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Opie J, Verburgh E, Bailly J, Mayne E, Louw V. Hematological Complications of Human Immunodeficiency Virus (HIV) Infection: An Update From an HIV-Endemic Setting. Open Forum Infect Dis 2024; 11:ofae162. [PMID: 38601746 PMCID: PMC11004791 DOI: 10.1093/ofid/ofae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/17/2024] [Indexed: 04/12/2024] Open
Abstract
Medical professionals, particularly in regions with a high burden of human immunodeficiency virus (HIV), should be alert to the hematological complications of HIV, which may include cytopenias, malignancy, and coagulation disturbances. Patients may present with these conditions as the first manifestation of HIV infection. Hematological abnormalities are often multifactorial with opportunistic infections, drugs, malignancy, and HIV infection itself contributing to the clinical presentation, and the diagnosis should consider all these factors. Life-threatening hematological complications requiring urgent diagnosis and management include thrombotic thrombocytopenic purpura, superior mediastinal syndrome, spinal cord compression, and tumor lysis syndrome due to aggressive lymphoma. Antiretroviral therapy is the therapeutic backbone, including for patients with advanced HIV, in addition to specific therapy for the complication. This article reviews the impact of HIV on the hematological system and provides a clinical and diagnostic approach, including the role of a bone marrow biopsy, focusing on perspectives from sub-Saharan Africa.
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Affiliation(s)
- Jessica Opie
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Estelle Verburgh
- Division of Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Jenique Bailly
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Elizabeth Mayne
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Vernon Louw
- Division of Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
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Bailly J, Jenkins N, Chetty D, Mohamed Z, Verburgh ER, Opie JJ. Plasmablastic lymphoma: An update. Int J Lab Hematol 2022; 44 Suppl 1:54-63. [PMID: 36074710 PMCID: PMC9545967 DOI: 10.1111/ijlh.13863] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/20/2022] [Indexed: 12/22/2022]
Abstract
Plasmablastic lymphoma (PBL) is a highly aggressive B cell non-Hodgkin lymphoma frequently associated with immunosuppression, particularly human immunodeficiency virus (HIV) infection. Although PBL is rare globally, South Africa has a high burden of HIV infection leading to a higher incidence of PBL in the region. Laboratory features in PBL may overlap with plasmablastic myeloma and other large B cell lymphomas with plasmablastic or immunoblastic morphology leading to diagnostic dilemmas. There are, however, pertinent distinguishing laboratory features in PBL such as a plasma cell immunophenotype with MYC overexpression, expression of Epstein-Barr virus-encoded small RNAs and lack of anaplastic lymphoma kinase (ALK) expression. This review aims to provide a summary of current knowledge in PBL, focusing on the epidemiology, pathophysiology, laboratory diagnosis and clinical management.
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Affiliation(s)
- Jenique Bailly
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Nicholas Jenkins
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Dharshnee Chetty
- Division of Anatomical Pathology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Zainab Mohamed
- Department of Radiation Oncology, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Estelle R Verburgh
- Division of Haematology, Department of Internal Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Jessica J Opie
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
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Lohlun RK, Chapanduka ZC. Factors associated with bone marrow involvement in lymphoma staging bone marrow examination: A South African single-centre retrospective study. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2022. [DOI: 10.4102/sajo.v6i0.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Accurate detection of bone marrow involvement (BMI) in lymphoma is important as it signifies stage 4 disease. Staging bone marrow examination (BME), therefore, influences treatment decisions and prognostication. The prevalence of BMI depends on multiple factors at presentation including lymphoma subtype, age, sex, human immunodeficiency virus (HIV) status and haematological parameters.Aim: To determine risk factors for BMI in lymphoma staging.Setting: The study was conducted in the department of haematological pathology, Tygerberg Hospital, Cape Town, South Africa.Methods: Retrospective cross-sectional descriptive study in adult patients, reviewing BMI and associated parameters, during their initial lymphoma staging procedure between 2016 and 2019.Results: Of a total of 387 lymphoma staging cases that were evaluated, 30.0% of them showed BMI. Diffuse large B-cell lymphoma, Hodgkin lymphoma and high-grade B-cell lymphoma were the most frequent subtypes diagnosed. The highest prevalence of BMI was in low-grade lymphomas. There was a statistically significant association between BMI and advanced age, pancytopenia and bicytopenia (anaemia with leucopenia, anaemia with thrombocytopenia or leucopenia with thrombocytopenia). Bicytopenia and pancytopenia showed high positive predictive values of BMI, respectively, 61.0% and 69.0%. Human immunodeficiency virus positivity (34.6%) was not predictive of BMI across all lymphoma subtypes. Normal blood counts had a high negative predictive value for BMI.Conclusion: BME remains an important part of lymphoma staging with 30.0% of all lymphomas showing BMI.
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Post-Lugano classification usage of bone marrow biopsy in the staging of lymphoma. J Hematop 2021. [DOI: 10.1007/s12308-021-00476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Alves de Souza Rios L, Mapekula L, Mdletshe N, Chetty D, Mowla S. HIV-1 Transactivator of Transcription (Tat) Co-operates With AP-1 Factors to Enhance c-MYC Transcription. Front Cell Dev Biol 2021; 9:693706. [PMID: 34277639 PMCID: PMC8278106 DOI: 10.3389/fcell.2021.693706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
HIV-1 infection often leads to the development of co-morbidities including cancer. Burkitt lymphoma (BL) is one of the most over-represented non-Hodgkin lymphoma among HIV-infected individuals, and displays a highly aggressive phenotype in this population group, with comparatively poorer outcomes, despite these patients being on anti-retroviral therapy. Accumulating evidence indicates that the molecular pathogenesis of HIV-associated malignancies is unique, with components of the virus playing an active role in driving oncogenesis, and in order to improve patient prognosis and treatment, a better understanding of disease pathobiology and progression is needed. In this study, we found HIV-1 Tat to be localized within the tumor cells of BL patients, and enhanced expression of oncogenic c-MYC in these cells. Using luciferase reporter assays we show that HIV-1 Tat enhances the c-MYC gene promoter activity and that this is partially mediated via two AP-1 binding elements located at positions -1128 and -1375 bp, as revealed by mutagenesis experiments. We further demonstrate, using pull-down assays, that Tat can exist within a protein complex with the AP-1 factor JunB, and that this complex can bind these AP-1 sites within the c-MYC promoter, as shown by in vivo chromatin immunoprecipitation assays. Therefore, these findings show that in HIV-infected individuals, Tat infiltrates B-cells, where it can enhance the expression of oncogenic factors, which contributes toward the more aggressive disease phenotype observed in these patients.
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Affiliation(s)
| | - Lungile Mapekula
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Nontlantla Mdletshe
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Dharshnee Chetty
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Shaheen Mowla
- Division of Haematology, Department of Pathology, University of Cape Town, Cape Town, South Africa
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Kroft SH, Sever CE, Bagg A, Billman B, Diefenbach C, Dorfman DM, Finn WG, Gratzinger DA, Gregg PA, Leonard JP, Smith S, Souter L, Weiss RL, Ventura CB, Cheung MC. Laboratory Workup of Lymphoma in Adults: Guideline From the American Society for Clinical Pathology and the College of American Pathologists. Arch Pathol Lab Med 2021; 145:269-290. [PMID: 33175094 DOI: 10.5858/arpa.2020-0261-sa] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The diagnostic workup of lymphoma continues to evolve rapidly as experience and discovery led to the addition of new clinicopathologic entities and techniques to differentiate them. The optimal clinically effective, efficient, and cost-effective approach to diagnosis that is safe for patients can be elusive, in both community-based and academic practice. Studies suggest that there is variation in practice in both settings. OBJECTIVE.— To develop an evidence-based guideline for the preanalytic phase of testing, focusing on specimen requirements for the diagnostic evaluation of lymphoma. DESIGN.— The American Society for Clinical Pathology, the College of American Pathologists, and the American Society of Hematology convened a panel of experts in the laboratory workup of lymphoma to develop evidence-based recommendations. The panel conducted a systematic review of literature to address key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation approach, recommendations were derived based on the available evidence, strength of that evidence, and key judgements as defined in the Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision framework. RESULTS.— Thirteen guideline statements were established to optimize specimen selection, ancillary diagnostic testing, and appropriate follow-up for safe and accurate diagnosis of indolent and aggressive lymphoma. CONCLUSIONS.— Primary diagnosis and classification of lymphoma can be achieved with a variety of specimens. Application of the recommendations can guide decisions on specimen suitability, diagnostic capabilities, and correct use of ancillary testing. Disease prevalence in patient populations, availability of ancillary testing, and diagnostic goals should be incorporated into algorithms tailored to each practice environment.
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Affiliation(s)
- Steven H Kroft
- From the Department of Pathology, Froedtert Hospital and the Medical Colleges of Wisconsin, Milwaukee (Kroft)
| | - Cordelia E Sever
- Pathology Associates of Albuquerque, Albuquerque, New Mexico (Sever)
| | - Adam Bagg
- The Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia (Bagg)
| | - Brooke Billman
- Governance Services (Billman), College of American Pathologists, Northfield, Illinois
| | - Catherine Diefenbach
- The Department of Medicine, New York University School of Medicine, New York, New York (Diefenbach)
| | - David M Dorfman
- The Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts (Dorfman)
| | - William G Finn
- The Department of Pathology and Laboratory Medicine, Warde Medical Laboratory, Ann Arbor, Michigan (Finn)
| | - Dita A Gratzinger
- The Department of Pathology, Stanford Health Care, Stanford, California (Gratzinger)
| | - Patricia A Gregg
- The Department of Pathology, Lehigh Regional Medical Center, Lehigh Acres, Florida (Gregg)
| | - John P Leonard
- The Department of Hematology and Oncology, Weill Cornell Medical College, New York, New York (Leonard)
| | - Sonali Smith
- The Department of Medicine, University of Chicago Medicine, Chicago, Illinois (Smith)
| | - Lesley Souter
- Souter is in private practice in Wellandport, Ontario, Canada
| | - Ronald L Weiss
- The Department of Pathology, ARUP Laboratories Inc, Salt Lake City, Utah (Weiss)
| | - Christina B Ventura
- The Pathology and Laboratory Quality Center (Ventura), College of American Pathologists, Northfield, Illinois
| | - Matthew C Cheung
- The Department of Medicine, Odette Cancer Centre/Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Cheung)
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Kroft SH, Sever CE, Bagg A, Billman B, Diefenbach C, Dorfman DM, Finn WG, Gratzinger DA, Gregg PA, Leonard JP, Smith S, Souter L, Weiss RL, Ventura CB, Cheung MC. Laboratory Workup of Lymphoma in Adults. Am J Clin Pathol 2021; 155:12-37. [PMID: 33219376 DOI: 10.1093/ajcp/aqaa191] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The diagnostic workup of lymphoma continues to evolve rapidly as experience and discovery lead to the addition of new clinicopathologic entities and techniques to differentiate them. The optimal clinically effective, efficient, and cost-effective approach to diagnosis that is safe for patients can be elusive, in both community-based and academic practice. Studies suggest that there is variation in practice in both settings. THE AIM OF THIS REVIEW IS TO develop an evidence-based guideline for the preanalytic phase of testing, focusing on specimen requirements for the diagnostic evaluation of lymphoma. METHODS The American Society for Clinical Pathology, the College of American Pathologists, and the American Society of Hematology convened a panel of experts in the laboratory workup of lymphoma to develop evidence-based recommendations. The panel conducted a systematic review of the literature to address key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, recommendations were derived based on the available evidence, the strength of that evidence, and key judgments as defined in the GRADE Evidence to Decision framework. RESULTS Thirteen guideline statements were established to optimize specimen selection, ancillary diagnostic testing, and appropriate follow-up for safe and accurate diagnosis of indolent and aggressive lymphoma. CONCLUSIONS Primary diagnosis and classification of lymphoma can be achieved with a variety of specimens. Application of the recommendations can guide decisions about specimen suitability, diagnostic capabilities, and correct utilization of ancillary testing. Disease prevalence in patient populations, availability of ancillary testing, and diagnostic goals should be incorporated into algorithms tailored to each practice environment.
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Affiliation(s)
- Steven H Kroft
- Department of Pathology, Froedtert Hospital and the Medical Colleges of Wisconsin, Milwaukee
| | | | - Adam Bagg
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Brooke Billman
- Governance Services, College of American Pathologists, Northfield, IL
| | | | - David M Dorfman
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - William G Finn
- Department of Pathology and Laboratory Medicine, Warde Medical Laboratory, Ann Arbor, MI
| | | | - Patricia A Gregg
- Dept of Pathology, Lehigh Regional Medical Center, Lehigh Acres, FL
| | - John P Leonard
- Department of Hematology and Oncology, Weill Cornell Medical College, New York, NY
| | - Sonali Smith
- Department of Medicine, The University of Chicago Medicine, Chicago, IL
| | | | - Ronald L Weiss
- Department of Pathology, ARUP Laboratories, Salt Lake City, UT
| | - Christina B Ventura
- Pathology and Laboratory Quality Center, College of American Pathologists, Northfield, IL
| | - Matthew C Cheung
- Department of Medicine, Odette Cancer Centre/Sunnybrook Health Sciences Centre, Toronto, Canada
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Tshabalala WS, Pillay S, Wilson DPK. Diagnostic outcomes of bone marrow aspirate and trephine biopsies performed at a hospital in KwaZulu-Natal, South Africa. Afr J Lab Med 2020; 9:1028. [PMID: 32158640 PMCID: PMC7057739 DOI: 10.4102/ajlm.v9i1.1028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/26/2019] [Indexed: 11/28/2022] Open
Abstract
Background Bone marrow aspiration and trephine biopsy (BMAT) are widely performed in adults to evaluate haematological and malignant conditions. However, the diagnostic yield from the procedure in unselected patients in the South African public sector has not previously been described. Objectives We identified the main indications and most common diagnoses encountered for BMAT and described the demographic and blood profiles of patients, including HIV-positive patients, who had undergone the procedure at a tertiary hospital in KwaZulu-Natal. Methods We retrospectively reviewed laboratory data from January 2016 to December 2016 for all patients aged ≥ 13 years who underwent the procedure and stratified findings by demographic data. Results Among 120 BMAT biopsies studied, 80 (67%) cases were performed to evaluate suspected malignancy and a further 40 (33%) cases for non-malignant indications. The main indications for bone marrow examination were: cytopenias 38 (32%), lymphoma 35 (29%), leukaemia 21 (18%), and multiple myeloma 17 (14%). BMAT results revealed that 60 cases (50%) were malignant in origin, 30 cases (25%) were non-malignant and 30 cases (25%) were classified as normal. The common diagnoses were: leukaemia, 24 (20%); multiple myeloma, 16 (13%) and lymphoma, 13 (11%). Cases aged ≥ 50 years were more likely to have a malignant diagnosis (odds ratio: 5.8 (95% confidence interval: 2.2–17.1) p-value < 0.001). Conclusion The diagnostic yield of BMAT was high, with significant abnormalities detected in three quarters of cases. Haematological malignancy was the more common diagnosis. Increasing age was associated with an increase in reporting of haematology malignancy.
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Affiliation(s)
- Wanda S Tshabalala
- Department of Internal Medicine, Grey's Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Somasundram Pillay
- Department of Internal Medicine, Edendale Hospital, Pietermaritzburg complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Douglas P K Wilson
- Department of Internal Medicine, Edendale Hospital, Pietermaritzburg complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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Opie J, Antel K, Koller A, Novitzky N. In the South African setting, HIV-associated Burkitt lymphoma is associated with frequent leukaemic presentation, complex cytogenetic karyotypes, and adverse clinical outcomes. Ann Hematol 2020; 99:571-578. [PMID: 31955214 DOI: 10.1007/s00277-020-03908-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/13/2020] [Indexed: 01/10/2023]
Abstract
South Africa (SA) has a high prevalence of human immunodeficiency virus (HIV) infection. People living with HIV are at markedly increased risk of developing Burkitt lymphoma (BL), which is characterized by the MYC translocation. There is a paucity of survival data of HIV-associated Burkitt lymphoma/leukaemia (HIV-BL) cases from SA, and the relationship between karyotype and outcomes has not been widely reported. Here we report the clinico-pathological characteristics of a cohort of cytogenetically confirmed HIV-BL cases. A retrospective, descriptive review was conducted of clinico-pathological features of HIV-BL patients newly diagnosed and treated between 2005 and 2014 at our tertiary academic institution in Cape Town. Only HIV-BL patients with cytogenetic evidence of a MYC translocation were included for analysis. A multivariable Cox proportional hazards model assessed the impact of variables on overall survival (OS). Forty-nine patients met inclusion criteria. Their median age was 37 years (IQR 30-43 years) and 57% (n = 28) were females. Their median CD4 count was 240 cells/μl (IQR 103-423 cells/μl). The majority, 61% (n = 30), had leukaemic presentation, and 20% (n = 10) had a complex karyotype on conventional karyotyping. Seventy-seven percent (n = 36) received various protocols of combination intensive chemotherapy, excluding rituximab. Their OS was 64% (95% CI 45-77%) at 6 months, and 34% (95% CI 17-51%) at 5 years. Leukaemic presentation and a complex karyotype gave a 2.7-fold (95% CI 1.0-6.7) and 2.6-fold (95% CI 1.1-6.6) increased risk of mortality respectively, which were statistical significant (p < 0.05). We report 49 newly diagnosed, cytogenetically confirmed HIV-BL patients at our institution over a 10-year period. There was a high proportion of complex karyotypes and leukaemic presentation, which both independently adversely affected survival. This may be due to differences in the pathobiology of HIV-BL that requires further study and could lead to therapeutic advances in this patient group.
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Affiliation(s)
- Jessica Opie
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.
| | - Katherine Antel
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Ania Koller
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Nicolas Novitzky
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
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