Hypercoagulable State in Five Thalassemia Intermedia Patients

Fifty-three patients of thalassemia intermedia and 40 controls were studied for clinical evidence of thrombosis and laboratory evidence of hypercoagulable state. Thrombotic episodes were detected in 5 (9.4%) patients. Two of these 5 patients with thrombosis were splenectomized. Laboratory evaluation showed presence of thrombocytosis in 8 (15%), 5 of these were splenectomized. Platelet hyperaggregation was detected in 12 (22.2%) patients. Although rate of aggregation was slow in 7 (13.2%) patients, degree of aggregation was normal in these 7 patients and platelet hypoaggregation was not detected in any patient. Level of coagulation inhibitors protein C and protein S, and antithrombin III were decreased in 31 (58.4%) patients. There was no correlation between low level of protein C and protein S with hepatic dysfunction and iron overload. Antithrombin III level was decreased only in 8 (15%) patients. There was a statistically significant association between the lower level of this inhibitor and hepatic dysfunction. In conclusion, this study provides evidence for the existence of a chronic hypercoagulable state in patients with β thalassemia intermedia, and suggests that expression of a procoagulant surface by thalassemia intermedia red blood cells may be the major underlying factor giving rise to platelet and coagulation inhibitor abnormalities in these patients. These alterations are not related to iron overload or hepatic dysfunction.

Cryptogenic hepatic insult, failing heart and advancing age: a case report

Background

Weakness and fatigue are accepted as normal accompaniments of aging. Usually, older individuals are not investigated with much enthusiasm but a treatable cause is discernible on several occasions.

Case presentation

We had a 67 year old hypertensive lady with a mitral stenosis, presenting in ischemic or hypertensive heart failure with underlying valvular disease, without pulmonary hypertension in sinus rhythm. She had pancytopenia with severe anemia and raised liver enzymes. Bone marrow examination showed aplastic anemia. She was treated with ATG and improved subsequently to become transfusion free. However, she succumbed to an unrelated sudden cardiac death.

Conclusion

Our patient is unique in her uncommon presentation, complex management issues and a favorable outcome after a long and persevering therapeutic intervention and finally her sudden death.

Autoimmune hemolytic anemia in India: clinico-hematological spectrum of 79 cases

The clinico-hematological profile and treatment outcome of patients with autoimmune hemolytic anemia (AIHA) were assessed using a retrospective case record analysis. There were 79 (52 primary; 27 secondary) consecutive patients identified with a median age of 30.5 years. The main presenting complaints were pallor (94%), fever (46%), jaundice (51%), bleeding manifestations (10%) and splenomegaly (68%). Jaundice was much more common in primary (63%) as opposed to secondary (26%) disease. The direct antiglobulin test was negative in six patients. Oral prednisolone produced remission in 87.5% patients. Six patients (three children, three adults) relapsed after a median period of 2 months after response. All of these responded to a second course of steroids, in a median period of 14 days. No correlation was found between response and the parameters of age, sex, jaundice, low pretreatment hemoglobin, reticulocyte count, total leucocyte count (TLC), platelet count, subtype of AIHA and hepatosplenomegaly. Relapse correlated with increased duration between the onset of symptoms and treatment (r = 0.996; p = 0.0001).

Synchronous occurrence of breast carcinoma and acute myeloid leukemia: case report and review of the literature

We present a case of breast carcinoma, which was followed by acute leukemia within 1 month of diagnosis of the former. She had undergone a modified radical mastectomy for her breast cancer and had not received chemotherapy or radiotherapy. Acute leukemia as a result of chemotherapy for breast carcinoma is well known. However, patients developing synchronous breast carcinoma and acute leukemia, in the absence of any chemotherapy or radiotherapy, are rare.

Anti-D immunoglobulin in the treatment of idiopathic thrombocytopenic purpura

Anti-D was evaluated in 8 RhD positive patients (6 males, 2 females) aged 2-21 years (mean 10 years) with Idiopathic Thrombocytopenic Purpura (ITP). Five patients with chronic ITP and 3 patients with acute ITP were administered Anti-D in the dosage of 50 micrograms/kg intramuscularly (IM) for 3 consecutive days. One patient of chronic ITP received two courses of Anti-D. Patients were followed up for 7 to 16 months (mean 9 months). All three cases of acute ITP had a complete response and are in remission between 3 to 12 months of follow up. Two of five cases of chronic ITP had a partial response. Rise in platelet count was observed within 72-124 hours, and duration of response varied between 10 to 15 days. None of these patients had any significant side effects of anti-D immunoglobulin therapy. Intramuscular administration of Anti-D is safe, effective and low cost alternative to IVIgG in the treatment of acute ITP.

Platelet function disorders in north India

BACKGROUND

Platelet function disorders are a fairly common cause of bleeding manifestations. Although their relative types and incidence are well documented, data from India are lacking.

METHODS

Between 1970 and 1991, we studied the clinical and laboratory features of 144 north Indian patients who presented to our hospital with a bleeding diathesis in whom coagulation disorders, von Willebrand's disease and a history of drug ingestion were absent.

RESULTS

Isolated platelet factor 3 availability defect was the commonest (56 cases) followed by the thrombasthenias (49 cases), arachidonic acid pathway defect (26 cases), storage pool disease (8 cases) and the Bernard-Soulier syndrome (3 cases). Isolated platelet factor 3 deficiency was rare (2 cases). Two varieties of thrombasthenia were seen--the classical Glanzmann's (13 cases) and thrombopathic (36 cases). The latter was characterized by absent or sub-normal platelet aggregation with agonists along with a reduced (to less than 50% of normal) total platelet factor 3 content. This has not been reported from western countries. Patients with classical Glanzmann's thrombopathic thrombasthenia with absent platelet aggregation and isolated platelet factor 3 deficiency were severe bleeders. Their family history suggested an autosomal recessive transmission in Glanzmann's and thrombopathic thrombasthenia and a possible autosomal dominant transmission in isolated platelet factor 3 availability defect and isolated platelet factor 3 deficiency.

CONCLUSION

The frequency of various types of platelet function disorders in Indians is similar to that in western populations except that the incidence of thrombopathic thrombasthenias is higher in India.

Efficacy of intrathecal methotrexate with and without cranial radiotherapy in preventing central nervous system relapses in acute lymphocytic leukemia

Introduction of CNS chemoprophylaxis was a major milestone in the development of current therapy for acute lymphocytic leukemia. However, controversies are still existing for ideal form of CNS chemoprophylaxis. The present study was conducted to determine the efficacy of intrathecal methotrexate (IT-MTX) with and without cranial radiotherapy in preventing CNS relapses in Indian children. CNS chemoprophylaxis comprising of six injections of intrathecal methotrexate (12 mg/M2) was administered alone or along with cranial radiotherapy (2000 GY) in 76 children each after successful induction remission. Cranial radiotherapy (RT) with intrathecal methotrexate (IT-MTX) was observed to be more effective as CNS relapses were seen in 11.8% of children as compared to 16.8% of children receiving IT-MTX alone. IT-MTX along with cranial RT delayed the occurrence of CNS relapses and prolonged the event free survival periods.

Causes of mortality in children with acute lymphocytic leukemia

Fifty five deaths between January, 1982 to September, 1989 in children with acute lymphoblastic leukemia (ALL) were evaluated to determine the cause of mortality. Fifty cases died during remission. Infection alone was responsible for death in 26 of 55 (47.3%) cases while hemorrhage was seen in 7 (12.7%) children. Infection and hemorrhage together were responsible in another 13 cases. Gastrointestinal tract and pulmonary system were the major sites of bleeding. Infections either alone or in combination with other factors were responsible for death in 42 of 55 (76.5%) of children. Septicemia (n = 11), gastrointestinal (n = 15) and pulmonary infections (n = 10) and meningitis in 2 cases were the major sites of infections. Pseudomonas and Klebsiella in 6 cases each accounted for 54.5% of isolates.

Pure red cell aplasia with rheumatoid arthritis. A case report and review of literature

Pure red cell aplasia (PRCA) is an extremely uncommon treatable manifestation of rheumatoid arthritis. Here we describe a case of long standing rheumatoid arthritis with severe refractory anaemia, which was proven to be due to PRCA.