1
|
Menter T, Dirnhofer S, Tzankov A. [Differential diagnosis of reactive cytopenias]. PATHOLOGIE (HEIDELBERG, GERMANY) 2022; 43:263-270. [PMID: 35925221 DOI: 10.1007/s00292-022-01076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 06/15/2023]
Abstract
Reactive cytopenias are a frequent cause for bone marrow investigations, including bone marrow trephine biopsies, especially if clinical examination and laboratory analyses (e.g., detection of substrate deficiencies) cannot provide a sufficient explanation. The evaluation of such biopsies is primarily concerned with the exclusion of diseases that displace the normal hematopoiesis (infiltrates of acute leukemias or lymphomas and metastases), the exclusion of a myelodysplastic syndrome that classically results in ineffective hematopoiesis, or the detection of specific diseases, particularly infectious or histiocytic diseases (e.g., hemophagocytic lymphohistiocytosis).In this review, we describe characteristic morphologic changes of reactive cytopenias, focus on specific infectious and noninfectious clinical pictures, and distinguish them from malignant changes, especially myelodysplastic syndrome and underlying leukemia of large granular T lymphocytes. Drug-induced changes in hematopoiesis are described in another article in this issue.
Collapse
Affiliation(s)
- Thomas Menter
- Pathologie, Institut für Medizinische Genetik und Pathologie, Universitätsspital Basel, Universität Basel, Schönbeinstrasse 40, 4031, Basel, Schweiz
| | - Stefan Dirnhofer
- Pathologie, Institut für Medizinische Genetik und Pathologie, Universitätsspital Basel, Universität Basel, Schönbeinstrasse 40, 4031, Basel, Schweiz
| | - Alexandar Tzankov
- Pathologie, Institut für Medizinische Genetik und Pathologie, Universitätsspital Basel, Universität Basel, Schönbeinstrasse 40, 4031, Basel, Schweiz.
| |
Collapse
|
2
|
Hendricks CL, Naidoo A, Thejpal R, Rapiti N, Neethling B, Goga Y, Buldeo S. Childhood aplastic anaemia with paroxysmal nocturnal haemoglobinuria clones: A retrospective single-centre study in South Africa. Afr J Lab Med 2022; 11:1537. [PMID: 35811748 PMCID: PMC9257717 DOI: 10.4102/ajlm.v11i1.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/10/2022] [Indexed: 11/01/2022] Open
Abstract
Background: Paroxysmal nocturnal haemoglobinuria (PNH) clones in children are rare but commonly associated with aplastic anaemia (AA) and myelodysplasia.Objective: This study aimed to determine the prevalence of PNH clones in paediatric patients with idiopathic AA, identify differences in clinical and laboratory features and outcomes, and determine the impact of clone size on clinical presentation.Methods: Patients with confirmed idiopathic AA who were tested for PNH between September 2013 and January 2018 at the Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, South Africa, were included. PNH clones were detected in neutrophils and monocytes by flow cytometry using fluorescent aerolysin, CD24, CD66b and CD14.Results: Twenty-nine children with AA were identified and 11 were excluded. Ten patients (10/18, 55.6%) had PNH clones ranging from 0.11% to 24%. Compared to the PNH-negative group, these children were older (median: 10 years vs 4 years, p = 0.02) and had significantly lower total white cell counts (median 1.7 × 109/L vs 3.2 × 109/L; p = 0.04). There was no difference in median absolute neutrophil count or haemoglobin concentration. Four patients in each group received immunosuppressive therapy (IST). At six months, all four patients with PNH clones had responded, compared to one in the PNH-negative group.Conclusion: More than half of children with AA had a PNH clone. The size of the clone did not impact clinical severity; however, IST use may positively impact prognosis. We recommend early initiation of IST in patients with AA to avoid delays associated with human leukocyte antigen typing.
Collapse
Affiliation(s)
- Candice L Hendricks
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Ashen Naidoo
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Rajendra Thejpal
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Nadine Rapiti
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Beverley Neethling
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Yasmin Goga
- Department of Paediatric Haematology, Faculty of Health Sciences, School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatric Haematology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Suvarna Buldeo
- Department of Haematology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| |
Collapse
|
3
|
Naim F, Saraf A, Dass J, Arya V, Langer S, Gupta N, Sharma A, Kotwal J. A Prospective, Cross Sectional Study of PNH Clone in MDS Patients Using High Sensitivity Flowcytometry: A Single Center Experience. Indian J Hematol Blood Transfus 2020; 36:519-525. [PMID: 32647427 PMCID: PMC7326846 DOI: 10.1007/s12288-019-01219-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022] Open
Abstract
Subclinical PNH can be present in patients with bone marrow failure like aplastic anemia and myelodysplastic syndrome (MDS). Such clone may have prognostic and therapeutic implications. In literature around 1-10% MDS cases have shown a PNH clone, however, data from India is relatively scarce. A high sensitivity PNH assay was employed using a single tube combination of FLAER, CD157, CD64, CD15 and CD45 antibodies in adult patients of MDS at presentation. A clone size of > 0.01% was taken as significant. A total of 30 patients were included. PNH clone was present in 30% cases. Correlation done between PNH clone size and LDH values showed moderately positive correlation (r = 0.735, p = 0.001, r2 = 0.541). As per this study a LDH cut off of 247 IU is likely to predict a PNH clone (> 1%) with moderate sensitivity and specificity. High sensitivity PNH assay is able to detect small PNH clone. Calculating the cut-off of LDH to predict PNH positivity can help us judiciously prescribe this test in MDS patients in resource constrained settings.
Collapse
Affiliation(s)
- Faran Naim
- Department of Clinical Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Amrita Saraf
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, 110060 India
| | - Jasmita Dass
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, 110060 India
| | - Vandana Arya
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, 110060 India
| | - Sabina Langer
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, 110060 India
| | - Nitin Gupta
- Department of Clinical Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajay Sharma
- Department of Clinical Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Jyoti Kotwal
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, 110060 India
| |
Collapse
|
4
|
Manivannan P, Tyagi S, Pati HP, Saxena R. FLAER Based Assay According to Newer Guidelines Increases Sensitivity of PNH Clone Detection. Indian J Hematol Blood Transfus 2019; 36:526-534. [PMID: 32647428 DOI: 10.1007/s12288-019-01220-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 11/21/2022] Open
Abstract
Flow cytometry has become 'gold standard' for detecting abnormal clones in paroxysmal nocturnal hemoglobinuria (PNH), aplastic anemia (AA) and myelodysplastic syndrome (MDS). This pilot study was conducted in 2015 with a primary aim to evaluate the utility of single tube fluorescent aerolysin (FLAER) based testing and its comparison with two tubes non-FLAER based testing (CD55, CD59, CD24 and CD66b) in detecting abnormal PNH clones in these newly diagnosed cases. The secondary aim was an attempt to distinguish PNH from AA/MDS cases associated with PNH clones based on clinical, laboratory features and clone size at diagnosis. In this study, the abnormal PNH clones were detected using a single tube FLAER based testing and two tubes non-FLAER based testing in all cases of PNH (n = 12), healthy subjects (n = 18) and AA/MDS with PNH clone (n = 9) and compared with clinical and laboratory features at diagnosis. The receiver operator curve (ROC) analysis defined the optimal cut-offs for FLAER in granulocytes (> 0.7%) and monocytes (> 0.9%). There was significant positive correlation between FLAER and non-FLAER based testing in these cells (r > 0.3 and p < 0.05). FLAER based testing helped us in picking up smaller clones which were missed by latter technique in four patients thereby increasing its sensitivity and also technically proved to be cost-effective (Rs. 1800 vs. Rs. 2100). Even in PNH patients, the clone size was slightly higher by using FLAER when compared to non-FLAER based antibodies panel. The clone size of monocytes was always higher than granulocytes in both PNH and AA/MDS groups. Bone marrow cellularity and mean size of granulocytes and monocytes clone at diagnosis showed a striking statistically significant 'p' value of < 0.0001 between these groups. In this pilot study, a single tube FLAER based PNH testing had improved clone detection in all cases of PNH, AA/MDS with PNH clones. The clone size was > 30% in majority of PNH cases whereas in AA/MDS, it was usually < 10% at diagnosis. Hence this newer technique not only increased the sensitivity of PNH clone detection but also proved to be cost-effective.
Collapse
Affiliation(s)
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
| |
Collapse
|
5
|
Abstract
Unexplained cytopenia is one of the most common indications for performing trephine bone marrow (BM) biopsy (BMB). The histopathological examination in this regard must be seen in the broader context of a multimodal approach in order to reach an as entity-specific as possible diagnosis, considering medical history, physical examination, laboratory data, peripheral blood morphology, BM aspiration smear, flow cytometry results and, if indicated, cytogenetics and molecular genetics. The particular irreplaceability of the histopathological work-up and the expectations to the BMB lie especially in the detection of fibrosing and/or focal processes (e.g. localized islets of blasts) and disorders extrinsic to the BM such as e.g. metastases, thrombotic microangiopathies, granulomatous myelitides etc. We propose a systematic combined histopathological pattern-based and blood count-based approach that can be applied in such circumstances to achieve a precise diagnosis or, at least, a clinically useful differential diagnosis, particularly taking into consideration specific morphologic pitfalls and application of ancillary techniques. Constitutional BM failure syndromes will not be profoundly addressed.
Collapse
|
6
|
Kotru M, Sharma R, Pramanik SK, Purohit A, Singh G, Singh AK, Muterja D, Mishra P, Seth T, Tyagi S, Mahapatra M, Pati HP, Saxena R. Value of CD16/CD66b/CD45 in comparison to CD55/CD59/CD45 in diagnosis of paroxysmal nocturnal haemoglobinuria: An Indian experience. Indian J Med Res 2018; 146:362-368. [PMID: 29355143 PMCID: PMC5793471 DOI: 10.4103/ijmr.ijmr_195_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background & objectives: Diagnosis of paroxysmal nocturnal haemoglobinuria (PNH), a rare haematopoietic stem cell disorder, is challenging in patients with bone marrow failure (BMF) syndrome like aplastic anaemia (AA). This study was conducted with the aim to test the efficacy of the newly recommended markers viz. anti-CD16 and CD66b antibody over the existing anti-CD55 and CD59 antibody for PNH diagnosis in India. Methods: This study was conducted on 193 suspected cases of PNH by flow cytometry using lyse wash technique to stain the granulocytes with CD16/CD66b and CD55/CD59. Results: Of the 193 suspected cases, 62 patients showed the presence of PNH clone. Forty six patients were detected by CD55/CD59/CD45, whereas 61 were detected by CD16/CD66b/CD45. CD16/CD66b detected 16 (25.8%) additional patients over CD55/CD59 (P<0.05) and was more sensitive in detecting the PNH clone with higher negative predictive value. Most of the patients (11/16) who were picked up by CD16/CD66b were of AA who had small clone sizes. Further, the PNH clones were more discreetly identified in CD16/CD66b plots than by CD55/CD59. Clone size assessed by CD16/CD66b which reflects the clinical severity of classical PNH (thrombosis/haemolysis), was more representative of the underlying clinical condition than CD55/59. Interpretation & conclusions: In our experience of 62 patients of PNH, CD16/CD66b proved to be more efficacious in detecting PNH. The new panel was especially useful in monitoring PNH associated with BMF which had small clone sizes.
Collapse
Affiliation(s)
- Mrinalini Kotru
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Sharma
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Suman Kumar Pramanik
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Purohit
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Gurmeet Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Avinash Kumar Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Muterja
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Pravas Mishra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
7
|
Manivannan P, Ahuja A, Pati HP. Diagnosis of Paroxysmal Nocturnal Hemoglobinuria: Recent Advances. Indian J Hematol Blood Transfus 2017; 33:453-462. [PMID: 29075054 PMCID: PMC5640555 DOI: 10.1007/s12288-017-0868-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic stem cell disorder with its protean clinical manifestations. This is due to partial or complete absence of 'glycophosphatidyl-inositol-anchor proteins' (GPI-AP). The main aim of this review is to highlight various diagnostic modalities available, basic principle of each test and recent advances in the diagnosis of PNH. Recently among various tests available, the flow cytometry has become 'the gold standard' for PNH testing. In order to overcome the difficulties encountered by the testing and research laboratories throughout the world, International Clinical Cytometry Society has come up with guidelines regarding the indications for testing, protocol for sample collection, processing, panel of antibodies as well as gating strategies to be used, how to interpret the test and reporting format to be used. It is essential to test at least two GPI-linked markers on at least two different lineages particularly on red cells and granulocytes/monocytes. The fluorescent aerolysin combined with other monoclonal antibodies in multicolour flow cytometry offered an improved assay not only for diagnosis but also for monitoring of PNH clones. It is equally important to diagnose this rare entity with high index of suspicion.
Collapse
Affiliation(s)
| | - Ankur Ahuja
- Department of Laboratory Services, Army Hospital for Research and Referral, New Delhi, India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| |
Collapse
|
8
|
Rahman K, Gupta R, Yadav G, Husein N, Singh MK, Nityanand S. Fluorescent Aerolysin (FLAER)-based paroxysmal nocturnal hemoglobinuria (PNH) screening: a single center experience from India. Int J Lab Hematol 2017; 39:261-271. [DOI: 10.1111/ijlh.12619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 11/21/2016] [Indexed: 01/19/2023]
Affiliation(s)
- K. Rahman
- Department of Hematology; SGPGI; Lucknow India
| | - R. Gupta
- Department of Hematology; SGPGI; Lucknow India
| | - G. Yadav
- Department of Hematology; SGPGI; Lucknow India
| | - N. Husein
- Department of Hematology; SGPGI; Lucknow India
| | - M. K. Singh
- Department of Hematology; SGPGI; Lucknow India
| | | |
Collapse
|
9
|
Gatti A, Del Vecchio L, Geuna M, Della Porta MG, Brando B. Multicenter validation of a simplified method for paroxysmal nocturnal hemoglobinuria screening. Eur J Haematol 2017; 99:27-35. [PMID: 28332730 DOI: 10.1111/ejh.12885] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) diagnostic guidelines recommend single-tube five- to six-color or two-tube four-color assays. PNH clones are detectable in only a fraction of patients at risk, and screening for new PNH cases can be complex and expensive. In this multicenter study, we have validated a simplified, one-tube two-color FLAER-based assay suitable for PNH screening. METHODS Six laboratories received samples containing spiked PNH leukocyte clones to be analyzed in parallel with a common six-color cocktail (FLAER/CD24/CD45/CD64/CD15/CD14) and a simplified two-color mixture (FLAER/CD15), a shared calibration procedure, and a common analysis protocol. Replicate precision and sensitivity tests were performed on PNH patients, from undiluted to 1:10 000. Specificity tests were performed on normal donors to identify the possible sources of artifacts. RESULTS The performance comparison between six-color and two-color assays showed an excellent agreement for granulocyte PNH clones. Dilution experiments showed an accurate detectability down to 0.01% sensitivity level for granulocyte PNH clones and to 1% for monocytes. Specificity experiments disclosed that basophils and platelets can contaminate the monocyte gate and generate false PNH events. CONCLUSIONS A simplified two-color (FLAER/CD15) PNH screening test has been validated in a highly standardized multicenter study and proved feasible and effective in ongoing regional programs. Precision, sensitivity, and specificity of the simplified test for granulocytes were comparable to the more complex and expensive six-color assay and applicable for screening also in peripheral laboratories. The diagnostic confirmation of PNH should be always performed by a reference center using the established technique on all cell lineages.
Collapse
Affiliation(s)
- Arianna Gatti
- Haematology Laboratory and Transfusion Center, Western Milan Area Hospital Consortium, Legnano General Hospital, Legnano(Milano), Italy
| | - Luigi Del Vecchio
- Molecular Medicine and Medical Biotechnology Department, Federico II University, Naples, Italy
| | - Massimo Geuna
- Department of Pathology, Mauriziano Umberto I Hospital, Turin, Italy
| | - Matteo G Della Porta
- Cancer Center - IRCCS Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Bruno Brando
- Haematology Laboratory and Transfusion Center, Western Milan Area Hospital Consortium, Legnano General Hospital, Legnano(Milano), Italy
| |
Collapse
|