A baseline neutrophil count was recorded in 58 files (48.3%). Clozapine was stopped in 6 out of the 120 patients due to 'neutropaenia' (absolute neutrophil counts ranging from 1.18 to 1.6); none developed agranulocytosis. Their duration of Clozapine treatment ranged from 2 weeks-15 years. Conclusion Haematological monitoring frequency and documentation of patients receiving Clozapine were not in compliance with the hospital's adapted guidelines and may have resulted in the termination of treatment before true neutropaenia developed. Patients developed neutropaenia at low doses of Clozapine and after many years of treatment. Contribution These results suggest local Clozapine monitoring guidelines should be more strictly adhered to.
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Affiliation(s)
- Michelle V Daniels
- Department of Psychiatry, Faculty of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Suvira Ramlall
- Department of Psychiatry, Faculty of Health Sciences, University of KwaZulu Natal, Durban, South Africa
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Yan AP, Gruda-Sussman R. Culturally competent care for Canadian children with 'low' neutrophil counts. Paediatr Child Health 2023; 28:336-337. [PMID: 37744751 PMCID: PMC10517238 DOI: 10.1093/pch/pxac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/25/2022] [Indexed: 09/26/2023] Open
Affiliation(s)
- Adam P Yan
- Division of Hematology and Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Blavatnik Institute of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Raizl Gruda-Sussman
- Division of Haematology/Oncology, Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
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Oyogoa E, Mathews R, Olson S, DeLoughery T, Shatzel JJ, Martens KL. Clinical outcomes of patients referred for asymptomatic neutropenia: A focus on racial disparities in hematology. Eur J Haematol 2023; 111:41-46. [PMID: 36951011 PMCID: PMC10272056 DOI: 10.1111/ejh.13963] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Asymptomatic neutropenia is a common hematology referral, though standardized reference ranges and published clinical outcomes are lacking. METHODS In our retrospective analysis, we evaluated demographics, laboratory, and clinical outcomes of adult patients referred to an academic hematology practice for evaluation of neutropenia from 2010 to 2018. Primary and secondary outcomes included incidence of hematologic disorders and rates of Duffy-null positivity by race, respectively. In a separate analysis, we reviewed absolute neutrophil count (ANC) reference ranges from publicly available Association of American Medical Colleges Medical School Member laboratory directories to assess institutional variations. RESULTS In total, 163 patients were included, with disproportionate number of Black patients referred compared to local demographics. Twenty-three percent of patients (n = 38) were found to have a clinically relevant hematologic outcome (mean ANC of 0.59 × 109 /L), and only six were identified with ANC ≥1.0 × 109 /L. Incidence of hematologic outcomes was lowest among Black patients (p = .05), and nearly all Blacks who underwent Duffy-null phenotype testing were positive (93%), compared to 50% of Whites (p = .04). In separate review of laboratory directories, we confirmed wide variation in ANC lower limit of normal (0.91-2.40 × 109 /L). CONCLUSION Hematologic disorders were rare in patients with mild neutropenia and among Blacks, highlighting the need to standardize hematological ranges representative of non-White communities.
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Affiliation(s)
- Emmanuella Oyogoa
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Rick Mathews
- Department of Biomedical Engineering, Oregon Health & Science University, School of Medicine, Portland, Oregon, USA
| | - Sven Olson
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas DeLoughery
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kylee L Martens
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
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Zhou J, Zhou N, Liu Q, Xie ZP, Xu Y, Dai SC, Lu J, Bao ZY, Wu LD. Prevalence of neutropenia in US residents: a population based analysis of NHANES 2011-2018. BMC Public Health 2023; 23:1254. [PMID: 37380948 DOI: 10.1186/s12889-023-16141-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/17/2023] [Indexed: 06/30/2023] Open
Abstract
AIMS Neutrophils play a pivotal in immunity and inflammation. We aim to investigate the prevalence of neutropenia in the United States. METHODS In this cross-sectional study, participants from the National Health and Nutrition Examination Survey (NHANES) (2011-2018) were enrolled. Demographic information, hematologic measurements, smoking status of all participants were collected for all participants. All statistical analyses were performed utilizing the NHANES survey weights. Covariate-adjusted linear regression was used to compare hematologic indices in different population grouped by age, sex, ethnicity, and smoking. We also employed multivariate-logistic regression to estimate the weighted odds ratio with a 95% confidence interval and predict the neutropenia risk among. RESULTS 32,102 participants from NHANES survey were included, represented 286.6 million multiracial population in the United States. Black participants had lower mean leukocyte count (mean difference (MD): 0.71 × 109/L; P < 0.001) and lower neutrophil count (MD: 0.83 × 109/L; P < 0.001) compared with white participants after adjusting for age and sex. Furthermore, t a notable observation was the significant downward shift in the distribution curves of leukocyte count and neutrophil count among black participants. Smokers had a higher mean leukocyte count (MD: 1.10 × 109 cells/L; P < 0.001) and a higher mean neutrophil count (MD: 0.75 × 109 cells/L; P < 0.001) comparing with nonsmokers. The estimated prevalence of neutropenia was 1.24% (95% CI: 1.11 - 1.37%), which corresponds to approximately 35.5 million individuals in the United States. The prevalence of neutropenia in black participants was significantly higher than other races. Results of logistic regression analysis showed that black individuals, male individuals, and children younger than 5 years had a higher risk of neutropenia. CONCLUSIONS Neutropenia is more common in the general population than we thought, especially in black individuals and children. More attention should be paid to neutropenia.
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Affiliation(s)
- Jing Zhou
- Department of Infectious Diseases, Affiliated Wuxi Fifth Hospital of Jiangnan University, The Fifth People's Hospital of Wuxi, Wuxi, 214065, China
| | - Nan Zhou
- Department of Nursing, Huadong Sanatorium, Wuxi, 214065, China
| | - Qing Liu
- Department of Nursing, Huadong Sanatorium, Wuxi, 214065, China
| | - Zhi-Ping Xie
- Department of Nursing, Huadong Sanatorium, Wuxi, 214065, China
| | - Yun Xu
- Department of Anesthesiology, Huadong Sanatorium, Wuxi, 214065, China
| | - Si-Cheng Dai
- Department of Nursing, Huadong Sanatorium, Wuxi, 214065, China
| | - Juan Lu
- Department of Nursing, Huadong Sanatorium, Wuxi, 214065, China.
- Department of Anesthesiology, Huadong Sanatorium, Wuxi, 214065, China.
| | - Zheng-Yang Bao
- Department of Internal Medicine, Wuxi Maternity and Child Health Care Hospital, Women's Hospital of Jiangnan University, Jiangnan University, Wuxi, 214002, China.
| | - Li-Da Wu
- Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China.
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Crawford KS, Volkman BF. Prospects for targeting ACKR1 in cancer and other diseases. Front Immunol 2023; 14:1111960. [PMID: 37006247 PMCID: PMC10050359 DOI: 10.3389/fimmu.2023.1111960] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
The chemokine network is comprised of a family of signal proteins that encode messages for cells displaying chemokine G-protein coupled receptors (GPCRs). The diversity of effects on cellular functions, particularly directed migration of different cell types to sites of inflammation, is enabled by different combinations of chemokines activating signal transduction cascades on cells displaying a combination of receptors. These signals can contribute to autoimmune disease or be hijacked in cancer to stimulate cancer progression and metastatic migration. Thus far, three chemokine receptor-targeting drugs have been approved for clinical use: Maraviroc for HIV, Plerixafor for hematopoietic stem cell mobilization, and Mogalizumab for cutaneous T-cell lymphoma. Numerous compounds have been developed to inhibit specific chemokine GPCRs, but the complexity of the chemokine network has precluded more widespread clinical implementation, particularly as anti-neoplastic and anti-metastatic agents. Drugs that block a single signaling axis may be rendered ineffective or cause adverse reactions because each chemokine and receptor often have multiple context-specific functions. The chemokine network is tightly regulated at multiple levels, including by atypical chemokine receptors (ACKRs) that control chemokine gradients independently of G-proteins. ACKRs have numerous functions linked to chemokine immobilization, movement through and within cells, and recruitment of alternate effectors like β-arrestins. Atypical chemokine receptor 1 (ACKR1), previously known as the Duffy antigen receptor for chemokines (DARC), is a key regulator that binds chemokines involved in inflammatory responses and cancer proliferation, angiogenesis, and metastasis. Understanding more about ACKR1 in different diseases and populations may contribute to the development of therapeutic strategies targeting the chemokine network.
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Affiliation(s)
- Kyler S. Crawford
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI, United States
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Borinstein SC, Agamasu D, Schildcrout JS, Bastarache L, Bagheri M, Davis LK, Roden DM, Michael Stein C, Van Driest SL, Mosley JD. Frequency of benign neutropenia among Black versus White individuals undergoing a bone marrow assessment. J Cell Mol Med 2022; 26:3628-3635. [PMID: 35642720 PMCID: PMC9258701 DOI: 10.1111/jcmm.17346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/14/2022] [Accepted: 04/05/2022] [Indexed: 01/01/2023] Open
Abstract
Healthy individuals in the United States identified as having Black race have lower neutrophil counts, on average, than individuals identified as having White race, which could result in more negative diagnostic evaluations for neutropenia. To test this hypothesis, the proportion of evaluations where the final diagnosis was clinically insignificant neutropenia for Black and White individuals who underwent an evaluation by a haematologist that included a bone marrow (BM) biopsy to investigate neutropenia was assessed. 172 individuals without prior haematological diagnoses who underwent a haematological evaluation to investigate neutropenia. Individuals diagnosed with clinically insignificant neutropenia between Black and White individuals were compared using a propensity-score-adjusted logistic regression. Of 172 individuals, 42 (24%) were classified as Black race, 86 (50%) were males, and the 79 (46%) were over 18 years old. A BM biopsy did not identify pathology in 95% (40 of 42) of Black individuals and 68% (89 of 130) of White Individuals. Black individuals (25 of 42 [60%]) received a final diagnosis of clinically insignificant neutropenia, compared to White individuals (12 of 130 [9%]) (adjusted odds ratio =7.9, 95% CI: 3.1 - 21.1). We conclude that black individuals were more likely to receive a diagnosis of clinically insignificant neutropenia after haematological assessment.
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Affiliation(s)
- Scott C Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Minoo Bagheri
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lea K Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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Oloyede E, Dzahini O, Barnes N, Mijovic A, Gandhi S, Stuart-Smith S, de Witte T, Taylor D, Whiskey E. Benign ethnic neutropenia: an analysis of prevalence, timing and identification accuracy in two large inner-city NHS hospitals. BMC Psychiatry 2021; 21:502. [PMID: 34645395 PMCID: PMC8515765 DOI: 10.1186/s12888-021-03514-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benign ethnic neutropenia (BEN) is the most common cause of chronic neutropenia seen in individuals of African, Middle Eastern and West Indian descent. This phenotype is broadly defined by an absolute neutrophil counts (ANC) below 1.8 × 109 cells/L in the absence of other causes, without an increased risk of infection. BEN has been implicated as a potential source of disparity in patients treated with clozapine, the antipsychotic of choice in treatment-resistant schizophrenia. Our main objective was to examine the current level of BEN recognition in a cohort of patients treated with clozapine and the potential impact of unidentified BEN on the initiation and maintenance of clozapine treatment. METHODS This was an observational, retrospective analysis of patients registered with clozapine haematological monitoring systems in two large mental health trusts, chosen because they serve an ethnically diverse population. The first objective was to establish certified BEN prevalence in current users of clozapine. The second objective was to explore the stage of treatment at which BEN was identified. The third objective was to evaluate the extent of unrecognised BEN in patients registered on the Central Non-Rechallenge Database (CNRD), a database for patients whose haematological parameters fall below set thresholds when receiving clozapine treatment, meaning they cannot ordinarily be prescribed clozapine again. RESULTS The study population comprised of 2020 patients on the clozapine register. 111 patients were monitored under BEN criteria. BEN was mostly identified after a below threshold haematological result or clozapine rechallenge (68%) compared to at clozapine initiation (32%). Eight of the 18 (42%) black patients registered on the CNRD were classified as BEN after assessment by a haematologist. Of these 8 patients, none would have met CNRD criteria again if monitored with BEN criteria at clozapine initiation. CONCLUSIONS Current evidence suggests that BEN remains an uncommonly recognised haematological phenotype. Improved timely identification of BEN will reduce unnecessary interruption or discontinuation of clozapine treatment. Our results suggest consideration should also be given to determining BEN status prior to initiating clozapine. Moreover, adoption of current FDA BEN monitoring criteria in the UK may further reduce clozapine discontinuation due to perceived neutropenia as drug toxicity, particularly in treatment-refractory schizophrenia patients.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK. .,King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.
| | - Olubanke Dzahini
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
| | - Nigel Barnes
- grid.450453.3Pharmacy Department, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Aleksandar Mijovic
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Shreyans Gandhi
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Sara Stuart-Smith
- grid.13097.3c0000 0001 2322 6764Kings College London NHS Foundation Trust, London, UK
| | - Theo de Witte
- grid.5590.90000000122931605Radboud University Medical Center, Radboud University Nijmegen, Nijmegen, Netherlands
| | - David Taylor
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
| | - Eromona Whiskey
- grid.37640.360000 0000 9439 0839Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK ,grid.13097.3c0000 0001 2322 6764King’s College London, Institute of Pharmaceutical Science, London, UK
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9
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Van Driest SL, Abul-Husn NS, Glessner JT, Bastarache L, Nirenberg S, Schildcrout JS, Eswarappa MS, Belbin GM, Shaffer CM, Mentch F, Connolly J, Shi M, Stein CM, Roden DM, Hakonarson H, Cox NJ, Borinstein SC, Mosley JD. Association Between a Common, Benign Genotype and Unnecessary Bone Marrow Biopsies Among African American Patients. JAMA Intern Med 2021; 181:1100-1105. [PMID: 34180972 PMCID: PMC8239990 DOI: 10.1001/jamainternmed.2021.3108] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Up to two-thirds of African American individuals carry the benign rs2814778-CC genotype that lowers total white blood cell (WBC) count. OBJECTIVE To examine whether the rs2814778-CC genotype is associated with an increased likelihood of receiving a bone marrow biopsy (BMB) for an isolated low WBC count. DESIGN, SETTING, AND PARTICIPANTS This retrospective genetic association study assessed African American patients younger than 90 years who underwent a BMB at Vanderbilt University Medical Center, Mount Sinai Health System, or Children's Hospital of Philadelphia from January 1, 1998, to December 31, 2020. EXPOSURE The rs2814778-CC genotype. MAIN OUTCOMES AND MEASURES The proportion of individuals with the CC genotype who underwent BMB for an isolated low WBC count and had a normal biopsy result compared with the proportion of individuals with the CC genotype who underwent BMB for other indications and had a normal biopsy result. RESULTS Among 399 individuals who underwent a BMB (mean [SD] age, 41.8 [22.5] years, 234 [59%] female), 277 (69%) had the CC genotype. A total of 35 patients (9%) had clinical histories of isolated low WBC counts, and 364 (91%) had other histories. Of those with a clinical history of isolated low WBC count, 34 of 35 (97%) had the CC genotype vs 243 of 364 (67%) of those without a low WBC count history. Among those with the CC genotype, 33 of 34 (97%) had normal results for biopsies performed for isolated low WBC counts compared with 134 of 243 individuals (55%) with biopsies performed for other histories (P < .001). CONCLUSIONS AND RELEVANCE In this genetic association study, among patients of African American race who had a BMB with a clinical history of isolated low WBC counts, the rs2814778-CC genotype was highly prevalent, and 97% of these BMBs identified no hematologic abnormality. Accounting for the rs2814778-CC genotype in clinical decision-making could avoid unnecessary BMB procedures.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noura S Abul-Husn
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph T Glessner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,The Center for Applied Genomics, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon Nirenberg
- Department of Scientific Computing, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Meghana S Eswarappa
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gillian M Belbin
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank Mentch
- The Center for Applied Genomics, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John Connolly
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hakon Hakonarson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy J Cox
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott C Borinstein
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Mosley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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Abstract
The term "benign ethnic neutropenia" describes the phenotype of having an absolute neutrophil count (ANC) <1500 cells/μL with no increased risk of infection. It is most commonly seen in those of African ancestry. In addition, ANC reference ranges from countries in Africa emphasize that ANC levels <1500 cells/μL are common and harmless. The lower ANC levels are driven by the Duffy null [Fy(a-b-)] phenotype, which is protective against malaria and seen in 80% to 100% of those of sub-Saharan African ancestry and <1% of those of European descent. Benign ethnic neutropenia is clinically insignificant, but the average ANC values differ from what are typically seen in those of European descent. Thus, the predominantly White American medical system has described this as a condition. This labeling implicitly indicates that common phenotypes in non-White populations are abnormal or wrong. We believe that it is important to examine and rectify practices in hematology that contribute to systemic racism.
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11
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Awan ZA, Al Amoudi SM, Saboor M, Alkhaldy HY. Isolated Neutropenia/Benign Ethnic Neutropenia: A Common Clinical and Laboratory Finding in Southern and Western Saudi Arabia. Int J Gen Med 2021; 14:451-457. [PMID: 33623417 PMCID: PMC7894867 DOI: 10.2147/ijgm.s300690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/28/2021] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Isolated mild neutropenia is a common clinical problem in some ethnicities including Arabs and Middle Eastern population. The current study aims to authenticate the prevalence of isolated neutropenia in Southern and Southwestern Saudi Arabia, explore the effect of altitude or regional differences and to suggest a new reference range for neutrophil count. METHODS In this retrospective cross-sectional study, laboratory results of a commercial laboratory were screened over a period of 5 years (2016-2020) in seven different cities of different altitudes in South and southwestern Saudi Arabia. Participants' laboratory investigations were reviewed and excluded for any abnormal complete blood count, renal profile, liver profile, lipid profile, thyroid function test, fasting blood glucose, or HbA1c findings. Descriptive analysis and 95th percentile range were calculated using standard statistical methods. RESULTS A total of 91,880 complete blood count results were included in the final analysis. Isolated neutropenia was common laboratory finding, with a prevalence ranging from 11% to 23%. The 2.5th percentile of the neutrophil count was lower than currently utilized 1.5×109/L in all studied seven cities. CONCLUSION Mild to moderate neutropenia is common in Southern and Southwestern Saudi Arabia. Benign ethnic neutropenia (BEN) likely explains this high prevalence. Since BEN has no clinical significance, the reference range for normal neutrophil counts needs to be adjusted to reflect the effect of BEN.
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Affiliation(s)
- Zuhier A Awan
- Department of Clinical Biochemistry, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Clinical Pathology, Al-Borg Medical Laboratories, Jeddah, Saudi Arabia
| | - Saeed M Al Amoudi
- Department of Clinical Pathology, Al-Borg Medical Laboratories, Jeddah, Saudi Arabia
| | - Muhammad Saboor
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Jazan University, Gazan, Saudi Arabia
- Medical Research Centre (MRC), Jazan University, Jazan, Saudi Arabia
| | - Husain Y Alkhaldy
- Department of Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
- Research Center for Advanced Materials Science, King Khalid University, Abha, Saudi Arabia
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12
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Tschernin D, Fruchtman Y, Sergienko R, David O, Leibovitz R, Mazar J, Leibovitz E. The etiologic, microbiologic, clinical and outcome characteristics of immunocompetent young children <2 years of age hospitalized with acute neutropenia. Pediatr Neonatol 2021; 62:26-35. [PMID: 32847741 PMCID: PMC7419265 DOI: 10.1016/j.pedneo.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/20/2020] [Accepted: 08/05/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To describe the etiologic, microbiologic, clinical and outcome characteristics of acute neutropenia (absolute neutrophil count, ANC, <1.5 × 109/L) in hospitalized immunocompetent children. METHODS Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, alveolar pneumonia, Brucellosis and Rickettsiosis. RESULTS 431/671 (64.2%) healthy infants and children hospitalized with acute neutropenia were <2 years of age; 176 (40.8%), 167 (38.8%) and 88 (20.4%) patients were aged 0-3, 4-12 and 13-24 months, respectively. There were 19 (4.4%), 53 (12.3%), 140 (32.5%) and 209 (50.8%) patients with ANC count <200, 200-500, 501-1000 and 1001-1500 × 109 cells/L, respectively. Severe neutropenia (<500 × 109/L) was recorded in 72 (16.7%) patients. Fever >38 °C was present in 208/431 (48.3%) patients. Blood cultures were positive in 10 (2.3%), with Brucella melitensis, Staphylococcus aureus and Enterobacter spp. identified in 4, 3 and 2 patients, respectively; 5/10 patients with positive blood cultures were <3 months of age. Overall, 55/431 (12.7%) and 65/431 (15.1%) patients were diagnosed with SBIs and bacterial infections, respectively. Nasal washings-PCR for respiratory viruses was positive in 139/293 (47.4%) patients tested. An infectious etiology (bacterial and/or viral) was diagnosed in 190/431 (44.1%) patients. Three patients were diagnosed with acute lymphocytic leukemia. Resolution of neutropenia was achieved in 111/208 (53.4%) evaluable patients (63%, 50.6% and 48% of patients aged 0-3, 4-12 and >12 months, respectively and 56.8%, 53.5% and 52% of patients with severe, moderate and mild neutropenia, respectively). CONCLUSION Acute neutropenia is common in immunocompetent children <2 years of age and is frequently associated with viral infections. We showed a substantial involvement of bacterial infections and particularly SBIs in the etiology of acute neutropenia. After a 1-month follow-up, resolution of neutropenia occurred in half of the patients, without association with age subgroups and with neutropenia severity.
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Affiliation(s)
- Dov Tschernin
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Yariv Fruchtman
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Ruslan Sergienko
- Department of Public Health, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Odeya David
- Division of Pediatrics, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Ron Leibovitz
- Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Julia Mazar
- Laboratory of Hematology, Ben-Gurion University, Israel,Soroka University Medical Center, Ben-Gurion University, Israel,Faculty of Health Sciences, Ben-Gurion University, Israel
| | - Eugene Leibovitz
- Division of Pediatrics, Ben-Gurion University, Israel; Soroka University Medical Center, Ben-Gurion University, Israel; Faculty of Health Sciences, Ben-Gurion University, Israel.
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13
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Legge SE, Christensen RH, Petersen L, Pardiñas AF, Bracher-Smith M, Knapper S, Bybjerg-Grauholm J, Baekvad-Hansen M, Hougaard DM, Werge T, Nordentoft M, Mortensen PB, Owen MJ, O’Donovan MC, Benros ME, Walters JTR. The Duffy-null genotype and risk of infection. Hum Mol Genet 2020; 29:3341-3349. [PMID: 32959868 PMCID: PMC7906776 DOI: 10.1093/hmg/ddaa208] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 11/26/2022] Open
Abstract
Many medical treatments, from oncology to psychiatry, can lower white blood cell counts and thus access to these treatments can be restricted to individuals with normal levels of white blood cells, principally in order to minimize risk of serious infection. This adversely affects individuals of African or Middle Eastern ancestries who have on average a reduced number of circulating white blood cells, because of the Duffy-null (CC) genotype at rs2814778 in the ACKR1 gene. Here, we investigate whether the Duffy-null genotype is associated with the risk of infection using the UK Biobank sample and the iPSYCH Danish case-cohort study, two population-based samples from different countries and age ranges. We found that a high proportion of those with the Duffy-null genotype (21%) had a neutrophil count below the threshold often used as a cut-off for access to relevant treatments, compared with 1% of those with the TC/TT genotype. In addition we found that despite its strong association with lower average neutrophil counts, the Duffy-null genotype was not associated with an increased risk of infection, viral or bacterial. These results have widespread implications for the clinical treatment of individuals of African ancestry and indicate that neutrophil thresholds to access treatments could be lowered in individuals with the Duffy-null genotype without an increased risk of infection.
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Affiliation(s)
- Sophie E Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
| | - Rune H Christensen
- Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen 2605, Denmark
| | - Liselotte Petersen
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, 8210, Denmark
- Centre for Integrated Register-Based Research, Aarhus University, Aarhus, 8210, Denmark
- The Lundbeck Foundation for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus 8210, Denmark
| | - Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
| | - Matthew Bracher-Smith
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
| | - Steven Knapper
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | - Jonas Bybjerg-Grauholm
- Centre for Neonatal Screening, Department for Congenital Disorders, Statens Serum Institut, Copenhagen 2300, Denmark
| | - Marie Baekvad-Hansen
- Centre for Neonatal Screening, Department for Congenital Disorders, Statens Serum Institut, Copenhagen 2300, Denmark
| | - David M Hougaard
- Centre for Neonatal Screening, Department for Congenital Disorders, Statens Serum Institut, Copenhagen 2300, Denmark
| | - Thomas Werge
- Institute of Biological Psychiatry, Mental Health Centre Sct. Hans, Mental Health Services Copenhagen, Roskilde 4000, Denmark
| | - Merete Nordentoft
- Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen 2605, Denmark
- The Lundbeck Foundation for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus 8210, Denmark
| | - Preben Bo Mortensen
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, 8210, Denmark
- Centre for Integrated Register-Based Research, Aarhus University, Aarhus, 8210, Denmark
- The Lundbeck Foundation for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus 8210, Denmark
| | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
| | - Michael C O’Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
| | - Michael E Benros
- Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen 2605, Denmark
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
| | - James T R Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff CF24 4HQ, UK
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14
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Atallah-Yunes SA, Ready A, Newburger PE. Benign ethnic neutropenia. Blood Rev 2019; 37:100586. [PMID: 31255364 DOI: 10.1016/j.blre.2019.06.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/09/2019] [Accepted: 06/20/2019] [Indexed: 01/30/2023]
Abstract
Benign ethnic neutropenia (BEN) is one of the most common causes of chronic neutropenia seen in individuals of African, Middle Eastern and West Indian descent, affecting many individuals worldwide. Despite its prevalence, many physicians are not familiar with this benign condition, resulting in unnecessary evaluation and testing for neutropenia in otherwise healthy individuals. Clinically, patients with BEN are at no increased risk of infection despite their neutropenia. Implications of this condition are highlighted in those patients receiving therapies that have a known side effect of neutropenia, most commonly chemotherapy agents. Studies have suggested that disparities in survival among those patients receiving chemotherapy between patients of European decent and African decent may be attributed to measured neutropenia in these populations, questioning whether BEN could be an influential factor. This review encompasses all aspects of benign ethnic neutropenia, providing information about this condition and helping to guide clinical decision-making as to when an aggressive work up and referral are indicated and when it is appropriate to monitor. Additionally, we review the role of genetic studies in identifying the genes related to BEN, summarize the theories that offer the most accepted mechanisms behind the condition, and address the importance of pursuing larger studies to assess the implication of BEN in oncology patients as well as patients taking neutropenia-causing medications.
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Affiliation(s)
- Suheil Albert Atallah-Yunes
- Department of Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01103, USA.
| | - Audrey Ready
- Department of Medicine, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA 01103, USA
| | - Peter E Newburger
- Departments of Pediatrics and Molecular, Cell and Cancer Biology, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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15
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Lakhotia R, Aggarwal A, Link ME, Rodgers GP, Hsieh MM. Natural history of benign ethnic neutropenia in individuals of African ancestry. Blood Cells Mol Dis 2019; 77:12-16. [PMID: 30909074 DOI: 10.1016/j.bcmd.2019.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/17/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Benign ethnic neutropenia (BEN), defined by neutrophil count <1.5 k/μL in the absence of other causes, is an asymptomatic condition more commonly observed in individuals of African ancestry. However, the natural history of this condition has been less well described. METHODS Individuals with BEN were retrospectively identified by chart review or referral to hematology clinics. They were then invited to enroll in a prospective natural history study. Retrospective and prospective clinical and laboratory data were combined for descriptive analyses. FINDINGS 46 participants, younger and older adults from 2 institutions, had BEN. Hypertension was reported in 30%, musculoskeletal disorders in 15%, and upper respiratory infection in 33% of these adults. Their leukopenia resulted from isolated neutropenia, ranging from 1000 and 1500 cells/μL. The severity of infections was mild and the frequency was similar to other healthy individuals in the ambulatory clinic. INTERPRETATION In this group of BEN participants, their leukopenia was stable over time, and they had low rates of infections or common medical disorders, confirming the benign nature of this condition. The presence of BEN in children, younger adults, and older adults suggest a hereditary pattern for BEN.
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Affiliation(s)
- Rahul Lakhotia
- Hematology Branch, NHLBI, NIH, United States of America.
| | - Anita Aggarwal
- Department of Hematology and Oncology, Veterans Administration Hospital, Washington DC, United States of America.
| | - Mary E Link
- Molecular and Clinical Hematology Branch, NHLBI, NIH, United States of America.
| | - Griffin P Rodgers
- Molecular and Clinical Hematology Branch, NHLBI, NIH, United States of America.
| | - Matthew M Hsieh
- Molecular and Clinical Hematology Branch, NHLBI, NIH, United States of America.
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16
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Koen A, Jose L, Madhi SA, Fix A, Cryz S, Groome MJ. Neutrophil Counts in Healthy South African Infants: Implications for Enrollment and Adverse Event Grading in Clinical Trials in an African Setting. THE JOURNAL OF PEDIATRICS: X 2019; 1:100005. [PMID: 32734176 PMCID: PMC7376988 DOI: 10.1016/j.ympdx.2019.100005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/09/2019] [Accepted: 06/11/2019] [Indexed: 12/22/2022] Open
Abstract
Absolute neutrophil counts are used to assess eligibility and safety during clinical trials but the toxicity grading scale used can affect enrollment and reporting of adverse events. During a trial investigating a parenteral rotavirus vaccine in South Africa, we excluded otherwise healthy infants without HIV infection from participation owing to neutropenia. Trial registration ClinicalTrials.gov: NCT02109484.
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Affiliation(s)
- Anthonet Koen
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Jose
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Michelle J Groome
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
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17
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Rappoport N, Simon AJ, Amariglio N, Rechavi G. The Duffy antigen receptor for chemokines, ACKR1,- 'Jeanne DARC' of benign neutropenia. Br J Haematol 2018; 184:497-507. [PMID: 30592023 DOI: 10.1111/bjh.15730] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Benign neutropenia, observed in different ethnic groups, is the most common form of neutropenia worldwide. A specific single nucleotide polymorphism, rs2814778, located at the promoter of the ACKR1 (previously termed DARC) gene, which disrupts a binding site for the GATA1 erythroid transcription factor, resulting in a ACKR1-null phenotype, was found to serve as a predictor of low white blood cell and neutrophil counts in African-Americans and Yemenite Jews. Individuals with benign neutropenia due to the ACKR1-null allele have been found to have an increased susceptibility to human immunodeficiency virus infection and, on the other hand, a protective effect against malaria. The associated protective effect may explain the spread of the ACKR1-null allele by natural selection. The reviewed relationships between ACKR1 polymorphism and various pathological states may have important clinical implications to individuals with and without benign neutropenia. Potential mechanisms for ACKR1 (previously termed DARC) modulation during neutrophil recruitment to inflammation, and chemokine bioavailability in the circulation and in local tissue are reviewed and discussed.
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Affiliation(s)
- Naama Rappoport
- Cancer Research Centre, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos J Simon
- Cancer Research Centre, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Haematology, Sheba Medical Centre, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ninette Amariglio
- Cancer Research Centre, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Haematology, Sheba Medical Centre, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Mina and Everard Goodman Faculty of Life Sciences, Bar Ilan University, Ramat-Gan, Israel
| | - Gideon Rechavi
- Cancer Research Centre, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Palmblad J, Höglund P. Ethnic benign neutropenia: A phenomenon finds an explanation. Pediatr Blood Cancer 2018; 65:e27361. [PMID: 30117263 DOI: 10.1002/pbc.27361] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 01/29/2023]
Abstract
Ethnic benign neutropenia (ENP) is the most common form of neutropenia (NP) worldwide, if an absolute blood neutrophil count (ANC) of < 1.5 G/L is used as definition. In 2009, ENP was associated with a gene variation in the ACKR1/DARC gene, the same variation that also confers the Duffy-null trait. In 2017, a novel mechanism for ENP was introduced, questioning if ENP is a true neutropenic state, when the body's total neutrophil count (TBNC) is concerned. Here, we summarize the current knowledge of ENP, asking (1) How well does the peripheral blood ANC predict the TBNC? (2) Can we improve methods for assessing TBNC? (3) Will estimates of TBNC predict infection propensity and reduce the need for further, costly workup?
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Affiliation(s)
- Jan Palmblad
- Department of Medicine Karolinska Institutet, The Hematology Center, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Petter Höglund
- Department of Medicine Karolinska Institutet, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital Huddinge, and Center for Hematology and Regenerative Medicine (HERM), Stockholm, Sweden
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19
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Charles BA, Hsieh MM, Adeyemo AA, Shriner D, Ramos E, Chin K, Srivastava K, Zakai NA, Cushman M, McClure LA, Howard V, Flegel WA, Rotimi CN, Rodgers GP. Analyses of genome wide association data, cytokines, and gene expression in African-Americans with benign ethnic neutropenia. PLoS One 2018; 13:e0194400. [PMID: 29596498 PMCID: PMC5875757 DOI: 10.1371/journal.pone.0194400] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/04/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Benign ethnic neutropenia (BEN) is a hematologic condition associated with people of African ancestry and specific Middle Eastern ethnic groups. Prior genetic association studies in large population showed that rs2814778 in Duffy Antigen Receptor for Chemokines (DARC) gene, specifically DARC null red cell phenotype, was associated with BEN. However, the mechanism of this red cell phenotype leading to low white cell count remained elusive. METHODS We conducted an extreme phenotype design genome-wide association study (GWAS), analyzed ~16 million single nucleotide polymorphisms (SNP) in 1,178 African-Americans individuals from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and replicated from 819 African-American participants in the Atherosclerosis Risk in Communities (ARIC) study. Conditional analyses on rs2814778 were performed to identify additional association signals on chromosome 1q22. In a separate cohort of healthy individuals with and without BEN, whole genome gene expression from peripheral blood neutrophils were analyzed for DARC. RESULTS We confirmed that rs2814778 in DARC was associated with BEN (p = 4.09×10-53). Conditioning on rs2814778 abolished other significant chromosome 1 associations. Inflammatory cytokines (IL-2, 6, and 10) in participants in the Howard University Family Study (HUFS) and Multi-Ethnic Study in Atherosclerosis (MESA) showed similar levels in individuals homozygous for the rs2814778 allele compared to others, indicating cytokine sink hypothesis played a minor role in leukocyte homeostasis. Gene expression in neutrophils of individuals with and without BEN was also similar except for low DARC expression in BEN, suggesting normal function. BEN neutrophils had slightly activated profiles in leukocyte migration and hematopoietic stem cell mobilization pathways (expression fold change <2). CONCLUSIONS These results in humans support the notion of DARC null erythroid progenitors preferentially differentiating to myeloid cells, leading to activated DARC null neutrophils egressing from circulation to the spleen, and causing relative neutropenia. Collectively, these human data sufficiently explained the mechanism DARC null red cell phenotype causing BEN and further provided a biologic basis that BEN is clinically benign.
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Affiliation(s)
- Bashira A. Charles
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America
| | - Matthew M. Hsieh
- Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, United States of America
| | - Adebowale A. Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America
| | - Daniel Shriner
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America
| | - Edward Ramos
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America
- National Institute of Biomedical Imaging and Bioengineering, NIH, Bethesda, Maryland, United States of America
| | - Kyung Chin
- Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, United States of America
| | - Kshitij Srivastava
- Warren Grant Magnuson Clinical Center, NIH, Bethesda, Maryland, United States of America
| | - Neil A. Zakai
- Departments of Pathology and Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
| | - Mary Cushman
- Departments of Pathology and Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
| | - Leslie A. McClure
- School of Public Health, University of Alabama, Birmingham, Alabama, United States of America
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - Virginia Howard
- School of Public Health, University of Alabama, Birmingham, Alabama, United States of America
| | - Willy A. Flegel
- Warren Grant Magnuson Clinical Center, NIH, Bethesda, Maryland, United States of America
| | - Charles N. Rotimi
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, United States of America
- * E-mail: (CNR); (GPR)
| | - Griffin P. Rodgers
- Molecular and Clinical Hematology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, United States of America
- * E-mail: (CNR); (GPR)
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20
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Abstract
Neutropenia, usually defined as a blood neutrophil count <1·5 × 109 /l, is a common medical problem for children and adults. There are many causes for neutropenia, and at each stage in life the clinical pattern of causes and consequences differs significantly. I recommend utilizing the age of the child and clinical observations for the preliminary diagnosis and primary management. In premature infants, neutropenia is quite common and contributes to the risk of sepsis with necrotizing enterocolitis. At birth and for the first few months of life, neutropenia is often attributable to isoimmune or alloimmune mechanisms and predisposes to the risk of severe bacterial infections. Thereafter when a child is discovered to have neutropenia, often associated with relatively minor symptoms, it is usually attributed to autoimmune disorder or viral infection. The congenital neutropenia syndromes are usually recognized when there are recurrent infections, the neutropenia is severe and there are congenital anomalies suggesting a genetic disorder. This review focuses on the key clinical finding and laboratory tests for diagnosis with commentaries on treatment, particularly the use of granulocyte colony-stimulating factor to treat childhood neutropenia.
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Affiliation(s)
- David C Dale
- Department of Medicine, University of Washington, Seattle, WA, USA
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