Antiphospholipid Antibody Testing: An Audit on Testing Practices in a Public Tertiary Care Center

BACKGROUND

Antiphospholipid antibodies (aPLs) are antibodies directed against cell membrane components and can be associated with clinical features or be asymptomatic. Testing and interpreting these antibodies is associated with many challenges and pitfalls in clinical practice.

OBJECTIVE

To review all antiphospholipid antibody testing and describe the testing practices, indications for testing and interpretation of results to infer local challenges with aPL testing and subsequently address ways to overcome those challenges.

METHODS

This is a retrospective analysis of all aPL testing done in a tertiary center between 2014 and 2018. Characteristics of study patients collected through chart review were described using the mean and standard deviation for continuous variables and proportion for categorical variables. Group differences were compared between patients with any aPL-positive result and those with no positive result using chi-square or Fisher's exact test as appropriate for categorical variables and a simple regression model for numerical variables.

RESULTS

Among 414 patients undergoing aPL testing, mainly adult females, 62 (14.9%) patients had at least one positive antibody, of those, 26 (42%) had repeat testing done. Testing was mostly done for obstetric indication (107, 25.8%), with 36 patients having one or two early pregnancy losses <10 weeks as their testing indication. A total of 27 (6.5%) patients were labeled with APS/possible APS based on chart review, but on review of the testing of those patients according to classification criteria, only nine patients satisfied the criteria for APS.

CONCLUSION

This study highlights the clinical challenges associated with aPL testing, including the controversies around indication for testing, the low rates of repeat testing to confirm persistence, and the common misinterpretation of results. Having an aPL testing profile, explicit reference ranges, results commentary, and close interaction between ordering physicians and laboratory staff might be starting points to overcome these challenges.

A Saudi multicenter experience on therapeutic plasma exchange for patients with thrombotic thrombocytopenic purpura: A call for national registry

BACKGROUND

The improvement in the clinical care for patients with thrombotic thrombocytopenic purpura (TTP) is evolving, and many efforts are being put to standardize it. Here, we aimed to assess the provided care at a national level and identify deficiencies.

METHODS

A national Saudi retrospective descriptive study was carried out at six tertiary referral centers and included all patients who underwent therapeutic plasma exchange (TPE) for the diagnosis of TTP between May 2005, and July 2022. Collected information included demographic data, clinical features on presentation, and the results of laboratory investigations at admission and discharge. In addition, the number of TPE sessions, days till the first session of TPE, usage of immunological agents, and clinical outcomes were all collected.

RESULTS

One hundred patients were enrolled, predominantly female (56%). The mean age was 36.8 years. At diagnosis, 53% of patients showed neurological involvement. The mean platelet count at presentation was 21 × 109 /L. All patients had anemia (mean hematocrit 24.2%). Schistocytes were present in the peripheral blood film of all patients. The mean number of TPE rounds was 13 ± 9.3, and the mean days to start TPE since admission for the first episode was 2.5 days. ADAMTS13 level was measured in 48% of patients and was significantly low in 77% of them. Assessing for clinical TTP scores, 83%, 1000%, 64% of eligible patients had an intermediate/high PLASMIC, FRENCH, and Bentley scores, respectively. Caplacizumab was used on only one patient, and rituximab was administered to 37% of patients. A complete response for the first episode was achieved in 78% of patients. The overall mortality rate was 25%. Neither time to TPE, the use of rituximab or steroid affected survival.

CONCLUSIONS

Our study shows an excellent response to TPE with a survival rate approximate to the reported international literature. We observed a deficiency in using validated scoring systems in addition to confirming the disease by ADAMTS13 testing. This emphasizes the need for a national registry to facilitate proper diagnosis and management of this rare disorder.

Association of Genetic Variant FVIII Gene and Factor VIII: A Pilot Study Among Hemophilia A Female Relatives in Saudi Arabia

Hemophilia A (HA) is an X-linked recessive disorder that results from mutations in the factor VIII gene (FVIII). Most affected patients are males due to the inheritance of mutations in the FVIII gene from their mothers. Females are mostly found to be carriers unless they inherited the mutation from both parents. Obligate carriers of HA are mothers whose sons are affected with HA, or daughters who inherit the mutation from their affected fathers. A possible carrier of HA could be any female who has one or more affected relatives with HA in her family. Hemophilia A carriers (HACs) could present with similar symptoms to affected patients, including low factor VIII level, and risk of bleeding especially after surgical procedures or postpartum hemorrhage.

OBJECTIVES

 Assessing the phenotype of possible HAC and its association with genetic variants in the FVIII gene for better screening methods for HAC.

METHODS

From the period between 25 June and 25 October 2021, the study was conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. We recruited seven mothers whose sons were affected with HA, and 18 possible HAC who are relatives to sever affected patients with HA. All 25 candidates were assessed for the FVIII level, activated partial thromboplastin time (APTT), and bleeding risk and sequenced a part of Exon14 in their FVIII gene.

RESULTS

Twenty-five percent of the participants show a low level of FVIII, however, none of them have prolonged bleeding nor suffer from bleeding tendency. We also identified two missense variants in six of the candidates, but the clinical significance of these variants has not been determined previously.

CONCLUSION

This pilot study is the first to explore the phenotype of several HAC in Saudi Arabia. A larger scale study with more HA patients and their female relatives is needed to understand the correlation between phenotype and genotype for better screening for HAC.

Blastocystis sp.-An emerging cause of diarrhea post stem cell transplantation

Key Clinical Message

Protozoans are endemic in the Middle East and diarrhea workup post stem cell transplant should always include stool examination for ova and parasites.

Abstract

We present a case of Blastocystis sp. infection in a multiple myeloma patient who developed diarrhea on day five of post-autologous stem cell transplantation. Diarrhea is a major complication and a potential cause of mortality in this population. Testing for endemic protozoan is recommended.

Outcomes of Cholelithiasis Among Patients With Sickle Cell Disease: A Tertiary Care Center Experience

BACKGROUND

Sickle cell disease (SCD) is a significant health burden in Saudi Arabia that leads to chronic hemolysis with subsequent formation of cholelithiasis. The prevalence of cholelithiasis in the Middle East varies in patients with SCD. The aim of our study was to determine the prevalence of cholelithiasis among SCD patients at a large tertiary care center, King Abdulaziz University Hospital, Jeddah, Saudi Arabia, where more than 300 patients with hemoglobinopathies were followed up.

METHODS

In this cross-sectional retrospective study conducted from May 2006 to May 2022, we reviewed 414 patients with SCD who were divided into two groups according to the presence or absence of cholelithiasis. Demographic data, SCD phenotype, splenectomy, cholecystectomy, and hydroxyurea were reviewed from the patient's medical records. They were analyzed to suggest a correlation between the incidence of cholelithiasis and the chances of cholecystectomy.

RESULTS

A total of 414 patients with SCD were reviewed. The mean age of participants was 31 years (10-82), with 52% male. Patients with homozygous sickle hemoglobin (HbSS) constituted 73% of the cohort. The rest (26%) had HbS/β-thalassemia. Thirty-three patients (8%) had splenectomy done. Compliance with hydroxyurea was observed in 174 patients (42%). A total of 64.7% of patients had cholelithiasis (n=269), out of which 159 patients (59.1%) had cholecystectomy done. Surprisingly, a significant association was found between cholecystectomy and the use of hydroxyurea (p=0.003). Additionally, there was a significant association found between the development of cholelithiasis and increasing age (p=0.037).

CONCLUSION

There was a high prevalence of cholelithiasis found in patients with SCD. It correlated significantly with high-age groups. Further research is warranted to confirm the relationship between hydroxyurea and cholelithiasis.

Association of blood group with COVID-19 disease susceptibility and severity in Saudi Arabia

BACKGROUND

Novel SARS-CoV-2 (COVID-19) virus has rapidly spread worldwide and was declared a pandemic, making identifying and prioritizing individuals most at risk a critical challenge. The literature describes an association between blood groups and the susceptibility to various viral infections and their severity. Knowing if a specific blood group has more susceptibility to COVID-19 may help improve understanding the pathogenesis and severity of the disease. We aimed to assess the association between ABO/RhD and COVID-19 susceptibility and severity, and to compare results with similar studies in Saudi Arabia.

STUDY DESIGN AND METHODS

This study was conducted between March and October 2021 on 600 patients confirmed positive for COVID-19 infection. Patients' data were collected and analyzed. As a control, 8423 healthy blood donors were enrolled as a sample representative of the population for blood group distribution.

RESULTS

More individuals had blood group B in the COVID-19 group in comparison with the control group (24.2% vs. 18%), The opposite was observed among individuals of group O (39.5% vs. 47.3%). The B blood group was predictive of higher risk of mortality. No significant difference in the distribution of RhD was observed between the COVID-19 and the control groups. Neither ABO nor RhD was significantly associated with the severity of COVID-19.

DISCUSSION

Although there was no significant association with the disease severity, the B blood group may be associated with a higher risk for COVID-19 infection. Further studies with a larger sample size are necessary to evaluate this correlation.

Unusual Presentation of Leukemic-Phase Mantle Cell Lymphoma: A Case Report

Mantle cell lymphoma (MCL) is a rare subtype of B-cell lymphoma that can present in a variety of ways, including the leukemic phase, where it can occasionally be mistaken for acute leukemia due to the unusually high or rapidly growing number of leukocytes and the presence of circulating cancer cells that are morphologically similar to leukemic blasts in myeloid or acute lymphoblastic leukemia. We present the case of an 83-year-old Yemeni woman with multiple comorbidities who presented with abdominal pain and constitutional symptoms. She was found to have diffuse lymphadenopathy on clinical and radiological assessments. Her white blood cell count at presentation was 221 × 10⁹/L with marked monocytosis (72.8%). Lymph node biopsy and bone marrow studies, including CCND1/IGH molecular studies, confirmed MCL, the pleomorphic subtype. The patient was deemed unfit for standard-of-care chemotherapy and was started on single-agent rituximab with a slow introduction to ibrutinib but succumbed to death after two weeks of ibrutinib 280 mg daily. This case serves as a reminder to keep an open mind and take into account atypical disease presentations when formulating differential diagnoses to prevent late diagnosis and any unnecessary intervention that can postpone appropriate therapy.

Does Up-front Autologous Stem-Cell Transplantation at First Relapse Improve Outcome in Transplant-Eligible Follicular Lymphoma Patients Whose Disease Relapses Within 24 Months?

BACKGROUND

In Canadian adults, follicular lymphoma (FL) is the most common subtype of non-Hodgkin lymphomas. Approximately 20% of patients with FL experience progression of disease within 2 years of first-line chemoimmunotherapy. Those patients have an expected overall survival of less than 5 years. The optimal second-line treatment for these high-risk patients is unclear.

PATIENTS AND METHODS

We analyzed data from the Blood and Bone Marrow Transplantation Center at Ottawa Hospital to determine whether autologous stem-cell transplantation as up-front therapy for first relapse can improve outcomes in this high-risk FL subgroup. We identified 17 patients who underwent up-front autologous stem-cell transplantation between February 2012 and February 2019.

RESULTS

The disease of all patients had relapsed within 24 months after receipt of their first rituximab-based chemotherapy. Overall survival at 2 and 5 years was 86.2% (95% confidence interval [CI], 55-96) and 71.8% (95% CI, 31-91), respectively. The progression-free survival at 2 and 5 years was 62.6% (95% CI, 35-81) and 53.6% (95% CI, 25-75), respectively.

CONCLUSION

Overall survival is improved when receiving autologous hematopoietic stem-cell transplantation as up-front therapy at first relapse in transplant-eligible FL whose disease relapses within 24 months of first-line therapy. Data from our single center look promising, but the data need to be replicated with a larger sample size.

A strategy of Day14 bone marrows and early intervention is not superior to a strategy of noDay14 bone marrows and delayed intervention in patients with acute myeloid leukemia

We conducted a retrospective study of 364 acute myeloid leukemia patients treated using a Day14 or a noDay14 strategy. Under the Day14 strategy, patients received an interim marrow at 7-10 days following chemotherapy and, in case of residual disease, received immediate reinduction chemotherapy. Under the noDay14 strategy patients were only evaluated at end-of-induction (EOI). Overall induction mortality was higher in the Day14 cohort (8.3 vs. 3.6%, p = .12) but rates of remission (75.4 vs. 83%, p = .13) and refractory disease (14.3 vs. 13.4%, p = .87) at EOI were similar in the Day14 and noDay14 cohorts as were relapse rates (37.9% vs. 34.3%, p = .616), median relapse-free survival (14.8 vs. 15 months, p = .658) and median overall survival (25.3 vs. 37.2 months, p = .264). In multivariate analysis, the use of a Day14 strategy did not impact outcomes suggesting that a Day14 strategy is not superior to a noDay14 strategy.

Attitude of 100 Saudi Female Doctors towards their Health

Objective

To assess the overall health status, lifestyle behavior, and attitude towards menopause, hormonal replacement therapy (HRT) and human papilloma virus (HPV) vaccination among female Saudi doctors.

Materials and methods

This is a cross-sectional study that was conducted over a period of 2 months (November and December 2011). The study population was comprised of Saudi female physicians that are actively working. Ethics approval was obtained prior to conducting the study. A structured self-administered questionnaire was answered by the subjects. Inclusion criteria were any female physician who was willing to participate and was actively practicing at time of the study.

Results

One hundred responses were received. Forty-six subjects were <30 years and 31 subjects were >40 years of age. Obesity was defined as a body mass index (BMI) of >25 and morbid obesity as a BMI >30. Eight subjects had a normal BMI, 27 subjects were overweight, and 16 were morbidly obese. Six subjects were smokers and 13 had chronic illnesses such as diabetes. Only five of the subjects performed regular breast self-examination, and 40 subjects have a breast examination done by a physician. Pap smear was done at least once on only 17% of the subjects. Forty-eight subjects were willing to prescribe HRT to their patients. Sixty-five subjects were willing to administer the HPV vaccination to patients.

Conclusion

The overall health status, lifestyle, and attitude of Saudi female physicians towards their own health is suboptimal. This study shows that even physicians need to improve their lifestyle behavior and attitude towards their own health.