Drug-induced hematologic syndromes

Using portable X-ray fluorescence elemental analysis to explore porous skeletal lesions: Interplay of sex, age at death, and cause of death

OBJECTIVES

Search for possible associations between bone elemental concentration and the presence of porous skeletal lesions (PSLs), considering the sex, age, and cause of death (COD) of the individuals.

MATERIALS AND METHODS

The sample comprised 107 non-adult individuals (56 females, 51 males) aged 0-20 (x̄ = 13.2, SD = 5.8) from the Coimbra and Lisbon Identified Skeletal Collections. Cribra cranii, orbitalia, humeralis, and femoralis were recorded as present/absent, and elemental concentrations were assessed by portable x-ray fluorescence (pXRF). A multivariate statistical approach was applied.

RESULTS

Well-preserved skeletons with minimal diagenesis showed no sex-related elemental variations or PSL associations. In contrast, age-at-death correlated with elevated Ca, P, Sr, and Pb levels. Cribra cranii increased with age while other cribra declined post-adolescence. Higher concentrations of Fe and lower of S were linked to cribra cranii. Respiratory infections as COD increased the odds of expressing cribra femoralis (OR = 5.25, CI = 1.25-15.14), cribra cranii (OR = 2.91, CI = 0.97-8.69), and cribra orbitalia (OR = 2.76, CI = 1.06-7.24).

DISCUSSION

Feasible pXRF results and low cribra intraobserver error assure replicability. Elevated Ca, P, and Sr in older individuals may relate to skeletal growth, while increased Pb suggests bioaccumulation. Cribra's increase with age reflects different rates of marrow conversion and bone remodeling. Higher Fe and lower S in individuals with cribra cranii possibly reflects poor nutrition, early alcohol use, and sideroblastic anemia, aligning with 19th-20th-century Portugal's living conditions. Respiratory infections increased cribra expression, revealing intricate interplays among inflammation, anemia(s), marrow expansion, and diet. This research highlights a complex scenario and blazes a new path for cribra interpretation.

The Role of Fe, S, P, Ca, and Sr in Porous Skeletal Lesions: A Study on Non-adult Individuals Using pXRF

Portable X-ray fluorescence is a new tool in the study of human bone. This research aims to investigate if variations in bone elemental concentrations are related with porous skeletal lesions (PSLs). One hundred well-preserved non-adult skeletons aged 0-11 years were selected from the archaeological site Convent of São Domingos, Lisbon (18th-19th century). Measuring a standard reference material and calculating the technical error of measurement assured elemental data reliability. Moreover, measuring soil samples excluded possible contamination of bones with elements from the soil, except for Pb. Additionally, the Ca/P ratio indicates maintenance of bone integrity. Cribra cranii, orbitalia, humeralis, and femoralis were recorded as present/absent, and the estimated intra-/inter-observer errors were low. The multivariate analysis found higher odds of having cribra orbitalia (OR = 1.76; CI = 0.97-3.20) and cribra femoralis (OR = 1.42; CI = 0.73-2.74) in individuals with lower Fe and higher S. Furthermore, higher levels of P, Ca, and Sr increased the odds of individuals developing cribra femoralis (OR = 2.30; CI = 1.23-4.29). Age also correlated with increased odds of exhibiting cribra orbitalia (OR = 1.86; CI = 0.94-3.68), cribra femoralis (OR = 6.97; CI = 2.78-17.45), and cribra humeralis (OR = 8.32; CI = 2.71-25.60). These findings suggest a shared etiology for these three cribras, contrasting with the higher Fe levels in individuals with cribra cranii. Lower Fe and higher S levels in individuals with cribra suggest a complex etiology, possibly involving conditions like megaloblastic or chronic disease anemia(s). Age-related elemental changes support the hypothesis that age influences cribra frequencies. This study highlights PSL complexity and opens new avenues for research.

Aplastic anaemia following antibiotic use for urinary tract infection

Aplastic anaemia is often associated with recent viral illnesses to include EBV and parvovirus along with certain medications such as anticonvulsants and sulfa containing antibiotics. We describe a case report of a female patient in her 70s who presented with pancytopenia after being treated with nitrofurantoin and ciprofloxacin for suspected urinary tract infection. She underwent an extensive workup to rule out alternative aetiologies of her pancytopenia to include a broad viral, autoimmune and malignancy evaluation which were unrevealing. Given her recent exposure to ciprofloxacin and nitrofurantoin and marrow recovery following removal of these agents, it was presumed that antibiotic exposure was the underlying cause of her aplastic anaemia.

Aplastic anemia secondary to adjuvant Osimertinib therapy: a case report and a review of literature

Aplastic anemia is a rare hematological disorder characterized by suppressed hematopoiesis and pancytopenia. Although several drugs have been associated with aplastic anemia, its occurrence in response to Osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is extremely rare. We present a case report of a 63-year-old patient with locally advanced non-small cell lung cancer (NSCLC) who developed aplastic anemia following adjuvant treatment with Osimertinib. Extensive investigations ruled out infectious etiology, and the absence of bone marrow involvement or other identifiable causes suggested a drug-induced etiology, specifically Osimertinib. This case report emphasizes the importance of recognizing this adverse event and considering it as a potential complication of Osimertinib therapy. Vigilant monitoring and prompt management are essential for optimizing patient outcomes. Further studies are needed to better understand the risk factors, underlying mechanisms, and management strategies for Osimertinib-induced aplastic anemia in the adjuvant settings.

Hematological adverse events associated with anti-MRSA agents: a real-world analysis based on FAERS

This study investigated the patterns of hematological adverse events related to daptomycin (DAP), tigecycline (TIG), vancomycin (VAN) and linezolid (LIN) in the FDA Adverse Event Reporting System (FAERS). Adverse event associations were analyzed through calculating reporting odds ratio (ROR), proportional reporting ratio (PRR), multiple gamma Poisson shrinkage (MGPS), and Bayesian confidence propagation neural network (BCPNN). A comprehensive descriptive analysis was also conducted considering factors such as age, gender, daily dose, cumulative dose, and time to onset. The leading hematologic adverse events were eosinophilia for daptomycin, coagulation abnormalities and thrombocytopenia for tigecycline, thrombocytopenia, neutropenia, and anemia for linezolid, and thrombocytopenia, eosinophilia, and neutropenia for vancomycin. Most of the affected patients were over 55 years old. Daily doses for the tigecycline and daptomycin groups exceeded the standard daily dose. The times to onset were 14.00 days for daptomycin (interquartile range [IQR], 4.00-21.00), 6.00 days for tigecycline (IQR, 2.00-9.00), 10.00 days for linezolid (IQR, 4.00-16.5), and 10.00 days for vancomycin (IQR,5.00-20.00). It is essential to intensify early monitoring and identification of these adverse events, especially in the context of off-label dosages and for elderly patients and individuals taking medication for over one week.

Vancomycin-Induced Leukopenia and Neutropenia: Time Will Tell

Purpose: Neutropenia is an uncommon adverse effect associated with prolonged vancomycin therapy. Methods: This was a case report on a 62-year-old African American male with hypertension, paranoid schizophrenia, and a history of polysubstance abuse developed foot osteomyelitis. The patient was initially maintained on intravenous Vancomycin & Ceftriaxone for ~3 weeks but adjusted to Daptomycin & Ceftriaxone while in hospital due to neutropenia. Patient's neutropenia quickly resolved once discontinuation of Vancomycin occurred. Results: Vancomycin is a potential cause of drug induced leukopenia and neutropenia. Monitoring of leukocytes and neutrophils is warranted in patients receiving long term intravenous Vancomycin therapy. Conclusion: Vancomycin is a bactericidal glycopeptide antibiotic with activity against gram-positive organisms such as Staphylococci. Well-known adverse drug events include nephrotoxicity and ototoxicity. Vancomycin-induced neutropenia on the other hand is less common and reported at lower rates. It is defined as an ANC less than 1000 µL in patients maintained on Vancomycin infusions. According to Black et al, neutropenia is more likely associated with prolonged therapy; generally occurring at least 20 days after initiation.

Impact of anti-tuberculosis treatment on hematological parameters in newly diagnosed tuberculosis patients at Jimma town: a longitudinal prospective study

Tuberculosis (TB) is a significant public health problem affecting one-third of the world's population. In 2021, 1.6 million people died from TB. TB is the 13th leading cause of death and the second leading cause of infectious death after coronavirus disease 2019. Most anti-TB drugs affect hematological parameters in patients.

METHODS

This longitudinal prospective study was conducted from 03 January to 30 December 2019. Patients who completed a course of TB treatment were candidates for analysis. Sputum and blood samples were collected from each study participant and analyzed by the Gene X-pert machine and a HumaCount 30 hematology analyzer (Human GmbH). SPSS version 20 and R programming software version 4.2.3 were used for data analysis. Friedman's test was used to assess statistical significance. P-values ​​less than 0.05 were considered statistically significant.

RESULTS

A total of 148 patients who completed the course of TB treatment correctly were a candidate for final analysis. Ninety-one (61.5%) study participants were male; the median age was 27.6±9.8 years. Moreover, most of the study participants (84.4%) had pulmonary TB. Most of the hematological parameters had changed in the phases of TB treatment. After anti-TB treatment, there is a significant difference in hematological parameters in red blood cell count, hemoglobin concentration, hematocrit percentage, platelet count, and white blood cell count.

CONCLUSION

Anemia and leucopenia are the most significant problems after TB treatment. Regular checking of these parameters is essential for the patient.

Ceftriaxone-Induced Neutropenia Successfully Treated With Alternative β-Lactam Antibiotics: A Case Report and Review of the Literature

Ceftriaxone-induced neutropenia is a rare and severe adverse effect of the drug. It usually resolves in one to three weeks following the cessation of ceftriaxone and the administration of granulocyte colony-stimulating factor (G-CSF). After neutrophil recovery, patients are often treated with non-β-lactam antibiotics instead of ceftriaxone due to the possibility of cross-reactivity associated with β-lactam allergy. However, in some cases, β-lactam antibiotics are superior to non-β-lactam antibiotics. Few cases of the readministration of β-lactam antibiotics for patients who developed ceftriaxone-induced neutropenia have been reported so far. Moreover, its pathogenesis and management have still not been established. We describe a case of successful readministration of β-lactam antibiotics for a patient who had developed ceftriaxone-induced neutropenia. A 37-year-old man with a prosthetic aortic valve was admitted to our hospital with a fever. Blood culture on admission revealed methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, and transesophageal echocardiography (TEE) showed aortic valve vegetation with multiple septic emboli seen on brain CT. We diagnosed MSSA infective endocarditis with central nervous complications. He underwent an operation and was treated with ceftriaxone. On admission day 28, he developed neutropenia (33/μL), and ceftriaxone-induced neutropenia was suspected. Vancomycin was started instead of ceftriaxone, and his neutrophil count recovered within two weeks with the administration of G-CSF. After recovery, on day 40 of admission, ampicillin sodium was administered instead of vancomycin. Although he developed mild eosinophilia, he did not exhibit neutropenia and was discharged with an amoxicillin prescription on day 60 of admission. Our report suggests the possibility that patients who develop ceftriaxone-induced neutropenia can be treated safely with an alternative β-lactam antibiotic, ampicillin sodium, without causing β-lactam cross-reactivity of neutropenia.

Severe pancytopenia and coagulopathy discovered during anesthesia after pre-anesthetic evaluation - A report of two cases

BACKGROUND

Pre-anesthetic evaluation is an important aspect of perioperative patient management. However, anesthesiologists often encounter challenges during anesthesia due toconditions that are not detected during pre-anesthetic evaluations.

CASE

Case 1 involved a 74-year-old female patient scheduled for cranioplasty and meningioma excision. Severe pancytopenia was detected during anesthesia. Cranioplasty was onlyperformed, the surgery was terminated, and drug-induced pancytopenia was diagnosed andtreated. The pre-anesthetic test results were normal, except for anemia. Case 2 involved a71-year-old male patient who discovered large ecchymosis during general anesthesia preparation in the operating room for choledochal cyst surgery. Surgery was canceled to evaluatethe bleeding tendency, and acquired coagulation factor VIII deficiency was diagnosed andtreated. The pre-anesthetic tests were normal, except for prolongation of the activated partial thromboplastin time.

CONCLUSIONS

Abrupt hematologic and hemostatic changes may occur during anesthesiaeven though pre-anesthetic evaluation findings are normal.

Structural Analysis and Prediction of Hematotoxicity Using Deep Learning Approaches

Hematotoxicity has been becoming a serious but overlooked toxicity in drug discovery. However, only a few in silico models have been reported for the prediction of hematotoxicity. In this study, we constructed a high-quality dataset comprising 759 hematotoxic compounds and 1623 nonhematotoxic compounds and then established a series of classification models based on a combination of seven machine learning (ML) algorithms and nine molecular representations. The results based on two data partitioning strategies and applicability domain (AD) analysis illustrate that the best prediction model based on Attentive FP yielded a balanced accuracy (BA) of 72.6%, an area under the receiver operating characteristic curve (AUC) value of 76.8% for the validation set, and a BA of 69.2%, an AUC of 75.9% for the test set. In addition, compared with existing filtering rules and models, our model achieved the highest BA value of 67.5% for the external validation set. Additionally, the shapley additive explanation (SHAP) and atom heatmap approaches were utilized to discover the important features and structural fragments related to hematotoxicity, which could offer helpful tips to detect undesired positive substances. Furthermore, matched molecular pair analysis (MMPA) and representative substructure derivation technique were employed to further characterize and investigate the transformation principles and distinctive structural features of hematotoxic chemicals. We believe that the novel graph-based deep learning algorithms and insightful interpretation presented in this study can be used as a trustworthy and effective tool to assess hematotoxicity in the development of new drugs.

Life-threatening chlorpromazine-induced acquired haemophilia A in a patient with a cavernous malformation involving the medulla oblongata

INTRODUCTION

Chlorpromazine is a commonly used drug in several medical conditions associated with a wide range of side effects. Few cases of hemostatic disorder have been reported in the literature.

CASE REPORT

A 39-year-old man had previously been diagnosed with a cavernous malformation of the medulla oblongata. Chlorpromazine was started to treat persistent hiccups. Twenty days later, the patient presented hepatitis and a pruritic rash. Haemostasis tests revealed a prolonged partial thromboplastin time associated with isolated decrease of factor VIII level and anti-factor VIII antibodies. Magnetic resonance imaging revealed recent asymptomatic bleeding. Introduction of eptacog alfa and prednisone allowed clinical and biological improvement as well as a prolonged remission after 12 months of follow-up.

Selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia: a cross-sectional study

Background

Asthma is a chronic inflammatory disease that affects the lungs. Variation in whole blood cell lines is caused by the progression and severity of asthma. Common hematological abnormalities encountered during asthma include eosinophilia, neutrophilia, leukocytosis, and increased erythrocyte sedimentation rate. The main aim of this study was to assess the selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia from March to May 2021.

Methodology

A hospital-based cross-sectional study was conducted on a total of 320 asthmatic patients in Northwest Ethiopia. A simple random sampling technique was employed to select study participants. A pre-tested structured questionnaire and a checklist were used to collect data. Blood samples were collected from asthmatic patients for complete blood count and erythrocyte sedimentation rate determination. Hematological profiles were analyzed by Unicel DxH 800 (Beckman Coulter, Ireland). The erythrocyte sedimentation rate was determined by using the Westergren method. The data were entered into EpiData version 3.0.4 and analyzed with a statistical package for social science version 20 software. The bi-variable and multi-variable binary logistic regression models were used to assess the factors associated with hematological abnormalities. A p value of less than 0.05 in the multivariable logistic regression analysis was considered statistically significant.

Results

The overall prevalence of neutrophilia, eosinophilia, thrombocytopenia, leukocytosis, and basophilia was 35.3%, 20%, 11.9%, 10.3%, and 4.1%, respectively. Neutrophilia was associated with a lack of physical activity (AOR = 3.25; 95% CI 1.43–7.37) and a history of taking non-asthmatic drugs within the previous three months (AOR = 2.63; 95% CI 1.22–5.65). Being admitted to the emergency department (AOR = 0.27; 95% CI 0.11–5.67) was found to be associated with eosinophilia. In addition, being admitted to the emergency department (AOR = 5.44; 95%CI: 2.6–11.3) was associated with thrombocytopenia.

Conclusion

The current study demonstrated the predominant prevalence of neutrophilia, followed by eosinophilia, among asthma patients. Therefore, hematological abnormalities should be taken into account for proper monitoring and management of asthmatic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02020-z.

Myeloid-Derived Suppressor Cells Are Increased in Lung Transplant Recipients and Regulated by Immunosuppressive Therapy

Lung transplantation remains as a primary treatment for end-stage lung diseases. Although remarkable improvement has been achieved due to the immunosuppressive protocols, long-term survival for lung transplant recipients (LTR) is still limited. In the last few decades, an increasing interest has grown in the study of dysregulation of immune mechanisms underlying allograft failure. In this regard, myeloid-derived suppressor cells (MDSCs) could play an important role in the promotion of graft tolerance due to their immune regulatory function. Here, we describe for the first time circulating subsets MDSCs from LTR at several time points and we evaluate the relationship of MDSCs with sort-term lung transplant outcomes. Although no effect of MDSCs subsets on short-term clinical events was observed, our results determine that Mo-MDSCs frequencies are increased after acute cellular rejection (ACR), suggesting a possible role for Mo-MDSCs in the development of chronic lung allograft dysfunction (CLAD). Therefore, whether MDSCs subsets play a role as biomarkers of chronic rejection remains unknown and requires further investigations. Also, the effects of the different immunosuppressive treatments on these subpopulations remain under research and further studies are needed to establish to what extend MDSCs immune modulation could be responsible for allograft acceptance.

Hematotoxic, oxidative and genotoxic damage in rainbow trout (Oncorhynchus mykiss) after exposure to 3-benzoylpyridine

Pyridine is a basic heterocyclic organic compound. The pyridine ring is present in many important compounds, including agricultural chemicals, medicines and vitamins. Due to their widespread industrial use, bioaccumulation and non-target toxic effects are being considered as a great risk to human and environmental health. In this study, we aimed to evaluate the hematological, oxidative and genotoxic damage potentials by different concentrations (1, 1.5, and 2 g/L) of the ketone 3-Benzoylpyridine (3BP) on rainbow trout (Oncorhynchus mykiss). Alterations in the biomarker levels of oxidative DNA damage (8-hydroxy-2'-deoxyguanosine (8-OHdG)), apoptosis (Caspase-3), malondialdehyde (MDA) as well as antioxidant enzyme activities including superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), myeloperoxidase (MPO), paraoxonase (PON), and arylesterase (AR) were assessed in brain, liver, gill and blood tissues. Acetylcholinesterase (AChE) activity was also determined in brain tissue. In addition, we analyzed micronucleus (MN) rates and hematological indices of total erythrocyte count (RBC), total leukocyte count (WBC), hemoglobin (Hb), hematocrit (Hct), total platelet count (PLT), mean cell hemoglobin concentration (MCHC), mean cell hemoglobin (MCH), and mean cell volume (MCV) in blood. LC₅₀-96h value of 3BP was calculated as 5.2 g/L from the data obtained. A significant decrease in brain AChE activity was determined in clear time and dose dependent manners. While SOD, CAT, GPx, PON, and AR levels were decreased, MDA, MPO, 8-OHdG and Caspase-3 levels were increased in all tissues (p < 0.05). Again, the 3BP led to increases of MN formation at all applied concentrations in the rates of between 45.4 and 72.7%. Significant differences (p < 0.05) were found out in between all studied hematology parameters between 3BP-exposed and the control fish. In conclusion, ours study firstly indicated that the treatment doses of 3BP induced distinct hematological and oxidative alterations as well as genotoxic damage in rainbow trout.

Acute Lower Extremity Arterial Thrombosis Associated with Osimertinib-Induced Erythrocytosis

Patient: Male, 70-year-old

Final Diagnosis: Drug induced polycythemia

Symptoms: Sural pain

Medication: —

Clinical Procedure: Endovascular treatment

Specialty: Oncology • Pulmonology

The Relationship of Drug Therapy to Aplastic Anemia in Pakistan: A Hospital-Based Case Control Study

Introduction

Drug-induced aplastic anemia has long been a menacing outcome of modern pharmacotherapy. The incidence of idiosyncratic, drug-induced aplastic anemia varies depending on the genetic susceptibility and the associated drug. Only scarce studies have explained the epidemiology and actual incidence of this reaction.

Purpose

The aim of the study was to establish the association between drugs and aplastic anemia.

Methods

A case-control study was conducted with 191 cases and 696 controls at a tertiary hospital for blood diseases in Karachi-Pakistan. Cases were patients of aplastic anemia diagnosed through bone marrow biopsy. The controls did not have either AA or chronic diseases. Each case was paired with four sex and age group match controls. Cases and controls were compared with respect to the drugs used. Univariate and multivariate analysis were performed in order to delineate the association.

Results

Median age of the study-participants was 27 years (04-69 years). The majority 84 (44%) were from age group 16 to 30 years. The male-to-female ratio was 2:1. Among study participants, various drugs were significantly associated with aplastic anemia. Treatment of epilepsy with carbamazepine showed a positive association (OR=2.7, 95% C.I, 1.0-6.8). An increased risk of aplastic anemia was noted with exposure to thiazide (OR=3.1, 95% C.I, 1.3-7.4) and mebendazole (OR=3.7, 95% C.I, 1.5-9.2). However, risks were not increased with chloramphenicol, trimethoprim/sulfamethoxazole, benzodiazepines, antihistamines, oral contraceptives, and herbal medicine.

Conclusion

This large-scale case-control study provide association of aplastic anemia with exposure to carbamazepine, thiazides and mebendazole in population of Pakistan. Patients should be monitored with complete blood indices for early detection of drug toxicity.

Hematological Consequences of Valproic Acid in Pediatric Patients: A Systematic Review with a Mechanistic Approach

PURPOSE

Although valproate (VPA) has several advantages in controlling seizures, it may cause serious hematological consequences. Hematotoxicity of VPA is particularly important in pediatrics because patients at this age are at a growing risk of leukemia. For a conclusive agreement about the toxicity of VPA, in this study, we systematically reviewed the literature in which the hematological consequences of VPA had been emphasized. <P> Methods: A systematic literature search was performed in June 2021 on electronic databases to find original research on the association between VPA therapy and hematotoxicity in pediatric patients. For this purpose, the following search terms "hematotoxicity", "valproic acid" and "pediatrics" with different spellings and similar terms, were searched in the title, keywords, and abstracts of articles. The data were collected and used for qualitative data description. <P> Results: A total of 36 relevant articles with an overall 1381 study population were included. The results showed that VPA could cause severe hematotoxicity in children even at therapeutic doses. Neutropenia, thrombocytopenia, and bone marrow depression are the most common complications associated with VPA therapy. Also, findings showed that after discontinuation of VPA and starting other antiepileptic drugs or reducing the administered VPA dose, hematologic damages were entirely resolved, and all the hematological parameters improved during two weeks. <P> Conclusions: This review showed that VPA therapy could cause hematotoxicity in children; hence, it is recommended to monitor hematological indices during VPA therapy. Also, according to the suggested mechanistic pathways of VPA side effects, a combination of VPA with antioxidants may reduce hematological side effects.

Portomesenteric venous thrombosis in a postmenopausal female with testosterone implant: a case report

Background

Acute portal vein thrombosis is a rare medical event usually seen in liver disease, but it can also occur due to any inherited or acquired procoagulable state that triggers venous occlusion. Hormonal therapies have been associated with an increased risk of prothrombotic states. This case report documents a portomesenteric venous thrombosis in a postmenopausal woman with testosterone implant for the treatment of hypoactive sexual desire and discusses the importance of identifying hypercoagulable risk factors before initiating hormone replacement therapy. We want to improve the awareness of an unusual medical complication associated with hormone replacement therapy and shed light on how testosterone implants could facilitate a thrombotic event related to other risk factors such as obesity and chronic hypoxic states, as well as the importance of differential diagnosis in the evaluation of postmenopausal women on testosterone replacement therapy presenting with acute abdominal pain.

Case presentation

A 55-year-old obese postmenopausal Hispanic female with medical history of chronic obstructive pulmonary disease presents with intractable abdominal pain, is found to have elevated hemoglobin and hematocrit, and an abdominopelvic computed tomography scan revealing portal and superior mesenteric vein thrombosis. Further evaluation excluded inherited and acquired thrombophilia but revealed elevated testosterone levels. The patient was treated with anticoagulation, which resulted in recanalization of the portal and superior mesenteric veins.

Conclusion

Supraphysiologic levels of testosterone caused by testosterone implants as a treatment of hypoactive sexual desire in postmenopausal women can contribute to thrombotic events in the presence of additional prothrombotic risk factors. Therefore, testosterone therapy should include a thorough risk assessment for prothrombotic states, be tailored to patients’ physiologic testosterone levels, and have close follow-up with testosterone level monitoring.

Symptomatic methemoglobinemia in a patient with metastatic clear cell renal cell carcinoma treated with pembrolizumab and axitinib combination therapy: a case report

Background

Combination regimens that include immune checkpoint (ICI) and vascular endothelial growth factor (VEGF) inhibition have opened the door to new treatment opportunities for patients with metastatic renal cell carcinoma (mRCC). While these treatment options have provided improved tolerability and better outcomes compared to older regimens, many patients still experience a myriad of treatment-related adverse events. Given that these regimens were recently approved for mRCC, the complete side effect profile may not be fully elucidated yet.

Case presentation

We report a case of a 73-year old White male with mRCC who was managed with an ICI-VEGF inhibitor combination regimen. He experienced a partial response (Fig. 1) but had side effects including symptomatic cyanosis diagnosed as methemoglobinemia which led to treatment discontinuation. Upon holding his therapy, his methemoglobinemia and cyanosis resolved.

Conclusions

Combination VEGF-ICI therapy provide novel regimens for advanced solid tumor malignancies including mRCC. While shown to have improved efficacy in clinical trials, it is crucial that oncologists uncover the full side effect profile of these novel agents especially as their use becomes more standard in the management of advanced malignancies. To our knowledge, this is the first reported case of a patient experiencing symptomatic methemoglobinemia as an adverse event associated with a VEGF-ICI combination regimen. While the cause of this side effect is unclear, in this paper we attempt to elucidate a process that is in line with the mechanism of action of these therapies to explain how these agents, specifically the axitinib, could have caused the methemoglobin to rise to a symptomatic level.

Ceftriaxone-induced Agranulocytosis

Ceftriaxone is a widely used antibiotic regarded as safe and effective. Drug-induced agranulocytosis is a life-threatening adverse reaction and few reports related to ceftriaxone were found in a review of the literature. The authors present a case of ceftriaxone-induced agranulocytosis, in which a brain abscess was diagnosed and ceftriaxone was commenced. Neutropenic fever occurred on the 29th day of therapy with a cumulative dose of 116 g ceftriaxone and a neutrophil nadir of 0.1×10⁹/l. Ceftriaxone was withheld, filgrastim was administered for 3 days and neutrophil normalization was achieved. Although rare, ceftriaxone-induced agranulocytosis may occur in patients on a long course of ceftriaxone therapy. Prompt recognition and drug withdrawal are required.

LEARNING POINTS

Ceftriaxone-induced agranulocytosis is rare but may occur in patients with high cumulative doses.Prompt recognition, drug withdrawal and administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF) are the mainstay approach.

The effects of favipiravir on hematological parameters of covıd-19 patients

INTRODUCTION

This study aims to evaluate changes in hematological parameters after the follow-up of patients who received treatment with favipiravir due to COVID-19 infections.

METHODS

Sixty-two cases receiving favipiravir treatment for at least five days due to COVID-19 infection were evaluated retrospectively. Parameters including age, gender, nasopharyngeal swab positivity, and chronic diseases were analyzed. Hematologic parameters were analyzed before and after the treatment.

RESULTS

The mean age of the patients receiving treatment with favipiravir was 63.7±12.3 years. Nasopharyngeal swab positivity was detected in 67.7%. The most common comorbid conditions detected in patients were hypertension in 25 cases (40.3%) and diabetes in 16 cases (25.8%). In the statistical analysis of the hematological parameters before and after treatment with favipiravir, WBC, PT-PTT-INR levels were found to be unaffected; the mean RBC was found to have decreased from 4.33 ± 0.58 M/uL to 4.16 ± 0.54 M/uL (p:0.003); the median hemoglobin level was found to have decreased from 12.3 g/dl to 11.9 g/dl (p:0.041); the hematocrit level decreased from 38.1% ± 4.8 to 36.9% ± 4.2 (p:0.026); the median neutrophil count decreased from 4.57 K/uL to 3.85 K/uL (p:0.001); the mean lymphocyte count increased from 1.22 ± 0.53 K/uL to 1.84 ± 1.19 K/uL (p:0.000); and the mean platelet count increased from 244.1 ± 85.1 K/uL to 281.9 ± 103.3 K/uL (p:0.005).

CONCLUSION

We concluded that the pathological effect of treatment with favipiravir on the hematologic system was the suppression in the erythrocyte series, and there were no adverse effects in other hematologic parameters.

Photoacoustics resolves species-specific differences in hemoglobin concentration and oxygenation

SIGNIFICANCE

Photoacoustic imaging (PAI) enables the detection of blood hemoglobin (HB) concentration and oxygenation (sO2) with high contrast and resolution. Despite the heavy use of photoacoustically determined total hemoglobin (THb) and oxygenation (sO2) biomarkers in PAI research, their relationship with underlying biochemical blood parameters and the impact of intra- and interspecies genetic variability have yet to be established.

AIM

To explore the relationship between THb and sO2 photoacoustic biomarkers and the underlying biochemical blood parameters in a species-specific manner.

APPROACH

Experiments were performed on blood in vitro using tissue-mimicking agar phantoms. Blood was extracted from mouse, rat, human, and naked mole-rat (Heterocephalus glaber), anticoagulated in ethylenediaminetetraacetic acid, and measured within 48 h. THb and sO2 were measured using a commercial photoacoustic tomography system (InVision 128, iThera Medical GmBH). Biochemical blood parameters such as HB concentration (g/dL), hematocrit (HCT, %), and red blood cell (RBC) count (μL  -  1) were assessed using a hematology analyzer (Mythic 18 Vet, Woodley Equipment).

RESULTS

A significant correlation was observed between THb and biochemical HB, HCT, and RBC in mouse and rat blood. Moreover, PAI accurately recapitulated interspecies variations in HB and HCT between mouse and rat blood and resolved differences in the oxygen dissociation curves measured using sO2 between human, mouse, and rat. With these validation data in hand, we applied PAI to studies of blood obtained from naked mole-rats and could confirm the high oxygen affinity of this species in comparison to other rodents of similar size.

CONCLUSIONS

Our results demonstrate the high sensitivity of photoacoustically determined hemoglobin biomarkers toward species-specific variations in vitro.

CIN or not: An approach to the evaluation and management of chronic idiopathic neutrophilia

Neutrophilia refers to an increase in the number of circulating neutrophils in the peripheral blood. Some common etiologies include infection, inflammatory conditions, myeloproliferative disorders, malignancies, endocrinopathies, drugs, and anemia. Rare disorders such as leukocyte adhesion deficiency can also cause neutrophilia. In many cases, there is an elevation of neutrophil count that persists for months or even years with no clear underlying cause in an otherwise asymptomatic patient. This is referred to as chronic idiopathic neutrophilia (CIN). Despite being a condition encountered by many physicians, there is a paucity of literature addressing CIN. Certain conditions such as stress, exercise, smoking, obesity, and obstructive sleep apnea have been associated with CIN and may provide explanations for neutrophilia previously thought to be idiopathic. Herein, we present a review of the literature on CIN and propose a systematic approach to this commonly encountered clinical condition.

Post-finasteride syndrome: a surmountable challenge for clinicians

Post-finasteride syndrome (PFS) is a constellation of serious adverse side effects manifested in clinical symptoms that develop and persist in patients during and/or after discontinuing finasteride treatment in men with pattern hair loss (androgenetic alopecia) or benign prostatic hyperplasia. These serious adverse side effects include persistent or irreversible sexual, neurological, physical and mental side effects. To date, there are no evidence-based effective treatments for PFS. Although increasing number of men report persistent side effects, the medical community has yet to recognize this syndrome nor are there any specific measures to address this serious and debilitating symptoms. Here we evaluate the scientific and clinical evidence in the contemporary medical literature to address the very fundamental question: Is PFS a real clinical condition caused by finasteride use or are the reported symptoms only incidentally associated with but not caused by finasteride use? One key indisputable clinical evidence noted in all reported studies with finasteride and dutasteride was that use of these drugs is associated with development of sexual dysfunction, which may persist in a subset of men, irrespective of age, drug dose or duration of study. Also, increased depression, anxiety and suicidal ideation in a subset of men treated with these drugs were commonly reported in a number of studies. It is important to note that many clinical studies suffer from incomplete or inadequate assessment of adverse events and often limited or inaccurate data reporting regarding harm. Based on the existing body of evidence in the contemporary clinical literature, the author believes that finasteride and dutasteride induce a constellation of persistent sexual, neurological and physical adverse side effects, in a subset of men. These constellations of symptoms constitute the basis for PFS in individuals predisposed to epigenetic susceptibility. Indeed, delineating the pathophysiological mechanisms underlying PFS will be of paramount importance to the understanding of this syndrome and to development of potential novel therapeutic modalities.

Bone marrow dyspoiesis associated with severe refractory anaemia in liver cirrhosis

BACKGROUND AND AIM

Peripheral cytopaenias and dyspoiesis are common in cirrhosis; however, the prevalence of dyspoiesis and its contribution in cirrhosis-related cytopaenias has not been studied. We aimed to study the bone marrow (BM) dyspoiesis and its impact on peripheral blood cell counts and refractory anaemia in patients with cirrhosis.

PATIENTS AND METHODS

We reviewed all the BM aspirates and biopsies of cirrhotic cases, done from 2011 to 2018 for clinical indications. Dyspoiesis was considered if >5% of the precursor cells of any of the three lineages showed dyspoietic changes. Primary haematological or non-haematological malignancies, chronic kidney disease, drug intake, acute and chronic hepatitis and granulomatous disease were excluded.

RESULTS

Of 608 these, 82 cases (13.5%) showed dyspoiesis in the BM precursors. There was no difference in age (p=0.16), gender (p=0.58) and spleen size (p=0.35) in cases with or without dyspoiesis. Majority of the cases had dyspoiesis in erythroid series (62, 75.6%) and megakaryocytes (15, 18.2%). Dyspoiesis was more prominent in alcoholics 44 cases (53.6%) and autoimmune diseases 13 cases (15.8%). Erythroid hyperplasia (47.7±14.4 vs 40±11.1; p<0.001) was more in cases with dyserythropoiesis, indicating ineffective erythropoiesis. Patients with dyspoiesis had lower haemoglobin (7.5±1.9 vs 9.3±2.2 g/dL, p<0.001). 54 (8.07%) had refractory anaemia with dyspoiesis present in 48 (88.8%) (p<0.01). Dyspoiesis was independently associated with refractory anaemia when adjusted for age, gender, aetiology and liver disease severity.

CONCLUSIONS

BM dyspoiesis, especially dyserythropoiesis, is associated with severe refractory anaemia in patients with cirrhosis and requires new therapeutic approaches.

T-Cell Activation by Low Molecular Weight Drugs and Factors That Influence Susceptibility to Drug Hypersensitivity

Drug hypersensitivity reactions adversely affect treatment outcome, increase the length of patients' hospitalization, and limit the prescription options available to physicians. In addition, late stage drug attrition and the withdrawal of licensed drugs cost the pharmaceutical industry billions of dollars. This significantly increases the overall cost of drug development and by extension the price of licensed drugs. Drug hypersensitivity reactions are characterized by a delayed onset, and reactions tend to be more serious upon re-exposure. The role of drug-specific T-cells in the pathogenesis of drug hypersensitivity reactions and definition of the nature of the binding interaction of drugs with HLA and T-cell receptors continues to be the focus of intensive research, primarily because susceptibility is associated with expression of one or a small number of HLA alleles. This review critically examines the mechanisms of T-cell activation by drugs. Specific examples of drugs that activate T-cells via the hapten, the pharmacological interaction with immune receptors and the altered self-peptide repertoire pathways, are discussed. Furthermore, the impacts of drug metabolism, drug-protein adduct formation, and immune regulation on the development of drug antigen-responsive T-cells are highlighted. The knowledge gained from understanding the pathways of T-cell activation and susceptibility factors for drug hypersensitivity will provide the building blocks for the development of predictive in vitro assays that will prevent or help to minimize the incidence of these reactions in clinic.

Immunodeficiency as a side effect of anabolic androgenic steroid abuse: a case of necrotizing myofasciitis

Even if there are well-known consequences of anabolic androgenic steroid (AAS) abuse, their full pathway of action is still being investigated. In this context, the presented case report aims to discuss and provide evidence of unusual adverse effects linked to immunodeficiency in an AAS abuser. In fact, this kind of chronic complication, even if not usually considered, may lead sudden death. In this case a 31-year-old aesthetic weightlifter, who presented to the emergency department due to an accidental fall that resulted in left thigh trauma. This subsequently developed into left thigh necrotizing myofasciitis in the following few days. Although surgery and hyperbaric therapy were carried out, the man died. An autopsy with complete biological sampling for toxicological studies was performed. This case highlights the close relationship between AAS abuse and immunodeficiency and highlights it's importance for further studies. However, it should be considered that of all the dangerous effects produced by AAS use, necrotizing fasciitis is not such an unusual consequence.

Genomic insult oriented mitochondrial instability and proliferative hindrance in the bone marrow of aplastic mice including stem/progenitor population

Aplastic anemia is the bone marrow failure condition characterized by the development of hypocellularity in both marrow and peripheral blood compartments. Anti-tumor chemotherapeutic agents often exert secondary effect on hematopoietic system leading to aplastic anemia by marrow failure. The precise mechanisms behind the marrow ablative effects of the drugs remain yet to be established. The present study holds a mechanistic approach to unveil the mystery. Aplastic anemia was generated in mice with the administration of busulfan and cyclophosphamide followed by the characterization of the disease with peripheral blood hemogram, histopathological and cytochemical examinations of bone marrow. To gain deep knowledge about the molecular mechanisms of the hematopoietic disruption, cytotoxicity assay, DNA damage measurement, apoptosis study, replicative senescence analysis, redox balance study, mitochondrial membrane potential change assessment, flowcytometric expressional analysis of p21, p53, ATM, Chk-2, Necdin, Gfi-1, c-myc, KU-80 and Sod-2 were done with marrow hematopoietic stem/ progenitor cells (HSPCs). Severe blood pancytopenia and marrow hypocellularity was found in aplastic mice. Proliferative hindrance and apoptosis of marrow cells were identified as the cause behind the hematopoietic catastrophe. The genotoxic effects of the drugs triggered chromatin damage and induced replicative senescence in aplastic HSPCs by upregulating p21 in a p53 independent manner. Moreover, accumulation of genomic insults also caused apoptotic elimination of marrow cells due to disruption of mitochondrial membrane potential by generating redox imbalance. The study established the underlying mechanisms behind hematopoietic disruption during drug induced marrow aplasia. Outcome of the study may be helpful in successful designing of therapeutic strategies for the disease concerned.

Challenges in Diagnosing Myelodysplastic Syndromes in the Era of Genetic Testing: Proceedings of the 13th Workshop of the European Bone Marrow Working Group

The 13th workshop of the European Bone Marrow Working Group in Utrecht, The Netherlands, was devoted to studying myelodysplastic syndromes (MDS) and their boundaries. The panel received 44 cases submitted to the 3 invited categories, which included: reactive cytopenias with dysplasia, idiopathic cytopenia of undetermined significance, clonal haematopoiesis of indeterminate potential, idiopathic dysplasia of uncertain significance and overt MDS. For this summary, we have selected 17 cases that highlight difficulties in separating true MDS from other causes of cytopenia and the intricate relationship between clonal haematopoiesis and true MDS. In addition, cases of overt MDS with challenging features were also selected. All cases were stained for p53 expression. Using instructive submitted cases we discuss the following: (1) cytopenia with clonal haematopoiesis not fulfilling MDS criteria, (2) cytopenia and/or dysplasia with germline mutations and/or familial history suggesting an underlying gene defect, (3) MDS based on a recurrent chromosomal abnormality and (4) overt MDS with diagnostic difficulties due to concurrent treatment or disease. The lively discussion in the open forum of the workshop illustrated the need for better integrative understanding of the evolution of acquired genetic abnormalities in haematopoiesis, and the challenge of diagnosing true MDS in cytopenic patients with genetic abnormalities, either germline or acquired.

Acquired Inhibitor of Factor VIII Presenting as Delayed Wound Healing

Acquired coagulation factor VIII inhibitor leads to a rare disease i.e., acquired haemophilia which is idiopathic in majority of cases and is seen with autoimmune diseases, haematologic and solid tumours, infections, in the post-partum period and also with certain long-term use of drugs like penicillin and its derivatives, phenytoin, sulfa antibiotics, chloramphenicol, methyldopa, chlorpromazine, levodopa, interferon-α, fludarabine, clopidogrel. We report a case here, with acquired Factor VIII (FVIII) inhibitor acquisition which presented with delayed wound healing as a result of protracted bleeding into the wound. The inhibitor was acquired due to prolonged chlorpromazine use.

Exploring anti-malarial potential of FDA approved drugs: an in silico approach

BACKGROUND

The critically important issue on emergence of drug-resistant malarial parasites is compounded by cross resistance, where resistance to one drug confers resistance to other chemically similar drugs or those that share mode of action. This aspect requires discovery of new anti-malarial compounds or formulation of new combination therapy. The current study attempts to contribute towards accelerating anti-malarial drug development efforts, by exploring the potential of existing FDA-approved drugs to target proteins of Plasmodium falciparum.

METHODS

Using comparative sequence and structure analyses, FDA-approved drugs, originally developed against other pathogens, were identified as potential repurpose-able candidates against P. falciparum. The rationale behind the undertaken approach is the likeliness of small molecules to bind to homologous targets. Such a study of evolutionary relationships between established targets and P. falciparum proteins aided in identification of approved drug candidates that can be explored for their anti-malarial potential.

RESULTS

Seventy-one FDA-approved drugs were identified that could be repurposed against P. falciparum. A total of 89 potential targets were recognized, of which about 70 are known to participate in parasite housekeeping machinery, protein biosynthesis, metabolic pathways and cell growth and differentiation, which can be prioritized for chemotherapeutic interventions. An additional aspect of prioritization of predicted repurpose-able drugs has been explored on the basis of ability of the drugs to permeate cell membranes, i.e., lipophilicity, since the parasite resides within a parasitophorous vacuole, within the erythrocyte, during the blood stages of infection. Based on this consideration, 46 of 71 FDA-approved drugs have been identified as feasible repurpose-able candidates against P. falciparum, and form a first-line for laboratory investigations. At least five of the drugs identified in the current analysis correspond to existing antibacterial agents already under use as repurposed anti-malarial agents.

CONCLUSIONS

The drug-target associations predicted, primarily by taking advantage of evolutionary information, provide a valuable resource of attractive and feasible candidate drugs that can be readily taken through further stages of anti-malarial drug development pipeline.

Successful clozapine re-challenge in a patient with three previous episodes of clozapine-associated blood dyscrasia

A case is presented of a 30-year-old female with treatment-resistant schizoaffective disorder who was referred to a tertiary-level specialist psychosis service. We describe the history of clozapine trials and associated episodes of agranulocytosis and neutropenia, followed by the successfully tolerated third clozapine re-challenge within our service.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Leukocytosis and Leukemia

Leukocytosis is among the most common findings on peripheral blood smear. A wide range of causes may mediate this finding, and careful clinical and laboratory evaluation assist in differentiating between benign and malignant causes of increased white blood cell counts. In this article, various nonmalignant causes are explored, including infectious, inflammatory, autoimmune, and allergic. In addition, malignant causes of leukocytosis are discussed, including myeloproliferative disorders, acute leukemia, and chronic leukemia, as well as treatment and monitoring for patients with these diseases.

Copper-64 labeled liposomes for imaging bone marrow

INTRODUCTION

Bone marrow is the soft tissue compartment inside the bones made up of hematopoietic cells, adipocytes, stromal cells, phagocytic cells, stem cells, and sinusoids. While [¹⁸F]-FLT has been utilized to image proliferative marrow, to date, there are no reports of particle based positron emission tomography (PET) imaging agents for imaging bone marrow. We have developed copper-64 labeled liposomal formulation that selectively targets bone marrow and therefore serves as an efficient PET probe for imaging bone marrow.

METHODS

Optimized liposomal formulations were prepared with succinyl PE, DSPC, cholesterol, and mPEG-DSPE (69:39:1:10:0.1) with diameters of 90 and 140nm, and were doped with DOTA-Bn-DSPE for stable ⁶⁴Cu incorporation into liposomes.

RESULTS

PET imaging and biodistribution studies with ⁶⁴Cu-labeled liposomes indicate that accumulation in bone marrow was as high as 15.18±3.69%ID/g for 90nm liposomes and 7.01±0.92%ID/g for 140nm liposomes at 24h post-administration. In vivo biodistribution studies in tumor-bearing mice indicate that the uptake of 90nm particles is approximately 0.89±0.48%ID/g in tumor and 14.22±8.07%ID/g in bone marrow, but respective values for Doxil® like liposomes are 0.83±0.49%ID/g and 2.23±1.00%ID/g.

CONCLUSION

Our results indicate that our novel PET labeled liposomes target bone marrow with very high efficiency and therefore can function as efficient bone marrow imaging agents.

Inhaled corticosteroids increase blood neutrophil count by decreasing the expression of neutrophil adhesion molecules Mac-1 and L-selectin

OBJECTIVE

The objective was to investigate the effect of commonly used inhaled corticosteroids on white blood cell count (WBC) and to examine the mechanisms involved.

METHODS

This randomized comparative study comprised 60 healthy adults. We measured the effects of budesonide (by face mask inhalation or aerosol inhaler), fluticasone (by inhaler), and saline inhalation (control) on WBC and the differential leukocyte count, especially the absolute neutrophil count (ANC). To elucidate the mechanisms involved, we measured the expression of the adhesion neutrophil ligands Mac-1 (CD11b) and L-selectin (CD62L), and granulocyte colony-stimulating factor serum levels.

RESULTS

Six hours after a single-dose inhalation of budesonide, mean increases of 23.4% in WBC (95% confidence interval [CI], 11.3-35.4) and 30.1% in ANC (95% CI, 7.2-53.0) were noted. The percentage of neutrophils increased from 54.6% to 58.1% (P< .001). Inhaled fluticasone increased WBC and ANC by 12.6% (95% CI, 1.5-23.7) and 22.7% (95% CI, 6.2-39.2), respectively (P< .01 for both). The absolute lymphocyte and eosinophil counts did not change significantly from baseline. The expression of Mac-1 and L-selectin decreased by 51.0% (P< .01) and 30.9% (P= .02), respectively, following face mask inhalation of budesonide and by 39.8% (P= .01) and 17.4% (P= .17), respectively, following inhalation of fluticasone. No significant changes in granulocyte colony-stimulating factor levels were noted.

CONCLUSIONS

Glucocorticoid inhalation increases WBC by increasing ANC. Reduced neutrophil adhesion to the endothelial surface, mediated by decreased adhesion molecule expression on neutrophils, is a plausible mechanism. Physicians should be aware of the effect of inhaled corticosteroids on WBC, as it may influence clinical decisions, especially in the emergency department.

Effect of anti-tuberculosis drugs on hematological profiles of tuberculosis patients attending at University of Gondar Hospital, Northwest Ethiopia

BACKGROUND

Tuberculosis (TB) treatment may present significant hematological disorder and some anti-TB drugs also have serious side effects. Although many other diseases may be reflected by the blood and its constituents, the abnormalities of red cells, white cells, platelets, and clotting factors are considered to be primary hematologic disorder as a result of tuberculosis treatment. The aim of this study was to determine hematological profiles of TB patients before and after intensive phase treatment.

OBJECTIVE

The aim of this study was to determine hematological profiles of TB patients before and after intensive phase treatment.

METHODS

Smear positive new TB patients were recruited successively and socio-demographic characteristics were collected using pre-tested questionnaire. About 5 ml of venous blood was collected from each patient and the hematological profiles were determined using Mindry BC 3000 plus automated hematology analyzer.

RESULT

The hematological profiles of TB patients showed statistically significant difference in hematocrit (38.5 % versus 35.7 %), hemoglobin (12.7 g/lversus11.8 g/l) and platelet (268 × 10(3)/μlversus239 × 10(3)/μl) values of patients before initiation of treatment and after completion of the intensive phase of tuberculosis treatment, respectively (P < 0.05). The red cell distribution width (RDW) of treatment naïve TB patients was by far lower (17.6 ± 7.09 %) than the corresponding RDW (31.9 ± 5.19 %) of intensive phase treatment completed patients. Among TB patients that had high platelet distribution width (PDW) (n = 11) before initiation of TB treatment, 10 demonstrated lower PDW values after completion of the intensive phase. There was no significant difference on total white blood cell count among TB patients before and after completion of the 2 month treatment.

CONCLUSION

The levels of hemoglobin, hematocrit and platelet count of the TB patients were significantly lowered after completion of the intensive phase of TB treatment. Significant variation of the RDW and PDW were also observed among treatment naïve and treatment completed patients. Hematological abnormalities resulted from TB treatment should be assessed continuously throughout the course of tuberculosis therapy.

Computational Modelling Approaches on Epigenetic Factors in Neurodegenerative and Autoimmune Diseases and Their Mechanistic Analysis

Neurodegenerative as well as autoimmune diseases have unclear aetiologies, but an increasing number of evidences report for a combination of genetic and epigenetic alterations that predispose for the development of disease. This review examines the major milestones in epigenetics research in the context of diseases and various computational approaches developed in the last decades to unravel new epigenetic modifications. However, there are limited studies that systematically link genetic and epigenetic alterations of DNA to the aetiology of diseases. In this work, we demonstrate how disease-related epigenetic knowledge can be systematically captured and integrated with heterogeneous information into a functional context using Biological Expression Language (BEL). This novel methodology, based on BEL, enables us to integrate epigenetic modifications such as DNA methylation or acetylation of histones into a specific disease network. As an example, we depict the integration of epigenetic and genetic factors in a functional context specific to Parkinson's disease (PD) and Multiple Sclerosis (MS).

Aplastic anemia associated with oral terbinafine: a case report and review of the literature

Onychomycosis (OM) is a common fungal infection of the toenails and/or fingernails that is highly prevalent in the general population and also responsible for significant morbidity. OM is caused by dermatophytes, nondermatophytic molds, or yeast. Today systemic antifungal agents are considered as the gold standard for all types of OM. Here we report a case of aplastic anemia associated with oral terbinafine use and a review of the literature on hematological toxicities associated with terbinafine.

A Case of Leukemoid Reaction in Pancreatic Ductal Adenocarcinoma

Leukemoid reaction is defined as leukocytosis exceeding 50,000 cells/mm(3). When it occurs in a patient with a malignancy, secondary causes such as infections, drugs, hematologic diseases and hemorrhage need to be ruled out. After excluding such causes, paraneoplastic leukemoid reaction can be considered as a diagnosis of exclusion. Paraneoplastic leukemoid reactions have been described in association with lung, gastrointestinal, genitourinary and head and neck cancers. However, pancreatic cancer with leukemoid reaction has been rarely reported. We diagnosed a case of a 55-year-old Korean woman with extreme leukocytosis associated with advanced pancreatic cancer.

Drug-Immune Thrombocytopenia with Thrombosis versus Heparin-Induced Thrombocytopenia: A Critical Clinical Controversy

Heparin-induced thrombocytopenia (HIT) is a type of drug-induced immune thrombocytopenia (DITP). DITP is a rare and challenging clinical issue, especially when it is associated with thrombosis. A 62-year-old woman was admitted to our institution with end-stage renal failure. She received heparin for hemodialysis. Six days later, she became febrile and was treated with vancomycin and amikacin antibiotics. Two days after starting the vancomycin, she developed severe thrombocytopenia with extensive gangrenous deep vein thrombosis in her right leg, which required a below-the-knee amputation. The HIT test yielded positive results when heparin was already stopped, but her platelet count did not regenerate even after 3 months of heparin-free treatment. Courses of vancomycin treatment were given during several febrile episodes over the long period of severe thrombocytopenia. The patient was given both anti-immune thrombocytopenia and anticoagulant treatments because of both severe persistent thrombocytopenia and recurrent thrombotic episodes. The patient died as a result of severe thrombocytopenia, recurrent infection, and blood loss from the amputation site. Vancomycin is known to cause DITP, thrombosis, and immune complexes. DITP is a bleeding disorder, whereas HIT is a controversial thrombotic disorder. HIT tests can be influenced by cross-reacting antibodies and many other factors. Thus, there is no single method that can be considered 100% effective in confirming the HIT diagnosis. Anticoagulants must be used with great caution in patients with suspected DITP. Treatment of HIT-positive cases requires both clinical correlation and experience rather than reliance on HIT tests alone.