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The Sri Lanka Journal of Haematology
Volume 7, Issue 1, July 2015 ISSN 1391 - 7919 Dr. Hemali W. W. Goonasekera
MBBS, Dip.Path, MD(Haematology)
Dr. Indira Wijesiriwardena
MBBS, Dip.Path, MD(Haematology) Dr. Arundathi P. Kurukulasuriya
MBBS, Dip.Path. MD(Haematology), FRCPA,
ASTHE, Dip.Buddhist Phil., SFSEDA, FSLCH
Dr. Nishadya N. Ranasinghe
MBBS, Dip.Path, MD(Haematology), FRCPA
The Sri Lanka College of Haematologists
No. 6, Wijerama House Phone: 0112685088 Printed by
Ananda Press
82/5, Sir Ratnajothi Saravanamuttu Mawatha
Colombo 13
E-mail: [email protected]
The Sri Lanka Journal of Haematology
Volume 7, Issue 1, July 2015
History of bone marrow transplantation
Setting up a blood and marrow transplant (BMT)
program in South Asia: Rewards and challenges
Treatment of elderly acute myeloblastic leukaemia with
azacitidine after failure of decitabine
MB Agarwal
Hospital admission rate, pattern of lower limb deep vein
thrombosis (DVT) and its relationship to acquired risk factors
among patients admitted to Colombo South Teaching Hospital
(CSTH) during the year 2010
HE Alwis, N Ranasinghe
CME article
Theme: Acute trauma coagulopathy and massive
transfusion
HWCK Kulathilake, I Wijesiriwardena Case report I
Paroxysmal cold haemoglobinuria in a pregnant woman
leading to severe anaemia and fetal loss
EL Asfir, N Senadheera, S Jayasinghe, H Liyanage
Case report II
Lupus anticoagulant – hypoprothrombinaemia syndrome
ONKD Gamage, MM Jayatilaka, PM Punchihewa
Images in
A case of Large Granular Lymphocytosis
MN Dilhani, S Suresh, J Thennakoon HWW Goonasekera. SLJH. 2015; 7
(1): 1-4 JH. 2015; 7(1): 1-4
Bone marrow transplantation in Asia – a historical perspective
The healing power of bone marrow (BM) had even experiment which showed presence of donor cells been recognized in Greek mythology; which in a recipient mice tagged with a chromosome mention the use of bone marrow extracts from marker.9 The main turning point in determining the animals to treat injured warriors. In modern success of BMT was the discovery of the human medical literature the earliest reports of BM for leucocyte antigens (HLA) initially described by the therapy records oral administration to a patient French scientist Jean Dausset in 195810 and later with leukaemia in 18961 and intravenous infusion (IVI) of small volumes of allogeneic BM in 1939 toa 19-year-old girl with aplastic anaemia (AA) from E. Donnall Thomas based on his own experimental her sibling.2 The first successful human bone findings of allogeneic BMT using outbred dogs and marrow transplant (BMT) was in 1956 by E. Donnall knowledge of the HLA system; carried out the first Thomas and his team in New York who adminis- allogeneic transplant for leukaemia11 and alloge- tered BM by IVI following total body irradiation (TBI) neic transplantation for aplastic anaemia by early to two patients with leukaemia from syngeneic 1970s.12 The first successful matched unrelated twins;3 their leukaemia initially went into remission, donor (MUD) transplant was reported by Thomas but recurred by 7 and 12 weeks in both. Although et al. in 1980.13 E. Donnall Thomas; who is regarded the patients did not survive, it demonstrated that as the father of BMT; for his discoveries in cell it was possible to induce leukaemia remission by transplantation for treatment of human disease and isologous BMT following TBI and irradiation doses Joseph E. Murray (who performed the first successful which can induce remission but not produce side kidney transplant in 1954) were awarded the Nobel effects such as radiation sickness were described; Prize in Physiology or Medicine in 1990.14 For their which was important in the context of the concerns work on the discovery of the HLA system the Nobel regarding use of irradiation to treat human disease Prize in Physiology or Medicine was awarded to present at that time.
Jean Dausset with Baruj Benacerraf and George D.
Snell in 1980.
The basic foundations for modern day BMT werebased on the seminal experiments carried out by Transplantation extended to conditions other than Jacobson et al. in the middle of the last century leukaemia and the first transplant for immune- demonstrated that lethally irradiated mice were deficiency was performed in 1967 on a 5-month- able to survive if the spleen, or even parts of liver, old male child diagnosed with severe combined head and limbs were shielded by lead.4,5 Other immunodeficiency, from his eight-year-old sister; animal model experiments followed which also both peripheral blood and bone marrow were showed that irradiation followed by marrow infused intraperitoneally and the patient had infusion resulted in survival, especially if the survived.8,15 The first successful use of cryopre- marrow was derived from mice of similar strain6 served autologous marrow to treat lymphomas or autologous marrow was used7 and these and were reported in 197816 and BMT using syngeneic other experiments proved the hypothesis that a twins for chronic myelogenous leukaemia (CML) cellular factor instead of a humoral factor was with successful eradication of the Philadelphia responsible for this protective effect8; including the positive clone was reported in 1979.17 SuccessfulHLA-matched allogeneic BMT for Thalassaemia18and Sickle cell anaemia19 were reported in July 1982and June 1988 respectively.
1Senior Lecturer/Consultant Haematologist, By early 1990s, BMT became established therapy Department of Anatomy, Faculty of Medicine, for malignant and non-malignant haematological University of Colombo, Sri Lanka. conditions, immunodeficiency disorders and solid The Sri Lanka Journal of Haematology HWW Goonasekera. SLJH. 2015; 7(1): 1-4
tumors.20 In April 1977, Dr. Thomas et al. reported haematopoietic reconstitution following transfusion BMT and post BMT sequelae of 100 patients with of autologous blood cells collected from CML patients acute leukaemia describing the complications of prior to chemotherapy and TBI32 and by late 1980s, BMT and recommended early BMT in acute leu- the advantages of peripheral blood derived haemato- kaemia for those who have a HLA matched sibling poietic stem cells (PB-HSC) over BM derived stem cells were recognized and autologous transplantsusing PB-HSC started being reported.33,34 In 1981 From the outset, the main factors for successful Gluckman et al. published the first report of um- outcomes following BMT were graft-versus-host bilical cord blood transplantation (CBT) in a boy disease (GVHD), graft rejection, relapse, infections with Fanconi's anaemia from his sibling sisters' and HLA matched donors.8,11,15,21 Cyclosporin A to cryopreserved cord blood.35 Since then by 2009 over prevent GVHD was first described by Powles et al. 20,000 CBTs have been done, with establishment in 198022 and prevention of GVHD using a of cord blood banks.36 combination of cyclosporine with methotrexatewas reported in 1986.23 Additionally in 1980s T-cell Bone marrow transplantation (BMT) has finally depleted donor marrow to prevent GVHD wasdescribed.24 Use of donor lymphocyte infusion taken firm roots in Sri Lanka with starting off of (DLI) were initially described in relapsed patients BMT programmes in two leading private hospitals with CML in 199025 and further modifications to and plans are underway to set up BMT units in the improve the efficacy of DLI is being explored.26 main paediatric hospital, Lady Ridgway Hospital for Use of recombinant granulocyte-macrophage Children and the leading cancer care centre, Cancer colony-stimulating factors to reduce morbidity and Institute, Maharagama; which are two leading mortality following transplantation was initially Government Hospitals, in the near feature. In this described in late 1980s and its effectiveness in context, Dr. Rajkumar's leading article which lymphoid malignancies were proved by Nemunaitis appears in this issue of the Sri Lanka Journal of et al. in 1991.27 As allogeneic BMT transplants Haematology is timely since he eloquently describes became more widely used donor registries were the background and factors pertaining to BMT in the established to find a suitable donor; the Anthony leading article titled "Setting up a blood and Nolan trust in London became the first registry of marrow transplant (BMT) program in south Asia: unrelated bone marrow donors, established by the Rewards and challenges". Dr. Kumar's article also mother whose son had Wiskott-Aldrich syndrome.28 includes details pertaining to BMT programmes in By the year 2013, over 25,000 allogenic BMTs were our region which will be useful for the Haemato- being performed worldwide and marrow donor logists who are currently in the process of setting programs and marrow transplant registries having up of BMT programmes in the above mentioned been established with over 20 million registered hospitals as well as the Haematology trainees who volunteer unrelated donors.29 will have to take up the challenge of carrying theseinitiatives forward once they qualify and become In the latter part of the last century advances made Consultant Haematologists in local BMT units.
in genetic technology rapidly became incorporatedinto the field of BMT enabling better transplant Furthermore, Dr. Agarwal's perspective on treat- outcomes. Shifting of HLA typing from serological ment for leukaemia will be read with enthusiasm to molecular methods ensured less donor mismatch especially by the Haematologists who are actively and a better chance of marrow engraftment.30 In involved in treating haemafo-oncology patients.
1988 minimal residual disease (MRD) monitoringusing polymerase chain reaction technology inplace of conventional cytogenetics was reported and with further advances in technology it was 1. Quine WE. The remedial application of bone marrow.
possible to quantitate MRD in CML using real-time JAMA 1896; 26: 1012-13.
quantitative PCR by late 1990s and it soon became 2. Osgood EE, Riddle MC, Mathews TJ. Aplastic anemia used in other haematological malignancies.31 treated with daily transfusions and intravenous
marrow; case report. Ann Intern Med. 1939; 13(2):
In 1981 Goldman et al. described successful 357-67. doi: 10.7326/0003-4819-13-2-357.
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3. Thomas ED, Lochte HL Jr. , Cannon JH, Sahler OD, 17. Fefer A, Cheever MA, Thomas ED, Boyd C, Ramberg R, Ferrebee JW. Supralethal whole body irradiation and Glucksberg H, Buckner CD, Storb R. Disappearance isologous marrow transplantation in man. J. Clin. of Ph1-positive cells in four patients with chronic Invest. 1959 Oct; 38: 1709-16.
granulocytic leukemia after chemotherapy, irra- 4. Jacobson LO, Simmons EL, Marks EK, Eldredge JH.
diation and marrow transplantation from an Recovery from irradiation injury. Science. 1951; 12:
identical twin. N Engl J Med. 1979 Feb 15; 300(7):
5. Jacobson LO, Marks EK, Robson MJ, Gaston EO, Zirkle 18. Thomas ED, Buckner CD, Sanders JE, Papayannopoulou RE. Effect of spleen protection on mortality following T, Borgna-Pignatti C, De Stefano P, Sullivan KM, Clift x-irradiation. J Lab Clin Med. 1949; 34: 1538-43.
RA, Storb R. Marrow transplantation for thalassaemia.
Lancet. 1982 July 31; 320(8292): 227-29.
6. Lorenz E, Uphoff D, Reid TR, Shelton E. Modification of irradiation injury in mice and guinea pigs by bone 19. Vermylen C, Fernandez Robles E, Ninane J, Cornu G.
marrow injections. J. Natl. Cancer Inst. 1951; 12:
Bone marrow transplantation in five children with sickle cell anaemia. Lancet. 1988 Jun 25; 1(8600):
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7. Mannick JA, Lochte HL Jr, Ashley CA, Thomas ED, Ferrebee JW. Autografts of bone marrow in dogs 20. Armitage JO. Bone marrow transplantation. N Engl J after lethal total-body radiation. Blood. 1960 Feb; Med. 1994 Mar 24; 330(12): 827-38.
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21. Thomas ED, Buckner CD, Banaji M, Clift RA, Fefer A, 8. de la Morena MT, Gatti RA. A history of bone marrow Flournoy N, Goodell BW, Hickman RO, Lerner KG, transplantation. Hematol Oncol Clin North Am. 2011 Neiman PE, Sale GE, Sanders JE, Singer J, Stevens M, Feb; 25(1): 1-15. doi: 10.1016/j.hoc.2010.11.001.
Storb R, Weiden PL. One hundred patients with acuteleukemia treated by chemotherapy, total body 9. Ford CE, Hamerton JL, Barnes DW, Loutit JF. Cytological irradiation, and allogeneic marrow transplantation.
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Mar 10; 177(4506): 452-4.
22. Powles RL, Clink HM, Spence D et al. Cyclosporin A to 10. Dausset J. [Presence of A & B antigens in leukocytes prevent graft-versus-host-disease in man after disclosed by agglutination tests]. C R Seances Soc allogeneic bone-marrow transplantation. Lancet. Biol Fil. 1954 Oct; 148(19-20): 1607-8. [Article in
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23. Storb R, Deeg HJ, Whitehead J, Appelbaum F, Beatty P, 11. Appelbaum FR. Hematopoietic-Cell Transplantation Bensinger W, Buckner CD, Clift R, Doney K, Farewell at 50. N Engl J Med. 2007 Oct 11; 357(15): 1472-5.
V, et al. Methotrexate and cyclosporine compared 12. Thomas ED, Storb R, Fefer A, Slichter SJ, Bryant JI, with cyclosporine alone for prophylaxis of acute graft Buckner CD, Neiman PE, Clift RA, Funk DD, Lerner KE.
versus host disease after marrow transplantation Aplastic anaemia treated by marrow transplantation.
for leukemia. N Engl J Med. 1986 Mar 20; 314(12):
Lancet. 1972 Feb 5; 1(7745): 284-9.
13. Hansen JA, Clift RA, Thomas ED, Buckner CD, Storb R, 24. Prentice HG, Blacklock HA, Janossy G, Gilmore MJ, Giblett ER. Transplantation of marrow from an Price-Jones L, Tidman N, Trejdosiewicz LK, Skeggs DB, unrelated donor to a patient with acute leukemia. N Panjwani D, Ball S, et al. Depletion of T lymphocytes Engl J Med. 1980 Sep 4; 303(10): 565-7.
in donor marrow prevents significant graft-versus- 14. Thomas ED. The Nobel Lectures in Immunology. The host disease in matched allogeneic leukaemic Nobel Prize for Physiology or Medicine, 1990. Bone marrow transplant recipients. Lancet. 1984 Mar 3; marrow transplantation – past, present and future.
Scand J Immunol. 1994 Apr; 39(4): 339-45.
25. Kolb HJ, Mittermüller J, Clemm C, Holler E, Ledderose 15. Gatti RA, Meuwissen HJ, Allen HD, Hong R, Good RA.
G, Brehm G, Heim M, Wilmanns W. Donor leukocyte Immunological reconstitution of sex-linked lympho- transfusions for treatment of recurrent chronic penic immunological deficiency. Lancet. 1968 Dec myelogenous leukemia in marrow transplant 28; 2(7583): 1366-9.
patients. Blood. 1990 Dec 15; 76(12): 2462-5.
16. Appelbaum FR, Herzig GP, Ziegler JL, Graw RG, Levine 26. Maury S, Redjoul R, Cabanne L, Vigouroux S, Legros L, AS, Deisseroth AB. Successful engraftment of Cohen JL. Regulatory T-cell depletion in donor cryopreserved autologous bone marrow in patients lymphocyte infusions for haematological malignancies: with malignant lymphoma. Blood. 1978 Jul; 52(1):
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27. Recombinant Nemunaitis J, Rabinowe SN, Singer JW, decades of transplantation for chronic myeloid Bierman PJ, Vose JM, Freedman AS, et al. Recombinant leukemia: what have we learned? Blood. 2011 Jan Granulocyte-Macrophage Colony-Stimulating Factor 20; 117(3): 755-63. doi: 10.1182/blood-2010-08-
after Autologous Bone Marrow Transplantation for 301341. Epub 2010 Oct 21.
Lymphoid Cancer. N Engl J Med. 1991 Jun 20; 324:
32. Goldman JM, Catovsky D, Goolden AWG, Johnson 1773-8. DOI: 10.1056/NEJM199106203242504.
Galton DAG. Buffy coat Autografts for patients with 28. Cleaver S. The Anthony Nolan Research Centre and chronic granulocytic leukaemia in transformation.
other matching registries. In: Treleaven J, Barret J Blut. 1981; 42: 149-55.
(eds). Bone Marrow Transplantation in Practice.
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33. Korbling M , Dorken B, Ho AD, Pezzutto A, Hunstein Unrelated donor hematopoietic stem cell trans- W, Fliedner TM. Autologous transplantation of blood- plantation. In: Atkinson K, Champlin RE, Ritz J, Fibbe derived hemopoietic stem cells after myeloablative WE, Ljungman P, Brenner MK, eds. Clinical bone therapy in a patient with Burkitt's lymphoma. Blood. marrow and blood stem cell transplantation.
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vigilance and surveillance in unrelated donors of 35. Gluckman E, Broxmeyer HE, Auerbach AD, et al.
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Fanconi's anemia by means of umbilical-cord blood doi: 10.1038/bmt.2013.104. Epub 2013 Jul 29.
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Malkki M, Gooley T. Major-histocompatibility-complex 36. Gluckman E. History of cord blood transplantation.
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The Sri Lanka Journal of Haematology Rajat Kumar SLJH. 2015; . S 7 LJH. 2015;
7(1): 5-14
Setting up a blood and marrow transplant (BMT) program in South Asia:
Rewards and Challenges
Rajat Kumar1
Key words: blood and bone marrow transplant, haematopoietic stem cell transplant, aplastic anaemia,
haploidentical transplants
transfused donor cells also "rescue" the bone Blood and marrow transplantation (BMT) or marrow from the effects of chemotherapy. (b)Non-malignant diseases – like aplastic anaemia, haematopoietic stem cell transplantation (HSCT) thalassaemia, Gaucher disease, etc. In these is a life-saving procedure for a number of malignant conditions the abnormal marrow is replaced by the and non-malignant life threatening diseases.1,2 healthy donor stem cells.
More than a million procedures have been com-pleted worldwide, and the annual transplant rateis close to 70,000 per annum with approximately 45% being allogeneic.3 The procedure itself has Stem cell source
many technical variations according to the primarydisease, age of the patient, facilities available and The three sources of stem cells used in HSCT are experience of the center. BMT may be autologous the bone marrow, peripheral blood and cord blood.
or allogeneic. When the patient's own cryopreserved The three sources differ in the stem cell content,composition and state of activation of immune haematopoietic stem cells are used to rescue bone cells. Quantitatively, peripheral blood represents marrow after high dose chemotherapy, the procedure the richest stem cell source and cord blood the is termed as autologous transplantation. Allogeneic poorest stem cell source. Peripheral blood contains BMT involves the transplantation of haematopoietic more lymphocytes than the other two sources. The stem cells derived from another individual, ideally most rapid engraftment is observed with peripheral a human leucocyte antigen (HLA) identical sibling, blood transplants and the slowest with cord blood into the patient. In this article, allogeneic HSCT will transplants. The risk of developing graft-versus- be discussed. As aplastic anaemia and thalassaemia host disease (GVHD) also varies with the source of major are common in South Asia, only these indi- stem cells. Peripheral blood stem cells (PBSC), cations will be highlighted.
which contain more T lymphocytes than marrowdoes, increase the incidence and severity of chronic Indications for HSCT
GVHD compared with bone marrow, while cordblood transplants have a lower risk of GVHD.4,5 The The indications for allogeneic (allo) haemato- trends in stem cell source for transplantation are poietic stem cell transplantation in haematological changing. A report from the European Group for disorders can be conveniently divided into two Blood and Marrow transplantation (EBMT) showed groups (Table 1): (a) Malignant disorders – like that in 2011 a total of 35,660 HSCT were reported leukaemias, myelodysplastic syndromes and with 41% allogeneic and 59% autologous by 651 lymphomas. In all these indications, the cure is by centers in 45 countries.6 Peripheral blood stem a combined effect of the high doses of chemo- cells were used as a stem cell source in 99% of therapy or radiation therapy, and a graft versus autologous and 73% allogeneic HSCT. Bone marrow tumor effect by the transfused donor cells. The was used as a stem cell source in allogeneic trans-plantation, primarily for nonmalignant disorders.
Cord blood was used for 6% of allogeneic HSCT,mainly from unrelated donors and no autologous 1 Professor, University of Manitoba, Canada. cord blood was used.6 The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
Table 1. Indications for allogeneic stem cell transplantation
Non malignant disorders
Acute myeloid leukaemia Thalassaemia major Acute lymphoblastic leukaemia Chronic lymphocytic leukaemia Fanconi's anaemia Chronic myeloid leukaemia Sickle cell anaemia Non-Hodgkin lymphoma Paroxysmal nocturnal haemoglobinuria Severe combined immunodeficiency Multiple myeloma (mainly autologous) Inborn errors of metabolism Donor requirement for allogeneic HSCT
Haploidentical related donors
Mendelian genetics dictate that each biologicalparent and each biological child of a patient is HLA- For an allogeneic BMT, an HLA identical sibling is the haploidentical, each sibling, half-sibling, aunt or ideal donor. A sibling who is identical in the HLA- uncle has a 50% likelihood of being HLA-haplo- A, B, DR loci is considered HLA identical implying a identical.3 Thus a haploidentical (haplo) donor can 6/6 match. In spite of HLA identity, there are always be found for nearly every patient requiring an allo- variations in the minor histocompatibility loci.
HSCT. Moreover, this is likely to be faster than a These antigenic differences lead to graft rejection search for an unrelated donor.
or graft versus host disease unless immunosup-pression is used. It is also possible to have a successfultransplant using a partially matched sibling as a Choice of donor
donor, or an unrelated HLA identical donor, but the The best outcomes for allo-HSCT are with a donor complications of GVHD and graft rejection increase.
who is a HLA-matched sibling. There is 25% chanceof each sibling being HLA-identical, and with the small family sizes, only 30% chance that a patientwill find a matched sibling donor.
For unrelated transplants, the HLA-C and HLA-DQloci are also tested and a 10/10 match is ideal. For The next alternative is a matched unrelated donor unrelated umbilical cord blood transplants, a 6/6 (MUD)7. The unrelated donor pool has expanded or even a 4/6 match is acceptable as the cord blood to more than 26 million donors worldwide, with cells are immunologically naïve and the risk of an increased number of unrelated allo-HSCTs GVHD is less. With improvements in HLA typing at being performed. With improvement in protocols, the molecular level, results of unrelated transplants outcomes with matched unrelated donor trans- are often equivalent to matched sibling transplants plants rival those after matched sibling tran- and at times may be preferred. The massive increase splants3. Suitable matched unrelated donors (MUD) of unrelated donor registries has increased the are found for 60% to 80% of white Caucasians but likelihood of finding a well-matched unrelated only for 10% of ethnic minorities.
donor in addition, there is increasing evidence thatthe well-matched donor in certain situations might For those who do not have HLA-matched related be preferable to a sibling donor, for example, in or unrelated donors, the options are (a) mis- the situation of an older male patient with the matched unrelated donor (MMURD) (b) unrelated choice between an older female sibling donor and donor umbilical cord blood or (c) HLA haplo- a young well-matched unrelated male donor.
identical, related donors.3,7 The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
Engraftment is considered established when theperipheral neutrophil count reaches 0.5 x 109/L on Myeloablative conditioning. The standard
3 successive days.
preparatory regimens given prior to HSCT aremyeloablative. Patients receive extremely high Peripheral blood stem cell transplantation (PBSCT)
doses of chemotherapy or radiotherapy or both.
The aim is threefold: (a) Eradication of malignant It is well known that the peripheral blood contains cells or, in cases of genetic disorders, it is eradication a small percent of circulating stem cells, approxi- of the abnormal clone of cells, (b) Suppression of mately 0.1%. This number can be increased by the immune system of the host (recipient) so that administration of colony stimulating factors, like the allograft is not rejected, and (c) Clearing a Granulocyte-colony stimulating factor(G-CSF), "physical space" to allow adequate growth of the which mobilize stem cells from the bone marrow.
donor stem cells. The conditioning, which is myelo- For allogeneic donors, administration of G-CSF for ablative, is also toxic to various organs like the liver, 4 to 5 days results in high circulating stem cells lungs, kidneys, gastrointestinal tract and repro- which can be collected by a cell separator. The ductive system.
procedure requires venous access and takes aboutthree to four hours. The donor need not be admitted, Non-myeloablative or reduced-intensity con-
does not require anesthesia and is spared the pain ditioning. The association of GVHD with diminished
of marrow aspiration. Haematopoietic reconstitution relapse rates following allogeneic HSCT, together is more rapid and predictable when PBSCs are with the dramatic responses sometimes seen used for transplantation. This translates in reduced following donor lymphocyte infusions demonstrates duration of neutropenia, fewer platelet transfusions, the potential of the human immune system to and shorter hospital stay (Table 2). Immune recon- eradicate haematological malignancies. The stitution may be better with PBSCT as there are curative potential of allogeneic BMT is mediated more lymphocytes in the graft as compared to in part by an immune mediated graft-versus-tumor effect. This has prompted some workers to focuson the use of donor T cells to eradicate both non- Cord blood stem cell transplantation
malignant and malignant cells of host origin, Placental blood, which is routinely discarded in without the use of myeloablative conditioning clinical practice, is potentially a vast supply of regimens. This reduced-intensity conditioning (RIC) allogeneic foetal haematopoietic stem cells. Cord aims to suppress the immunity of the recipient blood (CB) stem cells have distinctive proliferative sufficiently to allow allogeneic engraftment, advantages which include an (a) enriched pro- without destroying the recipient's marrow, with portion of immature stem cells, (b) higher clono- lower regimen related toxicity. This represents an genic growth advantage, (c) increased cell cycle important step in capitalizing on the allogeneic rate, (d) autocrine growth factors production and (e) increased telomere length.
Technical aspects of allogeneic transplantation
The main limitation of cord blood transplants (CBT)is the limited number of nucleated cells available Bone marrow transplantation
in a unit. As compared to bone marrow trans- The actual bone marrow transplant is not com- plantation, the time for engraftment in cord blood plicated. The donor's marrow is harvested by transplantation is much longer, taking a month for repeated aspiration from the posterior iliac crests, neutrophilic engraftment and more than fifty days under general or spinal anaesthesia. The marrow for platelet engraftment. There is also a higher is collected in a bag with anticoagulant. The number incidence of non-engraftment. The nucleated cell of marrow cells or total nucleated cells (TNC) dose available in a cord blood unit is critical, being required for successful engraftment is estimated 1 log less than in a bone marrow transplant. The to be at least 1 to 3 x 108 per kg of recipient's body minimum recommended dose for CBT is 2.0 to 2.5 weight. Bone marrow is transfused through the x 107 nucleated cells /kg for a successful outcome veins and the donor marrow cells home into the and at least a 4/6 HLA match. The main advantage recipient's marrow space and start engrafting.
of CBT is a lower incidence and severity of GVHD.
The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
Table 2. The advantages and disadvantages of PBSCT
1. Faster neutrophil recovery 2. Faster platelet recovery 3. Faster immunologic recovery Higher incidence of chronic GVHD 4. Less IV antibiotics 5. Shorter hospitalization 7. More graft versus tumor effect (?) 1. No general anesthesia 1. Venepuncture or central line 2. No marrow harvest 2. Side effects from growth stimulating factors, or citrate used for PBSC harvest 3. No hospitalization PBSCT – Peripheral blood stem cell transplantation, IV – Intravenous, GVHD – Graft-versus-host-disease,PBSC – Peripheral blood stem cell This allows a 1 to 2 HLA antigen mismatch even in developed in Italy. The average dose of cells is unrelated CBT. More than 600,000 cord blood units >10 x 106 CD34+ cells/kg body weight of recipient.10 have been stored worldwide and over 30,000 CBT have (2) The GIAC protocol used in China, comprising of been performed, mainly in the unrelated setting.9 G-CSF stimulation of donor; Intensified immuno-suppression using post-transplant cyclosporine, myco- The main problem in doing CBT in adults is the phenolatemofetil and short course methotrexate; limited number of nucleated cells/CD34+ cells in a ATG added to conditioning to aid engraftment and cord blood collection relative to the weight of an help prevent GVHD; and combination of PBSC and adult. Different strategies are being investigated BM allografts11. (3) High dose, post transplantation for this; these include (a) multiunit cord blood trans- plantation, (b) ex-vivo expansion of CB haemato-poietic stem cells (c) nonmyeloablative preparative Post-transplantation cyclophosphamide was first regimen to reduce the conditioning toxicity5,9.
developed in animal models and finally translatedinto clinical practice by groups at Johns Hopkinsand Fred Hutchinson Cancer Research Center.13 It was shown that cyclophosphamide is nontoxic In the past, results of haplo-HSCT were poor due to haematopoietic stem cells because of high to high incidence of graft failure or GVHD, due to expression of the detoxifying enzyme aldehyde bi-directional allo-reactivity. This is due to the high dehydrogenase. Moreover, cyclophosphamide is frequency of T lymphocytes that recognize major selectively toxic to dividing cells.
class I or II HLA disparities between the donor andrecipient.
With post-transplant cyclophosphamide, the firststep is selective killing of proliferating alloantigen- In the last two decades, the outcomes of haplo- stimulated T cells. As replicating T cells are uniquely HSCT have improved and results are comparable sensitive to cyclophosphamide, both anti-host and to unrelated HSCT for malignant disease indications.
anti-donor T cells are selectively destroyed. The There are three main approaches to control graft quiescent progenitor cells and memory T cells in failure or GVHD. (1) The megadose HSCT approach the graft are not affected. Persistence of donor using PBSCs positively selected for CD34+ cells, non-alloreactive T cells can provide the transplant The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
recipient with donor-derived immunity to fight dysplastic syndrome-2 and thalassaemia major-4.
infections. The second step is the development of The median age was 19 years (range 2.2-46) with peripheral tolerance. The third step is deletion of 29 male and 11 female participants. The 30-day donor stem cell derived anti-host T cells in the mortality was nil, and 100-day mortality was 1 thymus.12 Cylophosphamide is usually given on (2.5%). This experience suggests that allogeneic days 3 and 4 post stem cell infusion at doses of HSCT can be safely performed in non-HEPA filter 50mg/kg on each day.14 rooms in India.16 Updated results confirm that thisapproach is effective in high risk patients.17 This protocol is used widely in the United Statesand many other countries, including India. Number Venous access. The transplant process typically
of studies have used this protocol in myeloablative involves the use of a long term, silastic, multi- as well as reduced intensity conditioning, with BM lumen, flexible catheter for chemotherapy adminis- or PBSC as stem cell sources.13,14 This approach has tration, infusion of stem cells and supportive care shown acceptable incidence of GVHD and low non management including frequent blood sampling, relapse mortality. When myeloablative conditioning intravenous antibiotics, blood components and was used, the relapse rate was lower than with parenteral nutrition.18 RIC and results comparable to those with MUD orcord blood transplant. It is the most attractive Infections. Infection remains an important cause
protocol for haplo-HSCT in developing countries, of morbidity and mortality after BMT, with as no special equipment is needed for stem cell bacterial, fungal infections and viral infections manipulation, there is no need for expensive being the predominant cause.19 The EBMT analyzed medications, the cost of cyclophosphamide is low and a large homogeneous group of 14,403 patients it is given by simple intravenous administration.
transplanted for early leukaemia from an HLA-identical sibling and reported to the EBMT from 1980 to 2001. Of the 597 deaths with infection as Protective isolation. After transplantation of the
the primary cause of death, 217 (36%), were attri- marrow, it takes about two to three weeks before buted to bacteria, 183 (31%) to viruses, 166 (28%) engraftment occurs, that is the time when the stem to fungi and 31 (5%) to parasites. The cumulative cells start producing adequate number of neutro- incidence of deaths with infection at 5 years was phils, platelets and erythrocytes. During this 5% with a cumulative incidence of 1.8% attributed period very intensive support is required. Ideally to bacteria, 1.6% to viruses, 1.4% to fungi and 0.3% a high-efficiency particulate arrestance (HEPA) to parasites19. During the early neutropenic period, filtered unit should be available for hospitalization bacterial and fungal infections predominate while for transplantation. It is emphasized that the risk viral infections are frequent after engraftment of infections lasts for almost a year in allogeneic when the cell mediated immunity is impaired, the HSCT. Some centers have reported carrying out most important viruses being cytomegalo virus, stem cell transplants without protective isolation, herpes simplex virus, and varicella zoster. Bacterial or even in outpatient setting, without increase in infections with encapsulated organisms again morbidity or mortality.15 This is only feasible if the predominate after three to six months of engraft- home offers a clean environment, the patient can ment, akin to the condition in post splenectomised be monitored closely and admitted immediately, patients antimicrobials should be administered if required. At the All India Institute of Medical after establishing the cause of infection, but in Sciences (AIIMS), the department of haematology practice an aetiological agent is often not identified.
recently published its experience of performing During the neutropenic phase, early institution of 40 consecutive allogeneic transplants from July empirical antibiotics to cover gram-negative and 2004 to November 2007 in single non-HEPA filter gram-positive bacteria, with addition of antifungal rooms for a variety of indications. Source of stem drugs like amphotericin or voriconazole if fever cells was peripheral blood in 33, bone marrow in persists, is practiced in most centers in India16.
six and combined in one. The indications weresevere aplastic anemia-18, chronic myeloid Blood component support. After conditioning
leukaemia (CML)-7, acute myeloid leukaemia therapy, patients require multiple red cell and (AML)-7, acute lymphoblastic leukaemia-2, myelo- platelet transfusions during the 2-4 week period The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
of pancytopenia, till engraftment occurs. Patients are profoundly immunosuppressed and at risk of In allogeneic HSCT patients, a unique complication developing transfusion associated-graft versus occurs: GVHD. There are two types of GVHD, acute host disease (TA-GVHD) after receiving cellular and chronic.2 Acute GVHD: This occurs within the blood products. To prevent this, all cellular blood first 100 days after transplant. It classically affects products should be irradiated prior to transfusion,to inactivate the donor lymphocytes. Hence a blood three tissues, namely the skin, gut and liver and irradiator is essential for any allogeneic BMT center.
may be accompanied by fever. The severity can begraded according to the extent of skin involve- Haematopoietic growth factors. Haematopoietic
ment, degree of hyperbilirubinemia and severity colony stimulating factors like G-CSF are often of diarrhoea.2 Chronic GVHD: This usually develops administered to patients after infusion of stem later than 100 days after transplant and often cells in order to reduce the duration of neutropenia.
follows acute GVHD but may also develop de novo.
More recently, studies have shown that even It is classified as limited or extensive chronic GVHD.
without use of these factors there is no adverse Clinically it resembles autoimmune disorders like impact on outcome, and many centers use them scleroderma with skin rash, sicca complex, sclero- only in cases with delayed engraftment.
sing bronchiolitis and hepatic dysfunction. Themortality varies from 20% to 40%. Management is Toxicity related to conditioning. The conventional
with immunosuppressive agents like cyclosporine, myeloablative therapy given before infusion of prednisolone, tacrolimus, mycophenolate, sirolimus, bone marrow causes organ toxicity, in addition to methotrexate and cyclophosphamide in various myelotoxicity. These are: (a) veno-occlusive combinations. After a year or more, many patients disease (VOD) of the liver, more accurately termed develop self-tolerance and these drugs can be as "sinusoidal obstruction syndrome". It is charac- tapered off. GVHD is more common in older patients terized by (i) jaundice (ii) hepatomegaly and right and those with one or more HLA mismatches or upper quadrant pain (iii) ascites or (iv) unexplained unrelated HLA identical transplants. It is mainly for weight pain, (b) haemorrhagic cystitis characterized this reason that elderly patients do not do well by the presence of haematuria, dysuria, and urinaryfrequency in a patient with sterile urine, (c) seizures with allogeneic BMT due to severe GVHD. With the usually drug induced, (d) pulmonary complications use of PBSC, the time limits are not so well defined which can be infectious or non-infectious, and (d) and acute GVHD may occur later while classical skin and mucosal changes like alopecia, nail changes chronic GVHD may occur earlier.
and oral mucositis.
Failure of engraftment
A successful BMT does not always mean that the Failure to engraft after HSCT (graft dysfunction) or primary disease is cured. A certain number of to sustain engraftment (graft rejection) is a patients will relapse from the original malignancy, formidable complication due to many possible as the tumor cells survive the chemo/radiotherapy factors. These include inadequate stem cell and graft versus tumor effect. Relapses are higher numbers, infections, graft-versus-host disease and if the HSCT is performed when the disease is not in immunological mediated processes. The stem cell remission, or at an advanced stage, or is aggressive.
graft may get rejected by functional host lympho-cytes which survive the conditioning regimen.
Patients with haematological malignancies who Fortunately, this complication is uncommon. Multiple relapse after allogeneic bone marrow trans- treatment alternatives have been explored includinghaematopoietic growth factors, additional infusions plantation can be treated by infusing lymphocytes of stem cells alone, with augmented immuno- from the original stem cell donor. Donor lymphocyte suppression or with additional cytotoxic therapy.
infusion (DLI) induces complete remissions in the The incidence is higher in unrelated donor trans- majority of patients with CML in early-stage relapse plantation and whenever there is presence of any and in less than 30% of patients with relapsed HLA mismatch. Depleting the graft of T cells also acute leukemia, myelodysplasia, and multiple increases graft rejection.
The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
Requirements for BMT unit
matched siblings. A total of 134 grafts were PBSC The complexity of the transplantation procedure grafts, and 558 were bone marrow grafts. Rates highlights the need for adequate infrastructure, of haematopoietic recovery and grades 2 to 4 experience and teamwork, to manage patients chronic GVHD were similar after PBSC and bone who can potentially have multiple complications.
marrow transplantations regardless of age at A multispecialty approach is needed. An efficient transplantation. In patients older than 20 years, blood bank and transfusion center with facilities chronic GVHD and overall mortality rates were for blood component therapy is critical. Blood similar after PBSC and marrow transplantations. In irradiation facilities are essential. As infections are patients younger than 20 years, rates of chronic common in early and late phases, facilities for GVHD (relative risk [RR] 2.82; P=.002) and overall diagnosis and management of common and rare mortality (RR 2.04; P=.024) were higher after bacterial, fungal, viral and parasitic infections are transplantation of PBSCs than after transplantation needed. For organ toxicity and GVHD management, of bone marrow. These authors concluded that subspecialties of gastroenterology, pulmonology, bone marrow grafts are preferred to PBSC grafts in hepatology, cardiology, dermatology, ophthal- young patients undergoing HLA-matched sibling- mology, histopathology and others are required.
donor transplantation for SAA.21 A similar con- Documentation of all cases and prospective clusion was reached by another EBMT study.22 registries are needed. Guidance may be obtainedfrom the Center for International Blood and This view is not accepted by many experts in the Marrow Transplant Research (CIBMTR) or the EBMT.
developing world. Patients with aplastic anemia As a general guide, a center should be capable of who come for transplantation in developing successfully treating patients of AML, before embar- countries are often multi-transfused and the blood king on a BMT program.
products they receive are usually not leuco-depleted. They are therefore alloimmunised andhave a high risk of graft rejection. PBSC transplant Indications for allogeneic transplants
reduces the chances of graft rejection due to a In recent years, evidence based guidelines have higher stem cell dose and the higher T cell content.
been formulated for indications in haematologic Moreover, many patients are infected prior to disorders. These may change with improvements coming for transplant and a PBSC graft source has in non-transplant therapy. As an example, allo- the advantage of an earlier engraftment as well as HSCT was the first line treatment for patients of immune reconstitution. The transplant centers at CML who were eligible and had a donor, but with AIIMS New Delhi and Christian Medical College the availability of tyrosine kinase inhibitors, the (CMC) Vellore routinely use PBSC as a preferred indications of transplant have reduced radically.
source for allo-HSCT in aplastic anemia.23,24 Thesuccess rates of 70-80% survival suggest that in the Indian context, PBSC may be a preferred source ofstem cells in the high risk patients seen in India. A Severe aplastic anemia (SAA) is potentially curable recent analysis of 2374 HLA identical sibling with allo-HSCT, the only limiting factor being the transplants in SAA across different economic zones, transplant related morbidity and mortality.
confirmed the observation that overall, BM is a Guidelines suggest that in young patients with an better source than PBSC. However, there was no HLA matched sibling donor, allo-HSCT should be difference in overall survival between the two graft first line therapy, as the complications are much sources in upper-middle-income and lower-middle less (Table 3). In those who are older than 50 years, and lower-income countries, hence PBSC may be immunosuppression should be tried first.20 The an acceptable alternative in countries with limited source of stem cells is also controversial. A recent resources when treating patients at high risk of study showed better outcome with bone marrow graft failure and infective complications.25 The use versus peripheral blood. This was mainly due to a of haploidentical transplants is considered experi- higher GVHD in the PBSCT group.21 This study mental, but in future it may become a preferred analyzed the outcome of 692 patients with severe source for those without sibling donors, if the aplasticanemia receiving transplants from HLA- problem of graft rejection can be overcome.20 The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
Table 3. BMT in aplastic anaemia
If HLA identical sibling available.
The indications of age may be relaxed (a) Age < 50 yr: BMT 1st line treatment.
(b) Age >50yr: BMT as 2nd line treatment (a) Patients who are infected and would if immunosuppression fails not tolerate immunosuppression in 3-4 months.
or(b) very severe aplastic anaemia If only HLA identical unrelated donoravailable.
Age < 50 years: BMT ifImmunosuppression fails.
BMT – Blood and marrow transplantation, HLA – Human leucocyte antigen countries with limited resources, HSCT is pre-ferentially restricted to allogeneic transplants with A major indication for allo-HSCT in India is thalas- stem cells from family donors for non-malignant saemia major. This disease is potentially curable indications or chronic leukaemias29.
with an allogeneic transplantation. The results areexcellent if the transplantation is done prior to In India, the cost of an allogeneic HSCT varies as the complications of iron overload, transfusion per the indication and the type of hospital (Govern- complications and alloimmunisation. Results from ment funded or private). The cost of an allogeneic Pesaro, Italy, suggest more than 85% disease free transplant in AIIMS, New Delhi, varies between survival for patients transplanted early, in Pesaro US $6000 to 12,000. The cost of medication and Class 1.26 In India, similar results have been attained monitoring after engraftment is additional. In private at CMC, Vellore.27 When a child is diagnosed with corporate hospitals, the cost varies between US thalassaemia major, treatment should be started $15,000 to 30,000 for initial hospitalization. The with optimal blood transfusion and iron chelation variation in cost depends on the conditioning regi- instituted before there is a significant rise in ferritin men, complications and the use of anti-infectives levels. All siblings should be typed for an HLA and supportive drugs. Thus the use of anti-thymo- identical match. If a match is available, the child cyte globulin would significantly increase the cost should be referred to a transplant center. An allo- HSCT should be performed as soon as feasible. Forconvenience of nursing and post-transplant care, In terms of unrelated transplants, the cost of the allo-HSCT in India is generally performed after the graft source may have a major impact in choice of child is more than 3 years of age.
graft in developing countries. The approximate costof an unrelated umbilical cord blood unit is US $30,000 while the cost for a matched unrelateddonor stem cells varies between US $12,000 to Haematopoietic stem cell transplantation requires 30,000 based on the registry. From a purely significant infrastructure. In the first report by the financial aspect, haplo-identical donor would be Worldwide Network for Blood and Marrow cost effective, provided the outcome was similar Transplantation, it was concluded that no HSCTs to unrelated donor transplants.
were performed in countries with less than US $680gross national income (GNI) per capita28. Transplantactivity is concentrated in countries with higher governmental health care expenditures, higher Allogeneic HSCT should be offered to patients GNI per capita, and higher team density. In where the benefits outweigh the risks. Non- The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
transplant therapy should be compared to HSCT, blood in recipients of matched sibling allogeneic before making any recommendations. Counseling transplants for myeloid malignancies. Blood. 2002; of the patient and patient preference is extremely important, as HSCT involves considerable expense, 5. Ballen KK. New trends in umbilical cord blood often prolonged morbidity and potential fatality.
transplantation. Blood. 2005 May 15; 105(10): 3786-
In developing countries such as in South Asia, 92. Epub 2005 Jan 27.
where the cost is usually borne by the patient and 6. Gratwohl A, Baldomero H, Passweg J. Hematopoietic family, economic factors need consideration. In stem cell transplantation activity in Europe. Curr Opin general, early transplant offers better results than Hematol. 2013; 20(6): 485-93.doi: 10.1097/MOH.
HSCT performed in advanced disease, but in those disorders where non-transplant therapy offerssimilar outcomes, HSCT is offered when there is 7. Kekre N, Antin JH. Hematopoietic stem cell trans- plantation donor sources in the 21st century: failure of alternative therapy. Aplastic anemia and choosing the ideal donor when a perfect match does thalassaemia are the most common non-malignant not exist. Blood. 2014 Jul 17; 124(3): 334-43. doi:
indications for transplant in South Asia. In haemato- 10.1182/blood-2014-02-514760. Epub 2014 Jun 9.
logical malignancies, cytogenetic and molecularprognostic markers usually guide the timing of 8. Slavin S, Aker M, Shapira MY, Resnick I, Bitan M, Or R.
transplantation. Potential transplant candidates Reduced-intensity conditioning for the treatment ofmalignant and life-threatening non-malignant should be referred early to a transplant center where disorders. Clin Transpl. 2003: 275-82.
facilities for assessment are available. For moredetailed disease specific analysis, the original 9. Ballen KK, Gluckman E, Broxmeyer HE. Umbilical cord articles should be reviewed.
blood transplantation: the first 25 years and beyond.
Blood. 2013 Jul 25; 122(4): 491-98. doi: 10.1182/
blood-2013-02-453175. Epub 2013 May 14.
10. Aversa F, Terenzi A, Tabilio A, Falzetti F, Carotti A, Contribution: This is the sole work of Dr. Rajat Ballanti S, et al. Full haplotype-mismatched hemato- poietic stem-cell transplantation: a phase II studyin patients with acute leukemia at high risk of Conflict-of-interest disclosure: The author declares relapse. J Clin Oncol. 2005 May 20; 23(15): 3447-54.
no conflict of interest Epub 2005 Mar 7.
Correspondence: Dr. Rajat Kumar MD (Med), DNB 11. Huang XJ, Liu DH, Liu KY, Xu LP, Chen H, Han W, et al.
(Med), FRCP (London), FRCP (Edin), FRCPC Treatment of acute leukemia with unmanipulated Professor, University of Manitoba, Cancer Care HLA-mismatched/haploidentical blood and bone Manitoba, 675 McDermot Avenue, Winnipeg, MB marrow transplantation. Biol Blood Marrow R3E 0V9, Canada.
Transplant. 2009 Feb; 15(2): 257-65. doi: 10.1016/
j.bbmt.2008.11.025
12. Luznik L, O'Donnell PV, Fuchs EJ. Post-transplantation cyclophosphamide for tolerance induction in HLA- haploidentical bone marrow transplantation. Semin 1. Armitage JO. Bone marrow transplantation. N Engl J Oncol. 2012 Dec; 39(6): 683-93. doi: 10.1053/
Med. 1994 Mar 24; 330(12): 827-38.
2. Copelan EA. Hematopoietic stem-cell trans- 13. Reisner Y, Hagin D, Martelli MF. Haploidentical plantation. N Engl J Med. 2006 Apr 27; 354(17):
hematopoietic transplantation: current status and future perspectives. Blood. 2011 Dec 1; 118(23):
6006-17. doi: 10.1182/blood-2011-07-338822. Epub
3. Apperley J, Niederwieser D, Huang XJ, Nagler A, Fuchs 2011 Sep 14.
E, Szer J, et al. Haploidentical HCT – A Global Overview:Comparing Asia, EU and U.S. Biol Blood Marrow 14. Ciurea SO, Bayraktar UD. "No donor"? Consider a Transplant. 2016 Jan; 22(1): 23-6. doi: 10.1016/
haploidentical transplant. Blood Rev. 2015 Mar; j.bbmt.2015.11.001. Epub 2015 Nov 10.
29(2): 63-70. doi: 10.1016/j.blre.2014.09.009. Epub
2014 Sep 30.
4. Couban S, Simpson DR, Barnett MJ, Bredeson C, Hubesch L, Howson-Jan K, et al. A randomized multi- 15. Russell JA, Chaudhry A, Booth K, Brown C, Woodman center comparison of bone marrow and peripheral RC, Valentine K, et al. Early outcomes after allogeneic The Sri Lanka Journal of Haematology Rajat Kumar. SLJH. 2015; 7(1): 5-14
stem cell transplantation for leukemia and 23. Kumar R, Prem S, Mahapatra M, Seth T, Chowdhary myelodysplasia without protective isolation: a 10- DR, Mishra P, et al. Fludarabine, cyclophosphamide year experience. Biol Blood Marrow Transplant. 2000; and horse anti-thymocyte globulin conditioning regimen for allogeneic peripheral blood stem cell 16. Kumar R, Naithani R, Mishra P, Mahapatra M, Seth T, transplantation performed in non-HEPA filter rooms Dolai TK, et al. Allogeneic hematopoietic SCT for multiply transfused patients with severe aplastic performed in non-HEPA filter rooms: initial anemia. Bone Marrow Transplant. 2006 Apr; 37(8):
experience from a single center in India. Bone Marrow Transplant. 2009 Jan; 43(2): 115-19. doi: 10.1038/
24. George B, Mathews V, Viswabandya A, Kavitha ML, bmt.2008.307. Epub 2008 Sep 15.
Srivastava A, Chandy M. Fludarabine and cyclo- 17. Seth T, Kanga U, Sood P, Sharma V, Mishra P, phosphamide based reduced intensity conditioning Mahapatra M. Audit of peripheral stem cell trans- (RIC) regimens reduce rejection and improve outcome plantation for aplastic anemia in multitransfused in Indian patients undergoing allogeneic stem cell infected patients. Transplant Proc. 2012 May; 44(4):
transplantation for severe aplastic anemia. Bone Marrow Transplant. 2007 Jul; 40(1): 13-8. Epub 2007
18. Lazarus HM, Trehan S, Miller R, Fox RM, Creger RJ, Raaf JH. Multi-purpose silastic dual-lumen central 25. Kumar R, Kimura F, Ahn KW, Hu ZH, Kuwatsuka Y, Klein venous catheters for both collection and trans- JP, et al. Comparing Outcomes with Bone Marrow or plantation of hematopoietic progenitor cells. Bone Peripheral Blood Stem Cells as Graft Source for Marrow Transplant. 2000 Apr; 25(7): 779-85.
Matched Sibling Transplants in Severe Aplastic 19. Gratwohl A, Brand R, Frassoni F, Rocha V, Nieder- Anemia across Different Economic Regions. Biol wieser D, Reusser P, et al. Cause of death after Blood Marrow Transplant. 2016 Jan 18. pii: S1083- allogeneic haematopoietic stem cell transplantation (HSCT) in early leukaemias: an EBMT analysis of 26. Lucarelli G, Galimberti M, Polchi P, Angelucci E, lethal infectious complications and changes over Baronciani D, Giardini C, et al. Marrow trans- calendar time. Bone Marrow Transplant. 2005 Nov; plantation in patients with thalassemia responsive to iron chelation therapy. N Engl J Med. 1993 Sep 16; 20. Bacigalupo A. Bone marrow transplantation for acquired severe aplastic anemia. Hematol Oncol Clin 27. Chandy M, Srivastava A, Dennison D, Mathews V, North Am. 2014 Dec; 28(6): 1145-55. doi: 10.1016/
George B. Allogeneic bone marrow transplantation j.hoc.2014.08.004. Epub 2014 Oct 5.
in the developing world: experience from a center in 21. Schrezenmeier H, Passweg JR, Marsh JC, Bacigalupo India. Bone Marrow Transplant. 2001 Apr; 27(8):
A, Bredeson CN, Bullorsky E, Camitta BM, et al. Worse outcome and more chronic GVHD with peripheralblood progenitor cells than bone marrow in HLA- 28. Gratwohl A, Baldomero H, Aljurf M, Pasquini MC, matched sibling donor transplants for young patients Bouzas LF, Yoshimi A, et al. Hematopoietic stem cell with severe acquired aplastic anemia. Blood. 2007 transplantation: a global perspective. JAMA. 2010 Aug 15; 110(4): 1397-400. Epub 2007 May 2.
Apr 28; 303(16): 1617-24. doi: 10.1001/jama.
2010.491.
22. Bacigalupo A, Socie G, Schrezenmeier H, Tichelli A, Locasciulli A, Fuehrer M,et al. Bone marrow versus 29. Gratwohl A, Baldomero H, Gratwohl M, Aljurf M, peripheral blood as the stem cell source for sibling Bouzas LF, Horowitz M, et al. Quantitative and quali- transplants in acquired aplastic anemia: survival tative differences in use and trends of hematopoietic advantage for bone marrow in all age groups.
stem cell transplantation: a Global Observational Haematologica. 2012 Aug; 97(8): 1142-48. Epub 2012
Study. Haematologica. 2013 Aug; 98(8): 1282-90. doi:
10.3324/haematol.2012.076349. Epub 2013 Mar 18.
The Sri Lanka Journal of Haematology MB Agarwal 7 LJH. 2015;
(1): 15-18 7(1): 15-18
Treatment of elderly acute myeloblastic leukaemia with azacitidine after failure
of decitabine
MB Agarwal1
Key words: acute myeloblastic leukaemia, azacitidine, decitabine
purpuric spots all over the body and oral cavity. His A 72-year-old man was seen with acute myelo- haemoglobin (Hb) level was 51 g/L, platelet count blastic leukaemia (AML) after negligible response 26 x 109/L, WBC count 2.8 x 109/L with 18% blasts in to four cycles of decitabine. Patient was treated peripheral blood and 78% blasts in the marrow.
with subcutaneous 5-azacitidine 75 mg/m2 daily x There were dysplastic changes in all 3 cell lines.
7 days/cycle. Patient achieved complete remission Immunophenotyping confirmed AML with CD13, with incomplete recovery of blood counts (CRi) CD33, CD117, CD34, HLA-DR and cMPO posi- after 6 cycles and has been on maintenance cycles tivity. Cytogenetic studies showed 7-monosomy.
with the same schedule for another 8 months so far.
Molecular studies showed no evidence of nucleo- There is very little data to support use of 5-azacitidine phosmin (NPM1) gene mutation or FMS-like tyro- in elderly AML after failure of decitabine and hence sine kinase-3 internal tandem duplication muta- this report.
tions (FLT3/ITD) mutation. Patient had performancestatus of two. He had no comorbidities.
Case report
He desired therapy with minimal toxicity over and A 72-year-old man was seen for AML. He had above best supportive care. However, he had no symptoms of weakness and episodic fever. There interest in standard chemotherapy using 3+7 was easy bruising and one episode of epistaxis.
protocol or reduced intensity transplant. In view Earlier, at another centre, he was diagnosed as AML of this, he was started on subcutaneous (SC) 6 months earlier. He had presented with vague azacitidine 75 mg/m2 x 7 days every 28 days on systemic symptoms, pancytopenia with marrow outdoor basis. He was also on levofloxacin and showing 30% blasts. During those 6 months, he had voriconazole prophylaxis. The patient had local received 4 cycles of decitabine 20 mg/m2 daily x 5 reactions at injection sites, episodic significant days per cycle as intravenous infusion therapy.
gastrointestinal disturbances and continuous Throughout this period, patient was off and on requirement of blood products. However, by the extremely sick due to anaemia and recurrent end of third cycle, there was significant decrease infections needing repeated hospitalizations and in transfusion requirement and peripheral blood blood component support. Marrow repeated after counts showed improvement. By the end of 6th 2 cycles had shown 28% blasts and the same after cycle, he had a Hb level of 92 g/L, platelet count 4 cycles had shown 52% blasts. His subsequenttreatment was abandoned and he was advised of 86 x 109/L (unsupported), WBC count of 6.4 x best supportive care.
109/L with absolute neutrophil count (ANC) of 4.9 x109/L and no blasts in peripheral blood. Marrow At presentation to us, patient was sick, febrile with examination showed good cellularity, minimal mild hepatosplenomegaly (1 cm each) and trilineage dysplasia with blasts < 1%. Cytogeneticstudies showed persistence of 7-monosomy.
Patient was reluctant to continue further treat- 1Professor and Head, Department of Haematology, ment. However, he was convinced and he con- Bombay Hospital Institute of Medical Sciences, tinued the same treatment with almost no toxicity.
Mumbai, India. By May 2015, he had completed total of 14 cycles The Sri Lanka Journal of Haematology MB Agarwal SLJH. 2015; 7(1): 15-18
and he was in complete remission (CR) with Hb was revived as their use in low dose worked as level of 124 g/L, platelet count of 136 x 109/L, WBC differentiating agents with good success and count of 5.6 x 109/L with ANC of 2.9 x 109/L and no minimal toxicity. With accumulation of substantial blasts in the peripheral blood. Bone marrow was data, 5-azacitidine received United States Food and not repeated.
Drug Administration (US-FDA) approval for treat-ment of MDS in 2004 and decitabine received the same in 2006.
This is an interesting case where a number of Over last few years, HMA were considered as an lessons could be learnt.
attractive strategy for treating patients of AML whowere otherwise considered unsuitable for 3+7 The incidence of AML in patients over 70 years old therapy. Azacitidine was compared with various is > 20 times greater than that observed in younger conventional care regimens (CCR) which included subjects. Elderly AML differ from young patients LD-AraC, intensive chemotherapy or supportive in various ways; high incidence of poor prognostic cyto- care (phase 3 trial) in patients with intermediate- genetic abnormalities, high incidence of therapy- 2 and high-risk MDS. Interestingly, 113 patients in related leukaemia, association with a prior haema- this series had blasts between 20% and 29% and tological disease, often presence of multi-drug therefore, these were cases of AML with low blast resistance gene expression and high incidence of counts. Complete remission rates were similar in comorbidities and poor tolerance to chemotherapy.
the two arms (18% vs 16%)1.
Overall, there is reluctance in treating elderly AML, Subsequently, azacitidine vs CCR was studied in especially in the developing world. Achievement elderly AML with any blast count. Azacitidine of CR improves the quality of life and may also add showed improved median OS (10.4 months vs 6.5 to the duration of life. Hence, it makes sense to months, p=0.08). This was statistically significant.
have a therapeutic plan with positive intentions A pre-planned sensitivity analysis censored for even for such patients.
subsequent AML treatment showed a benefit in Although, there is no standard treatment regimen, terms of median OS of 12.1 months vs 6.9 months elderly AML can be treated with one of the follo- for azacitidine2. Currently, azacitidine has licensed wing options; standard induction therapy using 3+7 approval from European Medicines Agency (EMA) regime consisting of anthracyclin and cytosine for AML with 20% - 30% blast cell count.
arabinoside (Ara-C) with or without reduced intensitybone marrow transplantation, hypomethylating Decitabine 20 mg/m2 daily for 5 days per cycle has agents (HMA), low-dose cytosine arabinoside (LD- also been studied against CCR in a phase 3 trial of AraC), best supportive care (BSC) and clinical trial.
485 patients of AML above the age of 65 years.
There was a higher response (CR + CRi 17.8% vs Standard induction therapy which is best for 7.8%) and better survival. This reached statistical younger subjects may be the first choice even in significance (median OS 7.7 vs 5.0 months)3.
elderly AML, however, there is early death of 15% Currently, decitabine has approval by EMA for in most of the studies. Development of hypo- patients of 65 years and above with AML who are methylating agents (HMA) has brought out a new not considered candidates for standard induction ray of hope in this group of AML patients.
Hypomethylating agents were discovered almost Both azacitidine and decitabine have been 50 years ago. Initially, they were used in high doses approved by the US-FDA for AML with 20% to 30% for treating AML. Results with 3+7 protocol were of blasts. Studies have shown that Ten-Elevan- superior and hence HMA were almost forgotten.
Translocation-2 (TET2) and DNA methyltransferase In early part of this century, the interest in HMA 3A (DNMT3A) mutated AMLs benefit from these for treating myelodysplastic syndrome (MDS) epigenetic agents4.
The Sri Lanka Journal of Haematology MB Agarwal SLJH. 2015; 7(1): 15-18
Decitabine has also been used in another more may be no cross resistance between these two intensified dose schedule of 20 mg/m2 daily for 10 HMA. Recently, we have used azacitidine + lenali- days in 53 patients with median age of 74 years domide after failure of decitabine with good success and the outcome was encouraging5. Complete (unpublished observation). Future probably lies remission rate was 47% and CRIi 17%.
in rationally designed combination therapy inthese otherwise difficult to treat patients.
Dombret et al.6 have published the results ofinternational phase 3 study of azacitidine vs conventional care regimens in older patients with Contribution: This is the sole work of Dr. M.B.
newly diagnosed AML with >30% blasts. This is a study of 488 patients over the age of 65 years withnewly diagnosed AML having over 30% marrow Conflict-of-interest disclosure: The author declares blasts. Median overall survival (OS) was longer no conflict of interest.
with azacitidine vs CCR i.e. 10.4 months vs 6.5 Correspondence: Dr. M.B. Agarwal MD, Professor months. Univariate analysis showed favourable and Head, Department of Haematology, Bombay trends for azacitidine compared with CCR across Hospital Institute of Medical Sciences, Mumbai, all subgroups. They concluded azacitidine as an important treatment option for this difficult to treat AML population.
Ramos F et al.7 on behalf of European AML investi- gators have published their observations in using 1. Fenaux P, Mufti GJ, Hellström-Lindberg E, Santini V, azacitidine as frontline therapy for unfit AML Gattermann N, Germing U, et al. Azacitidine prolongs patients. This study includes newly diagnosed unfit overall survival compared with conventional care patients of AML treated in France, Austria and Italy.
regimens in elderly patients with low bone marrow European LeukaemiaNet response was achieved blast count acute myeloid leukaemia. J Clin Oncol. in 21.0% of 371 patients. This did not depend on 2010; 28(4): 562-569. DOI: 10.1200/JCO.2009.23.
bone marrow blast cell percentage. Median OS was 9.6 months and 40.6% of patients were alive at one 2. Dombret H, Seymour JF, Butrym A, et al. Results of a phase 3, multi-centre, randomized, open-label studyof Azacitidine vs conventional care regimens in older Lao Z et al.8 concluded that treatment of azacitidine patients with newly diagnosed AML. Haematologica. in elderly subjects with AML leads to fewer hospi- 2014; 99(S1). Abstract LB6212.
talisation days and infective complications but 3. Thomas XG, Arthur C, Delaunay J, Jones M, Berrak E, similar survival compared with intensive chemo- Kantarjian HM. A post hoc sensitivity analysis of survival probabilities in a multinational phase IIItrial of decitabine in older patients with newly Outcome of patients with AML who have failed diagnosed acute myeloid leukemia. Clin Lymphoma treatment with HMA is poor. Median survival is 6 Myeloma Leuk. 2014 Feb; 14(1): 68-72. doi: 10.1016/
months. There is no established therapy available j.clml.2013.09.007. Epub 2013 Oct 1.
except allogeneic haematopoietic stem cell 4. Im AP, Sehgal AR, Carroll MP, Smith BD, Tefferi A, Johnson DE, et al. DNMT3A and IDH mutations in acutemyeloid leukemia and other myeloid malignancies: The choice between azacitidine and decitabine as associations with prognosis and potential treatment the initial treatment of MDS or AML remains in strategies. Leukemia. 2014 Sep; 28(9): 1774-83. doi:
10.1038/leu.2014.124. Epub 2014 Apr 4.
5. Blum W, Garzon R, Klisovic RB, Schwind S, Walker A, Our patient is unique from the angle that Geyer S. Clinical response and miR-29b predictive azacitidine worked after failure of decitabine. This significance in older AML patients treated with a 10- goes to show that there are subjects where there day schedule of decitabine. Proc Natl Acad Sci U S A.
The Sri Lanka Journal of Haematology MB Agarwal SLJH. 2015; 7(1): 15-18
2010 Apr 20; 107(16): 7473-8. doi: 10.1073/pnas.
acute myeloid leukemia patients: clinical use and 1002650107. Epub 2010 Apr 5.
outcome prediction. Leuk Res. 2015 Mar; 39(3):296-
306. doi: 10.1016/j.leukres.2014.12.013. Epub 2014
6. Dombret H, Seymour JF, Butrym A, Wierzbowska A, Selleslag D, Jang JH, et al. International phase 3study of azacitidine vs conventional care regimens 8. Lao Z, Yiu R, Wong GC, Ho A. Treatment of elderly in older patients with newly diagnosed AML with patients with acute myeloid leukemia with >30% blasts. Blood. 2015 Jul 16; 126(3): 291-9. doi:
azacitidine results in fewer hospitalization days 10.1182/blood-2015-01-621664. Epub 2015 May 18.
and infective complications but similar survivalcompared with intensive chemotherapy. Asia Pac J 7. Ramos F, Thépot S, Pleyer L, Maurillo L, Itzykson R, Clin Oncol. 2015 Mar; 11(1): 54-61. doi: 10.1111/
Bargay J, et al. Azacitidine frontline therapy for unfit ajco.12331. Epub 2014 Dec 28.
The Sri Lanka Journal of Haematology WHE Alwis and N Ranasinghe. SLJH. 2015; 7(1): 19-23
SLJH. 2015; 7(1): 19-23
Hospital admission rate, pattern of lower limb deep vein thrombosis (DVT)
and its relationship to acquired risk factors among patients admitted to
Colombo South Teaching Hospital (CSTH) during the year 2010
WHE Alwis1, N Ranasinghe2
Key words: deep vein thrombosis, risk factors, hospital admission
Proximal DVT refers to involvement of poplitealveins or above and isolated calf vein thrombosis is Deep vein thrombosis (DVT) confers considerable considered as distal vein thrombosis.1 The clinical mortality and morbidity. However there is hardly conundrum is that symptoms (pain and swelling) any data available on prevalence and pattern of are often nonspecific or absent. However if left DVT among the Sri Lankan population. The study untreated a thrombus could become fragmented was carried out with the aim of assessing hospital or dislodged and migrate to obstruct the arterial admission rate, pattern of lower limb DVT (LL-DVT) supply to the lungs causing potentially life and its relationship to acquired risk factors among threatening pulmonary embolism. Over the past patients admitted to a tertiary care hospital. Total 25 years the pathophysiology of DVT has become of 34 patients were identified with LL-DVT for the much better understood. Over a century ago Rudolf year 2010. Data were collected from bed head Virchow described three features which are tickets of discharged patients, anti-coagulation critically important in the development of venous clinic records and doppler ultrasound scan lists. The thrombosis2; venous stasis, activation of blood hospital admission rate of LL-DVT among the study coagulation, and venous damage.
population was 25 per 100,000 admissions per year.
Sixty five percent (n=22) had proximal LL-DVT These factors are known as the "Virchow Triad".
whereas 21% (n=7) had distal LL-DVT. An acquired Under normal circumstances a physiologic balance risk factor was identified in 68% (n=23). Forty eight is present between factors that promote and retard percent (n=11) of patients had immobility as an coagulation. A disturbance in this equilibrium may acquired risk factor and 26% (n=6) of patients had result in the coagulation process occurring at an multiple risk factors. Eight patients (47%) with inopportune time or location or in an excessive proximal LL-DVT had non transient risk factors manner. Numerous factors, often in combination compared to none of the patients with distal LL- contribute to DVT. These may be categorized as DVT. Being more than 40 years and female had acquired or inherited. Acquired risk factors could more events of LL-DVT compared to <40 years and be of two types and include transient acquired risk males (P<0.05).
factors (e.g. pregnancy, post-operative) and non-transient acquired risk factors (cancer, antiphos- pholipid syndrome). The diagnosis of DVT histori- Deep vein thrombosis (DVT) refers to the cally required venography which is expensive and formation of one or more thrombi in one of body's invasive. Even though venography is considered large veins most commonly in the lower limbs.
the criterion of standard since 1990 most widelyused method for diagnosis is non-invasive sono-graphic examination.3 The simple and cheaper D- 1Speciality Doctor in Haematology, Great Western dimer test has been validated as an initial scree- Hospital, Swindon, UK. 2Consultant Haematologist, ning test and confers a high negative predictive Colombo South Teaching Hospital, Kalubowila, Sri value when it is negative with a low clinical pro- The Sri Lanka Journal of Haematology

WHE Alwis and N Ranasinghe. SLJH. 2015; 7(1): 19-23
Early recognition and appropriate treatment of DVT detected were 34. Therefore, the hospital admission and its complications can save many lives. Similarly rate of LL-DVT among the study population was 25 recognition of high risk individuals and initiation per 100,000 admissions per year. The age distri- of thromboprophylaxis can be not only lifesaving bution of the study population was from 19 years but also much more cost effective. There is no to 81 years and the median age was 41 years (Table country data for hospital admission rates for DVT 1). Females had significantly more LL-DVT com- and its pattern in Sri Lanka. The purpose of this pared to males being 73.5% vs 26.5% (p<0.001).
study was to determine the hospital admission Proximal DVT was higher than distal DVT (Table 2).
rate, pattern of lower limb DVT and its relationshipto acquired risk factors among patients admitted Table 1. Age distribution of the
to Colombo South Teaching Hospital during the Age category
A descriptive cross sectional study was carried out at the Haematology Department, Colombo SouthTeaching Hospital (CSTH) among patients admitted during the year 2010 with lower limb DVT (LL-DVT).
All patients with LL-DVT admitted during the year2010 were identified from the doppler ultrasound Table 2. Distribution of the site
scan list available at the Radiology Department, CSTH. This was further supported by the anti-coagulation clinic register at the Haematology Site of LL-DVT
Department, CSTH where there is a record of all the patients referred for further management and follow up. Patients' details such as demographicdata, risk factors for LL-DVT and investigations related to LL-DVT were obtained from their bed head tickets and the anticoagulation clinic book.
Transient risk factors for LL-DVT such as pregnancy, (LL - DVT : Lower limb deep vein thrombosis) postpartum period, immobility, post-operativeperiod, intensive care unit admission, pharma- An acquired risk factor was present in 68% (n=23) cological agents, trauma, other co-morbid factors (Figure 1). A single risk factor was present in 74% (e.g. presence of uterine fibroids) were recorded.
(n=17) and 26% (n=6) had multiple risk factors.
The non-transient risk factors assessed were anti- Immobility was the commonest risk factor identi- phospholipid syndrome (APLS), cancer, varicose fied, followed by pregnancy and puerperium, and veins, and congestive cardiac failure, and myelo- presence of APLS and cancer / a MPN (Table 3).
proliferative neoplasm (MPN). Data collection was When the risk factors were categorized 52 % (n=12) done for a period of three months. A data extraction were transient risk factors and 48% (n=11) were sheet was used for data collection. All components non-transient (Table 4).
of the data collection format were manuallychecked and data cleaning and coding was done.
Data entry and statistical analyses were done usingthe software package SPSS (version 15). Ethicalclearance for the study was obtained from theethical review committee of the CSTH.
Total admissions for the year 2010 to CSTH were Figure 1. Distribution of risk factors in the
136,794. The total number of LL-DVT patients The Sri Lanka Journal of Haematology WHE Alwis and N Ranasinghe. SLJH. 2015; 7(1): 19-23
Table 3. Distribution of risk factor types
Risk factor
Pregnancy and puerperium Intensive care unit admission Congestive cardiac failure Table 4. Distribution of risk factors by site
Site of LL-DVT
Non Transient
LL-DVT: Lower limb deep vein thrombosis In the study population proximal LL-DVT wascommoner than distal LL-DVT or LL-DVT occurring The annual hospital admission rate of LL-DVT in both distal and proximal veins (Table 2). Varying among the study population was 25 per 100,000 results have been reported in the world literature admissions. This is a rising trend compared to what for the frequencies of distal versus proximal vein White et al. reported in 2005 of the rate of DVTamong Asians/Pacific Islanders living in California thrombosis. Some report as distal DVT being com- which was 21 per 100,000.4 This may reflect the moner while others report an opposite view.9,10 rising trend in line with studies done in Singapore The diagnostic strategies looking mainly into which concluded that even though DVT is not proximal vein thrombosis could be a one reason common in Asians as it is in Caucasians, the pre- for this observation and it is also well recognized valence now is much higher than it was earlier.5-7 The that ultrasound scan being particularly user relationship of LL-DVT to age and gender was dependent and detection rates of distal LL-DVT similar to what is reported in other populations; vary considerably between operators and depart- where elderly females have a higher tendency to ments.11,12 Another contributing factor for this could be variations in lower limb venous anatomy.13 The Sri Lanka Journal of Haematology WHE Alwis and N Ranasinghe. SLJH. 2015; 7(1): 19-23
The relationship between LL-DVT and associated risk factors were analyzed in the study. Majority Contribution: Both authors contributed equally.
68% (n=23) had acquired risk factors. Immobilitywas the most common risk factor (47.8%), while Conflict-of-interest disclosure: The authors declare malignancy/ MPN, pregnancy and APLS were also no conflict of interest.
among the risk factors (Table 3). These results are Correspondence: Dr. WHE Alwis, Haematology similar to data reported in Asian DVT cohorts and Department, Great Western Hospital, Swindon, world literature.7,14,15 It is important to note that SN36B, United Kingdom.
26.1% of patients had multiple risk factors.
It was found that proximal LL-DVT and extensiveLL-DVT (LL-DVT involving both proximal and distalveins) are commonly associated with non-transient risk factors (malignancy, APLS, congestive heart The authors would like to acknowledge the director failure, autoimmune haemolysis and varicose of Colombo South Teaching Hospital, Kalubowila, veins). None of the patients with distal LL-DVT had Sri Lanka for giving permission to carry out this non-transient risk factors (Table 4). This finding study. They also gratefully acknowledge the support reported data on the risk factors on distal cooperation of all staff and patients involved in versus proximal thrombosis.9 Approximately equal percentages of proximal and distal LL-DVT wereassociated with transient risk factors; 41% and 43%respectively in this study. (9/22 patients with proximal DVT and 3/7 patients with distal DVT had 1. Guidelines on oral anticoagulation with warfarin – transient risk factors – Table 2 and Table 4). Therefore fourth edition. Keeling D, Baglin T, Tait C, Watson H, we cannot conclude that distal LL-DVT is more Perry D, Baglin C, Kitchen S, Makris M; British commonly associated with transient risk factors Committee for Standards in Haematology. Br J compared to proximal LL- DVT.9 Haematol. 2011 Aug; 154(3): 311-24. doi: 10.1111/
j.1365-2141.2011.08753.x. Epub 2011 Jun 14.
The main limitation of the study was the small 2. Dickson BC. Venous thrombosis: on the history of sample size. Smoking is well known risk factor Virchow's triad. University of Toronto Medical Journal. associated with DVT16. This was not analyzed as 2004; 81: 166-71.
the study was mainly based on case notes and 3. Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells patients were not directly interviewed. An PS, Stevenson MD, et al. American College of Chest acquired risk factor was not identified in a total of Physicians. Diagnosis of DVT: Antithrombotic Therapy 11 patients. These patients may have an acquired and Prevention of Thrombosis, 9th ed: American risk factor which was not studied or have an College of Chest Physicians Evidence-Based Clinical inherited risk factor. Inherited thrombophilia as a Practice Guidelines. Chest. 2012 Feb; 141(2Suppl):
risk factor was not analyzed during the study.
e351S-418S. doi: 10.1378/chest.11-2299.
4. White RH, Zhou H, Murin S, Harvey D. Effect of Conclusions and recommendations
ethnicity and gender on the incidence of venousthromboembolism in a diverse population in It is the standard practice in most of the developed California in 1996. Thromb Haemost. 2005 Feb; 93(2):
countries including United Kingdom to assess the risk of thrombosis in hospitalized patients and 5. White RH. The epidemiology of venous throm- provide appropriate thromboprophylaxis. It is boembolism. Circulation. 2003 Jun 17; 107(23 Suppl
widely accepted that this is the most cost effective way of reducing death associated with VTE, 6. Yeo DX, Junnarkar S, Balasubramaniam S, Tan YP, Low reducing the treatment cost in DVT and treatment JK, Woon W, et al. Incidence of venous thrombo- cost in long term complications.17 Therefore it is embolism and its pharmacological prophylaxis in important for us to think about a national guideline Asian general surgery patients: a systematic review.
and protocol based on the guideline for prevention World J Surg. 2015 Jan; 39(1): 150-7. doi: 10.1007/
of thrombosis.
The Sri Lanka Journal of Haematology WHE Alwis and N Ranasinghe. SLJH. 2015; 7(1): 19-23
7. Lee LH. Clinical update on deep vein thrombosis in institution. Thromb Haemost. 2009 Jun; 101(6):
Singapore. Ann Acad Med Singapore. 2002 Mar; 31(2):
13. Quinlan DJ, Alikhan R, Gishen P, Sidhu PS. Variations 8. Silverstein MD, Heit JA, Mohr DN, Petterson TM, in lower limb venous anatomy: implications for US O'Fallon WM, Melton LJ 3rd. Trends in the incidence diagnosis of deep vein thrombosis. Radiology. 2003 of deep vein thrombosis and pulmonary embolism: Aug; 228(2): 443-8. Epub 2003 Jun 23.
a 25-year population-based study. Arch Intern Med.
1998 Mar 23; 158(6): 585-93.
14. Wakefield TW, McLafferty RB, Lohr JM, Caprini JA, Gillespie DL, Passman MA. Executive Committee of 9. Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche the American Venous Forum. Call to action to prevent JP, Righini M, Brisot D, et al. OPTIMEV-SFMVInvestigators. Comparative study on risk factors and venous thromboembolism. J Vasc Surg. 2009 Jun; early outcome of symptomatic distal versus proximal 49(6): 1620-3. doi: 10.1016/j.jvs.2009.01.058.
deep vein thrombosis: results from the OPTIMEV 15. Rocha AT, Paiva EF, Lichtenstein A, Milani R Jr, study. Thromb Haemost. 2009 Sep; 102(3):493-500.
Cavalheiro CF, Maffei FH. Risk-assessment algorithm and recommendations for venous thromboembolism 10. Labruto F, Westerberg M, Magnusson M. Deep venous prophylaxis in medical patients. Vasc Health Risk thrombosis of the lower limb: no difference in Manag. 2007; 3(4): 533-53.
duration of symptoms between proximal and distal
disease. Clin Appl Thromb Hemost. 2011 Aug; 17(4):
16. Golomb BA, Chan VT, Denenberg JO, Koperski S, Criqui 393-5. doi: 10.1177/1076029610368672. Epub 2010 MH. Risk marker associations with venous throm- botic events: a cross-sectional analysis. BMJ Open.
2014 Mar 21; 4(3): e003208. doi: 10.1136/bmjopen-
11. Cowell GW, Reid JH, Simpson AJ, Murchison JT. A profile of lower-limb deep-vein thrombosis: thehidden menace of below-knee DVT. Clin Radiol. 2007 17. NICE guideline CG 92 Venous thromboembolism – Sep; 62(9): 858-63; discussion 864-5. Epub 2007
Reducing the risk for patients in hospital January 2010. Availabe at https://www.nice.org.uk/guidance/ 12. Ng HJ, Lee LH. Trends in prevalence of deep venous cg92/chapter/Introduction. [Accessed 15 February thrombosis among hospitalised patients in an Asian The Sri Lanka Journal of Haematology SLJH. 2015; 7(1): 24
CME Article (Series III)
Theme: Acute trauma coagulopathy and massive transfusion
HWCK Kulathilake1, I Wijesiriwardena1
Questions 1 and 2 are multiple choice questions to activate your brain cells to the pathogenesis of acute
trauma coagulopathy (ATC) and massive transfusion, as there are new insights into this subject.
Acute trauma coagulopathy is initiated by vascular endothelial damage b) protein C activation pathway is one of the major contributors to its pathogenesis has the same pathophysiology of disseminated intravascular coagulation (DIC) d) haemodilution is beneficial in prevention of ATC e) hypothermia aggravates the condition Complications of massive transfusion include e) metabolic alkalosis Answer Grid:
The answers are given in page 33 with the explanations.
1Senior Lecturer, Consultant Haematologist, Department of Pathology, University of SriJayawardenapura, Sri Lanka.
Correspondence: Dr. I WijesiriwardenaE-mail: [email protected] The Sri Lanka Journal of Haematology EL Asfir et al. . 2015; 7 JH. 2015;
(1): 25-28 7(1): 25-28
Case report I
Paroxysmal cold haemoglobinuria in a pregnant woman leading to severe
anaemia and fetal loss
EL Asfir1, N Senadheera2, S Jayasinghe3, H Liyanage3
Key words: paroxysmal cold haemoglobinuria; steroids; fetal loss
Case report
Paroxysmal cold haemoglobinuria (PCH) is an A 23-year-old female in her second pregnancy, pre- autoimmune haemolytic anaemia which gives rise sented to a local hospital at 32 weeks of gestation, to intravascular haemolysis and a varying degree with evidence of intravascular haemolysis and was of anaemia. Its presentation in pregnancy is rare transferred to our hospital, a tertiary care women'shospital for specialized care.
but can be potentially fatal to both mother andfetus. This case report describes a pregnant woman This presentation was while convalescing following with PCH presenting with acute severe anaemia a chickenpox infection, and she had developed which led to fetal loss. The mother was successfully fever and lower abdominal pain immediately after managed with blood transfusions and steroid a cold bath. This was associated with passage of therapy. We stress the importance of timely dark urine. On admission to the local hospital, she intervention when managing similar patients.
was very pale and icteric and the haemoglobin (Hb)level was 54 g/L. As facilities for transfusion wasnot available in this hospital she had to be trans- ferred to the nearest provincial general hospital.
Paroxysmal cold haemoglobinuria (PCH) is a rare There the investigations carried out detected a form of autoimmune haemolytic anaemia more positive direct antiglobulin test (DAT) and indirect commonly seen in children. Historically this was hyperbilirubinaemia. By this time she complained described in association with syphilis but nowa- of reduced fetal movements and an ultrasoundscan done showed absence of fetal heart beat con- days it's mostly seen following viral or bacterial firming an intrauterine fetal death (IUD). As com- infections1-5. The haemolysisin PCH is mediated patible blood for transfusion could not be provided by a biphasic IgG autoantibody that triggers com- she was transferred to our hospital.
plement – mediated intravascular haemolysis.1-4In adults, it is rare and represents less than 1% of On arrival she was drowsy, dyspnoeic, pale, icteric, all autoimmune haemolytic anaemias.6 blood pressure was 85/50mmHg. The Hb level was24 g/L, packed cell volume (PCV) 6.1%, white cell We report a case of a pregnant woman who pre- count (WBC) 17.3x109/L, with neutrophils – 78% sented with acute severe haemolysis and fetal loss, and lymphocytes – 21%. Platelet count – 437x109/L, and diagnosed as having PCH and successfully indirect bilirubin level – 8.4mg/dL and the potas- managed with blood transfusions and steroids. To sium level – 6.8mmol/L. Blood picture showed redcell agglutination, many spherocytes, occasional our knowledge PCH presenting in pregnancy has polychromatic cells, occasional fragmented red been reported only once before in the literature.7 cells and neutrophil erythrophagocytosis. (Figure1 & 2). Absolute reticulocyte count was 0.6 x 109/Land reticulocyte index was 0.2%. Serum LactateDehydrogenase (LDH) level was elevated (3250u/L). The DAT was strongly positive with anti-C3d but 1Senior Registrar, Critical Care Medicine, 2Consultant negative with anti-IgG. Mycoplasma antibody was Haematologist, 3Consultant Anesthetist, De Soysa negative. Indirect Donath-Landsteiner (DL) test was Hospital for Women, Sri Lanka. positive confirming PCH.
The Sri Lanka Journal of Haematology

EL Asfir et al. SLJH. 2015; 7(1): 25-28
Figure 1. Peripheral blood smear (Leishman
Figure 2. Peripheral blood smear (Leishman
stain, x 100) – Showing erythrocyte
stain, x 100) – Showing erythrophagocytosis
She was managed in the Intensive care unit as shewas drowsy and dyspnoeic, and then was keptwarm and two units of uncross matched O negativepacked red blood cells were given soon afteradmission via the blood warmer and followed byone unit of cross matched washed O positive redcell concentrates. Folic acid 5 mg daily wascommenced on the same day. At the end of dayone the Hb level increased to 80g/L. The dead fetuswas delivered spontaneously on the following day.
Figure 3. Showing the temporal profile of the
On the second day the Hb level dropped again to 69 g/L, and there was a persistently low absolute (IVMP – Intravenous methyl prednisolone, reticulocyte count of 1.7 x 109/L and reticulocyte OP – Oral prednisolone, LDH – Lactate index was 0.7%. This day the urine output reduced dehydrogenase level) to < 0.5ml/kg/h. Another unit of blood was trans-fused. Despite the blood transfusion the Hb level continued to fall and dropped from 80 g/L to 71 g/Lthe next 24 hours. Therefore intravenous (IV) At the time PCH was first described by Donath andLandsteiner in 1904, it was a chronic relapsing methyl prednisolone (MP) 500mg daily was com- condition affecting mainly adults and 90% were menced on day three. Following commencement secondary to syphilis. Since then the presentation of IVMP, the Hb level improved over the next four has changed due to the effective treatment of days to 90 g/L without any further blood trans- syphilis and now PCH is seen mostly in children as a fusions and the LDH level gradually came down to post viral syndrome commonly following infections 1400U/L (Figure 3). The IVMP was given for 3 days such as chickenpox, mumps and measles. Less com- followed by oral prednisolone 40mg daily. On monly, bacterial infections with Haemophilus discharge she was referred to the local hospital influenzae, Escherichia coli and Staphylococcus for follow up. Prednisolone was tailed off over a aureus have been implicated3,8. The acute non- few weeks. Her Hb level remained stable at her relapsing form of PCH has been documented to follow up visit to the local hospital.
occur in adults9.
The Sri Lanka Journal of Haematology EL Asfir et al. SLJH. 2015; 7(1): 25-28
Our patient had typical laboratory findings of PCH.
washed RBC units has not been proven to improve Her DAT was positive for complement C3d but transfusion safety, but this can be performed if negative for IgG. Although DL antibodies are of IgG patient's condition remains refractory to standard class, this is a common finding in PCH. There are warmed blood transfusions.13 also reported cases where DAT has been negative.
Non detection of DL antibodies can be due to low- The severity of anaemia and the reticulocytopenia affinity of the IgG, the immunoglobulins being RBC- prompted the initiation of steroids in our patient bound, or IgG levels being below the threshold resulting in a dramatic response. There is no uniform level of the test. Another postulation is that the IgG consensus on the role of steroids in the manage- autoantibodies are directed against reticulocytes ment of PCH but several reports show that it has or mature RBC precursors rather than red blood cells, been used successfully in similar circumstances.10 which is based upon the presence of reticulo- Usually, a remission can be seen in 1 to 3 weeks.
cytopenia in some cases.10 Use of special blood Once the haemolysis is controlled, corticosteroids bank techniques may overcome some of these can be tapered. Close monitoring for relapses is false negativities.
required for a few weeks, with slowing of cortico-steroid taper if signs of possible relapse develop.
Our patient had a relative reticulocytopenia whichagain is a known finding in PCH.11 This reflects an The other available treatment options are plasma- ineffective erythropoiesis either due to des- pheresis and rituximab therapy.10,14 Given the truction of precursor red cells by DL antibodies or transient and relatively brief production of DL a result of viral haematopoietic suppression.
antibodies after a viral infection, clearance of theantibody may be possible with plasma exchange.
A striking feature in the peripheral blood film was Another reason for the effectiveness of plasma- the erythrophagocytosis by neutrophils. Although pheresis in this condition is that the antibody pre- erythrophagocytosis by monocytes occur in autoim- ferentially binds to the RBC, shifting the antibody mune haemolytic anaemia of various aetiologies, equilibrium to the intravascular component, erythrophagocytosis by neutrophils is most strongly allowing easy removal.10 Rituximab has also been associated with PCH.12 Other cases where this has used successfully to treat relapses of chronic PCH been reported in are cold haemagglutinin disease, in an adult patient, where disease was unres- incompatible blood transfusions, haemolytic disease ponsive to steroids.14 Splenectomy is usually of the newborn and potassium chloride poisoning.12 ineffective as the haemolysis is intravascular.
Paroxysmal cold haemoglobinuria is usually self An important issue which was evident in the limiting and requires only supportive care during presentation of this patient was a lapse in the the period of acute haemolysis. However the degree emergency transfusion facilities in peripheral of haemolysis may vary between patients because hospitals. The DAT positivity can pose problems for the characteristics of the haemolytic antibody are the blood bank when selecting red cell units by routine highly variable. The amount of the antibody and methods. However it needs to be emphasized that the affinity of the antibody for the red blood cell transfusion of uncrossmatched group O blood in surface are important determinants of the severity such situations is justified and can be lifesaving15.
of haemolysis. Furthermore, some antibodies mayfix complement less efficiently.6 IgG antibodies cancross the placenta and result in haemolysis in the fetus. Our patient experienced severe haemolysis Contribution: All authors contributed equally.
and anaemia leading to IUD of the fetus.
Conflict-of-interest disclosure: The authors declareno conflict of interest.
Management includes avoidance of cold tem-perature, folic acid supplements and transfusion Correspondence: Dr. N Senadheera, Consultant of red cell concentrates. Uncross matched group O Haematologist, De Soysa Hospital for Women, blood can be given until group compatible blood Colombo 8, Sri Lanka.
is available after cross matching at 37°C. Utilizing The Sri Lanka Journal of Haematology EL Asfir et al. SLJH. 2015; 7(1): 25-28
Blajchman MA. Transient Donath-Landsteiner
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11. Sokol RJ, Booker DJ, Stamps R. Erythropoiesis: Paroxysmal Cold Haemoglobinuria: A Clinico- 4. Sokol RJ, Hewitt S, Booker DJ. Erythrocyte auto- Pathological Study of Patients with a Positive Donath- antibodies, autoimmune haemolysis, and myelody- Landsteiner Test. Hematology. 1999; 4(2): 137-64.
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Donath-Landsteiner Antibodies in a 5-year-oldFemale Presenting with Hemolytic Anemia. Lab Med. 13. Roy-Burman A, Glader BE. Resolution of severe 2010; 41(4): 209-12.
Donath-Landsteiner autoimmune hemolytic anemiatemporally associated with institution of plasma- 6. Petz LD. Cold antibody autoimmune hemolytic pheresis. Crit Care Med. 2002 Apr; 30(4): 931-4.
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Rituximab as successful therapy in a patient with 7. Akpoguma AO, Carlisle TL, Lentz SR. Case report: refractory paroxysmal cold hemoglobinuria.
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matched group-specific blood. Kathmandu Univ Med 8. Wolach B, Heddle N, Barr RD, Zipursky A, Pai KR, J (KUMJ). 2005 Jan-Mar; 3(1): 76-8.
The Sri Lanka Journal of Haematology ONKD Gamage et al. SLJH. 2015; 7
2015; 7(1): 29-31
Case report II
Lupus anticoagulant – hypoprothrombinaemia syndrome
ONKD Gamage1, MM Jayatilaka2, PM Punchihewa3
Key words: bleeding, lupus anticoagulant, acquired hypoprothrombinaemia, systemic lupus
erythematosus
acquired thrombocytopathy.2-4 Lupus anticoa-gulant – hypoprothrombinaemia syndrome (LA- Lupus anticoagulant – hypoprothrombinaemia HPS) is a rare acquired disorder caused by pro- syndrome (LA-HPS) is a rare acquired disorder thrombin antibodies, in adults or in children mostly caused by the combination of lupus anticoagulants associated with systemic lupus erythematosus (SLE), and anti-prothrombin antibodies. A 6-year-old girl has been reported to manifest with a bleeding was admitted with intractable bleeding from a diathesis caused by factor II(FII) deficiency.3,4 tooth. Both prothrombin time (PT) and activatedpartial thromboplastin time (aPTT) were prolonged We report the clinical case of a girl whose onset of with test to control ratio > 3 and aPTT did not getcorrected following 50:50 mix with pooled normal SLE was a bleeding manifestation caused by a fresh plasma (PNP); the inhibition was not time serious coagulopathy with prolonged PT and aPTT dependent. The PT got corrected following 50:50 in the presence of LA due to a LA-HPS.
mix. Both dilute Russell viper venom time (dRVVT)and kaolin clotting time (KCT) were strongly positive.
Case report
Antinuclear antibody (ANA) and anti-double A 6-year-old girl was admitted to ward 09, of the Lady stranded DNA (anti-dsDNA) were positive. Based Ridgeway Hospital with history of prolonged and on the coagulation derangements and positivity excessive bleeding following an accidental injury to for the lupus anticoagulant (LA) and ANA and DS/ a tooth. The clinical examination was unremarkable DNA the diagnosis of the rare lupus anticoagulant- other than the mild bleeding from the tooth socket.
acquired hypoprothrombinemia syndrome (LA- The girl had no past history of congenital coagulo- HPS) was made. The patient was treated with high pathy or other important illnesses. She had no family dose corticosteroids and normal coagulation test history of any bleeding disorder. She did not give a results were obtained.
history of or have clinical features to indicate SLE.
The laboratory investigations on admission were Lupus anticoagulant (LA) is a group of antibodies as follows: Full blood count haemoglobin (Hb) directed against phospholipid binding proteins.
level 131 g/L, red blood cells (RBC) 4.98 x 1012/L, These phospholipids are essential for the activation mean cell volume (MCV) 77.8fL, mean cell haemo- of main steps of the coagulation cascade.1 The LA, globin (MCH) 26.2 pg, mean cell haemoglobin con- results in thrombosis in-vivo than bleeding due to centration (MCHC) 33.7 g/dl, white blood cell count activation of phospholipids and binding proteins, (WBC) 12.6 x 109/L with neutrophils -56%, endothelial activation and inactivation of natural lymphocytes -34% and monocytes 4%, and platelet anticoagulants.1 The LA may manifest with bleeding count 410 x 109/L. Erythrocyte sedimentation rate when associated with an acquired factor VIII (ESR) 74 mm 1st hr. Blood picture: RBC showed inhibitor or rarely due to thrombocytopenia, or an moderate rouleaux formation and appeared normo-chromic normocytic. WBC and platelet morphologywere unremarkable. Reticulocyte count was 1%.
1Senior Registrar in Clinical Haematology, University Serum bilirubin levels were normal. Coagulation Medical Unit, Faculty of Medicine, Sri Jayawardena- tests: Bleeding time – 3 minutes (Control 0-6min), pura, 2Consultant Haematologist, 3Consultant PT 27.5s (control 11.0s), aPTT 81.7s (control 26.0s), Paediatrician, Lady Ridgeway Hospital, Colombo, thrombin time (TT) 18.2s (control 15.6s). Fibrinogen Sri Lanka. level (antigen) 3.3 g/L (normal range 1.5- 4.0/L) and The Sri Lanka Journal of Haematology ONKD Gamage et al. SLJH. 2015; 7(1): 29-31
fibrinogen activity by Clauss method 372 g/L lation inhibitor. The presence of a time dependent (normal range 150- 400g/L). Correction studies with inhibitor was excluded by the 2 hour incubation pooled normal fresh plasma (PNP) (50:50 mix): PT test. Both strongly positive dRVVT and KCT tests was corrected, and the aPTT remained prolonged indicated the presence of LA. Positive ANA, ds-DNA without correction. The inhibitor screening: and DAT indicated the presence of an autoimmune negative (difference of aPTT following 50:50 mix disease. Although the clinical criteria were not with PNP at and after 2 hours incubation was < 6 fulfilled for SLE and factor II assay and prothrombin sec). Lupus anticoagulant (LA) screening: dRVVT- LA antibody level was not performed due to the ratio 2.3 (normal < 1.2) and KCT test >5 min, control unavailability of the facilities to test; based on the 82s. Liver function tests and renal function tests were test results diagnosis of the rare lupus anti- normal. Urine analysis normal with no red cell casts.
coagulant – acquired hypoprothrombinemia Direct antiglobulin test (DAT) was positive with C3d syndrome (LA-HPS) was made. Repeating of the specificity. Anti-nuclear antibody (ANA) was posi- ANA, ds-DNA and the dRVVT test was planned to tive with a titre > 1/80 by direct immunofluorescence confirm persistent positivity after 12 weeks.
method. The ds-DNA antibody was positive byenzyme linked immunosorbent assay method.
The patient was treated with oral prednisolone1mg/kg/day and the coagulation test results Prolongation of aPTT without being corrected reverted to normal within 2 weeks of treatment following PNP mix indicated presence of a coagu- Table 1. Coagulation test results from the date of admission
Days Vs Tests
50:50 mix with PNP 50:50 mix with PNP Inhibitor screening (aPTT 50:50 mix with PNP)Fresh Mix (At) Incubated mix (Affter 2hrs) LA1(Screening test) LA2 (Confirmation test) 2.3 (1.2) (Stronglypositive) *50:50 correction = mixture of patient's plasma and pooled normal fresh plasma (PNP)at a ratio of 1:1, PT - prothrombintime, aPTT - activated partial thromboplastin time test, TT - thrombin time, dRVVT = dilute Russell viper venom time,KCT = kaolin clotting time, LA 1 = lupus anticoagulant screening reagent 1, LA 2 = lupus anticoagulant screening reagent 2,S = seconds, Min = minutes The Sri Lanka Journal of Haematology ONKD Gamage et al. SLJH. 2015; 7(1): 29-31
Patient was followed up at the paediatric clinic and patient LA-HPS was the first and the most impor- the haematology clinic regularly with the assess- tant clinical sign of the onset of the systemic illness.
ment of clinical parameters and the relevant hae- Our patient's LA-HPS was successfully treated with steroids, confirming that this treatment representsthe leading therapy for this coagulopathy.
Lupus anticoagulant is the coagulation based demonstration of antiphospholipid antibodies by Contribution: All authors contributed equally.
phospholipid dependent coagulation tests dRVVT Conflict-of-interest disclosure: The authors declare and KCT. Hypoprothrombinaemia results in pro- no conflict of interest.
longation of both PT and aPTT with normal TT andcorrected by mixture of patient's plasma and Correspondence: Dr. Gamage ONKD, Senior Registrar normal plasma at a ratio of 50:50 which can be Clinical Haematology, University Haematology Unit, confirmed by the factor II level assay.3-6 Colombo South Teaching Hospital, Kalubowila, SriLanka.
The LA-HPS is a rare acquired disorder associated with haemorrhagic manifestations. It appearsmostly in young females, even in infants. It presents as a complication of SLE or transient viralinfections.2,3 1. Mackie I, Moore GW, Greer IA, Greaves M. British Committee for Standards in Haematology. Guidelines The LA-HPS is characterised by a very strong LA and on the investigation and management of antiphos-
pholipid syndrome. Br J Haematol. 2012 Apr; 157(1):
presence of polyspecific antibodies. They bind to the epitopes of the anionic phospholipids and of Epub2012 Feb 8.
prothrombin, but they do not neutralise pro-thrombin. Therefore, a FII activity deficiency is not 2. Sarker T, Roy S, Hollon W, Rajpurkar M. Lupus anti- coagulant acquired hypoprothrombinemia syndrome due to an inhibitor, as suspected, but to an evident in childhood: two distinct patterns and review of the factor decrease owing to the higher clearance of the literature. Haemophilia. 2015 Nov; 21(6): 754-60.
prothrombin-antibody complex in the reticuloen-dothelial system.3,4 3. Vivaldi P, Rossetti G, Galli M, Finazzi G. Severe bleeding due to acquired hypoprothrombinemia-lupus anticoagulant syndrome. Case report and Corticosteroid therapy is the treatment of choice review of literature. Haematologica Haematologica. for LA-HPS associated with SLE; it normalizes the 1997 May-Jun; 82(3): 345-7.
PT time.2-4 In cases associated with a viral infection, 4. W Collins P, Chalmers E, Hart D, Jennings I, Liesner R, LA-HPS reverses spontaneously with the resolution Rangarajan S, et al. United Kingdom Haemophilia of the infection. Therefore, steroid therapy is not Centre Doctors' Organization. Diagnosis and manage- necessary.2-4 Given the complex coagulopathy of ment of acquired coagulation inhibitors: a guideline our patient, caused by an acquired inhibitor, and from UKHCDO. Br J Haematol. 2013 Sep; 162 (6):
the risk of serious major haemorrhage, we com- 758-73. doi: 10.1111/bjh.12463. Epub 2013 Jul 25.
menced steroid therapy and was able to obtain 5. Ghirardello A, Doria A, Ruffatti A, Rigoli AM, Vesco P, complete normalisation of PT and APTT after of Calligaro A, et al. Antiphospholipid antibodies (aPL) two weeks of treatment.
in systemic lupus erythematosus. Are they speci-fictools for the diagnosis of aPL syndrome? Ann Finally, we conclude that, LA not only produces Rheum Dis. 1994 Feb; 53(2): 140-2.
APTT prolongation, but may also produce a more 6. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey complex coagulopathy with PT prolongation-LA- RL, Cervera R, et al. International consensus state- HPS type. LA-HPS onset could be haemorrhage ment on an update of the classification criteria for related with an added FII deficiency and marked definite antiphospholipid syndrome (APS). J Thromb inhibitor effects of APTT dependent factors. In our Haemost. 2006 Feb; 4(2): 295-306.
The Sri Lanka Journal of Haematology

MN Dilhani et al. SLJH. 2015; 7
2015, 7: 32
Images in Haematology
A case of Large Granular Lymphocytosis
MN Dilhani1, S Suresh2, J Thennakoon3
Figure 1. Peripheral blood smear (Leishman stain, ×100) – a monomorphic population of moderate to large
lymphocytes with abundant pale cytoplasm containing many azurophilic granules, eccentric nuclei with
condensed chromatin.
A 65-year-old previously well female without with T cell large granular lymphocytic leukemia lymphadenopathy or organomegaly had peripheral blood lymphocytosis of 11.6x109/L. Total whitecell, neutrophil and platelet counts were 14.9x109/ LGL proliferations are either nonclonal in aetiology L, 2.9x109/L,250x106/L respectively. Haemoglobin (viral infections, auto immune conditions, post level was 11.4g/dL. Lymphocyte morphology re- splenectomy, bone marrow or solid organ trans- sembled large granular lymphocytes (LGL) (Figure plantation) or clonal (aggressive T-LGL leukaemia 1). Marrow aspirate showed 70% cells with LGL mor- and chronic or aggressive NK cell leukaemia).
phology, and immunophenotype was CD3+(89%), Clinical presentation and immunophenotype help CD8+( 84%), CD4+ (80%), CD57+(80%), CD2+(94%), to determine the diagnosis.
CD5+(88%), CD56-, CD7-TCRβ+(89%) and TCRγδ-.
Marrow biopsy had a 30% interstitial infiltrate of lymphocytes being CD 3+, CD5 +, CD 57+ and 1. Swerdlow SH, Campo E, Jaffe ES, Pileri S, Stein H, Thiele scattered positive for CD20/CD8.
J, Vardiman J. (2008) WHO Classification of Tumoursof Haemopoietic and Lymphoid Tissues, 4th edn.
Cellular morphology favored T or Natural Killer (NK) International Agency for Research on Cancer Press, cell disorder. Immunophenotype was compatible Lyon, France.
1Registrar in Haematology, Department of Pathology, Haematology Unit, Faculty of Medicine Ragama,2,3Consultant Haematologist, Department of Haematology, National Cancer Institute Maharagama,Sri Lanka. The Sri Lanka Journal of Haematology Answers for the CME: Acute trauma coagulopathy and massive transfusion
like in DIC but DIC can occur secondarily in ATC.
Coagulopathy of trauma is a distinct entity with When ATC becomes exacerbated by hypo- a strong impact on the outcome. Physiological thermia, acidosis and haemodilution (due to haemostasis controls blood fluidity and rapidly the rapid infusion of colloids) it is called IC.
induces haemostatic plug formation in order This then becomes a vicious cycle, enhancing to stop bleeding. Primary haemostasis (vascular more protein C activation and damage to and platelet mechanism), coagulation and fibrinolysis are closely linked to each other andprecisely regulated in order to efficiently close It has been shown that early recognition of vessel wounds, promote vascular healing and acute trauma coagulopathy, accompanied by maintain vessel patency.
appropriate and aggressive management, cancorrect coagulopathy, control bleeding, reduce There is limited understanding of the mecha- blood product use and improve outcome in nisms by which tissue trauma, shock and inflam- severely injured patients.
mation initiate trauma coagulopathy. Acutecoagulopathy of trauma-shock should be considered as a distinct entity from disseminated Massive transfusion is associated with numerous intravascular coagulation (DIC) as described inother conditions. Rapid diagnosis and directed and significant complications. In massive interventions are important in prevention.
transfusion, coagulopathy is frequently seendue to dilution of clotting factors and dilutional Coagulopathy of trauma is a haemostatic and thrombocytopenia. This is exacerbated by the haemodynamic depletion which is now recog- consumptive coagulopathy triggered by massive nized as acute trauma coagulopathy (ATC) and haemorrhage in trauma.
iatrogenic coagulopathy (IC).
Multiple factors contribute to hypothermia in Acute trauma coagulopathy has recently been trauma patients. Rapid transfusion of packed recognized as a multifactorial primary condition.
red cells stored at 4°C will lower the recipient's The principle drivers of ATC are tissue trauma, core temperature. Hypothermia leads to de- inflammation, hypo-perfusion/shock and acute creased production of clotting factors, platelet activation of the neurohumoral system. The dysfunction, impaired haemostasis and de- principle mechanisms of early ATC are (i) acti- creased citrate metabolism (citrate toxicity).
vation of the protein C pathway (ii) endothelialinjury (iii) hyperfibrinolysis (iv) platelet dys- Hypocalcaemia occurs due to citrate in additive function. Activation of the protein C pathway solution in packed red blood cells (PRBC), fresh and endothelial damage initiates the coagu- frozen plasma and platelets, especially in the lation system which ultimately leads to primary presence of hypothermia.
hyperfibrinolysis in ATC.
Potassium concentration increases in stored Endothelial injury may also be linked to PRBC, due to membrane Na+-K+ ATPase pump ‘autoheparinisation' as the entire endothelial inactivation. Therefore, transient hyperkalemia glycocalyx contains approximately 1 liter of non is common with rapid transfusions. Hypo- circulating plasma with significant amount of kalemia has been noted with massive trans- ‘heparin like substances'. When degranulated fusion due to restoration of membrane ATPase this automatically leads to autoheparinisation.
pump thus allowing potassium to re-enter the Therefore, initially the pathophysiology is not The Sri Lanka Journal of Haematology Citrate undergoes hepatic metabolism to and treatment of coagulopathy in massive hemor- bicarbonate and during a massive transfusion rhage and hemodilution. Anesthesiology. 2010 Nov; a metabolic alkalosis may occur.
3. Sihler KC, Napolitano LM. Complications of massive transfusion. Chest. 2010 Jan; 137(1): 209-20. doi:
1. Maegele M. The coagulopathy of trauma. Eur J Trauma Emerg Surg. 2014 Apr; 40(2): 113-26. doi: 10.1007/
4. Maxwell MJ, Wilson MJA. Complications of blood s00068-014-0389-4. Epub 2014 Mar 18.
transfusion. Contin Educ Anaesth Crit Care Pain. 2006; 2. Bolliger D, Görlinger K, Tanaka KA. Pathophysiology 6(6) 225-9. doi: 10.1093/bjaceaccp/mkl053.
The Sri Lanka Journal of Haematology The Sri Lanka Journal of Haematology is the official publication of the Sri Lanka College of Haematologists.
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Author Guidelines are available in the College website http://www.slchaem.lk/.
Publications by the Sri Lanka College of Haematologists:
Thalassaemia – M. Nanada Prematileke Anticoagulation with unfractionated heparin – Arundathi P. Kurukulasuriya Warfarin – Mala Tudawe Guidelines for the treatment of bleeding in haemophilia – Sudharma Vidyatilake What you should know about haemophilia (in Sri Lanka) – Sudharma Vidyatilake What you should know about ITP (in Sri Lanka) – Sudharma Vidyatilake What you should know about ITP (in Sri Lanka) (English, Sinhala and Tamil translations) – Dammika Gunawardena

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